Abstract Introduction Sleep loss impairs overall health and cognitive performance, including memory, attention, and executive function that is important for decision-making and risk assessment. In many high-demand occupations such as prolonged shift work, first responders, or military deployment, adequate sleep is often unattainable. The consequences of sleep loss in these professions are still high-stakes and are associated with accidents, workplace injuries, absenteeism, and long-term medical and psychiatric comorbidities. This highlights the need for simple, immediate treatment approaches to mitigate these effects, particularly when behavioral strategies that may take more time and effort are unfeasible. Our systematic review examines the current evidence on the use of creatine, an established ergogenic aid for strength performance and recovery, as a potential means of supporting cognitive function during periods of sleep loss. Methods We performed a systematic review to identify double blind, placebo-controlled studies in English assessing the effects of creatine supplementation on cognitive performance during sleep loss in healthy participants. The studies included in this review were identified through a search of PubMed, Web of Science, and PsycInfo. Two reviewers independently screened studies and resolved discrepancies by consensus. Results Of the 169 studies reviewed, only five met the inclusion criteria, which required a randomized controlled design, at least one cognitive performance outcome, and healthy participants experiencing some degree of sleep loss. In the included trials, participants underwent 3- 35 hours of sleep loss and received either a single creatine dose adjusted for body weight or a 7-day loading protocol. Cognitive performance outcomes varied across studies, but all reported modest improvements associated with creatine supplementation. Conclusion Collectively, these findings suggest that creatine may offer modest cognitive benefits during sleep loss, with the most consistent effects appearing at longer durations of sleep loss. However, confidence in these conclusions is limited due to small sample sizes, differing dosing protocols, wide variation in amount of sleep loss, and the diverse cognitive performance tasks used across studies. The limited number of studies that address the impact of creatine on cognitive performance highlight the need for additional studies in this area, especially in light of favorable outcomes. Support (if any)

BACKGROUND:Obstructive sleep apnea (OSA) is common and costly in the U.S. military health system (MHS). OSA is associated with poor health outcomes as well as increased economic burden borne by the Defense Health Agency. The MHS lacks the capacity to meet the available demand for sleep specialty care. Thus, most military OSA care is provided by private sector TRICARE-contracted civilian providers. Given the burden of OSA and limited access to OSA care, optimizing OSA care within the MHS is vital. TELE-SLEEP OSA is a randomized, parallel group, single blind, controlled clinical trial comparing OSA telehealth care to standard private sector TRICARE. METHODS:Participants will include 160 active-duty family members and Defense Enrollment Eligibility Reporting System beneficiaries who are referred for OSA consultation. Following informed consent, participants will complete baseline assessments prior to randomization. Participants randomized to private sector TRICARE will receive treatment as usual, including positive airway pressure (PAP) therapy. Participants randomized to OSA telehealth care will undergo telehealth consultation with a board-certified sleep medicine specialist, undergo home sleep apnea testing, receive auto-titrating PAP therapy, and receive ongoing support from educator-level sleep navigators throughout the study. Quantitative follow-up assessments will be completed at 30 and 90 days after treatment initiation. Qualitative focus groups to assess participant satisfaction and other implementation outcomes will be conducted with participants from both treatment groups. Outcomes include PAP adherence (primary outcome), OSA symptoms, implementation, and cost-effectiveness. CONCLUSION:Our telemedicine approach to OSA treatment aims to reduce costs and improve health outcomes within the MHS. CLINICAL TRIAL REGISTRATION:NCT07121452.

