Even as the United States reopens, it’s not just exposure to COVID-19 that sleep professionals need to worry about. With sharp increases in unemployment and many facilities seeing drops in revenue, the road ahead for sleep labs is likely to look different than what has been traveled before.
By Yoona Ha
To learn about how the landscape of sleep medicine might change, Sleep Review interviewed a dozen business owners and clinicians on what the new normal in sleep will feel like. What trends are here to stay? How will infection control practices grow and develop? Who’s left out of treatment? Which innovations will stick around post-pandemic?
Sure, the pandemic may be unprecedented, but there are patterns in how the sleep industry is responding that gives us hints to what to look out for when the virus subsides.
A Future of Digitally-Enabled Care
Even long-time advocates of telemedicine didn’t foresee that the explosion of sleep medicine practice over the Internet would happen so suddenly.
“Part of me feels like people have been almost forced into adapting telemedicine before they were ready, but then the other part of me feels like people were extremely ready for this change,” says Seema Khosla, MD, FCCP, FAASM, medical director of the North Dakota Center for Sleep, who has offered virtual visits for more than a decade.
A COVID-19 impact study conducted by artificial intelligence-powered diagnostics company EnsoData found that 64% of sleep center interviewees are using telehealth platforms during the pandemic. Uses include video and phone appointments, diagnostic evaluations, treatment discussions, and CPAP education. “Forward-thinking sleep centers may focus on sustainable changes to the gross proportions of at-home versus in-clinic care in a post-COVID-19 world,” the study notes, which may signal a new era for digitally-enabled care.1
Khosla, for one, talked about her mother, a primary care physician who had never imagined video chatting being a replacement for in-person visits.
“It’s not uncommon for providers needing to acclimate to tech-enabled solutions, but what’s interesting is that I’ve seen people like my mother start from a place of having trouble with telemedicine platforms getting better at it,” Khosla says. She has even seen her mother’s personal calls improve. “I used to stare at her ceiling a lot during video calls, but now her experience with telemedicine has translated into better Facetime sessions,” she says.
Long-term, Khosla anticipates providers will continue to leverage telehealth while also addressing gray areas. For example, they may direct patients on how to aim a phone camera to show the back of the throat.
Kholsa recommends setting up multiple telemedicine platforms in case technical glitches emerge on one. “Technology is supposed to improve our healthcare experience and sometimes we tend to get ahead of ourselves and forget that it’s the human behind these platforms that can be transformative for the patient,” she says.
Video visits have also proved to be transformative for some clinicians, particularly those who are caregivers for young children or older relatives.
Of course, in-person alternatives depend on clinical discretion. “Initiating therapy based on clinical judgment requires excellent follow-up to ascertain the effectiveness of therapy; this is possible using telemedicine, but triage is needed to ensure that patients are seen in a timely manner,” says Shannon Sullivan, MD, vice chair of the American Academy of Sleep Medicine (AASM) Public Safety Committee and medical director of the EVAL Research Institute in Palo Alto, Calif. “In addition, in many cases when labs are reopened, it will be important for clinicians to consider completing missing elements of the workup. A silver lining in all of this is that sleep physicians may, in some cases, welcome the opportunity to do what they do best—practicing sleep medicine based on their expertise and experience rather than checking the boxes of payer requirements, which may at times be overwrought.”
But still, given that insurance coverage for ongoing care in a post-pandemic world is not yet defined, it’s hard to predict how coverage for telemedicine will continue to evolve.
Is the Surge in Home Sleep Testing Here to Stay?
Pre-COVID volumes were 70% in-lab and 30% home sleep testing (HST), according to EnsoData’s survey, which found this in-lab to home testing ratio flipped during the pandemic.1
“It’s a big question—whether we’ll see the reversal of the prevalence of HSTs versus in-lab sleep studies continue after the pandemic,” says Chris Fernandez, EnsoData co-founder and CEO. “But I do think that the trends we see in sleep medicine—increases in HSTs and the accelerations we’ve seen in telemedicine—won’t go away post-COVID. We believe that sleep providers with a bias towards action and a care delivery model that enables them to shift gears when they need it will be the most resilient during and after a pandemic because this won’t be the last outbreak we’ll ever see.”
Indira Gurubhagavatula, MD, MPH, chair of the AASM Public Safety Committee and associate professor in the Perelman School of Medicine at the University of Pennsylvania, says sleep medicine has long been poised to adapt to telemedicine approaches. “Our primary diagnostic and therapeutic data, which comes from sleep studies and positive airway pressure devices, can be accessed electronically by leveraging remote, cloud-based networks without relying on smart cards and face-to-face appointments to retrieve data,” Gurubhagavatula says.
Ingvar Hjalmarsson, chief product officer of sleep diagnostics company Nox Medical, says Nox has helped patients on lengthy waiting lists gain access to OSA treatment through a “rental relief” program, which provides sleep centers short-term device rentals until they are able to reduce waits to manageable levels.
