Patient-facing apps might encourage patients to adhere to their therapy, but they don’t replace a good relationship with a sleep specialist.
It’s not human nature to strap a mask to your face before you fall asleep. Perhaps that’s why so many patients with sleep apnea struggle to comply with their physicians’ instructions when prescribed a positive airway pressure (PAP) device, even though such therapy is the gold-standard treatment for obstructive sleep apnea (OSA).
Sleep clinics and insurance companies have long collected data on usage to track patients’ progress. Now, some manufacturers are making that data available to patients themselves in the form of web-based portals and smartphone apps. With this information in hand, patients can keep tabs on how well the device is working for them.
Typically, the currently available software—which includes Philips Respironics’ DreamMapper, ResMed’s myAir, 3B’s iCodeConnect, Human Design Medical’s Nitelog, Drive DeVilbiss’ SmartLink, a multisystem compatible software called Somnoware, and an open source option called Sleepyhead—tracks mask seal, hours used, and apnea-hypopnea index (AHI). Some, like myAir, send patients daily summaries of their PAP usage and note particularly good nights.
“Seeing their daily myAir score and achievement badges gives patients both the confidence of knowing that CPAP is working for them and the encouragement to keep it up,” says Trevor Thinnes, a product manager at ResMed.
In general, the manufacturers who spoke with Sleep Review described their software as a means of positive reinforcement.
“Anecdotally, we already know that patients who take an active involvement in their sleep therapy learn and monitor their results, [and] increase adherence and compliance,” says Angela Giudice, 3B’s director of clinical sales and education.
Daily check-ins that note incremental progress go hand-in-hand with the emerging idea that PAP therapy and OSA have a dose-response relationship. That is, congratulating patients for using their therapy even at durations below the Centers for Medicare and Medicaid Services (CMS) compliance guidelines may then spur them to continue using the device for longer and longer durations, reaping increasingly more health rewards. “Some people may respond to negative coaching like ‘Oh, you’re going to lose your machine if you don’t use it more. But a lot more people, if they’re using and getting benefit, tend to say, ‘So if I use it even more, I might get more benefit. I want to keep doing this treatment because I’m feeling better,’” Barry Krakow, MD, told Sleep Review earlier this year.1
PAP Data Downloads Adapt to Changing Times
Collecting, organizing, and sharing data with patients has gotten easier as PAP machines become more and more sophisticated.
“SD card downloads were standard at one point, with early adopters offering cellular,” says 3B’s Giudice, referring to the memory cards that patients remove from devices and bring to sleep clinics for analysis. Some manufacturers switched to transmitting the data over cell networks, but that could be costly. “There are hard costs for any device to transmit data on carriers such as Verizon, AT&T, etc,” Giudice says. “WiFi data has no costs, provided that the patient has Internet service. The offsets are essentially whether the DME [durable medical equipment] provider is willing to invest the time to walk the patient through a one-time connection with the patient’s router.”
However patients get set up, having access to these apps may indeed be helpful. Studies conducted by manufacturers on their own software note a statistically significant difference between patients who use the apps and those who don’t.
In a study of about 128,000 people conducted by ResMed and presented at CHEST 2016, compliance with PAP machines went up 17% in myAir users, and they used their machines for about an hour longer on average per night.2 Similarly, an analysis of DreamMapper conducted by Philips in 2016 found that 78% of patients using the software met CMS compliance criteria for reimbursement at the end of 90 days versus 63% of patients without the software.3
A Double-edged Sword?
Ryan Wetzler, PsyD, CBSM, ABPP, a psychologist who treats patients with sleep disorders in Kentucky, sees a daily patient-facing compliance report as a double-edged sword. “Self-monitoring is a key piece of almost all behavioral treatment approaches. As such, it has the potential to be self-reinforcing, help people monitor their progress, get a sense of accomplishment, and hopefully that will continue.”
But “Self-monitoring can also reinforce a sense of failure, so if someone’s struggling to use it and every day they’re looking at their phone and seeing how terrible they’re doing with it, it eventually could be something that facilitates them giving up on it,” he says.
Wetzler recalled a patient who had become fixated on her data, calling the office several times a week to request pressure changes.
“There comes a point where you have to educate and be like, ‘This is going to fluctuate. This appears to be the right pressure.’ She always thought more was better,” he says.
In short, software can’t be a substitute for a good partnership with a sleep clinician, Wetzler says. “I think unfortunately many don’t understand what’s going on, why they’re struggling, and need some professional guidance.”
