The COVID-19 pandemic's impact on sleep medicine fellowship telemedicine training: a follow-up survey of program directors.

STUDY OBJECTIVES: Our 2019 survey of sleep medicine fellowship program directors (PDs) indicated that fellows' contact with telemedicine was limited. Within months, the coronavirus disease 2019 (COVID-19) pandemic significantly impacted the field. This survey describes fellows' telemedicine exposure, their PDs' attitudes toward it, and their formalized telemedicine training during the pandemic's third year. METHODS: A 33-item SurveyMonkey questionnaire was developed. Many quantitative (Likert scale) items were identical to items on the 2019 survey for direct comparison. An open-ended question was added for qualitative analyses. All 91 sleep medicine fellowship PDs were invited to participate. The SurveyMonkey platform provided quantitative item descriptive statistics. Qualitative data underwent thematic analyses using codebook methodology. RESULTS: Forty (97.5%) PDs indicated their program offers a telemedicine experience. Thirty-two (80%) PDs observed at least a 10% increase in sleep fellows' telemedicine encounters compared with prepandemic times. Although 27 (67.5%) PDs agreed that a national telemedicine curriculum could be useful, 8 (20%) of them offer a sleep telemedicine curriculum. Qualitative feedback revealed diverging attitudes toward telemedicine's place in sleep medicine practice, fellowship training, and the utility of a national curriculum. CONCLUSIONS: Sleep telemedicine utilization during fellowship training was markedly higher on this 2022 survey (97.5%) compared with a similar 2019 survey (33.3%), and most PDs agreed a standardized curriculum could be useful. However, relatively few programs offer formalized telemedicine training. These findings imply that, while most sleep medicine fellows participate in telemedicine, they lack the formalized training that may optimize their utilization of the medium in their postfellowship careers. CITATION: Fields BG, Kaur K, Dholakia S, Ioachimescu O. The COVID-19 pandemic's impact on sleep medicine fellowship telemedicine training: a follow-up survey of program directors. J Clin Sleep Med. 2024;20(2):201-210.

Telemedicine-based sleep services for a complex child: optimizing care during a pandemic and beyond.

A 12-year-old male with nonverbal autism and morbid obesity was referred to a pediatric sleep center during the SARS-CoV-2 pandemic for complaints of snoring with tonsillar hypertrophy and difficulty falling asleep. Due to social challenges, the family had not sought in-person care in the past. Through telemedicine consultation and home sleep apnea testing, the patient was diagnosed with obstructive sleep apnea as well as an irregular sleep-wake disorder. This unique utilization of the health care system in the care of a complex patient with multiple sleep disorders demonstrates the utility of remote care and testing. There is a great benefit to continuing to provide pediatric sleep care in this way beyond the pandemic.

Regulatory, Legal, and Ethical Considerations of Telemedicine.

Sleep telemedicine practitioners must ensure their practice complies with all applicable institutional, state, and federal regulations. Providers must be licensed in any state in which they provide care, have undergone credentialing and privileging procedures at outside facilities, and avoid real or perceived conflicts of interest while providing that care. Internet-based prescribing remains limited to certain circumstances. Whether or not a malpractice insurance policy covers telemedicine depends on the insurer, especially if interstate care is provided. All telemedicine programs must protect patient health information. Similarly, bioethical principles of autonomy, beneficence, nonmaleficence, and justice apply to both in-person and telemedicine-based care.

Performance of peripheral arterial tonometry-based testing for the diagnosis of obstructive sleep apnea in a large sleep clinic cohort.

STUDY OBJECTIVES: Peripheral arterial tonometry (PAT)-based technology represents a validated portable monitoring modality for the diagnosis of OSA. We assessed the diagnostic accuracy of PAT-based technology in a large point-of-care cohort of patients studied with concurrent polysomnography (PSG). METHODS: During study enrollment, all participants suspected to have OSA and tested by in-laboratory PSG underwent concurrent PAT device recordings. RESULTS: Five hundred concomitant PSG and WatchPat tests were analyzed. Median (interquartile range) PSG AHI was 18 (8-37) events/h and PAT AHI3% was 25 (12-46) events/h. Average bias was + 4 events/h. Diagnostic concordance was found in 42%, 41%, and 83% of mild, moderate, and severe OSA, respectively (accuracy = 53%). Among patients with PAT diagnoses of moderate or severe OSA, 5% did not have OSA and 19% had mild OSA; in those with mild OSA, PSG showed moderate or severe disease in 20% and no OSA in 30% of patients (accuracy = 69%). On average, using a 3% desaturation threshold, WatchPat overestimated disease prevalence and severity (mean + 4 events/h) and the 4% threshold underestimated disease prevalence and severity by -6 events/h. CONCLUSIONS: Although there was an overall tendency to overestimate the severity of OSA, a significant percentage of patients had clinically relevant misclassifications. As such, we recommend that patients without OSA or with mild disease assessed by PAT undergo repeat in-laboratory PSG. Optimized clinical pathways are urgently needed to minimize therapeutic decisions instituted in the presence of diagnostic uncertainty.

