Assessment of the impact of CPAP telemonitoring on therapy is often focused on CPAP compliance rather than on other outcomes. However, with regard to EDS, TM interventions were associated with an improvement in the Epworth Sleepiness Score (ESS) in 7 out of 16 studies in the meta-analysis Labarca et al.
[12]. The mean difference was low, 0.52 (95% CI 0.12–0.93), and did not reach the minimal clinically important difference (MCID) for ESS, which lies between 2 and 3
[13]. This can be explained by the poor performance of the ESS
[2], or by the inclusion of non-sleepy patients in seven studies, who generally exhibited an improvement of only 1 point on the ESS with CPAP
[14]. Indeed, ESS at baseline was not associated with adherence > 4 h/night. It should also be noted that, when comparing CPAP + TM versus CPAP alone, it is clear that, due to the limited increased in compliance obtained with TM, the subsequent difference in EDS is insignificant.
2.3.3. Cardiac Events: Interpretation of CPAP-Detected Central Sleep Apnea and Cheynes-Stokes Respiration
Particular attention should be given to patients with residual central events, as Prigent et al. have shown that the detection of incident Cheynes-Stokes respiration by CPAP telemonitoring is associated with a high prevalence of heart failure (31%) and arrhythmias (8%) based on a study of 555 patients followed during a one-year period
[15]. This highlights another benefit of TMg, an increased ability to consider, detect, and manage cardiovascular comorbidities.
2.3.4. Integrated Care for OSA and Associated Comorbidities, including Telemonitored CPAP
OSA patients, mainly males, exhibit a high prevalence of comorbidities, with half of them suffering from cardiovascular disorders and about 20–30% from diabetes and dyslipidemia
[16]. Comorbidities can either be a causal factor of OSA (e.g., diabetes, heart failure) or a consequence (e.g., stroke, hypertension). CPAP is one part of the overall treatment in these patients, that aims to reduce/control cardiometabolic risk. Integrated strategies using telehealth have been studied in OSA. For example, Pépin et al. studied 306 patients suffering from both OSA and high cardiovascular risk
[17]. Patients were randomized to CPAP or to multimodal TMg. In the TMg arm, self-measured morning and evening blood pressure (BP) and physical activity were measured by connected devices. The blood pressure monitor and the actigraph (collecting number of steps/day and sleep periods) were connected to a secure website, accessible for physicians and home care providers. CPAP adherence, leaks, and residual events were collected via TMg. Symptoms and quality of life were assessed using a questionnaire-based application. Multimodal TMg provided predefined interventions to home care providers (managing leaks, mask problems, or other side effects) while the medical team managed residual events or CPAP lack of efficacy. After 6 months, no differences in BP reduction or in physical activity were observed, but CPAP compliance (5.28 ± 2.23 vs. 4.75 ± 2.5 h/night), sleepiness, and QoL were significantly improved in the multimodal TMg arm
[17]. Further studies need to define the best way to provide a holistic approach to these patients, including TM tools.
2.4. Telemonitored CPAP Therapy: Patient Perspectives
From the patient’s perspective, TMg is often perceived as a mean of reassurance
[18]. In several RCTs, satisfaction rates were better in the TM arm using different tools (e.g., feedback by phone, TMg, televisits) compared to the UC group
[19][20] or equivalent
[21]. However, it is important to fulfill some prerequisites when starting TMg in patients. First of all, patient education about TM methods is important to assure that patients understand the method and are suitable candidates for TM. TM interventions have the theoretical advantage of allowing elderly people or patients living far away to avoid visits to the hospital; however, in real-life settings, the use of TM can be limited by technological barriers/fear, especially if it requires patient intervention to connect to healthcare providers (e.g., for videoconsultation). Costs billed to the patient can also be a source of worry. When restricted to remote TMg for CPAP-treated OSA patients, no special manipulation is required to allow data monitoring, such that there are virtually no limitations.
Considering concerns about privacy protection is also essential. Indeed, despite expressing satisfaction and agreement with the usefulness of online information, some patients have reported concerns about privacy, judging TMg to be intrusive
[22]. Bros et al. reported the same concerns, with a majority of patients finding TMg useful but 40% considering TMg to be intrusive
[22]. However, in a recent study from Carlier et al. related to interventions performed in telemonitored CPAP patients during the first 6 months of treatment, acceptance (obtained via informed consent) was as high as 87%
[23]. Similar data (acceptance of 78%) was also reported in another study
[22]. In the latter study, men had fewer concerns about TMg than women, and non-working people were more favorable toward TMg than active people
[22].