“We believe that our innovations are a great fit for the opportunities that the post-COVID-world introduces,” Hjalmarsson says, adding that its new dual PSG-HST device provides sleep professionals with more flexibility on study location.
“The trends we see in sleep medicine—increases in HSTs and the accelerations we’ve seen in telemedicine—won’t go away post-COVID”Chris Fernandez, EnsoData
Businesses that offer HST logistics have been popular.
“Our focus is on figuring out what sleep centers need, and we’ve identified pain points in the logistics: mailing, keeping track of monitors and supplies, scheduling studies, just to name a few,” says Hani Kayyali, CEO of CleveMed, which offers a mail-order service. “What health systems are finding out are the financial benefits of streamlining HST offerings. Some of the health systems we work with have doubled or tripled their volume of patients with existing staff, and that’s probably one area that’s become more obvious since the pandemic.”
Some HST providers who relied on in-person patient training or a classroom model could not continue to provide services during the pandemic, says sleep physician Dominic A. Munafo, MD, FABSM, chief medical officer of BetterNight, which offers sleep telehealth screenings, in-home testing, and remote initiation of PAP and insomnia therapies. “The ability to provide diagnostic and therapy services safely was the primary concern,” Munafo says. “Our existing protocols for sanitizing diagnostic recorders and offering ‘no-touch’ PAP setups were quite reassuring to new clients. Also, the use of disposable sleep recorders [Itamar WatchPAT ONE] was a vital tool to reassure both patients and doctors.”
Southern Sleep Society manager Marietta Bibbs, BA, RPSGT, CCSH, FAAST, says it makes sense for providers to shop around for better deals and partner with companies that provide leasing or renting options. “With the focus on infection prevention, the only place to really manage budgets is to manage staff like decreasing overtime, shorter work shifts, and making sure that night technologists score their sleep studies so that day staff can concentrate on patient follow-up and other accreditation requirements,” Bibbs says.
Advice for Resuming Operations
Managers also have to navigate how to protect staff and patients from potential exposure to coronavirus.
“Increasing telehealth availability, and all the coordination, staff training, hardware and software adaptations, and patient education this entails, is one arena,” says Sullivan, clinical associate professor of psychiatry and behavioral sciences at Stanford University. “In a field reliant on lab testing for complex respiratory disorders, hypersomnias, and some types of parasomnias, figuring out how to safely reopen has become essential.”
Since home sleep studies are only indicated for patients with a high pretest probability of sleep apnea, people who have symptoms of other sleep disorders have in many cases been waiting extra months for their diagnosis.
“Polysomnography and/or MSLT [multiple sleep latency test] are indicated in the work-up of non-respiratory sleep disorders as well, so I think there are burgeoning, unmet needs among all sorts of patients right now,” Sullivan says.
Challenges for sleep practices, according to Sullivan, include staff retention, procurement of personal protective equipment (PPE), cleaning services, altered staff-to-patient-ratios, and altered reimbursement profiles. Sleep labs may also face productivity reductions from keeping equipment out of service, reducing patient flow to minimize contact, deploying triage strategies, and addressing cancellations.
“There isn’t a one-size-fits-all approach to tackling this long list of concerns, but instead providers should continue to remain agile and creative in addressing these challenges for the foreseeable future,” Sullivan says.
Even before the pandemic, insomnia resources were inadequate to meet patient needs, says BetterNight’s Munafo. “With the advent of COVID, there has undoubtedly been an uptick in insomnia complaints,” Munafo says, adding that BetterNight’ makes a cognitive behavioral therapy for insomnia (CBT-I) app that can eliminate the need for in-person CBT-I.
Heightened Infection Control
Heightened scrutiny over anything that comes into contact with patients is likely to remain a priority for the foreseeable future. Managers will likely have to spend more money on PPE, hand sanitizer, thermometers, disinfection, on screening patients and staff for COVID-19 symptoms, and potentially on new equipment or supplies that may reduce transmission risk.
“Moving forward there will continue to be a need for in-person studies,” says John Blackburn, marketing operations manager for Sizewise. The mattress company makes a medical-grade wipe-down top that doesn’t degrade with the use of harsh cleaning chemicals, which Blackburn characterizes as “an important preventative piece for every facility’s infection control protocols.”
Even before the pandemic, Todd Eiken, RPSGT, FAAST, vice president of product development at Dymedix Diagnostics, saw increases in sales for disposable sensors. He described the boost during COVID-19 as the tipping point. “What we’re asking providers to consider is the costs: compare the costs of cleaning and disinfecting reusables along with the time costs of providers in charge of disinfection with the cost of using disposable sensors,” he says.
Eiken says the looming risk of liability combined with lingering concerns regarding sensors that sit under a person’s nose convince many to switch patient-adhered sensors to those that are discarded after single-use.
