Sleep Medicine - Primed for Disruption

Sleep Medicine - Primed for Disruption

By Lawrence Shulman, DO, Chief Medical Officer and Chief of the Division of Pulmonary and Sleep Medicine, ProHEALTH Care

Lawrence Shulman, DO, Chief Medical Officer and Chief of the Division of Pulmonary and Sleep Medicine, ProHEALTH Care

Technological advances in sleep medicine lag in comparison to other medical disciplines, yet according to the American Sleep Apnea Association; 50 million Americans suffer from sleep disorders. In the last decade, very little has changed in diagnosing and treating sleep disorders. For example, the clunky continuous positive airway pressure (cPAP) machine remains the primary solution to treating patients with a disrupted airflow during sleep. While the machine offers patients a good night’s sleep, the device hasn’t changed in overall concept and design.

In comparison to other areas of medicine, where technology is innovative and compact, the technology used in sleep medicine seems outdated. This makes the specialty primed for a technological revision to find new methods and mechanisms to improve diagnosis of sleep disorders and modernize therapies, especially in the treatment of obstructive and central sleep apnea. Additionally, sleep medicine needs new approaches to understand other sleep abnormalities such as insomnia and leg movement disorders.

"As medical practices move toward value-based care, focusing on patient health and preventative medicine, they will soon realize that targeting diagnostic and therapeutic arena of sleep may actually be the things that dreams are made of"

Diagnosis is stuck in the Dark Ages

There once was a time that sleep labs were scattered around the country and as ubiquitous as Starbucks. But those times are now in the past as both payers and patients have moved steadily toward home sleep studies. Sleep labs still have their place as more complex sleep disorders need additional monitoring and testing such as EEG, cardiac rhythm, and leg movement.

When conducting a dialogistic study of sleep in a lab, patients are often attached, from their head to their feet, to many sensors and wires to monitor behavior. Patients have expressed concern that they are unable to sleep normally when attached to the apparatuses. The tools used in sleep labs for diagnostics are cumbersome, but there have been some improvements to make monitoring much easier and more convenient. Yet, the technological advances in the discipline fail to keep up with the projected demand for diagnosis and treatment.

Sleep disorders in breathing–most commonly obstructive sleep apnea (OSA)–is estimated to affect about 25 million Americans. Increased weight and increased age both make the likelihood of sleep apnea worse. Given the obesity epidemic we are facing, along with the evidence-based correlation between OSA and hypertension, diabetes, and hyperlipidemia, the future prevalence of sleep apnea is extremely worrisome. We need to diagnose more patients with easier, more convenient, and more accurate methods.

If the ingredients for sleep disorder diagnosis are simply sensors, wires, and physician review, why can’t we bring our processes into the 21st century? Imagine this: Your provider receives an alert that based on a validated set of data rules (obesity, co-morbidities, family history, and biometric data, for example),a patient may have a positive diagnosis of sleep apnea. They send the patient a set of “leads” that can be easily placed on their body. The patient then downloads a smartphone app, syncs to the leads, and then sleeps normally with their phone at the bedside. Throughout the night, data from the leads is transmitted to a sleep physician who interprets it and sends a report directly to the referring doctor. The next day the patient meets, via telemedicine, with a sleep doctor for a “face to face” consult. The data is reviewed and the patient receives a diagnosis. However, this type of technology is not something that is currently available for diagnosing sleep disorders.

Apple Watch, Fitbit and the countless apps on the market today that have delved into the sleep tracking business, have not emerged with a comprehensive sleep disorder diagnostic tool. The ability of a personal device to provide actionable data to a provider has not yet risen out of the crowd. Additionally, insomnia, periodic limb movement disorders, narcolepsy, and REM behavior disorder are not part of what these devices monitor, and have not been brought to the level of consciousness of the public. In short: There’s just not an app for that.

Tap Tap Treatment

Technology has, not surprisingly, followed the money. That’s why advances in the treatment of sleep disordered breathing have far surpassed diagnostic modalities.

cPAP machines, for example,have seen major improvements over the last 10 years. They’ve evolved to use auto-titrating (adjusting) technology and advanced remote compliance monitoring, which means patients no longer need to come into the sleep lab to have an individual titration for their unique pressure needs. The auto-titrating (aPAP) machines do the work, monitoring and adjusting to pressure requirements throughout the night.

Bluetooth also plays a larger role in sleep disorder treatment. Compliance monitoring data can be transmitted to a patient’s phone, allowing them to track their own compliance, mask fit, and efficacy with a few swipes and taps. Cloud-based compliance is also the standard, which allows the provider (and the insurance company) to follow the patient’s progress.

Although clunky, the cPAP mask and the devices have improved quite a bit in the last ten years. Lighter and more comfortable, new cPAP mask technology has followed the financial opportunities for the manufacturers. But there’s still room for even bigger improvements. Technologies like 3D scanning and printing could theoretically give way to individualizing the mask fit for the specific patient, but these masks are at a significantly higher cost than the standard masks.

For mild sleep disorder cases, more and more people are turning to dental appliances (a.k.a. mandibular advancement devices). An over-the-counter device, this option lacks professional dental management. However, there are options that can be fit by dentists, but they’re expensive and not all payers provide coverage (although an increasing number do). Soon, we’ll likely see improved manufacturing and imbedded dental compliance will become the standard of care.

Surgical techniques lag far behind other improvements in treating sleep disordered breathing. That’s primarily because, aside from aggressive surgical procedures, surgery doesn’t work. A potential exception is Inspire, an implantable hypoglossal nerve stimulator that sits in the chest and is “wired” into the back of the throat. A patient activates the device prior to sleep and the device works throughout the night. Although screening criteria and appropriateness of patient anatomy is limiting, there is room for improvement and innovation.

One Thing We Know For Sure: A Good Night’s Sleep is Priceless

The field of sleep medicine is still in its infancy. The science behind why we sleep and what happens during normal sleep is significantly lacking. What we do know, definitively, is that poor sleep–insomnia, sleep apnea, narcolepsy–leads to significant health issues and even more quantifiable costs. As medical practices move toward value-based care, focusing on patient health and preventative medicine, they will soon realize that targeting diagnostic and therapeutic arena of sleep may actually be the things that dreams are made of.

Check out: Top Sleep Disorder Care Solutions Companies

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