Telemedicine in Sleep Medicine Lawrence J Epstein MD

Telemedicine in Sleep Medicine Lawrence J. Epstein, MD Brigham and Women’s Faulkner Hospital

Conflict Disclosure • Consultant to – American Academy of Sleep Medicine – AIM Specialty Health – evi. Core

Telemedicine in Sleep Medicine • • Defining Telemedicine Benefits Role in sleep medicine PAP adherence and telemedicine

What Is Telemedicine? • The use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. http: //www. americantelemed. org/about-telemedicine/what-is-telemedicine#. Vp 1 hh. I-c. F 9 M

Telehealth Vs. Telemedicine • Some use interchangeably • Telehealth: Broad term for electronic exchange of medical information – does not have to involve clinical services • Telemedicine: A patient/clinician encounter using electronic communication Singh J et al. J Clin Sleep Med 2015; 11(10): 1187 – 1198

Who Pays For Telemedicine? • Medicare – Yes with restrictions • remote radiology, pathology and some cardiology are covered simply as "physician services” • Videoconferencing • Medicaid – Covered in almost every state – states vary greatly in their coverage • Private insurance plans – 31 states and the District of Columbia require that private insurers cover telehealth the same as they cover in -person services – Coverage is plan dependent http: //www. americantelemed. org/about-telemedicine/what-is-telemedicine#. Vp 1 hh. I-c. F 9 M

States With Telemedicine Parity Laws For Private Insurance (2018)

Types of Tele-Services • Teleconferencing – Communication between multiple remote sites • Teleconsultation – Interaction between clinicians • Telemonitoring – Remote collection and transmission of data • Telemedicine – Patient/clinician encounter using electronic communication Sing J et al. J Clin Sleep Med 2015; 11(10): 1187 – 1198

Telemedicine Categories Synchronous live interactive visits Asynchronous interactions • Function as a live visit • Asynchronous in time and space – Same standards • Separated by distance • Real-time – – Remote Interpretation Store-and-Forward e-messaging Self-directed care (on-line CBTi) Singh J et al. J Clin Sleep Med 2015; 11(10): 1187 – 1198

Benefits of Telemedicine • • Increased access for remote patients Reduced wait times Cost effective Improved quality of care – Access to specialty care – Standardize to best practices • Patient Satisfaction

Cost Effectiveness • Meta-analysis: 23 studies – Assess cost & health outcomes: Economically worth doing? – Teleconsulting & telemonitoring • Multiple variables: Time, costs, productivity • Almost all cost effective Rojas & Gagnon Telemedicine & e -Health 2008; 11: 896 -904

Telemedicine Already Common in Sleep Medicine • • In-lab sleep studies (remote monitoring) Home-based sleep studies (store & forward) Compliance monitoring (store & forward) Teleconsultation (specialist – primary care)

• Access Reasons To Expand Sleep Tele. Medicine – High patient/specialist ratio – Geographic maldistribution • Improve quality – Most non-sleep MDs not trained in management of sleep patients – Current system fragmented • Majority of sleep patients not diagnosed – Untreated sleep disorders increase other disorders and healthcare costs • Sleep medicine well-suited to telemedicine • Effective in sleep patients

Tele. Sleep Applications Diagnostics and Therapeutics Patient Management • Remote in-lab monitoring • Home-based testing • Integration of wearable devices • Actigraphy, sleep diaries • On-line behavioral therapy for insomnia • Compliance monitoring • Patient evaluation • Physician-physician consultation • Test review and diagnosis • Patient education • Long-term follow-up • Compliance management

Patient Interest & Satisfaction • Survey sleep clinic patients about telemedicine – N= 126 – 28% response rate – 15 questions • Surveyed about – Clinic experience – Telemedicine experience – Willingness to use telemedicine types Kelly JM. ISRN Neurology 2012: 135329. Epub 2012 Jul 9

Clinic Experience Waiting time for clinic visits Kelly JM. ISRN Neurology 2012: 135329. Epub 2012 Jul 9 Challenges with in-person visits Barrier % Cost of parking 44 Time away from work/school 34 Cost of gas 26 I require family or other support to travel 19 Time away from family 6. 5 Hard to find transportation 6. 5 Cost of public transportation 6

Telemedicine Experience • Phone most common • Little videoconferencing experience, but willing Kelly JM. ISRN Neurology 2012: 135329. Epub 2012 Jul 9

Sleep Telemedicine: Outcomes • Prospective trial of 90 patients evaluated for OSA • Initial and follow-up sleep physician visits either: – In-person – Videoconference • Outcomes – Patient satisfaction – PAP adherence Parikh et al Telemedicine & e. Health 2011; 17: 609 -614.

