SLEEP APNEA BLOG

Many Americans have trouble falling asleep or staying asleep.1 The reasons for that are many and varied—stress, illness, pain, some medications, hot flashes or hormone fluctuations, age, blue light (cell phones, computer screens) and, of course, sleep environment—mattress comfort, noises, lights, pets, neighbors, other family members.2 

But people with rheumatoid arthritis are much more likely than the rest of the population to also suffer from obstructive sleep apnea (OSA). How much more likely? A recent study found the incidence rate of sleep apnea was 75% greater in people with RA than in those without the disease.1

Why is this true? Researchers are not certain.1 But, as with insomnia and other sleep problems, there are many possible explanations:

Structural differences of the head, neck, and spine

That increased sleep apnea risk could be due to structural anomalies of the head, neck, and spine that are common in people with RA, such as: 

– underdeveloped lower jaw

-reduction of the size of the upper airway due to the degeneration of the temporomandibular joints (TMJ)

-narrowing of the spaces between cervical vertebrae that can cause compression on the brain stem and affect the severity of sleep apnea1

Inflammation

Arthritis is generally thought of as an inflammatory disease.  RA in fact increases certain proinflammatory cytokines, such as tumor necrosis factor (TNF), and these intercellular signaling proteins are involved in the process of normal sleep regulation.1

Regina M. Taylor-Gievre, MD, who researches inflammatory arthritis and sleep disorders, says higher TNF levels have also been reported in sleep apnea. As she explained in an article for the International Journal of Clinical Rheumatology, in someone who has RA, it could be that this increase in TNF levels could increase susceptibility to OSA.1

Obesity

Obesity appears to be another common connection between OSA and RA. Half of people with sleep apnea are overweight, and two-thirds of people with RA are overweight or obese. Carrying extra weight increases the chance of having OSA, because weight gain can cause fat to accumulate in the neck area (which obstructs breathing, and so could lead to OSA). Also, fat cells release cytokines, so having more fat cells means more inflammation, which can also contribute to RA.

Dr. Taylor-Gievre says there is also speculation about the role of fatty tissue in promoting inflammatory processes like RA directly; meaning it’s possible increased cytokines from excess fat may actually lead to the development of sleep apnea and/or rheumatoid arthritis.

Other risks from sleep apnea and rheumatoid arthritis

Regardless of the reasons why OSA and RA are prevalent together, it’s important—maybe critically important—for people to find out whether they have a sleep disorder. Both sleep apnea and rheumatoid arthritis are associated with increased risks of cardiovascular disease, including heart attack or stroke. OSA is even associated with sudden death.

Screening and testing for sleep disorders

The discovery process usually begins in a doctor’s office, and often with a screening questionnaire such as the STOP-BANG (which guides the patient to answer question about Snoring, being Tired, whether anyone has Observed breathing stopping or choking or gasping, high blood Pressure, high Body Mass Index or BMI, Age, Neck size, and Gender).3 

If sleep apnea is suspected, a test would follow—either an overnight stay in a sleep lab using polysomnography, or a home sleep apnea test (HSAT). Diagnosis is relatively easy after testing, and so is treatment. Different kinds of treatments are available, from continuous positive airway pressure (CPAP) to oral devices and medical procedures. All are worth consideration for uninterrupted, restful sleep, which is really priceless. 

REFERENCES

1

Repinski K. Sleep apnea and rheumatoid arthritis: what to know about the link. Creaky Joints. Jun 18, 2019. https://creakyjoints.org/comorbid-conditions/sleep-apnea-rheumatoid-arthritis/

2

Santos-Longhurst A, Castiello L (medical reviewer). Why you can’t seem to stay asleep (plus, how to finally catch some zzz’s). Healthline. Jun 30, 2021. https://www.healthline.com/health/healthy-sleep/why-cant-i-stay-asleep

3

The Official STOP-BANG questionnaire. Toronto Western Hospital, University Health Network, University of Toronto. http://www.stopbang.ca/osa/screening.php

Over one billion individuals worldwide experience some form of sleep apnea, and the number is rising. Obstructive sleep apnea (OSA) can negatively influence quality of life (QOL) and potentially increase mortality risk.1

But the association between OSA and mortality has not been reliably estimated. However, a new review article estimates the risk of all-cause and cardiovascular mortality in individuals with OSA.1

The results are stunning:  Individuals with OSA had a nearly twofold higher risk of sudden death and cardiovascular mortality. The primary outcome of the review was the risk of all-cause sudden mortality in individuals with OSA compared with individuals without OSA. Cardiovascular mortality associated with OSA was the secondary outcome of interest.1

A team from Pennsylvania State University conducted a systematic review and meta-analysis looking at 22 studies involving more than 42,099 patients. Of these, 64% were men and the mean age was 62. The studies were geographically diverse, coming from North America, Europe, Asia, South America and Australia.1

The team’s findings showed that “people with obstructive sleep apnea had a greater risk of dying suddenly and the risk rose as patients aged.”2

Looking at the risk of all-cause sudden death associated with OSA, the relative risk (RR) for those with mild OSA was 1.16 (95% CI: 0.70 to 1.93, I2=66%), for moderate OSA was 1.72 

(95% CI: 1.11 to 2.67, I2=0%) and severe OSA was 2.87 (95% CI: 1.70 to 4.85, I2=0%).1

The point estimates of cardiovascular mortality ranged from 0.80 to 4.19. Overall, individuals with OSA had a nearly twofold higher risk than those without OSA (RR=1.94, 95% CI: 1.39 to 2.70, I2=32%).1

Certainly, sleep apnea diagnosis, treatments and interventions can help decrease this risk and other adverse outcomes are necessary to optimize survival and QOL.

“This [study] adds to the growing body of evidence that highlights the importance of screening, diagnosis and treatment of sleep apnea,” said Dr. Kannan Ramar, immediate past president of the American Academy of Sleep Medicine (AASM), quoted in U.S News & World Report.2

Ramar, who reviewed the findings, said they underscore the importance of recognizing a widespread and often underdiagnosed condition that has become a growing public health concern.2

The advent of reliable, convenient, at-home sleep apnea testing ensure that sleep physicians can prescribe and diagnose sleep apnea without a patient stepping foot in the sleep lab. This flexibility allows physicians to detect sleep apnea quickly and take the necessary steps to treat this growing health concern

REFERENCES: 

1

Heilbrunn ES, Ssentango P, Chinchilli VM, Oh J, Ssentango AE. Sudden death in individuals with obstructive sleep apnea: a systematic review and meta-analysis. BMJ Open Respiratory Research, Volume 8, Issue 1. https://bmjopenrespres.bmj.com/content/8/1/e000656

2

Reinberg, S. Sleep apnea doubles odds for sudden death. U.S. News & World Report. August 3, 2021. https://www.usnews.com/news/health-news/articles/2021-08-03/sleep-apnea-doubles-odds-for-sudden-death


Higher physical activity and less time spent sitting and watching TV was associated with a significantly lower risk of developing obstructive sleep apnea.1

But is the converse true? And does that mean more COVID cases=more OSA diagnoses?

The results from a recent study that appeared in the European Respiratory Journal looked at “the potential role of maintaining an active lifestyle in reducing [OSA] incidence.”2 The authors concluded that “being more active and spending less time sitting while watching television are behaviors linked to a lower risk of developing OSA.”2

As the United States and other countries see rising rates of COVID-19 infection (particularly from the Delta variant), more travel restrictions may be on the horizon, which could mean more of the risks associated with OSA. Certainly, during COVID-related shutdowns, people were more likely to stay home and spend time in front of a monitor (for work or otherwise). If this is on the horizon, what effect may it have on OSA?

Researchers from Brigham and Women’s Hospital and Harvard Medical School in Boston, MA and Johns Hopkins Bloomberg School of Public Health in Baltimore, MD and other institutions2

“evaluated the independent and joint associations of physical activity and sedentary behavior with risk of incident OSA in three ongoing prospective cohort studies of US healthcare professionals: the Nurses’ Health Study (NHS), Nurses’ Health Study II (NHS II), and Health Professionals Follow-up Study (HPFS).”1

The authors hypothesized that “(1) physical activity and sedentary behavior were independently associated with OSA incidence, (2) the observed associations were partly explained by metabolic dysfunction and body fluid retention, and (3) physical inactivity

interacted synergistically with sedentary behavior to influence OSA incidence.”1

In the analysis, “50,332 women from NHS (2002-2012), 68,265 women from NHS II (1995-2013), and 19,320 men (1996-2012) from HPFS were prospectively followed and assessed via questionnaires every two to four years for recreational physical activity, measured by metabolic equivalent of task (MET)—hours/week, and sitting time spent watching TV and at work/away from home.”1

Based on “follow-up, 8733 incident cases of OSA were found across the study cohort. In their findings, participants who spent the least amount of time per week (<4.0 hours) sitting watching TV were shown to be 78% less likely to develop OSA than those who spent at least 28 hours per week (pooled multivariable-adjusted HR, 1.49; 95% CI, 1.60-1.98; P trend <.001.”1

In comparison, “people who spent the most sedentary time at work/away from home were 49% more likely than those with the least time to develop the condition (pooled multivariable-adjusted HR, 1.49; 95% CI, 1.38-1.62; P trend <.001.”1

In a statement, Tianyi Huang, ScD, MSc, assistant professor of Medicine, Harvard Medical School, and associate epidemiologist, Brigham and Women’s Hospital, said, “We saw a clear relationship between levels of physical activity, sedentary behavior, and OSA risk. People who followed the current World Health Organization physical activity guidelines of getting at least 150 minutes of moderate activity per week, and who spent less than four hours per day sitting watching TV, had substantially lower OSA risk.”1

Huang also stated, as many others have, that “OSA is highly underdiagnosed.”2 With 1 billion adults aged 30 to 69 years estimated to be affected by mild to severe OSA worldwide, several risk factors have been implicated in the pathogenesis of the condition, which include obesity, systemic inflammation, and insulin resistance.1

That number—1 billion—reinforces the critical need for ongoing screening and diagnosis testing for OSA, by polysomnography or home sleep apnea tests (HSATs).

