Men and women reacting differently to the same situation isn’t news. But men and women reacting differently to the same medical condition

A recent article in Forbes suggests that may be true—that obstructive sleep apnea (OSA) affects women differently, and that women are underdiagnosed and undertreated for OSA compared with men.1

Why is this so?

Christine Won, MD, director of the Women’s Sleep Health Program at Yale Medicine, determined the sex differences in OSA are due to 2 factors1:

Women are more likely to have sleep apnea during rapid eye movement (REM) sleep than non-REM (NREM) sleep. “Since REM sleep is on average about 20% of our sleep duration,” Dr Won said, “this may mean women have less total number of apneas during the entire night. But during REM sleep, the apneas tend to be more severe, meaning longer and associated with significant drops in oxygen level.”1

Women may be more prone to upper airway resistance syndrome. “In this disorder (which is disruptive but less severe than sleep apnea), women still have snoring and collapsible airways, but they do not have frank apneas (a respiratory event where breathing has completely ceased) and do not have oxygen level drops,” Dr Won continued. “Airway resistance still leads to awakenings and sleep fragmentation.”

Dr Won noted another key difference between men and women with sleep apnea: women are more likely than men to wake up from apneas and suffer greater sleep disturbance.1

Dr Won also reasoned that women are diagnosed with sleep apnea significantly less often than men are because of the way the disease is defined.1 “Obstructive sleep apnea is diagnosed if you have, on average, more than 5 events per hour of sleep. Women may be less likely to have sleep apnea during NREM sleep but have just as much sleep apnea during REM sleep as men.”1 As mentioned above, REM sleep makes up only 20% of total sleep time, so the average number of events per hour is going to be less in women than men (leading to fewer diagnoses). 

“Therefore, even though women may have less sleep apnea events across the entire duration of sleep, since they appear to have just as many sleep apnea events during REM sleep, women may be just as susceptible as men” according to Dr Won, “to the ill effects of sleep apnea.”1

And what are those ill effects? Sleep apnea can increase the risk of asthma, atrial fibrillation, cancers, chronic kidney disease, cognitive and behavioral disorders, diseases of the heart and blood vessels (heart attack, heart failure, high blood pressure, and stroke), eye disorders, metabolic conditions, and even pregnancy complications.1

Some of the OSA risk factors for women are also different from those for men. While obesity may affect both populations, hormone status is a key risk factor for women. “Women’s risk of sleep apnea increases markedly  after menopause,” Dr Won said. “Female hormones may be protecting women from the NREM sleep apnea that occurs more normally in men.”1

Finally, OSA symptoms can also be quite different in men and women. Snoring, gasping, and witnessed apneas are classic symptoms exhibited by men. “Women may also have these symptoms but are also more likely to present with less ‘classic’ symptoms such as insomnia, sleep fragmentation, depressed mood, fatigue, or morning headaches,” according to Dr Won.1

Underdiagnosis is a significant health threat for women. The Society for Women’s Health Research estimates that 1 out of every 5 women has sleep apnea—and the vast majority (9 out of 10) are unaware of their condition.

The responsibility falls to physicians and clinicians to carefully screen patients for sleep apnea, referring patients to a sleep specialist when necessary. A sleep apnea diagnosis is generally based on medical history, a physical exam, and the results of a sleep study.1 Sleep studies can either be an overnight, observed, in-laboratory polysomnography study, or a home sleep test.2

At-home sleep apnea testing is an easy, cost-effective way to figure out whether you’re having trouble breathing,” said Susheel P. Patil, MD, PhD, clinical director of the Johns Hopkins Sleep Medicine Program. “If you are being told that you snore, snort and gasp, if you have disrupted sleep or are sleepy during the day, and you are overweight or obese, an at-home sleep apnea test may be very appropriate. Talk with your clinical provider about your options,” Dr Patel said.3



Groth L. Sleep apnea in women may be undertreated. Forbes. Updated June 29, 2021.


Chahine E. At-home sleep tests and studies. Sleep Foundation. Updated May 6, 2021.


What to know about an at-home sleep test. Johns Hopkins Medicine.