Equal Outcomes • No statistically significant differences in any measures Patient Satisfaction Scores Parikh et al Telemedicine & e. Health 2011; 17: 609 -614. % of Nights PAP Used > 4 hrs

Remote vs. Face-to-Face Management • Initial telemedicine evaluation via center to center connection. • Subsequent sessions via telephone Fields et al SLEEP 2016; 39: 501.

Remote vs. Face-to-Face Management Average Use/Night (min) 250 % Use > 4 Hrs 100% 90% 80% 200 70% 60% 150 50% 40% 100 30% 50 20% 10% 0 0% In Person Tele. Med • No statistically significant difference in PAP adherence or symptoms between groups • Patients expressed + experience with telemed. • Greater follow-up loss with telemed group (4 vs. 9) Fields et al SLEEP 2016; 39: 501.

Insomnia Treatment • Prospective trial of 5 patients treated with CBT for insomnia and depression • CBT – 10, 50 -minute, weekly treatment sessions • Telemedicine – Videoconferencing – Origination site: primary care MD office – Distant site: therapist office Lichstein KL et al J Clin Psychol. 2013 October ; 69(10): 1056– 1065

CBT via Telemedicine Sleep and Mood Scores at Baseline, Posttreatment, and Follow-up 45 40 35 30 25 20 15 10 5 0 SOL WASO Pre Lichstein KL et al J Clin Psychol. 2013 October ; 69(10): 1056– 1065 Post ISI Follow-up HSRD

Online CBTi • MD recommended web-based self-directed CBTi • N = 500 consecutive patients SHUTi data from Be. Health Solutions LLC, 2016

Starting A Telemedicine Program • • Evaluate if telemedicine is right for your practice Identify your target audience Center to Home (C 2 H) or Center to Center (C 2 C) Develop a workflow plan Identify hardware and software needs Understand telemedicine regulations How do I get paid? Singh et al. How to Get Started in Sleep Telemedicine. AASM, In Press.

Starting A Telemedicine Program

Case 1 • 58 yo male in Grayson, NC – No sleep center < 40 mi. • PCP recommended sleep eval • Existing relationship with ENT at sleep center – In-person referral and study vs. telemedicine referral • Patient opted for telemedicine visit – Center to Center (C 2 C) • NC not a parity law state but payer has approved use of telemedicine

Case 1 • Complaint – – Disruptive snoring Choking episodes in sleep Daytime sleepiness Worsening fatigue/energy level • Past History – Weight gain – Hypertension (on 2 meds) – Type II DM • Exam – 5’ 9”, 220 lbs, BMI 32. 4, Neck 17. 5” – Self BP 152/88 – Retrognathic, Mallampati II

Next Steps • Order HSAT • Arrange delivery to patient • Schedule followup telemedicine visit

Sleep Testing • HSAT sent by mail – Setup instruction by video – Tech available by phone at night • Study reviewed by BCSMP • AHI = 47, low O 2 sat =75%

Case 1 Follow-up • Study reviewed with patient by BCSMP via video • APAP provided by local DME • Compliance monitoring via machine modem • Clinical follow-up with BCSMP via video • Long-term care from PCP with consultation of BCSMP Case Lessons • clinical evaluation for OSA is feasible by C 2 H or C 2 C telemedicine • Testing and treatment tools utilize telemedicine • Establishing local contacts helpful for managing patients • Understand state and payer regulations

Telemedicine & PAP Management • PAP adherence not optimal • Devices collect information • PAP telemanagement strategies improve adherence

How To Use Telemedicine To Improve PAP Adherence • Active data monitoring – Regular intervals – Importance of early treatment period • Provide patient feedback – Per schedule vs. per need • Engage patients in their care – Teach to use machine or App data • Long-term monitoring

Telemedicine for PAP Adherence • Prospective, multi-center, randomized trial • Phone coaching vs standard support N = 379 Follow-up by home care provider Sedkaoui et al. BMC Pulmonary Medicine 2015; 15: 102

Telemedicine for PAP Adherence % > 3 hrs/N for 4 months Sedkaoui et al. BMC Pulmonary Medicine 2015; 15: 102 Mean PAP Use for 4 months