The effect of the current rise in COVID cases on OSA remains to be seen. Restrictions on travel and gathering, whether voluntary or mandated, should mean an increased effort to get as much exercise as is safely possible—such as walking indoors, using home gym equipment—and as one’s physician suggests or approves.

REFERENCE:

1

Liu Y, Yang L, Stampfer MJ, Redline S, Tworoger SS, Huang T. Physical activity, sedentary behavior, and incidence of obstructive sleep apnea in three prospective US cohorts. Eur Respir J. Published online July 21, 2021. doi:10.1183/13993003.00606-2021. https://www.ajmc.com/view/obstructive-sleep-apnea-linked-with-accelerated-vascular-aging-cvd-risk

2

Keifer, D. Sleep apnea: Exercise and cutting TV time cut risk. Medical News Today. Aug 3, 2021.https://www.medicalnewstoday.com/articles/sleep-apnea-exercise-and-cutting-tv-time-reduce-risk

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Association between sleep apnea and blood pressure control in African Americans

African Americans have a high prevalence of both hypertension and uncontrolled blood pressure (BP), each of which may be partially explained by untreated sleep apnea.1

In fact, African Americans have the highest prevalence of hypertension of any race/ethnic group in the United States and have 90% higher odds of uncontrolled BP compared with non-Hispanic whites.2,3 The reasons for these disparities are not widely understood. 

However, in the Multi-Ethnic Study of Atherosclerosis (MESA), 84% of African American participants who had sleep-disordered breathing did not report a physician diagnosis of sleep-disordered breathing, suggesting a high prevalence of untreated obstructive sleep apnea (OSA) in this population.4

The Jackson Heart Study

The Jackson Heart Study (JHS) is a longitudinal study of 5306 African American adults, aged 21 to 95, enrolled from three counties in Jackson, Mississippi between 2000 and 2004.  JHS was designed to study the cause of cardiovascular disease among African Americans. Three core examinations have been conducted to date. The current analyses use data from the JHSS, an ancillary study conducted between December 2012 and May 2016 after the third JHS examination.5

This current research included participants with hypertension (high BP, use of antihypertensive medication or self-reported diagnosis; N=773). Sleep apnea was assessed with a home sleep apnea device.6,7 The analysis was further restricted to exclude those without a valid home sleep apnea test (N=51), or those with missing data on hypertension, measured BP, or number of antihypertensive medications and diuretic use (N=58). The final sample consisted of 664 participants. 

What did the study find?

The study shows that OSA, defined by an elevated respiratory event index or overnight hypoxemia, is associated with resistant hypertension among African Americans. 1

Further, moderate or severe OSA was associated with resistant hypertension but not uncontrolled BP (high blood pressure while taking ≥3 medications to control their blood pressure), suggesting that OSA is associated with more severe forms of hypertension.1 

What are the clinical implications?

This study suggests that untreated OSA may contribute to hard-to-control blood pressure in African Americans.1 

The results of the study support hypertension guidelines which encourage OSA screening in patients with hypertension, particularly among those who require the use of ≥4 medications to control their blood pressure.1

REFERENCES

1

Johnson DA, Thomas SJ, Abdallah M, Guo N, Yano Y, Rueschman M, Tanner RM, Mittleman MA,  Calhoun DA, Wilson JG, Muntner P, Redline S. Association between sleep apnea and blood pressure control among blacks. Jackson Heart Sleep Study. Originally published10 Dec 2018https://doi.org/10.1161/CIRCULATIONAHA.118.036675Circulation. 2019;139:1275–1284

2

Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2015 update: a report from the American Heart Association.Circulation. 2015; 131:e29–322. doi: 10.1161/CIR.0000000000000152

3

Redmond N, Baer HJ, Hicks LS. Health behaviors and racial disparity in blood pressure control in the national health and nutrition examination survey.Hypertension. 2011; 57:383–389. doi: 10.1161/HYPERTENSIONAHA.110.161950

4

Chen X, Wang R, Zee P, Lutsey PL, Javaheri S, Alcántara C, Jackson CL, Williams MA, Redline S. Racial/ethnic differences in sleep disturbances: the Multi-Ethnic Study of Atherosclerosis (MESA).Sleep. 2015; 38:877–888. doi: 10.5665/sleep.4732

5

Fuqua SR, Wyatt SB, Andrew ME, Sarpong DF, Henderson FR, Cunningham MF, Taylor HARecruiting African-American research participation in the Jackson Heart Study: methods, response rates, and sample description.Ethn Dis. 2005; 15(4Suppl 6):S6–18. 

6

Oldenburg O, Lamp B, Horstkotte D. Cardiorespiratory screening for sleep-disordered breathing.Eur Respir J. 2006; 28:1065–1067. doi: 10.1183/09031936.00084406

7Dingli K, Coleman EL, Vennelle M, Finch SP, Wraith PK, Mackay TW, Douglas NJ. Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome.Eur Respir J. 2003; 21:253–259

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Study shows Hispanics/Latinos at greater risk of long-term cognitive decline from poor sleep

Poor sleep impacts the risk of long-term cognitive decline in Hispanic/Latino middle-aged and older adults differently than it does in non-Hispanic/Latino adults. This information comes from research led by the University of Miami (Florida) Miller School of Medicine neurology faculty and the largest long-term study of U.S. Hispanics/Latinos to date.1

During the seven years of follow-up, Hispanics/Latinos were more likely to develop cognitive declines in processing speed, mental flexibility, and verbal memory, if they had sleep-disordered breathing, such as obstructive sleep apnea, and long sleep duration of nine or more hours. The risk was especially high in middle-aged adults without metabolic syndrome and women without obesity or metabolic syndrome, according to the paper recently published in Alzheimer’s & Dementia, the Journal of the Alzheimer’s Association.2

Why is this true? Sonya Kaur, Ph.D, instructor in the Division of Neuropsychology at the Miller School said, “The work shows that the metabolic risk factors that predict neurocognitive decline in non-Hispanics/Latinos are not generalizable to Hispanics/Latinos.” Dr. Kaur continued, “In general, the relationship between sleep and cognition was not mediated by metabolic syndrome and obesity in Hispanics like it is in non-Hispanics. For Hispanics, sleep seems to be a much stronger predictor than obesity and metabolic syndrome that are traditionally thought of as predictors in terms of what causes cognitive decline in non-Hispanics.”2

This is especially important because, compared to non-Hispanic whites, Hispanics/Latinos are at a greater risk for metabolic syndrome, and are at four times the risk of Alzheimer’s Disease and related dementias, according to Dr. Kaur.2

Being at greater risk raises a question about how common or rare screenings for sleep apnea are in the Hispanic/Latino population. An earlier study with this same group found that “sleep-disordered breathing is prevalent in U.S. Latinos but rarely associated with a clinical diagnosis. Only 1.3% of participants reported a sleep apnea diagnosis.”4 This suggests a critical need for testing along with screening, whether in-laboratory polysomnography or home sleep apnea tests (HSATs). 

Alberto Ramos, M.D., M.S.P.H., Study Senior Author, Associate Professor of Neurology, and Research Director of Sleep Disorders program, University of Miami Miller School of Medicine:

“In the big picture, these findings have implications for how we can personalize treatment of sleep disorders to more effectively lessen cognitive decline, prevent neurocognitive disorders such as Alzheimer’s disease and preserve brain health.”

Ramos continued, “A surprising finding of this study of 5,500 U.S. Hispanic/Latino adults was that participants without obesity that had sleep apnea and long sleep duration had worse cognitive decline. To some extent, this was like a natural experiment where we removed the effect that obesity has on cognition and saw ‘the pure effect’ of sleep difficulties, such as sleep apnea, and long sleep duration on cognitive health.”2

The Miller School has long been a leader in identifying disorders and risk factors associated with dementia and Alzheimer’s and Hispanic health. Dr. Ramos is also an investigator of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), where he serves as primary consultant for Sleep Research at the Miami site. Dr. Ramos is supported by NIH/NIA to evaluate sleep phenotypes, neurocognitive decline, and incident dementia in HCHS/SOL.2,3

Previously, Dr. Ramos and his colleagues published data showing a high prevalence of sleep disorders associated with neurocognitive dysfunction, including memory decline, in a diverse population of Hispanic/Latino participants.2

Dr. Kaur concluded by saying, “We are conducting ongoing research on the cognitive effects of migration factors and genetic risk factors in Hispanic patients, because there is evidence that genetic risk factors in non-Hispanic whites do not predict cognition decline in the same way as in Hispanics.”2

REFERENCES

1

Kaur, S. S., et al. (2021) Modifying pathways by age and sex for the association between combined sleep disordered breathing and long sleep duration with neurocognitive decline in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Alzheimer’s & Dementiadoi.org/10.1002/alz.12361.

