ROFESSOR OF MEDICINE EMORY UNIVERSITY SCHOOL OF … Collop 3-23-17.pdfappointment in the Emory...

FUTURE OF SLEEP MEDICINE NANCY A. COLLOP, MD PROFESSOR OF MEDICINE EMORY UNIVERSITY SCHOOL OF MEDICINE ATLANTA, GA

Nancy A. Collop, MD, is the director of the Emory Sleep Center in Atlanta, Ga and was the 2011-2012 president of the American Academy of Sleep Medicine (AASM). She holds a primary appointment in the Emory School of Medicine as professor of Medicine in the Division of Pulmonary, Allergy, Critical Care Medicine and Sleep Medicine, as well as a secondary appointment as professor of Neurology. She became an AASM member in 1990 and earned board certification in sleep medicine from the American Board of Sleep Medicine in 1997. She has held ABMS board certification in internal medicine, pulmonary medicine, critical care and sleep medicine. Collop has held academic positions at the Medical University of South Carolina, University of Mississippi, and Johns Hopkins University in Baltimore, MD, where she was the medical director of the Johns Hopkins Hospital Sleep Disorders Center. She served on the AASM board of directors since 2006 and served as Secretary – Treasurer (2008-10) and President Elect (2010-11), President (2011-12) and Past President (2012-13). She has held numerous leadership positions in other professional societies and organizations. Collop has served on the American Board of Sleep Medicine (ABSM) board of directors since 1998, holding the position of ABSM president from 2002-2009. She was a member of the board of directors of the American Sleep Medicine Foundation, for which she previously served on the Executive Committee and as Secretary – Treasurer. Collop also was on the founding committee of the American Board of Medical Specialties Sleep Medicine Examination Committee representing the American Board of Internal Medicine (ABIM), and served for several years on the ABIM Pulmonary and Sleep Medicine Self Evaluation Process committees. She has served on the board of directors for the Chest Foundation. She was a Founding member of the Maryland Sleep Society and their first president; she served on the board of directors of GASP (Georgia Associated Sleep Professionals) from 2013-2015. Collop has been named one of the “Best Doctors in America” and a Distinguished Alumna for Natural Sciences by Edinboro University. She also has received several prestigious awards, including the Al Soffer Award for Editorial Excellence and the College Medalist from the American College of Chest Physicians, the Helmut S. Schmidt Award from the American Board of Sleep Medicine, the “Pulmonary Star” Award from the Emory Division of Pulmonary/Critical Care/Allergy/Sleep. She was awarded the “Distinguished Service Award” from the Maryland Sleep Society (2015) and at Sleep 2015 received the Nathanial Kleitman Distinguished Service Award from the AASM. She is currently the Editor-in-Chief of the Journal of Clinical Sleep Medicine and the Section Editor of Sleep Medicine for Up-To-Date. She was associate editor of the journal Chest for 22 years and

now is on their Editorial Board. A recognized expert in sleep-related breathing disorders, Collop has conducted research and co-authored numerous studies on topics such as diagnostic testing for sleep-disordered breathing, the treatment of obstructive sleep apnea (OSA), and the relationship between sleep apnea and comorbid medical conditions such as Down syndrome and chronic obstructive pulmonary disease. She has authored 74 manuscripts, 44 book chapters or monographs and numerous editorials, letters and case reports. Dr. Collop has chaired numerous important taskforces on the topic of home sleep testing and is considered an expert on this subject. She was the lead author of the landmark paper, “Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients,” which was published in the December 2007 was the task force chair and lead author of the AASM’s technology evaluation of OSA devices for out of center sleep testing, published in October 2011. OBJECTIVES: Participants should be better able to:

1. Understand the brief history of how sleep medicine has advanced over the last 3 decades;

2. Be knowledgeable about the role of home sleep apnea testing and current HSAT guidelines;

3. Appreciate the challenges to manage a growing number of patients with sleep disorders;

4. Be able to discuss future plans to deal with the challenges of too few providers and too many patients

THURSDAY, MARCH 23, 2017 11:15 AM

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DISCLOSURE

Dr. Collop has received research grants from Jazz Pharmaceuticals and Simmons Bedding and has received honorarium from UpToDate, but these do not create a conflict of interest related to the following presentation.