Abstract Introduction Insomnia and obstructive sleep apnea (OSA) are highly prevalent among active-duty U.S. military personnel, and co-occurrence of the conditions is common. Compared to either condition alone in civilian populations, comorbid insomnia and OSA (COMISA) is associated with worse health outcomes, greater healthcare resource utilization, and higher healthcare costs. The purpose of this study was to determine the economic burden of COMISA among active-duty military personnel. We hypothesized that relative to insomnia and OSA alone COMISA is associated with greater healthcare resource utilization and costs. Methods Data were derived from the Military Data Repository (MDR) from 2016-2021. Inclusion criteria were age < 65 years, active-duty military personnel, 12 months of continuous enrollment before and after insomnia or OSA diagnosis, and no evidence of prior insomnia or OSA. COMISA was defined as receipt of an insomnia diagnosis within 365 days of OSA diagnosis. Generalized linear models with log link were used to compare direct costs between individuals without sleep disorders, insomnia alone, OSA alone, or COMISA across multiple points of service: outpatient, inpatient, and emergency department (ED). Costs were adjusted for age, sex, military service, region, comorbidities and prior year costs. Results The final sample included n=183,961 active-duty military personnel without sleep disorders, n=40,278 with insomnia alone, n=27,103 with OSA alone, and n=3,956 with COMISA. Most participants were between ages 35-44 years (40.7%), and male (82.1%). Average adjusted outpatient costs were highest in the COMISA group (without sleep disorders: $4,036; insomnia alone: $9,940; OSA alone: $6,910; COMISA: $10,759; p< 0.001), as were average adjusted ED costs (without sleep disorders: $214; insomnia alone: $363; OSA alone: $395; COMISA: $500; p< 0.001), while average adjusted inpatient costs (without sleep disorders: $168; insomnia alone: $267; OSA alone: $3; COMISA: $169; p< 0.001) were highest in the insomnia group. Conclusion Relative to military personnel without sleep disorders, with insomnia alone, or with OSA alone, individuals with COMISA incur greater inpatient, outpatient, and ED costs. Future research should examine the effect of sleep disorders treatments on health and economic burden as well as military readiness in the U.S. military. Support (if any) U.S. Department of Defense, Military Health System Research Program, HT94022210006.

BACKGROUND AND OBJECTIVES:Insomnia is highly prevalent among military personnel, with many gaps in knowledge. The purpose of this study was to quantify the medical, psychiatric, and utilization burden of insomnia among active-duty military personnel. We hypothesized that insomnia is associated with worsened health and economic outcomes. METHODS:This was a retrospective case-control study. Data were derived from the Military Data Repository (2016-2021). Active-duty service members (ADSMs) younger than 65 years, with 12 months of continuous enrollment before and after first insomnia diagnosis and no evidence of previous insomnia or insomnia treatment, were matched 1:1 on demographic, clinical, and military characteristics to ADSMs without insomnia. Insomnia and psychiatric and medical comorbidities were defined using International Classification of Diseases, 10th Revision diagnostic codes. The impact of newly diagnosed insomnia on psychiatric and medical outcomes within 12 months was examined using time-to-event models. The impact of newly diagnosed insomnia on 12-month health care resource utilization (HCRU) was examined using generalized linear models. RESULTS:A total of 40,978 ADSMs met insomnia criteria and were matched to 40,978 ADSMs without insomnia. Participants were 78.6% male and 61.8% identified as White, with most younger than 44 years (90.3%). Insomnia was associated with increased risk of almost every studied physical and psychological health outcomes; relative to those without insomnia, ADSMs with insomnia demonstrated a 6-fold increased risk of post-traumatic stress disorder (hazard ratio [HR] 6.51, 95% CI 5.95-7.12, p < 0.001), as well as elevated risk of traumatic brain injury (HR 5.32, 95% CI 4.53-6.24, p < 0.001). ADSMs with insomnia demonstrated greater all-cause HCRU across all points of service (all p's < 0.001). DISCUSSION:Among active-duty personnel, new-onset insomnia was associated with substantially increased risk of adverse medical and psychiatric burden, as well as increased utilization, over 12 months. Key limitations include our observational study design.

Background Despite the significant health and economic burden associated with OSA among civilians, little is known about this burden among active-duty military personnel. Research Question What is the health and utilization burden of OSA among active-duty service members in the United States? Study Design and Methods Data were derived from the Military Data Repository (2016-2021). Participants included active-duty service members aged < 65 years with 12 months of continuous enrollment prior to and following a new OSA diagnosis and no evidence of prior OSA or OSA treatment. They were matched 1:1 on demographic, clinical, and military characteristics to those without OSA. OSA and medical and psychiatric comorbidities were defined based on International Classification of Diseases, 10th Revision, codes. The impact of newly diagnosed OSA on psychiatric and medical outcomes was examined by using time-to-event models. The impact on 12-month health care resource utilization was examined by using generalized linear models. Results A total of 59,203 service members with OSA were matched to 59,203 service members without OSA. Participants were 83% male and 65% White, with most < 44 years old (81%). OSA was associated with an increased risk for all physical and psychological health outcomes; relative to those without OSA, service members with OSA exhibited a fourfold increased risk for posttraumatic stress disorder (hazard ratio, 4.41; 95% CI, 4.04-4.82). In terms of utilization, OSA was associated with an additional 170,511 outpatient, 66 inpatient, and 1,852 emergency department encounters per year. Interpretation Our findings show that among US active-duty military personnel, OSA is associated with substantially increased risk for adverse physical and psychological health outcomes, as well as utilization burden over 12 months. Screening, triage, and treatment efforts could have broad impact in this population.