2

Henderson, E. Poor sleep increases risk of long-term cognitive decline in Hispanics/Latinos. News Medical Life Sciences. May 28, 2021. https://www.news-medical.net/news/20210528/Poor-sleep-increases-risk-of-long-term-cognitive-decline-in-HispanicsLatinos.aspx

3

University of Miami Miller School of Medicine, Evelyn F. McKnight Brain Institute, Albert Ramos biographical entry. mbi-umiami.org

4


Sleep-disordered breathing in Hispanic/Latino individuals of diverse backgrounds. The Hispanic Community Health Study/Study of Latinos.Redline S, Sotres-Alvarez D, Loredo J, Hall M, Patel SR, Ramos A, Shah N, Ries A, Arens R, Barnhart J, Youngblood M, Zee P, Daviglus ML.Am J Respir Crit Care Med. 2014 Feb 1;189(3):335-44. doi: 10.1164/rccm.201309-1735OC.PMID: 24392863 


pexels andrea piacquadio 3807626

The American Academy of Sleep Medicine (AASM) has released a bold new position statement declaring that sleep is a biological necessity, and insufficient sleep and untreated sleep disorders are detrimental for health, well-being and safety. The new statement supports the vison of the AASM that “Sleep is recognized as essential to health.1

The statement emphasizes that there is a significant need for greater emphasis on sleep health in education, clinical practice, inpatient and long-term care, public health promotion and the workplace.1

The AASM statement also references that Healthy People 2030 (an initiative from the federal government’s Office of Disease Prevention and Health Promotion) includes several sleep-related objectives with the goal to improve health, productivity, well-being, quality of life and safety—by helping people get enough sleep.2 In addition to adequate sleep duration, healthy sleep requires good quality, appropriate timing, regularity and the absence of sleep disorders.2 The statement also suggests that “more sleep and circadian research is needed to further elucidate the importance of sleep for public health and the contributions of insufficient sleep to health disparities.”2

The AASM further believes that “sleep education should have a prominent place in K-12 and college health education, medical school and graduate medical education and graduate programs for other health professionals.2 Clinicians should routinely inquire about sleep habits and symptoms of sleep and circadian rhythm sleep-wake disorders during patient encounters, and hospitals and long-term care facilities should optimize sleep conditions.2 Healthy sleep should be targeted by public health and workplace interventions to improve health-related outcomes, and behaviors that help people attain healthy sleep should be promoted.”2

Finally, the AASM noted that while “significant resources have been invested in individual and population-level interventions to address health-related lifestyle factors such as nutrition, exercise, and smoking, programs focusing on sleep health have been notably rare.2 To promote public health and safety, widespread support is needed to increase sleep education, improve sleep disorders screening with home sleep apnea testing, optimize sleep conditions for inpatients and residents of long-term care facilities, optimize sleep health through public health and workplace interventions, and expand sleep health research.”2

REFERENCES

1. American Academy of Sleep Medicine. {2021} Sleep is essential to health: New position statement. [Press Release]

2. Kannan Ramar, MD;  Raman K. Malhotra, MD;  Kelly A. Carden, MD;  Jennifer L. Martin, PhD;  Fariha Abbasi-Feinberg, MD; R. Nisha Aurora, MD, MHS; Vishesh K. Kapur, MD, MPH;  Eric J. Olson, MD; Carol L. Rosen, MD; James A. Rowley, MD; Anita V. Shelgikar, MD, MHPE; Lynn Marie Trotti, MD, MSc. “Sleep is essential to health: An American Academy of Sleep Medicine position statement.” J Clin Sleep Med. (accepted for publication June 2, 2021).

itamar multinight blog

Single-night sleep studies can lead to misclassification of sleep apnea severity for many reasons, including first night effect. If misdiagnoses from single-night studies are common, one solution may be the availability of a more technologically advanced, flexible and easy to use home sleep apnea test that can both produce a great deal of patient data (including body position) and can be used for multiple night studies.

It’s safe to say that many variables influence a sleep apnea diagnosis of OSA (obstructive sleep apnea). Chief among them, of course, is the number of apneas plus the number of hypopneas occurring, on average, per hour. This number creates the well-known Apnea-Hypopnea Index or AHI. But there are many other variables that can influence how your patients sleep. Some can be measured during a sleep apnea test, such as oxygen levels, heart rate, breathing rate and airflow. Other variables are known and can be used toward diagnosis—for example, patient age and medical history, including medications taken, and alcohol use. But some variables that can have a major impact on sleeping (and, therefore, the AHI) are not commonly considered, such as body position and the composition of sleep stages.1

A recent study looked carefully at this, to determine how influential these two variables (body position and sleep stage) were in calculating obstructive sleep apnea (OSA) severity. In the study, half of the patients had > 2-fold worsening of the AHI in REM sleep, and 60% had > 2-fold worsening of AHI while supine.1

Importantly, misclassification—”specifically underestimation of OSA severity—is attributed more commonly to body position (20% to 40%) than to sleep stage (~10%).1

For example, summarizing study results relative to sleep position dependence, the authors noted “the results suggest that in our cohort the potential for misclassification based on body position was substantial and affected all OSA severity categories; in some cases, those with overall AHI values <5/h had supine AHI values in the moderate or even severe range.1

As for sleep stage, the study pointed out that although “the population-level risk of AHI underestimation due to decreased time spent in REM sleep was small, individual patients can clearly be misclassified on this basis.1

The authors concluded that reliance “on a single night of sleep data continues to represent a challenge to OSA diagnosis, decision making, and research phenotyping because a single night of sleep often does not provide sufficient examination of all combinations of sleep stages and body positions.1”  

Home sleep apnea testing with the WatchPAT ONE, WatchPAT ONE-M and WatchPAT 300 devices utilizes PAT technology to provide a robust data set including; AHI, OSA and Central sleep apnea, body position, sleep stages and REM sleep all with an at home sleep study.

References:

  1. Eiseman NA; Westover MB; Ellenbogen JM; Bianchi MT. The impact of body posture and sleep stages on sleep apnea severity in adults. J Clin Sleep Med 2012;8(6):655-666.

A recent study looked at possible relationships between obstructive sleep apnea (OSA) and certain cancers. Specifically, the study analyzed severe OSA as well as severe nocturnal hypoxemia.1 Severe OSA was “significantly associated” with a 15 percent increased risk of developing cancer, compared to people who have not been diagnosed with OSA (HR, 1.15; 95% CI, 1.02–1.30; ARD, 1.28%; 95% CI, 0.20%–2.37%; and NNH ¼ 78).1 Severe nocturnal hypoxemia, or abnormally low levels of oxygen in the blood, was associated with a 30 percent greater risk (HR, 1.32; 95% CI, 1.08–1.61; ARD, 2.38%; 95% CI, 0.47–4.31; and NNH ¼ 42).

The study used data accumulated between 1994 and 2017 at four academic hospitals in Ontario (Canada).2 The researchers looked at 33,997 individuals who had taken part in a diagnostic sleep study and were free of cancer at baseline.2 These sleep studies were conducted at hospital-related sleep clinics rather than with home sleep apnea tests. The study concluded “the severity of OSA and nocturnal hypoxemia was independently associated with incident cancer.”2

The study also noted that disruption of circadian rhythm through sleep fragmentation and/or intermittent hypoxia associated with OSA may also influence tumor cell behavior, including DNA repair, regulation of the cell cycle, and apoptosis.3 Finally, an increase in sympathetic nervous system activity associated with the acute and long-term carotid body response to intermittent hypoxia may affect tumors and their microenvironments, causing progression and metastatic activity.3,4

The study’s first author, Tetyana Kendzerska, MD, PhD, said, “I believe our results are conclusive given that they are based on about 30,000 adults free of cancer at baseline, more than 2,000 of whom developed cancer.”1  Dr. Kendzerska added that the study looked at specific cancer subtypes, noting “…we found colorectal, kidney, lung and smoking-related cancer subtypes to be all directionally  consistently associated with increased hazard of incident cancer, adjusting for known risk factors.”1

Dr. Kendzerska did add that while “Chronic hypoxemia and fragmented sleep are mechanisms by which obstructive sleep apnea is proposed to contribute to cancer development, epidemiological evidence linking OSA and cancer is still inconclusive.”1

The study findings support the hypothesis on the association between OSA and cancer incidence through intermittent hypoxemia and/or sleep fragmentation, suggesting the need for more targeted cancer risk awareness in individuals with OSA. It also calls for additional research on the way cancer biology interfaces with sleep apnea pathophysiology, including the role of OSA treatment in decreasing cancer risk. The study’s authors further claim the findings “also assist in advocating for better care and research into new therapies.”1

References:

  1. Press release, “Some cancers may be related to sleep apnea,” thoracic.org, The Journal of the American Thoracic Society, May 6, 2020.
  2. Tetyana Kendzerska, Marcus Povitz, Richard S. Leung, et al. “Obstructive Sleep Apnea and Incident Cancer: A Large Retrospective Multicenter Clinical Cohort Study.” Cancer Epidemiol Biomarkers Prev 2021;30:295-304. Published OnlineFirst December 2, 2020.
  3. Hunyor I, Cook KM. Models of intermittent hypoxia and obstructive sleep apnea: molecular pathways and their contribution to cancer. Am J Physiol Regul Integr Comp Physiol 2018: 315: R669
  4. Cole SW, Nagaraja AS, Lutgendorf SK, Green PA, Sood AK. Sympathetic nervous system regulation of the tumour microenvironment. Nat Rev Cancer 2015: 15: 563-72. 
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Obstructive sleep apnea (OSA) and chronic insomnia are challenging enough as individual conditions. But together—they pose some real risks. If nearly 3 in 10 people with OSA also have chronic insomnia, as studies suggest, the major question becomes: are your prescribed home sleep apnea tests catching indications of chronic insomnia?