Nancy Collop, M.D.

Professor, Emory University

Atlanta, GA

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Objectives Review the history of the growth of sleep medicine as a field

Discuss current challenges to the field of sleep medicine

Consider the future of sleep medicine and how the field needs to position itself to continue to be successful

History Lesson “Study the past if you would define the future.” ― Confucius

“If you don't know history, then you don't know anything. You are a leaf that doesn't know it is part of a tree. ” ― Michael Crichton

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The Early Days Stanford Narcolepsy Clinic – 1964

Rechtschaffen and Kales edited sleep staging manual ‐1968 Ralph Berger, William Dement, Allan Jacobson, Laverne Johnson, Michel Jouvet, Lawrence Monroe, Ian Oswald, Howard Roffwarg, Bedrich Roth, Richard Walter

Stanford Sleep Center opened – 1970

Sleep Research and Treatment Center at Penn State University in Hershey (Anthony Kales) – 1971

BC of CA began reimbursing for sleep studies – 1975

Association of Sleep Disorders Centers forms ‐ 1975

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QUESTION #1When was the first sleep laboratory accredited by the American Sleep Disorders Association (now known as the American Academy of Sleep Medicine)?

A.1964B.1970C.1977D.1985E.1991

A. B. C. D. E.

2% 2%

46%42%

8%

QUESTION #1When was the first sleep laboratory accredited by the American Sleep Disorders Association (now known as the American Academy of Sleep Medicine)?

A. 1964B. 1970C. 1977D. 1985E. 1991

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First Sleep Center Accredited

April 27, 1977

Question #2Who was the first person to describe obstructive sleep apnea on a sleep study?

A.BurwellB.DickensC.KleitmanD.DementE.Gastaut

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A. B. C. D. E.

11% 14% 11%

41%

23%

Question #2Who was the first person to describe obstructive sleep apnea on a sleep study?

A. BurwellB. DickensC. KleitmanD. DementE. Gastaut

What Did We Know in 1980? Burwell (1956) described obesity hypoventilation syndrome

Dement, Kleitman (1957) described 5 stages of sleep including REM

Vogel (1960) noted REM sleep onset in narcolepsy

Gastaut (1966) described obstructive apneas on a sleep study

Gene for per discovered in Drosophila (1971)

Remmers (1978) found the upper airway collapse was associated with the genioglossus muscle

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Nasal CPAP Described ‐ 1981Lancet. 1981 Apr 18;1(8225):862‐5.

Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares.

Sullivan CE, Issa FG, Berthon‐Jones M, Eves L.

AbstractFive patients with severe obstructive sleep apnoea were treated with continuous positive airway pressure (CPAP) applied via a comfortable nose mask through the nares. Low levels of pressure (range 4.5‐10 cm H2O) completely prevented upper airway occlusion during sleep in each patient and allowed an entire night of uninterrupted sleep. Continuous positive airway pressure applied in this manner provides a pneumatic splint for the nasopharyngeal airway and is a safe, simple treatment for the obstructive sleep apnoea syndrome.

History of Organized Sleep Medicine “International Classification of Sleep Disorders Manual” published 1979

1st revision 1985

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History of Organized Sleep Medicine “International Classification of Sleep Disorders Manual” published 1979

1st revision 1985

2nd edition 2005

3rd edition 2013

Journal dedicated to sleep (Sleep) – 1978

National Center on Sleep Disorders Research (NCSDR) created within the NIH in 1993

Sleep Medicine recognized as a specialty by the AMA (1995)

AASM appointed seat in AMA house of delegates (1997)

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Education and Certification Education about sleep medicine varied between specialties

Certification examination as initial step to standardize education First exam on “clinical polysomnography” given 1978 ( 1st certificate given to DrWilliam Dement)

1980 – exam became 2 parts to cover all aspects of sleep medicine (initially part 2 as an oral exam)

1990 – became American Board of Sleep Medicine – 514 had passed exam to date; Helmet Schmidt was 1st president

Sleep Medicine Fellowship training committee formed in AASM in 1988 –set out to standardize training with ultimate goal to become recognized by ACGME

Summary of progress in 20th centuryNosology

Dedicated journal

National society

Annual meeting (SRS held first meeting in 1961)

Recognized specialty (AMA)