Sleep telemedicine training in fellowship programs: a survey of program directors.

STUDY OBJECTIVES: Telemedicine is a novel modality of health care delivery that can improve patients' access to sleep medicine services, but little is known about telemedicine training during sleep medicine fellowship. We studied telemedicine training prevalence, use, and attitudes of program directors (PDs) and other faculty members, PDs' receptiveness to a standardized telemedicine curriculum, and whether PDs have reviewed existing American Academy of Sleep Medicine (AASM) sleep telemedicine reference materials. METHODS: This was an anonymous online survey of all 86 PDs of accredited sleep medicine fellowships in the United States. RESULTS: Response rate was 45%. Thirteen (33.3%) of the PDs already offer telemedicine experience to their trainees, although none use a standard telemedicine curriculum. Among the 26 (66.7%) PDs not offering telemedicine experience, 38.5% plan to do so and 53.9% agree that it would benefit fellows. Most PDs (57.9%) report faculty using telemedicine now or within the next 3 years. Many PDs agree that telemedicine is technically feasible, but relatively few agree it is financially feasible (82.1% and 38%, respectively). Few PDs have reviewed both primary AASM telemedicine reference materials. Overall, 64.1% of PDs agree that a national sleep telemedicine curriculum could be useful. CONCLUSIONS: Although only a minority of current sleep medicine fellows are exposed to telemedicine, it is likely that most will get some exposure in the next 3 years. PDs' attitudes toward telemedicine vary significantly with respect to feasibility and importance to their programs. Nevertheless, most PDs believe a standardized sleep telemedicine training curriculum could be useful.

Competency-based sleep medicine fellowships: addressing workforce needs and enhancing educational quality.

None: The path for physicians to become credentialed sleep medicine specialists has changed in many ways in the last few decades. Currently, sleep medicine is recognized as an independent subspecialty with appropriately rigorous and comprehensive training required to become a board-certified sleep medicine physician. However, added time for requisite fellowship training, coupled with an aging sleep medicine physician workforce, have had the unintended consequence of decreasing the number of sleep medicine physicians at a time when the demands for sleep medicine care continue to rise. Thus, new training pathways that provide flexibility to trainees, while ensuring high-quality, comprehensive, and multidisciplinary sleep medicine training are needed to maintain a workforce that can meet the sleep health needs of the present and future. Here, we describe two pilot programs that apply principles of competency-based medical education to sleep medicine fellowship training. These novel models are likely to attract additional well-qualified physicians to the field who might otherwise not pursue a career in sleep medicine.

Sleep Telemedicine: An Emerging Field's Latest Frontier.

There is a widening gap between sleep provider access and patient demand for it. An American Academy of Sleep Medicine position paper recently recognized sleep telemedicine as one tool to narrow that divide. We define the term sleep telemedicine as the use of sleep-related medical information exchanged from one site to another via electronic communications to improve a patient's health. Applicable data transfer methods include telephone, video, smartphone applications, and the Internet. Their usefulness for the treatment of insomnia and sleep-disordered breathing is highlighted. Sleep telemedicine programs range in complexity from telephone-based patient feedback systems to comprehensive treatment pathways incorporating real-time video, telephone, and the Internet. While large, randomized trials are lacking, smaller studies comparing telemedicine with in-person care suggest noninferiority in terms of patient satisfaction, adherence to treatment, and symptomatic improvement. Sleep telemedicine is feasible from a technological and quality-driven perspective, but cost uncertainties, complex reimbursement structures, and variable licensing rules remain significant challenges to its feasibility on a larger scale. As legislative reform pends, larger randomized trials are needed to elucidate impact on patient outcomes, cost, and health-care system accessibility.

Remote Ambulatory Management of Veterans with Obstructive Sleep Apnea.

STUDY OBJECTIVES: Despite significant medical sequelae of obstructive sleep apnea (OSA), the condition remains undiagnosed and untreated in many affected individuals. We explored the feasibility of a comprehensive, telemedicine-based OSA management pathway in a community-based Veteran cohort. METHODS: This prospective, parallel-group randomized pilot study assessed feasibility of a telemedicine-based pathway for OSA evaluation and management in comparison to a more traditional, in-person care model. The study included 60 Veterans at the Philadelphia Veterans Affairs Medical Center and two affiliated community-based outpatient clinics. Telemedicine pathway feasibility, acceptability, and outcomes were assessed through a variety of quantitative (Functional Outcomes of Sleep Questionnaire, dropout rates, positive airway pressure [PAP] adherence rates, participant satisfaction ratings) and qualitative (verbal feedback) metrics. RESULTS: There was no significant difference in functional outcome changes, patient satisfaction, dropout rates, or objectively measured PAP adherence between groups after 3 months of treatment. Telemedicine participants showed greater improvement in mental health scores, and their feedback was overwhelmingly positive. CONCLUSIONS: Our pilot study suggests that telemedicine-based management of OSA patients is feasible in terms of patient functional outcomes and overall satisfaction with care. Future studies should include larger populations to further elucidate these findings while assessing provider- and patient-related cost effectiveness.