Diagnoses of military-relevant sleep disorders have increased substantially since the terrorist attacks of September 11, 2001. The cause of this increase appears to be complicated and multifactorial, with military and civilian populations clearly differing with respect to both the nature and distribution of sleep disorders diagnoses. In part, these differences may be attributable to the fact that a majority of service members are chronically sleep-restricted-an unavoidable consequence of continuous and sustained military operations that "set the stage" for development of specific sleep disorders. The purpose of this narrative review is to describe the military relevance of several common sleep disorders, assess the extent to which these disorders currently constitute a burden on the military health care system, and suggest strategies to alleviate that burden. The military health care system does not have enough sleep medicine providers to address the immediate and long-term consequences of sleep disorders in military personnel. Digital technologies and education packages can be leveraged to improve access to care.

Abstract Introduction Sleep disorders such as insomnia and obstructive sleep apnea (OSA) are common and costly in the US Military Health System (MHS). Further, demand for sleep specialty care greatly exceeds available supply. Many MHS beneficiaries are referred off-base to the TRICARE network to access private sector care. The purpose of this study was to compare military, demographic, and clinical characteristics between MHS beneficiaries newly diagnosed with either insomnia or OSA on-base (direct care) and off-base (private sector care). Methods We identified MHS beneficiaries with a first diagnosis of insomnia or OSA between years 2016-2021 within the Military Data Repository (MDR). This large data repository includes encounter, procedure, medication, and durable medical equipment information for Active Duty personnel, dependents, National Guard, and Reserves. Demographic and military information was obtained from the MDR. Sleep disorders and medical and psychiatric comorbidities were defined based on ICD-10 diagnostic codes. Determination of direct vs private sector care was based on an indicator in the MDR. Results 235,823 MHS beneficiaries were diagnosed with either insomnia (n=143,877) or OSA (n=91,946). Of beneficiaries with insomnia, the majority (n=119,923, 83.4%) were diagnosed in direct care. Of beneficiaries with OSA, the majority (n=51,014, 55.5%) were diagnosed in private sector care. Between-groups differences (direct vs private sector care) were observed in service branch (standard mean difference [SMD]=0.46) and beneficiary category (i.e., Active Duty, dependent, National Guard, or Reserve; SMD=0.37), with most Active Duty (n=131,321, 81.6%) and dependent (n=26,987, 53.5%) beneficiaries being treated via direct care. No between-groups differences were observed in medical and psychiatric comorbidities. In terms of comorbid sleep disorders, of beneficiaries diagnosed with hypersomnia (n=12,403), the majority (n=10,055, 81.1%) were diagnosed in private sector care. Conclusion Differences in service branch and beneficiary category were observed between individuals diagnosed with insomnia or OSA in direct and private sector care. Insomnia was more likely to be diagnosed in direct care, and OSA was more likely to be diagnosed in private sector care. Future research should examine health and economic outcomes associated with direct and private sector sleep care and identify opportunities (e.g., telehealth) to bring sleep care back into the MHS. Support (if any) DoD HT94022210006.