Certification examination

Training programs (31 AASM accredited fellowships)

NIH center

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The 21st Century ABSM continues to offer certification up until 2006

3445 diplomates

2000: AASM holds first meetings with ABIM and ABPN

2002: 53 AASM approved sleep fellowship programs; AASM submits application to ACGME

2003: ACGME approves certification for sleep fellowships; Application to ABMS submitted for certification examination in sleep medicine

2005: ABMS approves subspecialty examination; ACGME begins to accredit sleep fellowship programs

2007: 1st ABMS specialty examination in sleep medicine is administered

Snapshot of Today ~ 8000 board certified sleep specialists

75 sleep fellowship training programs representing 180 slots

2500 accredited sleep centers

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AASM Accredited Centers

Snapshot of Today ~ 8000 board certified sleep specialists

78 sleep fellowship training programs representing 180 slots

2500 accredited sleep centers

~10,000 members of the AASM

Annual meeting draws 5‐6000 attendees; > 125 sessions, 1500 abstracts

Associated societies: SRS, AADSM, AAST, SBSM

Certification examinations for technologists, dentists, behavioral sleep medicine specialists

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What have been the biggest changes? Diagnostic measurement of sleep – polysomnography

Billable procedure

CPAP and its commercialization

AASM center certification

AASM → ACGME sleep fellowships

ABSM → ABMS certification

Acceptance of home sleep apnea testing

Timeline of PM→ HST → HSAT

1994:

ASDA PP’s for the use of Portable Recording

Cardiovascular consequences for Sleep Apnea (SHHS) - Level II devices used > 6000 subjects

2004:

Trisociety Evidence review, Practice Parameters released;CMS re-evaluates PM2005: CMS agrees not ready

2007:

AASM PM Taskforce Guidelines publishedCMS releases 2 AHRQ Evidence Reviews and preliminary decision

2008: CMS decides PM is adequate to determine OSA diagnosis in order to provide CPAP

2010: CPT sleep codes are reviewed -preliminary decisions released

2011: CMS releases new reimburse-ment levels for PSG and makes PM codes no longer T codes

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Littner MR, Semin Respir Crit Care Med 2005;26:56-57

Timeline of PM→ HST → HSAT

1994:

ASDA PP’s for the use of Portable Recording

Cardiovascular consequences for Sleep Apnea (SHHS) - Level II devices used > 6000 subjects

2004:

Trisociety Evidence review, Practice Parameters released;CMS re-evaluates PM2005: CMS agrees not ready

2007:

AASM PM Taskforce Guidelines publishedCMS releases 2 AHRQ Evidence Reviews and preliminary decision

2008: CMS decides PM is adequate to determine OSA diagnosis in order to provide CPAP

2010: CPT sleep codes are reviewed -preliminary decisions released

2011: CMS releases new reimburse-ment levels for PSG and makes PM codes no longer T codes

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CAG # 00405N (3/9/09)Sleep Testing for Obstructive Sleep Apnea

CMS finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.

Therefore: Type I Polysomnography (PSG) is covered when used to aid the diagnosis of

obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility.

CAG # 00405N (3/9/09)Sleep Testing for Obstructive Sleep ApneaTherefore:

A Type II or a Type III sleep testing device is covered when used to aid the diagnosis of

obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative

of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

A Type IV sleep testing devicemeasuring three or more channels, one of which is airflow, is

covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms

indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep

lab facility.

A sleep testing device measuring three or more channels that include actigraphy,

oximetry, and peripheral arterial tone is covered when used to aid the diagnosis of OSA in

beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out

of a sleep lab facility or attended in a sleep lab facility.