Telemedicine for PAP Adherence RCT of 75 moderate to severe OSA patients Standard Care • Setup • Day 2: phone contact & troubleshooting • Day 30 -45: clinic visit with PAP coordinator & MD, compliance download & troubleshooting • Week 8: clinic visit with PAP coordinator • 3 months: sleep specialist clinic visit Fox N et al SLEEP 2012; 35(4): 477 -481 Telemedicine • Setup • Day 2: phone contact & troubleshooting • Daily modem download to monitored database • Patient contacted for: – – Nonuse Leak High AHI Intervention based on call • Day 30 -45: Clinic visit with PCP • 3 months: sleep specialist clinic visit

Telemedicine for PAP Adherence • Adherence to PAP greater in telemed group • Predictors of adherence: – Increased age – Increased ESS – Use of telemedicine Fox N et al SLEEP 2012; 35(4): 477 -481

Telemonitoring & PAP Adherence In-lab Dx & APAP titration Usual Care Telemonitoring Clinic visit at 1. 5 & 3 months Call for high leak, AHI>10, use < 3 hrs x 3 D N=46 Clinic visit at 1. 5 & 3 months Would telemonitoring reduce delay to intervention and increase adherence? Hoet et al. Sleep Med 2017; 39: 77

Telemonitoring & PAP Adherence Telemed Usual Care 0 10 20 30 40 50 Time (days) 60 70 80 Usual Care Telemed Hoet et al. Sleep Med 2017; 39: 77

Effect of Telemonitoring OSA Dx by HSAT Usual Care OSA Tele-Ed PAP Telemonitor • Usual Care: Group OSA & PAP education class • OSA Tele-Ed: On-line OSA education program • Telemonitor: PAP download-based automated feedback, +/- feedback based on meeting use threshold Hwang et al Am J Resp Crit Care Med 2018; 187: 117 Tele-Ed + Telemonitor • N = 556

PAP Adherence Average Hours/Night Meet Medicare Criteria 6 80% 70% 5 60% 4 50% 3 40% 30% 2 20% 1 10% 0 0% Usual Care Tele- Ed Telemon Both Hwang et al Am J Resp Crit Care Med 2018; 187: 117 Usual Care Tele-Ed Telemon Both

PAP Adherence Hwang et al Am J Resp Crit Care Med 2018; 187: 117

Factors Improving Adherence • • Remote monitoring Early intervention Data-directed feedback Long-term intervention

Case 2 • 53 yo long haul truck driver referred for OSA evaluation by occupational health MD as part of biannual DOT exam – Occupational health clinic in Puyallup, WA – Patient back on road following clinic visit, driving to Idaho • STOP BANG = 6/8 (high risk > 3) • HSAT ordered by OH MD • Patient selected C 2 H telemedicine clinical evaluation with BCSMP • WA is a parity state, eval paid by trucking co.

Case 2 • No complaint – Long-time snorer – Denies sleepiness, witnessed apneas, MVAs – Epworth Sleepiness Score = 0 • Past History – Obesity – Hypertension (1 med) • Exam – 5’ 8”, 252 lbs, BMI 38. 3, Neck circ 18” – Clinic BP 138/86 – No retro/micrognathia

Sleep Test • Device given at clinic with chain of custody • Slept with device in cab, mailed back next day • Study reviewed by BCSMP • AHI = 40, low O 2 sat =63%

Next Step • Study reviewed with patient by BCSMP via video • Driver given provisional DOT license by OH MD • APAP provided by local DME • Compliance monitoring via machine modem

Follow-up • DME monitored adherence data – Contacted patient by phone for nonuse – Changed mask for comfort – Directed to MD • Clinical follow-up with BCSMP via video – Nasal steroids for congestion – Educated on need for use

Follow-up • Clinical follow-up with BCSMP via video • Use and symptoms improved • Compliance data provided to OH MD for use in determining DOT status

Case Lessons • Telemedicine is a useful and successful method to provide sleep care to mobile patients – May increase willingness to undergo eval • CMV drivers require special tools (HSAT, chain of command, compliance monitors) that are amenable to telemedicine management • Understand state, federal and payer regulations

Summary • Telemedicine is already common in sleep medicine. • Most sleep patients can be evaluated and managed utilizing telemedicine. • Diagnostic and therapeutic tools for sleep patients are amenable to use with telemedicine. • PAP management is especially well suited for telemedicine. • A PAP adherence program utilizing data monitoring should be used whenever starting patients on PAP.