Chronic insomnia and OSA are 2 common sleep disorders, and both are considered independent risk factors for heart disease.1 Both have also been independently associated with other serious medical conditions beyond cardiovascular disease, including cerebrovascular disease, depression, dementia, and cancer.

These facts send an urgent message to the sleep medicine community to question patients fully during screening and to gather as much patient data as possible from prescribed sleep tests. A test to determine whether a patient has sleep apnea could overlook comorbidities like insomnia, which may be underreported by patients. Looking at the apnea-hypopnea index (AHI) alone may not be enough. 

A recent study showed out of 476 patients with OSA studied, nearly 30% had significant insomnia.1 Nearly twice as many patients in that group (OSA+I) were female. Additionally, the OSA+I patients had higher rates of heart disease—more than twice as high as those with only OSA.1 Finally, the OSA+I group also showed lower quality of life, lower quality of sleep, higher sleep propensity, and higher depression.1

This study was conducted in Korea, which reminds us that sleep apnea is a global problem.1 Fortunately, it is also studied globally, and each of us can play a role contributing to solving the problem. 

We have a difficult task. Not only did the study indicate a high prevalence of comorbid insomnia with OSA, but it also suggested that comorbid insomnia with OSA may constitute a cumulative risk factor for cardiovascular disease.1

Going forward, the authors of the study noted the higher rate of cardiovascular diseases among patients in the OSA+I group “establishes a strong association, rather than a causality; therefore, it warrants further investigations into its pathophysiology, which would help devise risk reduction strategies and treatment options.”1

In the meantime, until more research is done, every questionnaire, every test, and every diagnostic improvement are developments toward more widely and fully treating sleep disorders. 

References:

  1. Cho YW, Kim KT, Moon H, Korostyshevskiy VR, Motamedi GK, Yang KI. Comorbid insomnia with obstructive sleep apnea: clinical characteristics and risk factors. J Clin Sleep Med. 2018;14(3):409-417. doi: 10.5664/jcsm.6988
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Itamar®Medical paired with a Sleep Medicine Publication to conduct a survey aimed at understanding the dynamics of the sleep apnea diagnostic market as well as the impact of COVID-19 on the traditional clinic set-up.

The anonymous survey (so designed to mitigate bias) was conducted during February and March, 2021. The survey questionnaire was sent to the participants in two ways:  via email and through social media. More than 200 sleep professionals participated in the survey, representing backgrounds including physicians, technicians, respiratory therapists and director/managers. The survey included questions about both home sleep apnea tests and polysomnography (PSG, which is performed in sleep laboratories). 

What follows are the most significant topline results:

93% of the clinics use HSAT in their daily practice

-66% utilize HSAT for more than 50% of their patients. Only 29% utilize PSG more than HSAT.

This survey result is an indication that a shift is occurring within the daily operations of sleep clinics that was not present pre-COVID-19. With only 29% of sleep clinics using an in-lab study more than a home option, this is a number that seems likely to continue to shrink—since sleep clinics are now able to get the data they need from an at-home option. The availability of disposable HSATs, with no return shipping or quarantining of equipment necessary, also points to this trend continuing. Combined with an increased capability from home sleep apnea tests, including near-instant test results, fewer and fewer sleep clinics will need to rely on their in-lab studies to be able to move patients through from the screening phase, to their diagnosis and treatment. 

Most of the participants think that “insurance controls their use of HSAT.” However, when clinics are selecting an HSAT to diagnose their sleep apnea patients, “ease of use by the patient” is the most important feature in the decision-making process (i.e., more so than reimbursement policies). 

While we have seen a confirmation of certain truths around insurance reimbursement and its connection to clinic choices in this category, it is significant to see that clinics have ranked “patient ease of use” as the feature that affects their choice the most when they are deciding on a home sleep apnea test to prescribe. As home tests are more and more prevalent and patient participation in the screening and testing process becomes more and more important, the clinics recognize that choosing a test that will be user friendly– and will not get in the way of the diagnosis—is something that is important to them.    

-While a majority of the clinics are using airflow-type HSAT, 40% added PAT®-type HSAT to their practices. 

-Due to infection control measures and/or logistical reasons, 55% of the clinics implemented disposable HSAT into their practices. 

-During COVID, 67% of the clinics had moderate/significant decrease in PSG patients, while 66% had moderate/significant increase in home sleep apnea test use. A majority of the clinics (65%) believe that this trend will remain after COVID and HSAT will be their first choice for sleep apnea diagnosis. 

Survey information provided by Itamar® Medical.  As one of the leading home sleep testing companies in the US, Itamar® Medical has pioneered an innovative sleep apnea management program for patients and healthcare professionals. 

Trucker Image Sleep Blog Post 1

A major threat to OTR (over-the-road) truck drivers—obstructive sleep apnea—is getting more attention from larger carriers, according to a recent article in Transport Dive.1 Drivers can be hesitant to complain about sleep problems or seek help from physicians over fear of losing their medical cards.*1,3 Combined with some skepticism about the sleep disorders in general and wariness of treatment cost, sleep apnea can often go undiagnosed in drivers.1

One trucking company steps forward

That may be about to change, thanks to initiatives from trucking carriers like Schneider.1 The company’s website states, “Schneider provides sleep apnea screening and treatment for all of its drivers in an effort to promote a healthier, happier lifestyle and prevent accidents caused by daytime drowsiness.”2

Many positives from corporate focus on sleep apnea in drivers

Tom DiSalvi, Schneider vice president of safety and loss prevention, outlined in the Transport Drive article how the company reduced delays in screening and found a supplier for CPAP machines.1 Three big positives from this corporate focus on the health and safety of its drivers are:  Schneider made the process cost-free to insured drivers, the result is a health cost savings to the company of $441 per month per driver, and drivers with apnea were retained at a 30% improvement rate.1

Many other trucking companies “on board”

A number of other companies have sleep apnea and “fatigue management” (as the industry often calls it) programs—including Marten, Maverick, Old Dominion, Saia, and Southeastern Freight, according to Mary Convey of SleepSafe Drivers, who was interviewed for the article.1

Undiagnosed sleep apnea in the driver population

Sleep apnea is known to be underdiagnosed in the general population but is believed to be much more so among long-haul truckers.1 A study by the Virginia Tech Transportation Institute (VTTI) found that as many as 47% of drivers are at risk for sleep apnea because of weight (BMI) or neck size.1 In the general population, diagnosis of sleep apnea is believed to be between 6 and 17%. Among truck drivers, it’s about 33%, according to the VTTI.1

Existing medical conditions can be made worse 

As dangerous as undiagnosed sleep apnea can be to the general population, in the driver population it may be worse; potentially causing memory problems, headaches, daytime fatigue, and difficulty focusing on the road, according to the American Sleep Apnea Association.1 Sleep apnea also contributes to comorbid conditions like weight gain or obesity, high blood pressure, and heart issues that many OTR drivers are documented to have, as well as Type 2 diabetes.4

Physicians offer telemedicine, disposable diagnostic machines, and hope

In addition to trucking companies, physicians are changing how they approach screening and diagnosis of sleep apnea by using more remote and disposable options.1 The use of home sleep apnea tests (HSATs) or holding virtual visits are trends that continue to grow.5 For example, Dr. Jordan Stern, a New York-based physician, said he conducts his test through telemedicine and his sleep tests can be done at home.1 Stern said his office mails the patient a disposable home sleep apnea test that can be self-administered while the patient sleeps, according to the article.1 Dr. Stern reassures his reluctant patients that he is “going to get you fixed.”1 This is a testament to the way home sleep apnea tests (and disposal devices) like the WatchPAT® ONE provide critically needed relief to those who are unable or unavailable to do an in-lab study, which is often the case for OTR drivers. With a career that keeps them on the road for the majority of the time, telemedicine and home sleep tests can offer screening, diagnosis, and a faster path to treatment—all without truckers having to miss out on work that is 100% travel-based.