In addition, acceptance of TMg seems to be an additional predictive factor of adherence. Bros et al. showed that patients refusing TMg were more at risk of CPAP withdrawal
[22]. CPAP discontinuation was also more frequent in cases of TMg interruption.
Finally, TM has entered the daily life of many family households through the growing use of connected monitoring tools (e.g., apps, watches, accelerometers) that collect physiological parameters such as blood pressure, sleep measurements, physical activity, and weight. In the future, all of these parameters, including those concerning CPAP treatment, could be integrated into a more comprehensive health monitoring strategy
[10]. However, healthcare professionals should be careful to avoid dehumanization of care through TM. Increased use of technology could limit patient engagement if no attention is dedicated to human relationships. The first wave of the COVID pandemic was a good example of this drift, which was experienced as very negative for COVID patients but also for a large part of the general population who experienced limited access to general practitioners, increased use of teleconsultations, and delays in obtaining medical care. Other concerns have also been described in the context of telehealth in COPD patients: it can create high dependency for patients, increase the frequency of nurse–patient interactions, and finally be counterproductive, leading to overtreatment and overmedicalization of patients
[24].
2.5. Telemonitored CPAP Therapy: Healthcare Professional Perspectives
Many advantages of the use of TM by medical and paramedical providers are expected or have already been demonstrated. Considering compliance problems and the relationship of these problems to the initial days of use, TMg is a good strategy for identifying patients struggling with their therapy, and setting up intensive early interventions for selected patients. Hoet et al. demonstrated that TMg reduces delay to first technical intervention in CPAP-treated patients, a factor that was associated with improved compliance at 3 months
[14]. In this way, TMg also allows practitioners to avoid losing time in unnecessary nurse visits or medical follow-up with patients who do not need it
[25][26]. TMg could, therefore, help to forge a compromise between increasing needs in sleep disorder diagnosis and support, and limited health care resources. For example, Anttalainen et al. demonstrated, in 111 patients, a savings of 19 min in nursing time between TMg patients (39 min, range 12–132) and the UC group (58 min, range 40–180)
[25]. Reduced staff time was also documented by Munafo et al., who showed that the number of contacts per patient was reduced in the telehealth group (TMg) vs. UC: 2.2 ± 2.6/patient vs. 7.8 ± 4.1/patient
[26]. Time spent per patient by the staff was also significantly reduced, even in non-compliant patients. Finally, TMg also allows remote monitoring in patients living in medical desert areas, increasing healthcare accessibility
[27].
2.6. Telemonitored CPAP Therapy: Real Costs—Cost-Effectiveness
Few studies have focused on the cost-effectiveness of TMg. Turino et al. have analyzed the treatment and follow-up costs (direct and indirect) in a cohort of 100 TMg-followed CPAP patients
[20]. Clinical outcomes were similar in both groups. Three-month costs were lower in the TMg arm vs. UC: 124 Euro versus 171 Euro. In a previous study, Isetta et al. calculated the cost-effectiveness of a TM program versus UC in 139 newly-diagnosed OSA patients
[21]. At 6 months, clinical outcomes were similar in both groups and lower costs were billed in the TM arm. When considering medical visits, time to travel to the hospital, and time out of work, the mean cost was 168 Euro in the TM arm and 180 Euro in the control arm, despite the higher number of extra visits to nurses and physicians in the TM arm. The impact of TMg on cost effectiveness seems to be positive but it is not yet clear due to the paucity of the current data
[27].
The direct cost of TMg is still very variable from one country to another and from one hospital to another, according to provider policy and to local healthcare reimbursement policies (authorities still lack reimbursement of such tools in many countries). What should really be included in the provider’s billing remains unclear at this time: the access to the cloud? access to the stored data? price per access or all-inclusive price? software maintenance of the cloud or platform? guarantee that the system will be supported for several years?
More than TMg billing, discussion of the generalization of a fee for healthcare professionals managing data and alerts of telemonitored patients should also be started, as this represents additional work for sleep professionals, and is not yet covered by healthcare insurance.