The only thing that is constant is change.Greek Philosopher Heraclitus, c.535 c.475 BCEConsumer sleep technology (CST) is here to stay,1 but what does it mean for the sleep medicine community? The American Academy of Sleep Medicine's (AASM) recent formation of a Technology Presidential Committee and publication of a position statement on CSTs highlights the importance of this issue to our collective future.2 These actions demonstrate the AASM intends to shape this future rather than react to these imminent changes.Sleep disorders and the importance of sleep health are under-recognized by primary care physicians and their patients. Conversations with primary care as part of the AASM and Sleep Research Societies' National Healthy Sleep Awareness Project3 to engage them more deeply in sleep medicine care was largely rebuffed, no doubt a result of minimal sleep medicine education in medical school curricula, internships, and residencies and an overburdened primary care workforce. No wonder 85% of people with sleep apnea go undiagnosed and untreated,4 30% of the adult population does not get the recommended 7 or more hours of sleep on a nightly basis,5,6 and access to cognitive behavioral therapy for insomnia (CBT-I) is so limited.7 Indeed, only 13% of those with insomnia ever consult a health care provider for this sleep problem.8CSTs address these shortcomings by empowering those with sleep difficulties with objective data to better understand their sleep problem and provide physician reports to catalyze patient/provider interactions to address these sleep issues (Figure 1).9 These novel objective reports provide previously unobtainable longitudinal and ecologically valid sleep data. The resulting doctor-patient conversations will drive patients into sleep clinics for the care they need.Likelihood of seeing a doctor due to sleep issues.Likelihood of seeing a doctor due to sleep issues (eg, insomnia, sleep apnea, restless legs syndrome) detected by a consumer sleep technology device or application (n = 2,000; 2.19%).9Figure 1Likelihood of seeing a doctor due to sleep issues.(more ...)How do we deal with these increased referrals? With an approximate ratio of one board certified sleep physician for every 46,000 American citizens and vast swaths of the country devoid of sleep medicine expertise, it is clear we already have an access problem.10 The AASM is working to tackle this issue by growing sleep fellowship programs and exploring alternative pathways to board eligibility with the Accreditation Council for Graduate Medical Education through the Innovative Fellowship Model Implementation Presidential Committee.10 But even the best outcomes of these efforts will likely leave us with a shortage of sleep physicians. CSTs help this dilemma by steering people with sleep difficulties to solutions that optimize the sleep environment and facilitate proper sleep hygiene as first steps to address sub-optimal sleep. For example, CSTs can inform the consumer regarding habitual sleep duration and quality, the effect of alcohol, caffeine and nicotine on sleep, and aspects of the individual's sleep environment such as ambient temperature, sound, and light levels. Once this information is collected, some CSTs provide guidance for how to address these potentially problematic sleep issues and advance sleep health. Examples include referring individuals to digital CBT-I11,12 and/or home-based, timed, blue wavelength light suppressing technologies. Interventions such as these may obviate the need for specialist referral and deliver improved sleep health to a broader cross-section of society.The AASM position statement on CSTs focuses on the need for FDA approval and rigorous validation against current gold standards. This position is appropriate if CSTs seek to advance beyond devices focused on general sleep health and well-being into the realm of screening, diagnosis and treatment of sleep disorders. The AASM sets the bar high and the CST community is taking responsibility as evidenced by the Consumer Technology Association implementing early standardization efforts focused on definitions and methodologies.13,14The AASM focus on validation and FDA approval is aspirational and well-reasoned, yet it overlooks the complementary nature of CSTs and traditional sleep testing. CSTs assess aspects of a person's sleep life that heretofore were massive blind spots for the sleep medicine community. Polysomnography is a diagnostic test that measures sleep for one night, in a strange environment, in an obtrusive manner. But no two nights of sleep are exactly the same and inter-scorer agreement of polysomnography is just 83% highlighting the imperfection of PSG.15 Home sleep apnea tests are done in the person's typical sleep environment, but otherwise suffer from the same limitations as polysomnography. Actigraphy is an indirect measure of sleep that provides limited data and requires interaction with providers with sleep expertise
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