The answer may be “yes.” A recent study found that older adults who received positive airway pressure (PAP) therapy prescribed for obstructive sleep apnea (OSA) may be less likely to develop Alzheimer disease and other types of dementia.1 

The study, conducted by researchers from the Michigan Medicine Sleep Disorders Centers (University of Michigan), analyzed Medicare claims of more than 50,000 Medicare beneficiaries aged ≥65 who had been diagnosed with OSA.2 The question at the heart of the study was “were those people who used PAP therapy less likely to receive a new diagnosis of dementia or mild cognitive impairment over the next 3 years, compared with people who did not use PAP?”2

Lead author Galit Levi Dunietz, PhD, MPH, an assistant professor of neurology as well as a sleep epidemiologist said, “We found a significant association between positive airway pressure use and lower risk of Alzheimer’s and other types of dementia over 3 years, suggesting that positive airway pressure may be protective against dementia risk in people with OSA.”

Tiffany J. Braley, MD, MS, study principal investigator and associate professor of neurology noted, “If a causal pathway exists between OSA treatment and dementia risk, as our findings suggest, diagnosis and effective treatment of OSA could play a key role in the cognitive health of older adults.”2

The importance of adherence to PAP therapy

“Adherence to PAP therapy was also associated with lower odds of incident Alzheimer disease diagnosis,”2 the authors concluded. But adherence to therapy is a difficult issue. 

Despite the high efficacy of continuous positive airway pressure (CPAP) to reverse upper airway obstruction in sleep apnea, treatment effectiveness is limited by variable adherence to prescribed therapy. When adherence is defined as greater than 4 hours of nightly use, 46% to 83% of patients with OSA have been reported to be nonadherent to treatment. Evidence suggests that use of CPAP for longer than 6 hours decreases sleepiness, improves daily functioning, and restores memory to normal levels.3

One of the most dramatic immediate effects of any medical treatment is the ability of continuous positive airway pressure (CPAP) treatment to reverse the repetitive upper airway obstruction of sleep apnea and associated daytime sleepiness. Patients will describe the effect as emerging from a daytime fog and being able to live a productive and healthy life. CPAP, the primary treatment for OSA, has been shown to normalize sleep architecture, reduce daytime sleepiness, enhance daily function, elevate mood, reduce automobile accidents, and decrease blood pressure and other cardiovascular events.4

“As with any observational study,” the authors concluded, “causality and its direction cannot be established beyond doubt. While OSA diagnosis preceded the diagnosis of dementia, reverse causality cannot be fully ruled out. As noted, the typical age of OSA onset greatly precedes the typical age of dementia onset, but future studies over longer time intervals may be needed to confirm that the association in the present data between OSA treatment or adherence and lower incidence of dementia does not arise because dementia impedes subsequent OSA treatment and adherence.”2

Positive news for patients

Physicians and clinicians working with patients with sleep apnea are well aware of the negative reactions of many patients to using PAP therapy. However, the overwhelming evidence in favor of this therapy—including this exciting development regarding Alzheimer disease—should work in favor of better acceptance and adherence. 

Screening and testing for sleep apnea

The results of this study also point again to the continued need for increased screening and testing of patients suspected of having sleep apnea which must, of course, happen before the beginning of any treatment.  

Screening is done primarily by using one of 3 questionnaires, after learning of patient concerns regarding daytime sleepiness, and so forth. The questionnaires are the Epworth Sleepiness Scale (ESS), the STOP-BANG Sleep Questionnaire, and the Berlin Questionnaire.5

In addition to overnight, in-laboratory sleep studies using polysomnography, home sleep apnea tests (HSATs) are available that are portable, convenient, and less intrusive.6 HSATs have become popular with patients who, during the pandemic, prefer to stay at home, as well as patients fully embracing all forms of digital healthcare such as remote monitoring.



Otman H. Treating sleep apnea may reduce dementia risk. Med Xpress. Apr 10, 2021.


Dunietz GL, Chervin RD, Burke JF, Conceicao AS, Braley TJ. Obstructive sleep apnea treatment and dementia risk in older adults. Sleep. 2021;44(9):zsab076. doi: 10.1093/sleep/zsab076


Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173-178. doi: 10.1513/pats.200708-119MG


Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep 2006;29(3):381-401. doi: 10.1093/sleep/29.3.381


Three different ways you can screen for sleep apnea. HomeSleep, LLC, blog. Sept 21, 2018.


American Sleep Association. At-home sleep apnea test.