Abstract Introduction Insomnia and obstructive sleep apnea (OSA) are the two most common sleep disorders seen in clinical practice. Comorbid insomnia and OSA (COMISA) is a very common clinical presentation. The purpose of this study was to estimate the effect of COMISA on sleep, daytime symptoms, and healthcare resource utilization compared to OSA or insomnia alone among military personnel. Methods Military personnel with sleep problems were recruited from two military treatment facilities. Insomnia and OSA were defined using validated cutoffs on the Insomnia Severity Index and Berlin Questionnaire, respectively, and COMISA was defined as comorbid insomnia and OSA. Subjective and objective sleep were measured via standardized sleep diaries and a commercial wearable (Fitbit Inspire 2) over ten days. Daytime symptoms (e.g., sleepiness, depression, anxiety, pain) were assessed using standardized self-report questionnaires. Subjective cognition was assessed via three Likert items. Healthcare resource utilization (HCRU) was assessed using an established questionnaire tailored for this study. To compare differences between COMISA, OSA, and insomnia groups, one-way ANOVA was performed. Results The final sample included 201 participants (n=113, 43.8[%] men, mean age=44.5 [SD=12.7]) who self-reported being of White (111, 55.2%), Black (50, 24.9%), Hispanic (21, 10.5%) or Other (19, 9.5%) race. Of these, 22 (10.9%) were categorized as insomnia alone, 98 (48.8%) as OSA alone, and 81(40.3%) as COMISA. Relative to individuals with OSA, individuals with COMISA demonstrated worse subjective (but not objective) sleep; worse subjective daytime symptoms; worse subjective memory, attention, and executive function; and increased healthcare utilization including total HCRU and outpatient visits to internal medicine, neurology, emergency department, and urgent care. Some but few significant differences were observed between participants with insomnia relative to those with COMISA. Conclusion Among military personnel with sleep problems and relative to OSA alone, COMISA was associated with worse subjective sleep, worse daytime symptoms, worse subjective cognition, and greater HCRU. Future research should seek to seek to improve health and economic outcomes among individuals with COMISA. Support (if any) DoD (W81XWH1990006 via the Medical Technology Enterprise Consortium)

This study employed remote monitoring/ecological momentary assessment methods to test the hypothesis that prior-night sleep is associated with next-day symptoms. Military personnel with sleep problems (N = 270) completed daily sleep diaries and twice-daily symptom surveys via smartphone and wore a commercial wearable for ten days. In lagged analyses controlling for age and sex, prior-night sleep was robustly associated with next-day symptoms. Findings support remote approaches to assess sleep and next-day symptoms.

BackgroundThere is a gross shortage of sleep specialist providers within the military health system. Telehealth and mobile health represent promising approaches to increase access to high quality, cost-effective care in the U.S military.ObjectivesThis paper reports findings from a mixed-methods clinical implementation study of a novel sleep telehealth platform at two military treatment facilities in the National Capitol Region. The platform includes a mobile app and integrated wearable sensors (i.e., a commercial off-the-shelf sleep tracker [Fitbit]). The primary purpose was to evaluate the implementation of a 10-day remote monitoring assessment and provision of evidence-based sleep treatment recommendations to patients and providers. In addition, we sought to observe, in an exploratory manner, subsequent engagement with the app during 5 days of personalized sleep education and training.MethodsPatients with sleep problems completed an intensive 10-day remote monitoring assessment that included a baseline intake questionnaire, daily sleep diaries, twice daily symptom surveys, and Fitbit. Based on this assessment, patients received personalized assessment results. Concurrently, a provider report was generated that included provisional diagnoses and evidence-based treatment recommendations. Next, participants gained access to personalized sleep education and trainings within the mobile app. Within an established implementation science framework, outcomes were assessed via behavioral adherence (engagement with the app) and separate questionnaires for patients and providers. Last, we conducted four focus groups with patients and 12 key informant interviews with primary care managers (PCMs) and economic stakeholders to seek feedback and recommendations for future directions.ResultsTwo hundred and seventy patients participated in the study. Using validated research questionnaires, participants reported high-risk for obstructive sleep apnea (65.6%), moderate to severe insomnia (38.2%), and moderate to severe daytime sleepiness (38.5%), and moderate to severe anxiety (14.1%) and depressive (20.4%) symptoms. Total sleep time was 6.6 (SD = 1.8) h based on sleep diaries and 6.1 (SD = 1.8) h based on Fitbit. Regarding implementation, reach, effectiveness, adoption, implementation, and maintenance were all notably high, based on quantitative and qualitative data from participants and PCMs.ConclusionsSleep telehealth and mobile health represent promising approaches to increase access to cost-effective, evidence-based care for sleep disorders in the U.S. military.

