The founder of a virtual sleep center helps an obstructive sleep apnea patient requalify for and keep her therapy.
Telemedicine, or telehealth, is an emerging, multifaceted healthcare delivery modality that includes a number of applications such as remote physiological monitoring of patients, as well as clinician-to-clinician and clinician-to-patient interactions conducted via videoconferencing platforms. This case illustrates a common scenario in clinical sleep medicine where a patient exhibited poor CPAP compliance and lost her equipment, despite voicing motivation to use the therapy. Sleep telemedicine was utilized to remedy the situation.
“Dorothy” is a 61-year-old woman with a diagnosis of obstructive sleep apnea (OSA). Prior to her becoming a patient of virtual sleep center Singular Sleep, she had been referred by her primary care provider (PCP) for diagnostic polysomnography (PSG) for symptoms of snoring, sleep maintenance insomnia, and excessive daytime sleepiness in the setting of comorbid obesity (body mass index: 31.2), hypertension, and type 2 diabetes.
That study showed OSA with an apnea hypopnea index (AHI) of 16.4 and minimum oxygen saturation of 82%. Subsequently, she had a CPAP titration that recommended a setting of 9 cm of water pressure (CWP). Dorothy struggled with tolerating her CPAP machine. She had discussed this with her PCP, who was managing her OSA. He had given her a prescription for trazodone 50 mg to be taken every night at bedtime. Despite trying this medication, 2 mask refits, initiation of maximal expiratory pressure relief, and a trial of decreasing the pressure to 7 CWP, she did not meet her insurance company’s compliance requirements so the CPAP was repossessed. She expressed to her durable medical equipment (DME) representative that she was motivated to use CPAP but simply couldn’t keep it on during the night. Her DME representative informed her that she would need to “requalify” with another sleep study in order for her insurance to approve an additional trial of CPAP. Dorothy adamantly refused to return to the sleep lab for another study. She also declined returning to discuss the situation with her PCP because “all he wants to do is give me pills.” The DME representative suggested Dorothy contact Singular Sleep to discuss attempting to requalify via a home sleep test (HST).
After visiting www.singularsleep.com and discussing the situation with a Singular Sleep representative, Dorothy ordered an HST. The HST study reconfirmed OSA with an AHI of 24.1 with minimum oxygen desaturation of 77%. Dorothy scheduled a teleconsultation to discuss how she might improve her compliance. Review of previous medical records indicated a REM AHI of 39.8 on her diagnostic PSG. Careful review of her CPAP titration revealed that her recommended pressure had not been tested in REM-supine sleep. The patient complained about her experience during both in-lab sleep studies. She did not like knowing that someone was watching her sleep, and during the CPAP titration, she could hear someone in another room “coughing all night,” which kept her awake. Indeed, sleep efficiency was poor during both the diagnostic PSG and CPAP titration (78% and 71%, respectively). She tolerated the HST very well.
According to the patient’s self-reported sleep history, bedtime averaged 11:30 PM and rise time 6 AM. History was notable for normal sleep latency but a typical pattern of awakenings: usually around 1-1:30 AM, 3:30-4 AM, and then inability to sleep past 6 AM. Epworth Sleepiness Scale score was 12.
During her trial of CPAP, she initiated use of the machine every night. She had no difficulty falling asleep with the machine and estimated that her sleep latency was 10 minutes. However, she never woke up with the mask on in the morning. She did not remember taking the mask off during the night except for one occasion, when she felt compelled to remove the mask due to a vague sense of “claustrophobia.” She denied pressure intolerance, aerophagia, or mask discomfort. She used a nasal mask, and there was no evidence to suggest mouth leak as she denied dry mouth and dry throat. Review of a compliance download obtained previously from her DME showed unremarkable leak parameters and estimated AHI was not suspicious for uncontrolled OSA. CPAP intolerance due to insufficient pressure during REM sleep was suspected. I ordered the patient an APAP set from 9-20 CWP. I suggested that if her tolerance for PAP improved with these new settings, she could attempt to wean herself off trazodone over 2 weeks.
Telemedicine follow-up consultation 2 months later revealed vastly improved compliance. A machine download showed an average nightly use of 6 hours and 43 minutes and an estimated AHI of 1.2. She said she no longer removed the mask during the night. Her insomnia was resolved and her sleep was considerably more refreshing. Repeat Epworth Sleepiness Scale score had improved to 5. She reported that the quality of her life was significantly better with APAP and that she had successfully weaned herself off trazodone.
Telemedicine as a Resource for PCPs and DMEs
For many patients, it is their PCPs who primarily manage their OSA. PCPs are often overburdened by demands to manage multiple chronic medical illnesses during a 15- to 20-minute appointment and have limited knowledge of sleep medicine. In this author’s experience, it is common for PCPs to have a low threshold for prescribing sedative hypnotics for sleep disorder patients. Often, this approach simply masks the underlying issue and, in theory, could worsen sleep-disordered breathing if a benzodiazepine is used.
DMEs face different challenges. They are often quickly aware of compliance problems but are constrained in their troubleshooting options due to lack of prescribing capabilities. There is obvious benefit for DMEs to have a close working relationship with a sleep medicine physician who has expertise in the medical aspects of sleep apnea management.
In many parts of the country, particularly rural and certain urban areas, sleep medicine is underserved. The nearest board-certified sleep medicine physician may be hours away by car. In addition to geography, cost can be another barrier to patients consulting with sleep medicine physicians. Patients with high-deductible health plans may face a consultation fee of up to $300 to see a specialist physician. Due to cost savings on overhead, cash-based telemedicine companies such as Singular Sleep may offer significant savings to a subset of patients. Therefore, sleep telemedicine can be an effective resource for early intervention to improve CPAP compliance.
Telemedicine as a Pathway for PAP Requalification
Generally, to requalify patients for CPAP who did not meet insurers’ compliance goals, there must be an additional sleep study and face-to-face encounter. There is a large subset of patients who decline in-lab PSG for one or more of the following factors: discomfort, inconvenience, and cost. Patients may also be resistant to returning to their doctor’s clinic for a variety of factors. For those patients who do not wish to have an in-person consultation with their physician, do not have access to a local HST program, or are unable to have an HST performed in a timely fashion, a sleep telemedicine service with an in-house HST program may be an effective solution.
This case demonstrates how telemedicine practices with HST programs can work synergistically with DME companies and PCPs to improve outcomes in patients with OSA.
Joseph Krainin, MD, FAASM, is board certified in sleep medicine and neurology. He is the founder of Singular Sleep, a virtual sleep center.