Obstructive sleep apnea (OSA) is well-established as a disease that is also a risk factor for many other health problems. Studies continue to help increase understanding of why people develop sleep apnea, which people are more susceptible, when to test for it, how to treat it properly, and so forth. A recent study added to this knowledge, starting with a closer examination of OSA, a look at obesity, and then an uncommon possible influencing factor1

The Pathophysiology of OSA remains complex

The anatomical predisposition factors are present in all patients (in 30% of patients without other factors). In 70% of cases, there are 1 or more associated non-anatomical pathophysiologic factors. This is responsible for a different phenotype of the disease.2

There are 4 pathophysiologic factors involved in the pathogenesis of OSA:

  • Anatomic, which can lead to greater collapse of the upper airways in nonobese patients
  • Instability of ventilatory control, also known as high loop gain
  • Neuromuscular inefficiency of the dilator muscles of the upper airways
  • Increased propensity for nocturnal awakenings due to respiratory stimuli or a reduced awakening threshold, known as low arousal threshold (also called low respiratory arousal threshold, or LRAT).2

Nonobese patients with OSA: looking at an unusual cause

A recent study looked specifically at the role of LRAT in nonobese patients. Nonobese patients with OSA are a subgroup of individuals with clinical, polysomnographic, and pathophysiologic features.1 Little evidence exists regarding the role of LRAT.1 But, because there could be a non-anatomical pathological prevalent trait, this factor could explain the difficulty in treating OSA in nonobese patients.1 

How prevalent is low arousal threshold?

Low arousal threshold is present in 30% to 50% of all patients with OSA.2 Disturbingly, another study showed that LRAT was observed in more than 60% of African American patients evaluated for OSA. This study also showed a significantly higher LRAT score in African American females, nonsmokers, patients with body mass index (BMI) <25, and patients with mild sleep apnea severity.3 

Nonobesity by the numbers

Nonobese patients are those with a BMI <30 kg/m2. 1   Approximately 20% of adults with OSA are nonobese.4 The number of people with OSA is thought to be as many as 18 million in the United States—1 in 15 adults—with 80% undiagnosed. Some estimates are much higher. 

Uncommon characteristics

OSA in nonobese patients is usually less severe and less frequent. However, it is essential to identify these patients because they are 4 times more likely to develop hypertension than obese individuals without OSA.5 Nonobese patients are at risk for early atherosclerosis—approximately 2.7 times more than obese patients without OSA, and this risk increases as the severity of the syndrome increases.6 Also, nonobese patients with OSA are usually younger, so early detection and care could reduce long-term risk associated with the syndrome.7

Diagnosis and treatment

An in-laboratory overnight sleep study using polysomnography (PSG) is routinely indicated for the diagnosis of respiratory sleep disorders. The study authors point out that an excellent, alternative is nocturnal portable monitoring (PM), often known as home sleep apnea tests, or HSATs.

The treatment of choice is continuous positive airway pressure (CPAP); however, nonobese patients with OSA with a low arousal threshold have poorer adherence to CPAP therapy.8 CPAP may not be the right therapy for everyone. For some patients, other approaches such as mandibular advancement devices (MADs), maxillofacial surgery, hypoglossal nerve stimulation, or a pharmacological approach with targeted therapies may be more appropriate than CPAP.8 Non-anatomic interventions (e.g., non-myorelaxant sedatives) to increase the threshold for arousal, alone, or in combination with existing therapies (e.g., CPAP or oral appliances), may yield greater therapeutic success in this group of patients.2 Improved understanding of the pathophysiology of OSA in recent years provides an opportunity to develop individualized therapies based on subpopulations and mechanisms.

The study authors believe that further pathophysiologic studies are needed to better clarify the role of low arousal threshold in patients with OSA and in the nonobese subgroup.


1. Antonaglia C, Passuti G. Obstructive sleep apnea syndrome in non-obese patients. Sleep Breath. 2021. doi: 10.1007/s11325-021-02412-1

2. Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med. 2013;188(8):996-1004. doi: 10.1164/rccm.201303-0448OC

3. Moghalu O,  Whitesell P,  Kwagyan J. Low respiratory arousal threshold (LRAT) in African Americans with obstructive sleep apnea (OSA). 

Neurology. 2020;94(15 suppl):2740. 

4. Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015;3(4):310-318. doi: 10.1016/S2213-2600(15)00043-0

5. Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 Pt 1):608-613. doi: 10.1164/ajrccm.163.3.9911064

6. Luyster FS, Kip KE, Aiyer AN, Reis SE, Strollo PJ. Relation of obstructive sleep apnea to coronary artery calcium in non-obese versus obese men and women aged 45–75 years. Am J Cardiol. 2014;114(11):1690-1694. doi: 10.1016/j.amjcard.2014.08.040

7. Frey WC, Pilcher J (2003) Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg 13(5):676–683.

8. Gray EL, McKenzie DK, Eckert DJ. Obstructive sleep apnea without obesity is common and difficult to treat: evidence for a distinct pathophysiological phenotype. J Clin Sleep Med. 2017;13(1):81-88. doi: 10.5664/jcsm.6394

Itamar Medical’s WatchPAT® home sleep apnea test (HSAT) devices continue to grow in popularity among prescribers and patients, for many reasons. Patients can appreciate the ease of use and comfort, and prescribers acknowledge the reliability, accuracy, and reporting speed of these state-of-the-art products.