Help from Washington?

With more serious focus on sleep apnea from the trucking companies and medical community, help may also be on the way from the federal government. The Federal Motor Carrier Safety Administration (FMCSA), an agency of the Department of Transportation, is working “to develop guidelines and materials that enable motor carriers to implement a comprehensive Fatigue Management Program (FMP) and means of delivering a FMP to motor carriers throughout North America.”3

Heading in the right direction

It began with awareness, but now there is a movement toward better, easier diagnosis and treatment of sleep apnea among truck drivers. That diagnosis and treatment is more affordable and comes with the support of employers and physicians.  A healthier, more alert OTR driving population should mean safer roads as well, which is better for everyone.

References: 

1. Jim Simpson, Sleep apnea:  a slow killer lurks among OTR truck drivers. Transport Dive. https://www.transportdive.com/news/OTR-truck-drivers-sleep-apnea-schneider-safety/594568/ February 25, 2021. Access date 4/3/2021.

2. Driver Experience Fact Sheet. Schneider. Schneider.com. https://schneider.com/resources/whitepaper/driver-experience-fact-sheet Access date 4/3/2021.

3. North American Fatigue Management Program. FMCSA. Fmcsa.dot.gov. https://www.fmcsa.dot.gov/research-and-analysis/research/north-american-fatigue-management-program Access date:  4/3/2021.

4. Maria R. Bonsignore, Pierpaolo Baiamonte, Oreste Marrone. Obstructive sleep apnea and comorbidities: a dangerous liaison. https://mrmjournal.org/mrm/article/view/10

Multidisciplinary Respiratory Medicine journal 14, Article number 8, 2019. Access date: 4/6/2021.

5. How to maintain momentum on telehealth after COVID-19 crisis ends. American Medical Association. https://www.ama-assn.org/practice-management/digital/how-maintain-momentum-telehealth-after-covid-19-crisis-ends. Andis Robeznieks. June 30, 2020. Access date: 4/6/2021. 

This material is subject to a disclaimer available here.

*A US DOT medical card is a document usually carried in a commercial driver’s possession that states that the driver has had a physical examination by a registered and qualified medical doctor and is medically certified and physically qualified to operate a commercial motor vehicle.

The FMCSA website: “A person with a medical history or clinical diagnosis of any condition likely to interfere with their ability to drive safely cannot be medically qualified to operate a commercial motor vehicle (CMV) in interstate commerce. However, once successfully treated, a driver may regain their “medically-qualified-to-drive” status. It is important to note that most cases of sleep apnea can be treated successfully.” [emphasis added]

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Seven days of national focus on sleep health

As we covered in our earlier blog posting this month, The National Sleep Foundation (NSF) is dedicated to improving health and well-being through sleep education and advocacy, and as part of that goal they have instituted National Sleep Awareness Week®—March 14-20, 2021.2 One of the many helpful programs of the NSF is the campaign coincides with the beginning of Daylight Savings Time, when many Americans lose an hour of sleep. Losing an hour of sleep during that time in combination with reported negative sleep health symptoms that could be a sign of sleep apnea could serve as a conversation starter for many types of physicians with patients who find this time of year especially difficult to feel rested and get through their routine easily or with little issue. 

The NSF has a focus on research in sleep, and began in 2013 to develop a “a survey instrument to assess general sleep health.”1This became the Sleep Health Index (SHI). 

The development of the SHI involved “assembling a task force, identifying specific topic areas, developing and testing questions, surveying a beta version of the instrument, refining the instrument, and developing and testing the index.”1 This SHI is in addition to their annual National Sleep in America Poll where more specific symptom-related questions and patient response to symptom questions are a part of the study. 

These focused on disturbed sleep or daytime sleepiness—worthy topics to be sure, but not the specific benchmark of trends desired by the NSF to assess sleep health or sleep disorders like sleep apnea in the general population.2 Those allude to sleep apnea and other disorders, but do not provide definitive answers or indicators that point to a definite diagnosis or an immediate screening need. Part of the problem, is that sleep health is so broad that many patients do not view any symptoms they may be having as part of any disorder like sleep apnea, but merely a feeling they must manage their way through without medical intervention.3 

What is sleep health? 

Surprisingly, no uniform or accepted definition of “sleep health” exists (although the NSF is working on developing its own).1 Sleep health is “not merely the absence of a sleep disorder or problem.”1 Overall sleep health may include the quantity, quality, and impact of sleep—which are all essential, especially for the large portion of the population that does not suffer from sleep pathologies.1 Because of that fact, the burden of communication and awareness around sleep apnea and its effects on not only cardiac health but overall health and wellness is on you as the clinician. 

How did America do?

In simple terms, the SHI measures three separate but related elements of sleep health—duration, quality, and disorders. Americans earned an overall score of 76/100 (higher score reflects better sleep heath). The sub-index scores were 81/100 in disordered sleep, 79/100 in sleep duration, and 68/100 in sleep quality.1 The strongest independent predictors of sleep health were self-reported stress and overall health, which were also the strongest predictors of sleep quality.1 

How sleep clinicians can use this information in relation to sleep apnea

According to the NSF: “Research consistently demonstrates that sleep is a significant component of physical and mental health, as well as overall well-being.”1 The importance placed in the Sleep Health Index on self-reported stress and overall health for both sleep quality and sleep health emphasizes the need to include general practitioners, cardiologists, sleep clinicians and doctors of all other specialties in the discussion around sleep and sleep health. 


A huge start toward seeing improvements in the findings from the NSF’s SHI is to normalize the consideration of regularly screening for possible sleep disorders like sleep apnea with patients who are not viewing sleep as a part of their overall health considerations. Further fine-tuning of who to ask, what to ask and when to ask is evident with just these three predictors from the index alone. Furthermore, with up to 80% of moderate cases of sleep apnea still remaining undiagnosed, interest in sleep studies of this nature continues to be important across specialty. These studies and surveys are a way to open lines of communication with patients and justify clinical opinions or recommendations of running a sleep study even if the patient remains on the fence that they have a problem. 

Luckily, with the advent and the growing usage of home sleep test options, these recommendations for a sleep study are a lot less burdensome than they have been in previous years where an in-lab sleep study was needed just to scratch the surface in terms of exploring the implications of less than perfect sleep patterns in patients. Screening for disorders like sleep apnea can now be done with the help of a home sleep apnea test where a patient can easily follow the instructions and administer their own test in their own home. 

Every survey or study on sleep health, whether done by the NSF or another organization, is likely welcome to our community of medical professionals, especially those who specialize in sleep and have a deeper understanding of how a patients’ sleep patterns may lead down a road to more serious conditions like hypertension, narrowing or arteries, atrial fibrillation, or even heart failure. In summary, while the NSF’s SHI is eye opening for many types of clinicians to get the conversation started about the importance of screening and the possible implications of the symptoms of sleep disorders like sleep apnea. Knowledge is power, and more knowledge on how our patients are sleeping and responding to their poor sleep is more power. And that is a plus for the patients being treated as a result of these studies.

References: 

1. Sleep Health Journal,  The National Sleep Foundation’s Sleep Health Index. https://www.sleephealthjournal.org/article/S2352-7218(17)30102-X/fulltext#secst0005  Kristen L. Knutson, PhD  Julie Phelan, PhD (co-primary authors) Michael J. Paskow, MPH  Anita Roach, MS  Kaitlyn Whiton, MHS  Gary Langer, BA  Sunshine Hillygus, PhD. Michael Mokrzycki, BS  William Broughton, MD  Sudhansu Chokroverty, MD, FRCP. Kenneth Lichstein, PhD  Terri E. Weaver, PhD, RN, FAAN  Max Hirshkowitz, PhD, DABSM. June 19, 2017.

2. The National Sleep Foundation, Press Release. “National Sleep Foundation prepares for Sleep Awareness Week 2012” https://www.thensf.org/national-sleep-foundation-prepares-for-sleep-awareness-week-2021/  February 19, 2021.

3.   American Academy of Sleep Medicine. Press Release. https://aasm.org/aasm-response-to-screening-for-obstructive-sleep-apnea-in-adults-evidence-report-and-systematic-review-for-the-us-preventive-services-task-force/ February 24, 2021.

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Alarming findings from new survey

A new poll from the National Sleep Foundation (NSF) has revealed alarming findings about sleep health in America1—with significant implications for sleep apnea diagnoses—both obstructive sleep apnea and central sleep apnea. The Sleep in America® poll showed two particularly pertinent pieces of information that have implications for clinicians concerned with sleep health and disorders like sleep apnea:

  • Americans feel sleepy on average three times a week
  • 62% of those sleepy people cite “shaking it off” as their primary response

In summary, the Sleep in America poll shows a rising level of sleepiness and a low level of action to address it. These results understandably could cause concern for everyone in sleep medicine especially those clinicians who make sleep apnea screening, diagnosis and treatment a goal. While the sleep apnea symptoms and number of respondents who admitted to having the symptoms are something that clinicians might consider to be important, a concern that is even arguably more concerning is the perception of the respondents around these symptoms and a lack of action toward them. 