Geographic Localization of Housestaff Inpatients Improves Patient-Provider Communication, Satisfaction, and Culture of Safety.

This study assesses whether geographic localization of housestaff patients contributes to improved patient knowledge of diagnosis, patient satisfaction, provider satisfaction, and workplace culture of safety. Due to national changes to graduate medical education, housestaff patients were localized to a single general medicine ward. Ninety-three patients prelocalization, 64 patients postlocalization, 26 localized physicians, and 10 localized nurses were surveyed. Validated questionnaires assessed patients' experiences during hospitalization, and physician and nurse job satisfaction. Fifty-seven percent of patients knew their diagnosis prior to localization, compared to 80% postlocalization (p < .0001). Prior to localization, 39% of patients who reported experiencing anxieties or fears during hospitalization felt physicians frequently discussed these emotions with them compared to 85% after localization (p < .0001). Before localization, 51% of patients stated that doctors spent 4 min or more daily with them discussing care, compared to 91% after localization (p < .0001). Both physician and nurse opinion significantly improved regarding some but not all aspects of collaboration, teamwork, patient safety, appropriate handling of errors, and culture of safety. The average length of stay was unchanged and the change in 30-day readmission rate was not statistically significant. Localization of patients to a single inpatient ward improved patient knowledge and satisfaction, and some aspects of interprofessional communication and workplace culture of safety.

Master's-level practitioners as cognitive behavioral therapy for insomnia providers: an underutilized resource.

Despite the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in treating chronic insomnia, it remains underutilized. Lack of appropriately-trained CBT-I providers is a major reason. Master's-level practitioners (MLPs) may, in addition to doctoral-level psychologists, be uniquely positioned to fill this role, based not only on "goodness of professional fit" but also given a handful of studies showing these individuals' care outcomes meet or exceed standard outcomes. However, the ability of MLPs to provide CBT-I will be significantly restricted until a clear pathway is established that extends from training opportunities to credentialing. Further questions remain about how to attract and incorporate MLPs into established practices.

Screening for severe obstructive sleep apnea syndrome in hypertensive outpatients.

The authors attempted to validate a 2-stage strategy to screen for severe obstructive sleep apnea syndrome (s-OSAS) among hypertensive outpatients, with polysomnography (PSG) as the gold standard. Using a prospective design, outpatients with hypertension were recruited from medical outpatient clinics. Interventions included (1) assessment of clinical data; (2) home sleep testing (HST); and (3) 12-channnel, in-laboratory PSG. The authors developed models using clinical or HST data alone (single-stage models) or clinical data in tandem with HST (2-stage models) to predict s-OSAS. For each model, area under receiver operating characteristic curves (AUCs), sensitivity, specificity, negative likelihood ratio, and negative post-test probability (NPTP) were computed. Models were then rank-ordered based on AUC values and NPTP. HST used alone had limited accuracy (AUC=0.727, NPTP=2.9%). However, models that used clinical data in tandem with HST were more accurate in identifying s-OSAS, with lower NPTP: (1) facial morphometrics (AUC=0.816, NPTP=0.6%); (2) neck circumference (AUC=0.803, NPTP=1.7%); and Multivariable Apnea Prediction Score (AUC=0.799, NPTP=1.5%) where sensitivity, specificity, and NPTP were evaluated at optimal thresholds. Therefore, HST combined with clinical data can be useful in identifying s-OSAS in hypertensive outpatients, without incurring greater cost and patient burden associated with in-laboratory PSG. These models were less useful in identifying obstructive sleep apnea syndrome of any severity.

Comparing methods of respiratory event detection during the treatment of obstructive sleep apnea.

Renewed focus on comparative effectiveness research presents a unique opportunity to develop optimal clinical management pathways for patients with obstructive sleep apnea. With this momentum comes the challenge of measuring treatment effect on sleep-disordered breathing, especially in large, multisite studies. In-laboratory polysomnography, the current gold standard sleep assessment of obstructive sleep apnea severity, is costly and imposes significant participant burden. Alternatives include home unattended sleep testing and overnight pulse oximetry recording. Research studies using positive airway pressure treatment have the additional option of using the information recorded by the patient's positive airway pressure device to assess treatment effectiveness. Recent research has shown relatively good agreement between manual identification of residual respiratory events in overnight in-laboratory polysomnography and the automatic event detection utilized in positive airway pressure machines. In addition to assessing the effects of interventions on sleep disordered breathing, obstructive sleep apnea-related comparative effectiveness studies need to assess the impact of the interventions on patient burden, cost of therapy, timeliness of care, improved quality of life and other clinically relevant outcomes.

The residency application abyss: insights and advice.

Most medical students apply for residency training upon completion of medical school. The choice of specialty is one of a student's first major career decisions, and the application process often results in considerable anxiety, as it is competitive, unpredictable, and requires a significant investment of time and money. This article, which addresses several important facets of the residency application using both experiential and evidence-based data, is organized chronologically into sections that describe a logical approach to applying for residency: choice of a specialty, the personal statement, the interview day, and developing a rank list. A list of relevant websites is also included. This paper is a resource that provides timely and tangible guidance to medical students applying for residency training.