U.S. Army soldiers sleep in a hasty fighting position on a cold morning after a night patrol in the mountains near Sar Howza, Paktika province, Afghanistan, Sept. 4, 2009. Sleep disorders are common in U.S. servicemembers because of the nature of their duty. U.S. Army photo by Sgt. 1st Class Andrew Smith
BALTIMORE — Insufficient and disturbed sleep, as well as clinical sleep disorders such as obstructive sleep apnea, shift work disorder and nightmare disorder, are highly prevalent in the U.S. military and can result in increased accident risk and diminished military readiness.
But accessing traditional treatment for sleep disorders can be difficult, costly and inconvenient. “There is a gross shortage of trained specialist providers to address sleep problems. So demand for expert care far exceeds the available supply,” explained Emerson Wickwire, PhD, professor and section chief, Sleep Medicine, at the University of Maryland School of Medicine. “Further, traditional sleep interventions can be time- and resource-intensive, requiring multiple face-to-face treatment sessions that can be difficult to accommodate in military work schedules.”
Wickwire is the lead author of a new paper describing an economical and convenient alternative to traditional treatment using two widely-available pieces of technology: a smartphone app and a Fitbit fitness and sleep tracker.1
The paper, which was published in JMIR Formative Research, presents preliminary results from a pilot phase of a larger, ongoing clinical implementation project funded by the DoD. “In this study we engaged, for the first time, diverse military medical stakeholders with at-times competing interests, including patients with sleep problems, primary care providers and economic decision makers,” Wickwire said. Further, the researchers created a novel sleep telehealth platform that includes a native mobile app and integrated commercial off-the-shelf sleep tracker.
Patients for the study were recruited from the Internal Medicine Clinic and the Sleep Disorders Center at Walter Reed National Military Medical Center. Primary care managers (PCMs, including physicians, nurse practitioners and physician assistants) were recruited via word of mouth from the internal medicine clinic at WRNMMC.
Over a span of 10 days, patients underwent comprehensive remote monitoring, which included an initial intake questionnaire, daily sleep diaries and two daily symptom surveys. Additionally, they wore a Fibit Inspire 2 device throughout the study. Sleep data was captured in 1-minute epochs and integrated directly into the WellTap platform engine via an application programming interface. Variables included total sleep time, number of awakenings, wake after sleep onset and sleep efficiency.
Personalized Sleep Education
Following the remote-monitoring period, patients received assessment results and personalized sleep education in the mobile app. Providers received a provisional patient assessment report in an editable electronic document format. Patient engagement was assessed via behavioral adherence metrics that were determined a priori. Patients also completed a brief survey regarding ease of completion. Provider effectiveness was assessed via an anonymous survey.
A total of 35 individuals with sleep-related issues actively took part in the study, and notably there were no dropouts. The results demonstrated a significant level of involvement with the sleep telehealth platform, as every participant successfully completed the initial remote assessment, reviewed their personalized sleep assessment report and participated in the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Overall, patients expressed high satisfaction across various aspects of the remote monitoring assessment. Additionally, 24 primary care providers engaged in the study, completing an anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the U.S. military healthcare system.
These findings provide further evidence that telehealth approaches represent one promising pathway to increase access to cost-effective, evidence-based, sleep medicine care for military members who are at particular risk for sleep disorders due to “an unrelenting work tempo, travel across multiple time zones, and other factors—not to mention the pressures that we all feel to be more productive,” Wickwire said.
“In the MHS as well as in the broader health care universe, sleep telehealth approaches such as the one in this study can help to streamline consult efficiency while also helping PCMs to assess sleep complaints and triage patients to the appropriate level of evidence-based care, including specialist consultations when indicated,” Wickwire and his colleagues wrote, “Such an approach will empower patients and [primary care managers] to make evidence-based sleep treatment decisions and increase access to care”.
“If proven successful in larger studies, a sleep telehealth platform and remote monitoring holds great promise to increase patient and provider engagement in support of improved patient, health system, and military-relevant outcomes,” they wrote. “Such research efforts are currently underway.”
- Wickwire, E. M., Collen, J., Capaldi, V. F., Williams, S. G., et al. (2023). Patient Engagement and Provider Effectiveness of a Novel Sleep Telehealth Platform and Remote Monitoring Assessment in the US Military: Pilot Study Providing Evidence-Based Sleep Treatment Recommendations. JMIR formative research, 7, e47356. https://doi.org/10.2196/47356