NSF’s Sleep in America poll—a comprehensive study

The Sleep in America poll has been conducted annually since 1991 by the NSF. The NSF is dedicated to improving health and well-being through sleep education and advocacy.1 The organization shines a light on sleep apnea and other sleep disorders throughout the year, but with a special emphasis in March. 

Sleep Awareness Week—seven days of focus on sleep health

One of the many NSF education programs is Sleep Awareness Week®, March 14th-20th.2 The week is held leading up to the start of Daylight Savings Time, when most Americans lose an hour of sleep. It comes at a time that is especially pertinent. As specific parts of the poll along with the perceptions that the patients have communicated through the poll, prove the importance of awareness around sleep as an integral piece of the overall health puzzle. 

Americans open up about sleep problems

Nearly half of all respondents in the NSF’s Sleep in America poll1 reported feeling sleepy three to seven days a week, with many saying sleeplessness impacts their daily activities, mood, mental acuity, productivity and more. Headaches and irritability are also mentioned. These findings in combination with studies showing that up to 80% of sleep apnea cases are undiagnosed, increases the awareness around a problem that has been ongoing for a number of years. 

But what will study participants do about sleeplessness?

What is not mentioned by respondents is any kind of a permanent solution—or recognition that a solution may be needed. The overwhelming answer to the poll question “Do you think you have a sleep problem, or not?” was No. Second was Maybe and trailing was Yes.1 This specific point within the poll alludes to a need for increased patient awareness around what sleeplessness and other sleep-related symptoms could mean for their overall health.  

Unrecognized sleep disorders and undiagnosed sleep apnea

Obstructive sleep apnea (OSA) is a highly prevalent disease that remains underdiagnosed and undertreated.3 The reasons for that may be as complex as the disease. A lack of public knowledge about just what sleep apnea is, along with low awareness of sleep apnea tests and sleep apnea devices, may likely be significant reasons why. A possible consideration for sleep clinicians, general practitioners, cardiologists, and even dental professionals is to make talking points about sleep a part of their routine patient consultations, just as they would discuss diet or exercise in the context of overall health.

Another tool for sleep clinicians in the battle against sleep disorders

In addition to raising awareness with their patients, there are options that would make the screening, diagnosing, and treatment process much easier than the traditional protocol of the in-clinic PSG. An at-home sleep apnea test like the WatchPAT® ONE is a reliable, affordable, disposable option.4,5In the time of the COVID-19 pandemic, an at-home diagnostic could likely be more welcome to patients and clinicians alike. Once the simple test is delivered to the patient’s home and completed in their own beds, physicians can review the automatic results through the CloudPAT® and discuss them with the patient. This means that with home sleep tests like the WatchPAT® ONE, there is potential for getting a sleep apnea patient diagnosed without the need for any in-office visits. Quick, painless, accurate, and no risk of infection. An at-home diagnostic test like the WatchPAT®ONE is an important first step toward better sleep health. 

The time to act is now

The NSF’s Sleep in America poll is a comprehensive study of sleep health in the country.1 Beyond the numbers, it also highlights areas of concern. The two most alarming areas of concern are the two highlighted previously. This combination—high reported levels of sleeplessness, together with low reported levels of action regarding that lack of sleep—is two roads going in the wrong direction. Sleep clinicians could be leading the way toward addressing this troubling trend, and the NSF’s intention of increasing patient awareness could encourage other types of clinicians to include this frequently ignored area of health into their typical protocols. Everyone could sleep better knowing that.

References: 

  1. National Sleep Foundation Press Release. https://www.thensf.org/2020-sleep-in-america-poll-shows-alarming-level-of-sleepiness/  March 9, 2020.
  2. National Sleep Foundation Press Release. https://www.thensf.org/national-sleep-foundation-prepares-for-sleep-awareness-week-2021/  February 19, 2021.
  3. American Academy of Sleep Medicine. Press Release. https://aasm.org/aasm-response-to-screening-for-obstructive-sleep-apnea-in-adults-evidence-report-and-systematic-review-for-the-us-preventive-services-task-force/ January 24, 2017.
  4. Itamar Medical Blog. WatchPAT—Home Sleep Study Device https://www.itamar-medical.com/patients/watchpat-home-sleep-testing
  5. American Academy of Sleep Medicine. FDA clears disposable home sleep apnea test. https://aasm.org/fda-clears-disposable-home-sleep-apnea-test/  February 18, 2020.
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On December 1st, 2020, the Centers of Medicare and Medicaid Services (CMS) issued revisions to the Physician Fee Schedule (PFS) which outlines payment policies, rates, and quality provisions for services provided under Medicare.2 

The goal of the CMS revision was to prioritize primary care, chronic disease management and telehealth services. The revisions were designed to:2

  • Allow non-physician practitioners to provide care that they are licensed and trained to perform 
  • Expand coverage for telehealth services adding 144 services that will be covered through the end of COVID-19 pandemic
  • Increase payment rates for in-office and outpatient face-to-face evaluations and management (E/M) visits for chronic conditions

Then, on December 29th, 2020, some additional adjustments were made that amounted to the following items:1 

  • Provided a 3.75% increase in MPFS payments for CY 2021
  • Suspended the 2% payment adjustment (sequestration) through March 31, 2021
  • Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
  • Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024


Q: What does that mean for HSAT reimbursement?

A: These revisions led to reimbursement changes for different services and procedures, including home sleep apnea testing (HSAT). HSAT devices that include sleep time, such as the WatchPAT® Home Sleep Apnea Tests , saw an increase in the reimbursement level while traditional airflow tests without sleep time saw a decline in reimbursement.

cpt codes

Q. Do Medicare and third party payers have any restrictions on who can bill for HSAT? 

A: Yes. Medicare Administrative Contractors (MACs) require that physicians who interpret the sleep study have a sleep certification issued by specific specialty boards, or be an active member of an accredited sleep center or laboratory. Some MACs also require physicians that provide the sleep study to be credentialed. Check the LCD of your MAC for their requirements. Medicare also restricts durable medical equipment suppliers from providing any component of sleep testing. Third party payers make autonomous decisions in the development of their medical policies and the limitations they set. While some third party payers include sleep certification or accreditation requirements for HSAT in their policies, most do not. Please check payer policies for applicable limitations. 

Q. How often can HSAT be performed and qualify for reimbursement? 

A: Payers vary on the number of sleep studies that are considered medically necessary per year. Most payers allow two sleep studies per year unless it is medically necessary to repeat a study. It is recommended to seek prior authorization if the payer’s established frequency limitation is exceeded. 

Q. How many consecutive nights of study may be performed and reimbursed? 

A: Medicare and third party payers state that if you perform two or three nights of study it will only be reimbursed as one night of study. Third party payers may reimburse more than one night of study depending on your specific contract.

For more information about the CMS decision, visit the CMS website. And for additional questions regarding reimbursement with the Watch PAT® Home Sleep Apnea Test download our 2021 Reimbursement Guide

References: 

  1. Physician Fee Schedule. CMS. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched. Accessed February 26, 2021.
  2. Press release Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients. CMS.gov. https://www.cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-expansion-medicare-telehealth-services-and-improved-payment.
  3. Sleep Medicine Codes. AASM.org. https://aasm.org/clinical-resources/coding-reimbursement/sleep-medicine-codes/. Published December 14, 2018. Accessed January 31, 2021.
  4. Physician Fee Schedule Search. CMS.gov Centers for Medicare & Medicaid Services. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed January 31, 2021. Published December 1, 2020. Accessed January 31, 2021.
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There is little doubt that the year 2020 will be remembered for the devastating Covid-19 pandemic and the way it has negatively affected our world in ways many thought unimaginable just a short while ago. And while we could comment on the travel restrictions or the difficulties of attending large gatherings, we decided to close this year in a positive way, highlighting favorable trends that are currently happening within our space as well as celebrating the success we were able to achieve during this challenging time. 


The changing landscape of sleep studies

For most patients in years past, it was more common to complete a sleep study at a facility rather than at home due to several factors. Estimates showed that approximately 70% of sleep studies were done outside the home. However, for the last couple of years, we began to see a gradual decline in the number of PSG tests being requested versus HSAT. 

With Covid-19, the ratio has completely flipped, with 70%+ HSAT tests being administered vs ~30% for the more common PSG. At Itamar®, we are hopeful that over time, this ratio will move to a 50-50 split between PSG and HSAT. We also are aware that the better our diagnostic process, the more we can positively affect patient conditions and outcomes.  

Our WatchPAT® ONE made a huge difference during this crisis and we are excited to see so many sleep clinics see it as their primary choice for their patients, selecting it first over other competitors in the marketplace. 

Looking at CMS reimbursement

On the subject of CMS reimbursement – with the recently announced 2021 physician fee schedule, we are happy to note that HSAT reimbursement code 95800 which WatchPAT® falls under with its PAT® technology and sleep time was not affected compared to the dramatic (-13.9%) reduction in current rates for competitive Home Sleep Apnea Testing (HSAT) devices. This should also provide additional confidence to WatchPAT® users.