Background:Failure to effectively treat obstructive sleep apnea (OSA) and its symptoms is incompatible with military readiness. Continuous positive airway pressure (PAP) is the gold standard treatment for OSA, but it is impractical in austere environments. Another OSA treatment, hypoglossal nerve stimulation (HGNS), which is implanted, could have advantages for military patients but is unclear whether HGNS is efficacious. Methods:We conducted a review of randomized controlled trials and controlled trials published from 2013 to 2023. Primary outcome measures included the Apnea-Hypopnea Index and Epworth Sleepiness Scale. The quality of evidence was assessed using a rating of 1 to 5 based on a modification of the Oxford Centre for Evidence-based Medicine Levels of Evidence and Grades of Recommendation. Results:We identified 334 studies; 318 did not meet inclusion criteria. The remaining 16 articles were classified into 9 cohorts. Six articles were based on data from the STAR trial and 4 were based on data from a German postmarket long-term follow-up of upper airway stimulation for OSA efficacy. The remaining cohorts were smaller studies that examined moderate-to-severe OSA with nonadherence or failure, a randomized controlled crossover trial, and 1 direct comparator with PAP treatment. Conclusions:HGNS feasibility in military settings has not been adequately studied, considering the specific demands of operational settings and patient demographics. Understanding risks and benefits specific to military context will help guide practices and determine the suitability of HGNS for OSA in diverse military settings.