What sets WatchPAT® apart is, of course, the PAT® signal. The Peripheral Arterial Tone (PAT®) signal is a non-invasive measure of the arterial pulsatile volume changes at the fingertip. It is a proprietary technology used to identify respiratory events. 

Many medical professionals want to learn more about how the PAT® signal works, and offering best-in-class professional education is a core commitment of Itamar® Medical. 

The COVID-19 Outbreak

Every aspect of medicine has been affected by the COVID-19 pandemic. There has been a greater demand for remote technologies of all kinds including telemedicine, continuous remote monitoring, and digital prescriptions. For Itamar® Medical, the pandemic has produced a greater demand for HSATs, especially the WatchPAT® ONE fully disposable test. 

But the peer-to-peer classroom training with interactive courses and hands-on training–that was the standard operating procedure Itamar® Medical used for teaching–had to be shelved. Looking for a virtual solution to provide continuous education, PAT® Academy was formed.

PAT® Academy Basic and Advanced Courses

PAT® Academy is Itamar® Medical’s education platform that was designed for clinicians who would like to understand more about PAT® signal and WatchPAT® technology. PAT® Academy

offers different levels of courses in multiple languages and time zones.

The PAT® Academy basic course “Practice and Principles” is designed for physicians seeking to understand the PAT® signal physiology, WatchPAT® scoring algorithm and diagnosis capabilities. Topics covered include:

-Review WatchPAT® technology

-Evaluate hypnogram and sleep-disordered breathing patterns

-Identify salient features in WatchPAT® reports

-Target areas for greater scrutiny in WatchPAT® recordings

-Summarize impact of visual overreading in COMPASS study

The advanced course “Case Analysis” is geared toward physicians who would like to learn how to interpret the WatchPAT® report and recording and understand when and how to verify and edit WacthPAT® recordings by using the manual scoring guidelines. Topics covered include:

-Distinguish Obstructive vs. Cheyne-Stokes/Central Sleep Apnea

-Apply editing guidelines across a spectrum of sleep-disordered breathing

-Revisit a spectrum of obstructive sleep-disordered breathing patterns

-Recognize non-respiratory sleep disturbances

A Valuable Resource for Sleep Professionals

The PAT® Academy is designed to introduce physicians and sleep technologists to the analysis of WatchPAT® HSATs. Practitioners are encouraged to derive key inferences from WatchPAT®’s automated report, and to solidify those inferences with visual analysis of physiologic signals contained in the underlying recordings. 

This approach serves to highlight the importance of alterations in autonomic cardiorespiratory control in recognizing sleep-wake state and sleep-disordered breathing episodes. In a series of illustrative case examples, the PAT® Academy builds progressively on fundamental principles to enhance the clinician’s acumen and ability to accurately diagnose a variety of sleep-disordered breathing patterns and non-respiratory sleep disorders. This approach implements state-of-the-art scoring guidelines, which were developed from a rigorous comparison of WatchPAT® and polysomnographic (PSG) recordings. 

These courses were designed to take the practitioner from basic to advanced case analyses. Cases are specifically selected to illustrate key concepts required to render secure diagnoses of respiratory and non-respiratory sleep disorders. This approach teaches the practitioner how to leverage the automated analyses of WatchPAT® studies with efficient strategies to recognize, confirm, and edit the scored recordings. 

The PAT® Academy welcomes further input and insights from sleep professionals to reinforce and extend the curriculum with additional didactic material and interactive activities. 