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Outcome Studies• Several studies compared an HSAT algorithm to standard in‐lab testing

• For the most part those studies showed equivalence between HSAT and in‐lab PSG with regards to:

Patient satisfaction

Quality of Life

Epworth and other sleep measurement tools

CPAP adherence

• Caveat: Patients were chosen based on a high pretest probability

2007Published in 2007

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Clinical Practice Guideline for Diagnostic Testing for Adult OSA: An AASM Clinical Practice Guideline

Kapur V, et al; J Clin Sleep Med March 2017

Draft released on AASM website September 2016 available for public comment; revised and released Final in March JCSM

9 PICO questions addressed Patient/Population/Problem

Intervention

Comparison

Outcomes

Examined 7392 abstracts reviewed; 98 studies included in evidence base for recommendations (2005 start point) 86 included in meta‐analysis

Good Practice Statements:1. We recommend diagnostic testing for OSA be

performed in conjunction with a comprehensive sleep evaluation and adequate followup

2. We recommend PSG as the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation



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Recommendations:1. We recommend that clinical tools, questionnaires

and prediction algorithms NOT be used to diagnose OSA in the absence of PSG or HSAT (STRONG)

2. We recommend that PSG or HSAT with a technically adequate device be used for the diagnosis of OSA in uncomplicated adult pts presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA (STRONG)



Recommendations:3. We recommend that if a single adequate HSAT is

“negative”, inconclusive, or technically inadequate, PSG should be performed for the dx of OSA (STRONG)

4. We recommend that PSG, rather than HSAT, should be used for the diagnosis of OSA in pts with significant cardiorespiratory dz, potential respiratory muscle weakness due to a neuromuscular condition, awake hypoventilation or suspicion of sleep‐related hypoventilation, chronic opioid use, history of stroke or severe insomnia (STRONG)



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Recommendations:5. We suggest that if clinically appropriate, a split night

diagnostic protocol rather than a full night diagnostic protocol for attended PSG should be used for the diagnosis of OSA (WEAK)

6. We suggest that when the initial PSG is negative and clinical suspicion for OSA remains, a second PSG should be considered for the diagnosis of OSA (WEAK)



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Recommendations:1. We recommend that clinical tools,

questionnaires and prediction algorithms NOTbe used to diagnose OSA in the absence of PSG or HSAT (STRONG)



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STOP‐Bang Model1. Snoring: Do you snore loudly

(louder than talking or can be heard through closed doors)?

2. Tired: Do you often feel tired, fatigued, or sleepy during the daytime?

3. Observed: Has anyone observed you stop breathing during your sleep?

4. Blood Pressure: Do you have or are you being treated for high blood pressure?

5. BMI: BMI > 35 kg/m2?

6. Age: Age > 50?

7. Neck circumference: Neck circumference > 40 cm?

8. Gender: male?

Anesthesiology 2008; 108:812–21

High risk of OSA: answering yes to three or more itemsLow risk of OSA: answering yes to less than three items

Question #3What is the minimal length of time to run a home sleep apnea test for it to be considered adequate?

A.2 hoursB.3 hoursC.4 hoursD.5 hoursE.6 hours

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A. B. C. D. E.

8% 10%

53%

8%

23%

Question #3What is the minimal length of time to run a home sleep apnea test for it to be considered adequate?

A. 2 hoursB. 3 hoursC. 4 hoursD. 5 hoursE. 6 hours

Recommendations:2. We recommend that PSG or HSAT with a technically

adequate device be used for the diagnosis OSA in uncomplicated adult pts presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA (STRONG)



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HSAT should be one which uses:

nasal pressure, chest and abdominal RIP, oximetryOR

PAT with oximetry and actigraphy

Note that a HSAT should have 4 hours of adequate recording



Recommendations:

3. We recommend that if a single adequate HSAT is “negative”, inconclusive, or technically inadequate, PSG should be performed for the dx of OSA (STRONG)



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HSAT

Less sensitive than PSG in detection of OSA

False negative could result in an untreated patient

Repeating a negative HSAT is likely to result in a second negative so recommended PSG; further, patient may not be inclined to repeat

Recommendations:4. We recommend that PSG, rather than HSAT, should be

used for the diagnosis of OSA in pts with significant cardiorespiratory dz, potential respiratory muscle weakness due to a neuromuscular condition, awake hypoventilation or suspicion of sleep‐related hypoventilation, chronic opioid use, history of stroke or severe insomnia (STRONG)



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2017: Looking AHEAD

Physician Wo/Manpower Sleep Apnea

8% of US adult population (240,000,000) = 19,200,000

1% of US pediatric population (74,000,000) = 740,000

Total = 19,940,000

Insomnia 10% of US adult population = 24,000,000

Restless Legs Syndrome Estimate affects 12,000,000

TOTAL = 55,940,000 / 8000 BCSS = 7000 New Pts/yr

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Teaching Physicians about Sleep Medicine