Free AccessCommentaryBreathing new life into PTSD-related sleep disorders! Connie L. Thomas, MD, Vincent F. Capaldi, MD, Jacob F. Collen, MD Connie L. Thomas, MD Address correspondence to: Connie L. Thomas, MD, 503 Robert Grant Ave, Silver Spring, MD 20910; Email: E-mail Address: [email protected] Walter Reed Army Institute of Research, Silver Spring, Maryland Walter Reed National Military Medical Center, Bethesda, Maryland Uniformed Services University, Bethesda, Maryland , Vincent F. Capaldi, MD Walter Reed Army Institute of Research, Silver Spring, Maryland Walter Reed National Military Medical Center, Bethesda, Maryland Uniformed Services University, Bethesda, Maryland , Jacob F. Collen, MD Walter Reed National Military Medical Center, Bethesda, Maryland Uniformed Services University, Bethesda, Maryland Published Online:March 1, 2024https://doi.org/10.5664/jcsm.11008SectionsEpubPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONThe concept of insomnia as merely a consequence of psychiatric disorders—once labeled "secondary insomnia"— is evolving.1 Current research suggests that sleep difficulties not only exacerbate but also precipitate mental health problems, including onset, maintenance, and relapse of such conditions.2 Premorbid disordered sleep increases the risk of mental health conditions.3,4 Furthermore, disordered sleep is a recognized diagnostic criterion for multiple mental health conditions,5 including, but not limited to, major depressive disorder, generalized anxiety disorder and, posttraumatic stress disorder (PTSD), hinting at the complex interaction between sleep physiology and psychiatric conditions. Focusing treatment efforts on sleep problems may also result in improved outcomes for mental health conditions,6 while failure to adequately treat insomnia as part of comprehensive mental health disorder treatment may contribute to resurgence of psychiatric symptoms.7,8In this issue of the Journal of Clinical Sleep Medicine, DeViva et al explore a distinct PTSD and clinical insomnia phenotype.9 Veterans with this phenotype exhibited heightened intrusions, avoidance, anxious arousal, and dysphoric arousal compared with those with PTSD alone. Even when sleep-related PTSD symptoms (sleep disturbance and nightmares) were excluded from analyses, intrusions and anxious arousal symptoms of PTSD were independently associated with the PTSD and clinical insomnia overlap phenotype. Symptoms of physiological reactivity to trauma cues and exaggerated startle response—both of which are arousal responses triggered by trauma-related stimuli—best differentiated probable PTSD and clinical insomnia from PTSD alone. Physiologic arousal is the key to this PTSD–clinical insomnia overlap phenotype.Evidence supporting a common origin for PTSD and insomnia is limited. Utilizing the UK Biobank genome-wide association study, Lind et al10 found significant, moderate genetic correlations between insomnia symptoms, extremes of sleep duration (both oversleeping and under-sleeping), and PTSD. In another study, Cox et al11 examined 242 twin pairs who endorsed a lifetime trauma exposure. They identified a significant association between insomnia symptoms and intrusions and insomnia symptoms and avoidance with 36–44% of phenotypic variance accounted for by genetic contributions.DeViva et al expands our understanding, delineating a PTSD-insomnia phenotype with its own unique burden of symptoms. Will interventions that target insomnia in this phenotype prevent PTSD in the setting of trauma exposure or reduce overall symptom burden if PTSD develops? Conversely, could interventions for PTSD enhance sleep quality, thereby aiding emotional regulation and memory processes essential for recovery?The next steps are still unclear. There are no current pharmacologic interventions following acute trauma exposure that may prevent or mitigate the symptoms of an acute stress reaction and/or PTSD,12 although some evidence suggests that treatment of sleep disturbances early may reduce the likelihood of adverse mental health outcomes following traumatic exposure.13 Existing pharmacologic treatments for PTSD alter sleep architecture and can contribute to sleep disturbance, and real-world outcomes have been mixed. Selective serotonin reuptake inhibitors (SSRIs) are currently the only Food and Drug Administration–approved treatments for daytime symptoms of PTSD,14 but can suppress rapid eye movement (REM) sleep and contribute to insomnia.15 Similarly, serotonin and norepinephrine reuptake inhibitors are also prescribed for PTSD and can cause sleep difficulties.16 Prazosin appeared promising for treating PTSD-related sleep issues,17 but subsequent studies have cast doubts.18 Benzodiazepines, although less frequently prescribed for sleep, are contraindicated in PTSD.19 Z-drugs have fewer adverse side effects and reduced abuse potential, without altering sleep architecture, but few studies have demonstrated that they improve sleep in PTSD.20–22 Dual orexin receptor antagonists, which may increase REM sleep,23 have shown some promise in improving both sleep and PTSD symptoms, but concerns about increasing nightmares and their off-label status warrant caution.24 Cognitive behavioral therapy for insomnia (CBTi) can be an effective alternative to pharmacotherapy, reducing sleep latency, wake after sleep onset, and sleep efficiency, while decreasing daytime PTSD symptom severity.25,26 However, logistics are problematic. CBTi is a resource-intensive therapy for providers and requires a significant commitment from patients who may struggle with avoidance and fear of sleep.None of the prior studies have differentiated between PTSD phenotypes, which may explain frustrating earlier outcomes. Would a PTSD and clinical insomnia phenotype respond more favorably to an intervention that targets physiological reactivity to trauma cues and exaggerated startle response?DeViva et al's findings enrich our understand of PTSD phenotypes and their importance for understanding etiological models of PTSD and insomnia and implications for the prevention and treatment of a complex mental health condition. This enthusiasm for detail is desperately needed for those afflicted with PTSD!DISCLOSURE STATEMENTThe material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the author, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense. The authors report no conflicts of interest.REFERENCES1. Stepanski EJ, Rybarczyk B. Emerging research on the treatment and etiology of secondary or comorbid insomnia. Sleep Med Rev. 2006;10(1):7–18. CrossrefGoogle Scholar2. Alvaro PK, Roberts RM, Harris JK. A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep. 2013;36(7):1059–1068. CrossrefGoogle Scholar3. Baglioni C, Battagliese G, Feige B, et al.. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135(1–3):10–19. CrossrefGoogle Scholar4. Gehrman P, Seelig AD, Jacobson IG, et al.. 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CrossrefGoogle Scholar Next article FiguresReferencesRelatedDetails Volume 20 • Issue 3 • March 1, 2024ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationDecember 28, 2023Accepted for publicationDecember 28, 2023Published onlineMarch 1, 2024 Information© 2024 American Academy of Sleep MedicinePDF download