Signing Up for PAT® Academy Courses

The no-cost courses have high demand and limited openings. Participation is not limited to physicians. Anyone interested in learning to perform a manual scoring review, edit for WatchPAT® sleep studies, or learn more about PAT® signal and its capabilities is welcome to attend. Find out all the platform offers, get answers to questions and sign up for courses now at

A landmark study presented at the European Respiratory Society (ERS) International Congress 2021 says “using PAP (positive airway pressure) therapy as directed can significantly increase sleep apnea patients’ chances of living longer.”1

The study, “CPAP Termination and All-Cause Mortality:  A French Nationwide Database Analysis,” concluded people with obstructive sleep apnea (OSA) who continued PAP therapy were 39% more likely to survive than patients who didn’t.1 Researchers observed more than 

176,000 people in France with sleep apnea over a three-year period. Authors of the study say the survival rate gap remained significant when accounting for patients’ ages, overall health, other pre-existing conditions, and causes of death.1 

Adam Benjafield, study co-author, said “Treating sleep apnea with PAP therapy may help you live longer; that’s the key takeaway here for people with sleep apnea and their doctors.” Benjafield also noted “This finding underscores how critical it is to identify the hundreds of millions of people worldwide whose sleep apnea is undiagnosed and untreated.”1 

Diagnosing that population means medical professionals first need to screen patients for OSA. Several questionnaires exist for this purpose (for example, STOP-BANG).4 The next step is testing, either with an in-lab, overnight study using polysomnography, or with a home sleep apnea test (HSAT). 

And just how large is that population? Another study involving Benjafield suggests the number is staggering: an estimated 936 million people worldwide have sleep apnea2—but more than 80% remain undiagnosed.

A spillover benefit of this new study may be a reversal in so-called “CPAP Hesitancy.” New patients need to become familiar with their device and find one that works well for them (comfort, maintenance, etc.). Patients may also need the positive reinforcement that comes from reminding them of the benefits of CPAP therapy:

-Better Mood—When a patient has a proper night’s sleep, he or she will simply feel happier and more energized during the day. 

-Sharper Focus—Not only can therapy delay the onset of cognitive impairment, but it can also improve day-to-day concentration.5

-Health Risk Prevention—Compliance with CPAP therapy aids in overall risk reduction for many types of diseases: it can lower blood pressure and chances for heart disease and stroke. 

But the benefit of improved health and the chance to live longer eclipses everything else. 



Pepin JL et al. “CPAP termination and all-cause mortality: a French nationwide database analysis.” ERS abstract, 2021.


Benjafield AV et al. Lancet Resp Care 2019.


Young T et al. Sleep 1997.


American Sleep Apnea Association. Sleep apnea information for clinicians.

5Advanced Sleep Medicine Services, Inc. Sleep Blog. What CPAP machine should I choose?

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


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 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. 



Repinski K. Sleep apnea and rheumatoid arthritis: what to know about the link. Creaky Joints. Jun 18, 2019.


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.


The Official STOP-BANG questionnaire. Toronto Western Hospital, University Health Network, University of Toronto.

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



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.


Reinberg, S. Sleep apnea doubles odds for sudden death. U.S. News & World Report. August 3, 2021.

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.



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.


Keifer, D. Sleep apnea: Exercise and cutting TV time cut risk. Medical News Today. Aug 3, 2021.

sleep 11 8

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



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 2018 2019;139:1275–1284


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


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


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


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. 


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



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 &


Henderson, E. Poor sleep increases risk of long-term cognitive decline in Hispanics/Latinos. News Medical Life Sciences. May 28, 2021.


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


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 

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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

Itamar Medical is a global medical device company specializing in sleep apnea diagnosis & management with the WatchPAT home sleep apnea test (HSAT).


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.


  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


  1. Press release, “Some cancers may be related to sleep apnea,”, 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. 


  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.


1. Jim Simpson, Sleep apnea:  a slow killer lurks among OTR truck drivers. Transport Dive. February 25, 2021. Access date 4/3/2021.

2. Driver Experience Fact Sheet. Schneider. Access date 4/3/2021.

3. North American Fatigue Management Program. FMCSA. Access date:  4/3/2021.

4. Maria R. Bonsignore, Pierpaolo Baiamonte, Oreste Marrone. Obstructive sleep apnea and comorbidities: a dangerous liaison.

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. 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.


1. Sleep Health Journal,  The National Sleep Foundation’s Sleep Health Index.  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”  February 19, 2021.

3.   American Academy of Sleep Medicine. Press Release. 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.


  1. National Sleep Foundation Press Release.  March 9, 2020.
  2. National Sleep Foundation Press Release.  February 19, 2021.
  3. American Academy of Sleep Medicine. Press Release. January 24, 2017.
  4. Itamar Medical Blog. WatchPAT—Home Sleep Study Device
  5. American Academy of Sleep Medicine. 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


  1. Physician Fee Schedule. CMS. 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.
  3. Sleep Medicine Codes. Published December 14, 2018. Accessed January 31, 2021.
  4. Physician Fee Schedule Search. Centers for Medicare & Medicaid Services. 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.