Medical schools devote ~ 2 hours of teaching to sleep medicine (has not changed > 20 yrs)

Most residencies do not address sleep medicine topics other than sleep deprivation and fatigue; < 5% of board exams devoted to sleep medicine topics

83 Sleep fellowship programs – a full 40% of medical schools (147) do not have a sleep fellowship

Quantity and quality of fellow applicants is not of the highest quality for the NRMP sleep fellowship match

Numbers Game: Attracting medical students, residents and fellows to the field of sleep medicine

Teaching more sleep medicine in primary care specialties

Beyond Physicians: Education in other professional schools ‐nursing schools, NP programs, PA programs

2017: Looking AHEAD

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What’s Being Done To Improve This? AASM is trying to emphasize sleep medicine as a specialty

#Choose Sleep

SMIG – medical schools

Earmarking ASMF funding for research demonstrating the value of board certification in sleep medicine

Free attendance at annual meeting

Examine novel training requirements outside a formal 1 year sleep fellowship

Looking Ahead:Research funding

The average age at which an investigator with a medical degree receives their first R01 was less than 38 yrs old in 1980 – now more than 45 yrs old

More than twice as many R01’s are awarded to PI’s who are > 65 yrs old as are < 36 yrs old, a reversal from 15 yrs ago

NIH funding was cut for > a decade (2003)

In FY 2016, Congress raised the NIH budget by 5.9%

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Big Topics are Dementia, Cancer, Precision Medicine

Sleep is not likely to get independent funding and needs to “piggy – back” on these initiatives

Challenging to train sleep scientists – need novel funding streams for luring sleep fellows to a research tract

4 “T‐32’s” with a sleep emphasis

What’s Being Done To Improve This?

Affordable Care Act – New Administration promising to ?Repeal ‐ ? Replacement ‐ ? Repair

Declining reimbursements; increasing deductibles

Emphasis on Population Health

Increasing insurance (third party payor) impediments to delivering care

2017: Looking Ahead

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What’s Next? Insurance will move away from fee‐for‐service and will begin bundling payments

Population health is the BUZZWORD and since sleep disorders affect so many and result in comorbidity – we need to push those specialties to consider sleep disorders as part of the treatment

The Heart and OSA Atrial fibrillation

Up to 50% of afib patients have OSA

Treating OSA reduces rhythm conversion failure rates

Heart Failure 37% have OSA

Treatment of OSA improves cardiac function

Nontreatment of OSA increases risk of sudden death

Resistant Hypertension 70+ % have OSA

Treatment reduces BP med requirements

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Cardiology

Afib/EP pts

CHF

Resistant HTN

CAD

Endocrinology

Diabetes

Metabolic syndrome

Thyroid dz

Pulmonary

Asthma

COPD

Pulmonary HTN

Obesity hypoventilation

syndrome

Gastroenterology

GERD

Nonalcoholic Fatty Liver Dz

Sleep Specialist Nephrology

Microalbuminuria

Chronic kidney dz

ESRD

What’s Next Developing the Sleep “Team”

Develop a model of care in which PCP’s are paired with BCSS to help with training and oversight

HSAT in PCP offices – interpreted by BCSS

Followup care after initiation of treatment done by PCP

More training on sleep for APRN and PA’s

Developing on‐line educational modules

Using TELEMEDICINE to extend reach

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Telemedicine Successfully deployed in VA system

HSAT

CBT‐I

Reimbursement needs to catch up in order for sleep providers to adopt

Already successfully use telemedicine with CPAP adherence

Need sophisticated equipment – 2 way audio/video; secure data transfer; physical exam surrogate

What’s Next? Hypoglossal nerve stimulation and other neurostimulation therapies will continue to evolve and improve treatment options for other sleep disorders

Innovative technologies will continue to transform the way people regard their health

Smartphones and other wearables will diagnose sleep apnea and other sleep disorders

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Hypoglossal Nerve Stimulation

• Implanted device• Receives input from

sensing lead to time delivery of stimulation to nerve with onset of inspiration

• Outcome (STAR Trial): Reduced AHI by 68%;