Clinical validation

WatchPAT® technology was recently validated thanks to a study published in the December 2020 edition of Nature and Science of Sleep. Entitled ‘WatchPAT is Useful in the Diagnosis of Sleep Apnea in Patients with Atrial Fibrillation’, the study concluded that WatchPAT®, based on PAT® technology can diagnose sleep apnea events in AFib patients with and without nocturnal active AFib episodes with accuracy similar to the general population, with significant correlation to PSG testing outcomes. 101 patients from the US, Canada, Germany, and Israel took part in the use of WatchPAT® against in-lab polysomnogram (PSG) testing in the diagnosis of sleep apnea in patients with atrial fibrillation (AF). The study concluded that WatchPAT is a viable alternative to PSG for confirmation of clinically suspected sleep apnea that is based on peripheral arterial tone signal’s amplitude and rate, oxygen saturation, and actigraphy.

Advancing sleep technology

Finally, the National Sleep Foundation (NSF) awarded the team at Itamar® Medical with the 2020 SleepTech® Award. This honor recognizes our innovative efforts in advancing sleep technology while addressing the needs of consumers during this difficult time. 

“We are honored and delighted to receive the 2020 SleepTech® Award and to be recognized by the NSF for our achievements in the field of sleep medicine and technology. Sleep Apnea is a serious disease with serious consequences. We are very proud of the home-based innovative technology and the digital health platform we have built to deliver simple and reliable solutions for the diagnosis and management of this condition,” said Gilad Glick, CEO, Itamar Medical. 

The future

With 2020 almost behind us, we are now looking forward to continued success in 2021. As we move forward with the increased demand for home sleep testing, stable CMS reimbursement compared to airflow HSAT devices, and the clinical validation and awards our technology has garnered, we see a bright future on the horizon. 

Diabetes Awareness Month

Each year, The American Diabetes Association designates November as American Diabetes Month. This annual campaign lasts throughout the month, and is focused on a number of projects, including raising funds for research, increasing awareness about diabetes, supporting those who already suffer from its affects, and educating those who are potentially at risk for being diagnosed. 

As a physician responsible for the diagnosis and treatment of obstructive sleep apnea, or OSA, it’s important to note that Type 2 diabetes can develop due to the effects of OSA. As this study in Diabetes Spectrum summarizes:

Obstructive sleep apnea (OSA) alters glucose metabolism, promotes insulin resistance, and is associated with development of type 2 diabetes. Obesity is a key moderator of the effect of OSA on type 2 diabetes. However, chronic exposure to intermittent hypoxia and other pathophysiological effects of OSA affect glucose metabolism directly, and treatment of OSA can improve glucose homeostasis.

Both potential and active patients need to know that diabetes, just like OSA, can be treated. The possible effects of not doing so include heart disease, stroke, blindness, kidney damage, and lower extremity amputation. Offering to actively screen for OSA could give you the insight needed to make an effective plan for treatment, leading to a successful outcome that reduces the chance of a diabetes diagnosis.  


Season effects and the stress of 2020

As we all move toward the holiday season and the winter months ahead, the chances that your patients will consistently make good food choices while taking part in outdoor activities dramatically drops. Knowing that those already suffering from OSA are greatly increasing their risk of becoming diabetic should embolden you to offer guidance, encouragement, and support. These little moments could be all that’s needed to help someone make better choices. 

By taking the opportunity to screen patients for OSA with our WatchPAT®home sleep apnea devices, along with educating patients about the potential risks for diabetes early on, you can change the outcomes for many in your care. Impress on them the need to proactively care for themselves, and those that they love. After all, diabetes, just like OSA, is a preventable disease. Reaching out today just might make all the difference in someone’s life. 

Learn more about diabetes and how you can help at www.ada.org

Diabetes Spectrum 2016 Feb; 29(1): 14-19

sleep apnea vector

by Shiri Shneorson

VP & general manager, digital health business unit, Itamar Medical 

Until quite recently, anyone aiming to track their sleep outside a laboratory setting lacked access to any technology more sophisticated than a pen and notebook.

Now, amid a plethora of mobile apps, wearable devices, and sensors, we’ve seemingly entered a new era of greater precision and sophistication in tracking our sleep. These advances come at a time when they’re sorely needed: According to the Centers for Disease Control and Prevention, more than a third of Americans sleep less than the recommended seven or more hours per day, putting them at risk of heart disease, stroke, high blood pressure, mental illness, and other conditions.

But while more people are turning to sleep-tracking devices in a bid to improve their overall wellbeing, these devices come with major technological and medical limitations. While they may do a decent job measuring the timing and duration of our sleep, they still come up short when it comes to tracking the quality of our sleep, let alone serving as diagnostic tools. 

What are these devices’ shortfalls – and how, despite those flaws, can we harness these tools to live healthier, better rested lives?


Weighing the drawbacks

The current sleep tracking trend dates back nearly a decade. Fitness trackers like Jawbone and Fitbit and apps like Beddit – later acquired by Apple – have enabled users to monitor their nightly sleep habits albeit without delving into sleep quality or sleep cycles.

While existing sleep tracking apps have been able to provide some basic insights into the stages of sleep (light vs. deep), their overall effect has been to provide users a big-picture overview of how much they’re sleeping each night. That information is far from useless, of course, as for many users, this data alone can help them adjust their day- and night-time routines to promote healthier sleep habits.

But to understand the uses and limitations of these devices, it’s helpful to think about how they actually work. The technology used to measure sleep – like wrist-worn accelerometers, which monitor users’ movement throughout the night (with long periods of immobility characterised as sleep), movement-tracking bed sensors, or sleep-tracking headbands equipped with brain wave-reading electrodes – relies on a mixture of mobility and biomarker data like heart rate and respiration to evaluate users’ shut-eye. 

There are plenty of pitfalls to these methods: Restless sleepers who toss and turn, for instance, can easily confound motion-based monitors, tricking these devices into thinking they’re awake. Chronic insomniacs who remain motionless in bed for hours on end may be recorded as sleeping, despite being wide awake. Meanwhile, sleep technology experts say that movement and heart rate sensors fail to accurately measure sleep in the REM stage. While some products, including from Garmin and Fitbit, provide data on users’ sleep stages, they lack respiratory indices and the ability to diagnose conditions like sleep apnoea.

Indeed, sleep trackers generally fall significantly short in terms of diagnosing sleep conditions. In the diagnostic realm, polysomnography – not the most popular apps and devices – is the gold standard.  

Evaluating the overall merit of different sleep trackers is even more difficult given that most commercial products operate on undisclosed blackbox algorithms that determine what is and is not sleep. Sleep labs’ algorithms, on the other hand, are publicly shared, making it possible for independent experts to evaluate them.

Where these devices can help

For all their shortcomings, sleep tracking devices can still fulfil important functions. Rather than seeing the data generated by apps and wearables as the final word on all things sleep, users can treat it as supplementary information to help guide smarter decisions about when, where, and how they sleep. Users may find, for example, that they tend to sleep longer when they go to bed and wake up between certain times, or that they sleep better after an evening workout session. It’s also important to track variables like room temperature and diet, both of which can have a big impact on one’s ability to fall asleep and stay asleep.

Devices with snore-tracking features, while not to be treated as diagnostic tools, can help users determine whether they’re at risk of obstructive sleep apnoea; if so, they should seek further examine from their doctors. Indeed, the American Academy of Sleep Medicine, while noting that consumer products “are not substitutes for medical evaluation,” endorses consumer sleep technologies as tools that can “enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation.” In arming patients with preliminary data, these tools can also promote a sense of empowerment, which is vital for individuals looking to take charge of their own wellbeing.

Are sleep trackers sleeker and more innovative than the sleep journals of yore? Undoubtedly. Are they medical-grade diagnostic tools with flawless data capabilities? No – but to the extent that they make us more aware of sleep’s importance to our health, they can enable us all to live and sleep better.

Also Published at Med-Tec News

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CPAP Machine. Image: shutterstock


The incidence of obstructive sleep apnea syndrome (OSA) is estimated to be 25% in the adult population. That’s one-quarter of adults who are at risk for the consequences of the disorder, including fatigue, high blood pressure, heart disease, type 2 diabetes, and more. And, although CPAP, the most common treatment for sleep apnea typically reduces the presentation of these symptoms and complications and improve sleepiness, residual sleep disordered breathing (SDB), or some level of sleep apnea events despite the use of CPAP,  can still occur. For example, if patients suffer from severe sleep apnea with 35 events per hour aka AHI (Apnea Hypopnea Index) and they use of CPAP reduces the events to 12 events per hour, it is great relief , but this patient still suffer from mild sleep apnea. 

This means that despite the use of CPAP to manage their sleep apnea, patients with SDB may not achieve the full benefits of their treatment and instead, continue to suffer from symptoms and damage of OSA. Additionally, residual sleep disordered breathing has been associated with reduced CPAP adherence, further complicating treatment.

This makes monitoring and detecting clinically suspected residual SDB vital to ensuring adequate treatment in patients with OSA vital for optimal and effective patient care.


CPAP Machines Subject to Error

Unfortunately, existing practice is to rely on the CPAP machines themselves in order to detect residual breathing issues, since these machines utilize proprietary algorithms to quantify respiratory events and detect and report residual or untreated apneas.