BackgroundSleep problems are common and costly in the US military. Yet, within the military health system, there is a gross shortage of trained specialist providers to address sleep problems. As a result, demand for sleep medicine care far exceeds the available supply. Telehealth including telemedicine, mobile health, and wearables represents promising approaches to increase access to high-quality and cost-effective care. ObjectiveThe purpose of this study was to evaluate patient engagement and provider perceived effectiveness of a novel sleep telehealth platform and remote monitoring assessment in the US military. The platform includes a desktop web portal, native mobile app, and integrated wearable sensors (ie, a commercial off-the-shelf sleep tracker [Fitbit]). The goal of the remote monitoring assessment was to provide evidence-based sleep treatment recommendations to patients and providers. MethodsPatients with sleep problems were recruited from the Internal Medicine clinic at Walter Reed National Military Medical Center. Patients completed intensive remote monitoring assessments over 10 days (including a baseline intake questionnaire, daily sleep diaries, and 2 daily symptom surveys), and wore a Fitbit sleep tracker. Following the remote monitoring period, patients received assessment results and personalized sleep education in the mobile app. In parallel, 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. ResultsIn total, 35 patients with sleep problems participated in the study. There were no dropouts. Results indicated a high level of engagement with the sleep telehealth platform, with all participants having completed the baseline remote assessment, reviewed their personalized sleep assessment report, and completed the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Patients reported high levels of satisfaction with most aspects of the remote monitoring assessment. In total, 24 primary care providers also participated and completed the anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the US military health care system. ConclusionsMilitary patients with sleep problems and military primary care providers demonstrated high levels of engagement and satisfaction with a novel sleep telehealth platform and remote monitoring assessment. Sleep telehealth approaches represent a potential pathway to increase access to evidence-based sleep medicine care in the US military. Further evaluation is warranted.

Abstract Introduction The Psychomotor Vigilance Test (PVT), the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT) are widely used in both sleep research and clinical settings. The PVT measures reaction time to a visual stimulus, whereas time to sleep onset is measured in both the MSLT and MWT, which differ primarily with respect to the instructions (i.e., whether to try to fall asleep vs. stay awake). Compared to sleep latency tests, the PVT is relatively inexpensive and easy to administer, so it is advisable to delimit the conditions under which its administration is most appropriate. Methods A comprehensive search of sleep studies on healthy adults revealed 30 studies in which both PVTs and sleep latency tests were administered – usually to assess the effects of various interventions on sleepiness and vigilance. Two reviewers compiled findings from each study and graded the levels of outcome agreement based on whether a test intervention produced similar effects on vigilance across tests. Results Of the 13 studies that included both PVT and MWT of studies, a high level of agreement (based on the presence and direction significant effect on vigilance) between test outcomes was evident in 8 (61.5%) of the studies. In contrast, a considerably lower percentage of studies in which both the PVT and MSLT were performed (6 of 17 studies; 35.3%) had high agreement between test outcomes. It was also found that the MSLT was more sensitive to interventions (e.g., caffeine, sleep loss, and cognitive workload) than the PVT in the majority of studies in which there was low agreement (5 of 6 studies; 83.3%). Conclusion There is generally more agreement between PVT and MWT measures than between PVT and MSLT measures in studies involving sleep loss. This is most likely because the PVT and MWT both require application of effort to resist sleepiness, whereas the MSLT involves the withdrawal of resistance to sleepiness. This suggests that the PVT is potentially more useful in operational environments (where ability to sustain performance is the primary concern) than in clinical settings (where the focus is on determining the severity of sleepiness). Support (If Any) Department of Defense Military Operational Medicine Research Program (MOMRP)

The psychomotor vigilance test (PVT) is a widely-used, minimally invasive, inexpensive, portable, and easy to administer behavioral measure of vigilance that is sensitive to sleep loss. We conducted analyses to determine the relative sensitivity of the PVT vs. the multiple sleep latency test (MSLT) and the maintenance of wakefulness test (MWT) during acute total sleep deprivation (TSD) and multiple days of sleep restriction (SR) in studies of healthy adults. Twenty-four studies met the criteria for inclusion. Since sleepiness countermeasures were administered in some of these studies, the relative sensitivity of the three measures to these interventions was also assessed. The difference in weighted effect size (eta-squared) was computed for each pair of sleepiness measures based on available raw test data (such as average PVT reaction time). Analyses revealed that the sleep measures were differentially sensitive to various types of sleep loss over time, with MSLT and MWT more sensitive to TSD than the PVT. However, sensitivity to SR was comparable for all three measures. The PVT and MSLT were found to be differentially sensitive to the administration of sleepiness countermeasures (drugs, sleep loss, etc.), but PVT and MWT were found to be comparably sensitive to these interventions. These findings suggest the potential utility of the PVT as a component of next-generation fatigue risk management systems.