A Little Extra Help Can Go a Long Way
Pamela Minkley, RRT, CPFT, RPSGT, a respiratory therapist, consultant, and member of Sleep Review’s editorial advisory board, agrees. She sees “tremendous” potential in patient-facing software as long as it is coupled with help from trained professionals, especially in the early days of device usage. Minkley envisions a scenario in which the patient and clinician look at the app results together after the patient’s first night with the machine, forestalling problems that otherwise only come up at the next office visit.
“You can tweak some of the settings right then and make it more successful and give them the message that there’s help available,” she says. “While all their friends and neighbors have told them it’s really tough, hard to use, they can go, ‘Yeah, I have somebody who helps me and it’s not all that bad.’”
Some of these apps include links to videos explaining solutions to common problems and send automatic inquiries and alerts regarding a patient’s progress. iCode Connect, for example, communicates with patients through “a combination of automated IVR (interactive voice recognition) calls, emails, and text messages that, on behalf of the DME, greet the patient and welcome them on-board on day 1,” according to a press release announcing the partnership between iCode Connect and a management system called Patient TouchPoint.
“On day 3 we query the patient to find out how they are feeling. Any negative responses are routed directly to the DME’s designated employee responsible for the patient. On days 7, 30, and 60, we automatically upload compliance data. If any of the data from the uploads reflects a potential compliance issue, Patient TouchPoint directly notifies the appropriate person,” the release states.
Extra help is compelling to many patients. According to Thinnes, the ResMed spokesperson, over a thousand PAP users register for myAir every day. In the technology adoption life cycle, he sees users of myAir as the “early majority” type.
“We find that the more tech savvy end of the demographic is more likely to embrace this technology. They are used to checking for different information by using their phone,” says Wendy Frazer, marketing project manager with Human Design Medical, which makes Nitelog. These patients tend to be in the 40 to 60 age range, she adds.
“The most common obstacle we find is the patient’s lack of understanding of how to use their smartphone or tablet, so that they have trouble with capturing screen shots or sending out emails.”
Greg Evans, global product manager at Philips Respironics, which makes DreamMapper, thinks the technology is slowly becoming mainstream. “There is still a shift taking place, as more and more people recognize the benefits of using a comprehensive solution—including an application—to manage their sleep apnea,” he says.
Perhaps it’s not surprising that patients are open to this kind of self-monitoring, given the popularity of the Fitbit and apps that track everything from a person’s BMI to the last time they ovulated.
But even those patients who are less technologically savvy can be persuaded to try out an app if clinicians think it will work well for them. Raj Misra, vice president of marketing at Somnoware, which provides therapy management software compatible with many companies’ PAP devices, recommends starting the conversation early and focusing on the importance of complying with therapy to prevent sleep apnea from worsening over time.
“From there, they can talk about the fact that it’s a partnership. Managing sleep apnea requires a sustained effort, it’s not a one shot thing,” he says.
If a patient is having problems with therapy, they should contact their DME or physician. But if a patient (or provider) needs technical support with a PAP therapy management app, the software maker can likely assist. Here’s some contact information.
3B/iCodeConnect: www.3bmedical.supportsystem.com. Support tickets are usually responded to the same day.
Philips Respironics/DreamMapper: firstname.lastname@example.org or during business hours (Eastern time) at 855-699-6276
ResMed/myAir: https://myair.resmed.com/Support.aspx. For issues that cannot be resolved on the support page, there is a form where patients can email the support team.
Somnoware: Contact Irene Dilinila at 408-758-8705 or email email@example.com
Rose Rimler is associate editor of Sleep Review.
1. Perez C. Study Questions “Use It or Lose It” CPAP Principle. 9 May 2016. Available at www.sleepreviewmag.com/2016/05/study-questions-use-lose-cpap-principle.
2. ResMed press release. Results from World’s Largest Study on Sleep Apnea and Digital Connected Care. 25 October 2016. Available at www.resmed.com/us/en/consumer/newsandinformation/news-releases/2016/results-from-worlds-largest-study-on-sleep-apnea-and-digital-connected-care.html.html. (CHEST abstract available at journal.publications.chestnet.org/article.aspx?articleid=2568984 but contains outdated data versus the more recent press release)
3. Hardy W, Powers J, Jasko JG, Stitt C, Lotz G, Aloia MS. A mobile application and website to engage sleep apnea patients in PAP therapy and improve adherence to treatment. 21 November 2016. Available at www.sleepreviewmag.com/2016/11/whitepaper-philips-respironics-dreammapper.