However, recent data shows that for both fixed and auto-adjusting CPAP machines, of multiple leading brands,  this quantification may be subject to significant error.

This is a fact that is glaringly evident when patients with acceptable CPAP data present with new or even worsening symptoms and comorbidities of OSA, signs highly associated with residual sleep disordered breathing.

Accurate Detection of SDB

That’s why research reported in the Journal of Clinical Sleep Medicine set out to determine if there was a better, more accurate way to monitor for and detect residual SDB in patients on CPAP for obstructive sleep apnea.

Patients included in the study were actively using CPAP and had an apnea-hypoxia index (AHI) of five or fewer event per hour on their CPAP data report. Yet each was clinically suspected of being inadequately treated for their apnea. 

Clinical criteria that led to a suspicion of SDB included:

  • Weight gain of more than 10 pounds
  • Worsening or persistent daytime sleepiness
  • Poor or worsening sleep quality
  • Recurrent apneas
  • New or worsening comorbidities such as hypertension or atrial fibrillation

Patients next underwent a single night of home sleep apnea testing using Itamar Medical’s WatchPAT®️ 200, simultaneous with CPAP use at the usual prescribed settings.

What is WatchPAT®️?

WatchPAT®️ is an innovative diagnostic Home Sleep Apnea Test (HSAT) that utilizes the peripheral arterial tone signal.  The device measures up to 7 channels (PAT® signal, heart rate, oximetry, actigraphy, body position, snoring, and chest motion) via sensors on the wrist, chest and finger. And WatchPAT provides AHI and other indices based upon True Sleep Time as well as Sleep Staging and is clinically validated with an 89%1 correlation to polysomnography (PSG).

The Results

After simultaneous WatchPAT and CPAP monitoring of 100 patients, divided into two groups with similar mix of age, sex, and body mass index, participants were divided into two groups:

  • Group 1: 52 patients with similar CPAP AHI and WatchPAT AHI (5 or fewer events/h)
  • Group 2: 48 patients with s WatchPAT AHI greater than their CPAP AHI (with median AHI difference? significantly greater at 11 events/h)

This means that WatchPAT AHI was significantly higher than the AHI detected with CPAP in nearly half of patients with clinically suspected residual sleep disordered breathing.

Additionally, WatchPAT revealed instances of moderate or severe REM AHI in both groups 1 and 2, which CPAP machines cannot detect, as well as instances of significant oxygen desaturation index and significantly lower nadir oxygen saturation in group 2.

The Conclusion

Overall, the researchers concluded that WatchPAT detected additional respiratory events beyond those detected by the CPAP machines, including rapid eye movement-related apneas, respiratory effort-related arousals, and hypoxemia.

The results of this study mean that physicians treating patients with obstructive sleep apnea, when clinical symptoms are present,  can no longer rely upon CPAP machines alone to ensure detection of residual SDB.

Instead, simultaneous monitoring with home sleep apnea testing, such as WatchPAT, even for patients with a normal CPAP AHI is necessary to ensure adequate treatment and prevent the long-term complications of sleep apnea.

References: 

1- Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apnea, Epstein et. Al, Journal of Clinical Sleep Medicine, Vol 16, No 7

WatchPATone

There is little doubt that 2020 and the advent of COVID-19 will forever reshape the face of healthcare. From the meteoric rise in telemedicine to increasing stringency in infection prevention protocols, hospitals, clinics, and testing facilities must now adapt in order to succeed in the coming years.  And one prime example of adaptation is that of sleep apnea testing.

By its very nature, traditional sleep apnea testing is not only high-touch (thanks to the devices used and staff required) but also high exposure, due to the length of time patients are expected to spend within a clinic’s walls and the nature of aerosols spread during irregular breathing and snoring. While the area within these walls provides safety for patients during testing, the truth is that some studies show that the longer a person spends in a public setting – which a sleep clinic has to be – the more likely their chances of contracting the virus.

This is why doctors and clinics across the world are turning to home-based sleep apnea testing.

In order to get the clinical data necessary to treat their patients without compromising their safety, cardiologists and sleep physicians now see home testing as the preferred way to diagnose sleep apnea conditions, all in an environment that’s both safe and familiar to their patients.

However, while moving the location of the test from the clinic or hospital to the patients home is definitely a step in the right direction for patient safety, there are other areas of potential infection risk requiring more necessary actions to ensure the highest level of mitigation.


COVID, and the rise of disposable home sleep apnea tests

A second area of infection risk embedded with the home sleep testing devices that are typically dispatched from one patient home to the next.  

traditionally, all home sleep apnea testing devices on the market are designed to be re-used with some elements being disposable or washable, but this now serves as a potential risk of infection from previous patients or even staff to the next patients, as well as back again when the staff receives the device.

This creates vulnerability where there should be only a sense of safety, and is the driving force behind the recently issued American Association of Sleep Medicine “COVID-19 Mitigation Strategies” guideless and rise in demand for fully disposable home sleep apnea tests (HSATs).

WatchPAT®️ ONE – The first and only fully disposable HSAT

This need is exactly why Itamar Medical created WatchPAT®️ ONE, the first fully disposable HSAT. This one-time use device provides patients the comfort of sleep apnea testing in their own home and in their own bed, while ensuring they are never exposed to potential infection from reused devices and contamination transmitted from previous patients.

Patients simply:

  1. Attach the chest sensor
  2. Strap on the WatchPAT bracelet to their non-dominate hand
  3. Slip on the finger probe 
  4. WatchPAT ONE is connected with blue tooth to a simple smartphone app which in turn transmits the WatchPAT®️ ONE’s 7 channels of data to the cloud.  

As soon as the study is complete, the prescribing clinician or the assigned board-certified sleep physician can review the automatically scored study results and provide interpretation and the patient can safely throw the WatchPAT®️ ONE away. There is no need to mail the device or any part of it back, eliminating the chance that someone could be exposed to possible infection. Imagine, no delays in data transfer, which results in faster diagnosis, as well as protecting staff and patient alike.

And, since WatchPAT®️ has been clinically validated against the “Gold Standard”, polysomnography (PSG), with a documented correlation of up to 89%1, it provides not only outstanding patient compliance but also clinical reliability. 

In the COVID era, WatchPAT®️ is the answer sleep physicians and patients are searching for to provide the testing they need without compromising safety.  

References: 

1- Yalamanchali S, Farajian V, Hamilton C, Pott TR, Samuelson CG, Friedman M. Diagnosis of obstructive sleep apnea by peripheral arterial tonometry: meta-analysis. JAMA Otolaryngol. Head Neck Surg. December 2013;139(12):1343-1350

WPONE Man Sleeping White Probe

Before the Covid-19 pandemic, potential sleep apnea patients were usually tested in an overnight facility, where their conditions were monitored and recorded, all overseen by a small team of medical professionals. They were asked to spend the night sleeping in a bed unfamiliar to them, in a noisy room surrounded with monitors and equipment, all while staff checked in on them throughout the duration of the test. It wasn’t perfect, but you could at least get an idea of what your patient was dealing with as they slept.
Now, with the pandemic continuing to affect everyone in one way or another, your patients are faced with far fewer options than in the past. Most, if not all testing facilities and clinics have severely cut back operations or have been forced to close outright. These facilities will need to make considerable changes to operations in order to open again and even then, most will likely choose to close at least in the short-term due to litigation concerns, insurance costs, and potentially higher levels of regulation and oversight. The road will be rough for many of these facilities, with many shutting their doors permanently.


Home as the New Diagnostic Center


No matter what happens, your patients will still need you to diagnose and treat their sleep disorders. The question becomes – how can you do it safely and effectively? The need for a new solution to both monitor and detect sleep apnea conditions in safe, familiar environment has never been greater. Your patients are looking to you for help. And up until now, a simple, effective, one-time use device that they can use in their own home while sleeping in their own bed did not exist.
Introducing the WatchPAT® ONE, the world’s first and only disposable HSAT from Itamar® Medical. This innovative, FDA-cleared wrist mounted device was created to diagnose Sleep Breathing Disorders (SBD) in the comfort of the patient’s own home. The WatchPAT®️ has been clinically validated against the “Gold Standard”, polysomnography (PSG), with a documented correlation of up to 89%.1 Its simple design is both comfortable easy to use for outstanding patient compliance. It is clinically reliable, with 98% success rate.2 It measures “True Sleep Time” for the most accurate AHI, RDI, ODI and delivers:
* Complete sleep architecture for a comprehensive diagnosis
* Increased infection control with single-use design
* Scalable, cost effective solution for high volume workflow
* Automatically generated reports for fast diagnosis and treatment turnaround
* zzPAT -software with an advanced automatic algorithm for scoring of respiratory events
* CloudPAT-cloud based IT solution for convenient sleep diagnosis and secure patient data transfer
In a post-COVID world, ensuring patients can receive the diagnostic testing they need in the safety and comfort of their own home simply makes sense. Reach out today and talk to your Itamar representative about how to optimize sleep management in your practice.

1.Yalamanchali et al. JAMA Otolaryngnol Head Neck Surg, 2013, Diagnosis of Obstructive Sleep Apnea by Peripheral Arterial Tonometry (Meta-Analysis)

2. Data on file