29.3 to 9.0 Therapy maintenance

group showed sustained reduction

Now FDA approved and covered by many insurances

Looking Ahead:Technology

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Tracking Sleep and Beyond

Current Technologies Sleep diaries and logs

Smartphones with/wo sensors Passive monitoring of audio (snoring, sleep talking), sleep debt analysis, sleep latency

Active apps/devices Modify sleep/dreams with audio

Manage wake times with “smart alarms”

Facilitate relaxation

Prevent falling asleep away from your bed

Modify environment (temp and light)

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Current Technologies Smartphones

Sensors

Wearables

Wrist

Headband

Chest band

Eye mask

Ear piece

ankles

Question #4Most commercially available “sleep sensors” compared to polysomnography:

A. are usually accurate within 10 minutes of total sleep time

B.tend to overestimate total sleep time by more than 30 minutes

C.tend to underestimate total sleep time by more than 30 minutes

D.are well validated

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A. B. C. D.

5%

67%

24%

5%

Question #4Most commercially available “sleep sensors” compared to polysomnography:

A. Are usually accurate within 10 minutes of total sleep time

B. tend to overestimate total sleep time by more than 30 minutes

C. tend to underestimate total sleep time by more than 30 minutes

D. are well validated

Current Technologies: Are these helping or hurting us?

Benefits More interest in their sleep!! Motivate to improve

Modest agreement with PSG

Disadvantages Modest agreement with PSG

Of the 80 devices; 7 have FDA approval, 3 are used by NASA, 1 has been validated in a sleep trial

Have to sleep in a standard bed

Privacy risks

Competition – disappear from the market

May disrupt sleep

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Sleep Fellow Project

To determine the accuracy of 4 consumer sleep tracking devices

Methods: A nonrandomized prospective study of four consumer sleep tracking devices compared to PSG in patients in the Emory Sleep Lab undergoing diagnostic testing

Goal: 10 subjects for each device

Data CollectedParameters: Hypnogram

Sleep onset latency

Total sleep time (TST)

+/‐ Deep Sleep

+/‐Wake after sleep onset (WASO)

+/‐ Sleep score

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Gear4 Renew Sleep ClockThe Lark

Axbo ClockSleepTrackerWatch

SummaryParameters LARK Axbo Sleeptracker GEAR4 Average

Sleep onset latency 12.4 22.2 9.6 5.3 12.375Total sleep time 48.2 93.3 52 52.4 61.475Deep Sleep 26.2

WASO 36.8

1 2 3 4 5 6 7 8 9

SleepTracker 372 389 478 376 459 406 434 416 451

PSG 345 313 412 358 394 384 367 382 358

0

100

200

300

400

500

600

Min

utes

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20 subjects – no history of sleep disorders

Download app (Azumio) then used at home for 5 nights (so app can become acclimated)

Underwent PSG study and questionnaire

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Picture This:

Time For Bed

68⁰69⁰

70⁰71⁰

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Using Consumer Technology to Diagnose Sleep Disorders

Few validation studies

Direct to consumer (Walmart/Walgreen model):

Screening devices → take to their provider

May increase interest in their health

Must decide what to do with the information

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50 subjects (10 for development, 40 for validation)

Variable degrees of OSA

Smartphone taped to chest while undergoing diagnostic PSG

Measured “sound power dips (SPD)”: dip in given threshold last < 90 secs with descending and ascending portions steeper that the threshold values per 18 sec

Smart RDI = SPD/hour of test

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Smartphone App for SnoringLimitations:

tested in sleep lab environment

No bedpartner or pets

Little ambient noise

Tested on patients referred for sleep apnea

Not very accurate for mild – moderate OSA

Positive aspects Easy and lots of people have them

Technology will improve

More patients identified

Validation study of 62 ptsSimultaneous with PSGSensitivity 88%; Specificity 91%

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Summary Sleep Medicine has come a long way in the last 25 years: bonafidespecialty with certification exam, training programs, research centers, accreditation, meetings, journals, books

Biggest challenge is being able to manage the large volume of patients with sleep disorders in a system that is undereducated about sleep

Testing in the home will expand beyond sleep apnea and sleep knowledge among healthcare consumers will continue to grow

ROFESSOR OF MEDICINE EMORY UNIVERSITY SCHOOL OF … Collop 3-23-17.pdfappointment in the Emory...

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