Managers may also need to reeducate team members on best practices, for example, halting the practice of using a reusable electrode to scoop skin prep gel out of the jar. New practices may also need to be deployed, such as doing electrode and sensor hookups from the back of the patient, instead of the front. For procedures that can potentially aerosolize viruses, such as CPAP titrations, some sleep labs are opting to add bacterial/viral filters or blocking ventilation ports, though it’s best to check with your device manufacturer before making changes.
AASM guidance states that as long as effective mitigation strategies are in place (such as proper disinfection, time between patients of at least 72 hours, and PPE is worn during cleaning), reusable home sleep testing devices can be used with patients. But some find using a disposable HST like Itamar Medical’s WatchPAT ONE is a straightforward solution. “The WatchPAT ONE wirelessly transmits sleep data and eliminates the need to return shipment, cleaning and preparation, which significantly reduces patient and staff exposure to infection,” says Amit Shafrif, vice president and general manager – cardiology at Itamar Medical.
Economic Losses Will Linger
Bibbs, who is also manager of sleep and neurodiagnostics at Morton Plant Mease Healthcare, says the closure of sleep clinics has placed some sleep techs in a position of concern about future employment opportunities. “Those employed in freestanding facilities that are without pay are concerned that these facilities will not reopen again, and this has indeed been the case for some facilities,” she says. “I think that hospitals will reassess many of their outpatient services related to profitability due to the substantial losses resulting from the pandemic, and sleep services may be included in that model.”
On the other hand, hospital-owned sleep centers were better able to deal with the closure, according to Bibbs, with some sleep techs attending to other areas of care, including temperature screening and respiratory equipment.
Health Disparities Brought Forward
Bibbs says the pandemic’s disproportionate effect on Black patients has further highlighted the necessity of sleep clinicians to address the health disparities that medically underserved populations face.2
Reduced capacity and closed sleep clinics translate into reduced access to care; for some, the pandemic’s effect has proved fatal, according to Bibbs. She cited an example of a family member who passed away in their sleep after dealing with multiple comorbidities and sleep apnea.
Providers need to stay vigilant about providing equitable care to patients in all communities, Bibbs says. Before COVID-19, community health facilities that connect patients with devices and care would help uninsured patients, and in light of recent concerns about how CPAP could spread COVID-19, many facilities now also sanitize donated CPAP machines. She also sees telemedicine playing a role to reduce those gaps in access during and after the pandemic. “Sleep providers concerned in closing the gap in disparities can volunteer their time at these community medicine clinics and become visible members in their communities to earn the trust of those medically underserved patients,” Bibbs says.
“Sleep providers concerned in closing the gap in disparities can volunteer their time at these community medicine clinics and become visible members in their communities to earn the trust of those medically underserved patients”Marietta Bibbs
Accreditation Surveys Go Virtual
Throughout his many years with the Accreditation Commission for Healthcare (ACHC), program director Tim Safley’s focus has remained on the patient. During the pandemic, the accreditor started conducting its surveys virtually (in conjunction with limited on-site reviews in areas with less than 500 reported cases of COVID-19).
“From our standpoint, we know that in-person site visits will never go away, site verification is incredibly important so to ensure that we’re meeting safety protocols we are conducting virtual visits with the expectation that we can validate that they’re meeting our standards at any time without notice,” Safley says.
The experience of these virtual site surveys has been facilitated by secure, encrypted video platforms. “It’s no different from an on-site survey in terms of the thoroughness and what we’re looking for and the good news is that we have seen no pushback from providers,” he says.
Dottie Covey, RPSGT, an ACHC surveyor advocated for sleep clinics to look at their existing vendor relationships to identify opportunities for cost savings during a webinar on infection control in sleep labs that was attended by more than 400 people. “You need to be thinking differently about your current processes and what else you could be doing to improve,” she said in the webinar. “We should and always continue to operate as if the next patient that comes in could be a contagion; it’s not just during a pandemic that we need to heighten infection control practices.”3
This moment will serve as a unique time in history for incoming trainees in sleep medicine, which was heavily impacted by COVID-19, says Gurubhagavatula.
“With the move to telemedicine approaches, educators and learners have had to adapt quickly to achieve required metrics and competencies,” says Gurubhagavatula, director of the Sleep Disorders Clinic at the Crescenz VA Medical Center in Philadelphia. “Some challenges, as well as opportunities, exist in this new environment. Moving forward will require dynamic, innovative, and collaborative learning models.”
Yoona Ha is a freelance writer and healthcare public relations professional.
- COVID-19 sleep center impact study. EnsoData. 2020. Available at https://www.ensodata.com/landing-pages/covid-19-sleep-center-impact-study.
- COVID-19 in racial and ethnic minority groups. CDC. 4 June 2020. Available at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html.
- Infection control in the sleep lab. ACHC-U. 21 May 2020. Available at https://register.gotowebinar.com/register/7672731193098899211.
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