App Helps Patients Answer ‘How Are You Sleeping?’

Among more than 5,100 people who have used Cleveland Clinic’s free mobile application to screen for sleep disorders, 43% were at risk for moderate to severe obstructive sleep apnea (OSA), 50% had moderate or severe insomnia symptoms, and 44% were at high risk for shift work disorder — a circadian rhythm condition that can affect people who work nontraditional hours.

These and other findings underscore the utility of a simple tool that uses validated self-screening questions and educates users about steps for sharing the information with a clinician.

Why is a sleep app needed?

An estimated 70 million Americans have sleep disorders, but most go undiagnosed, says Nancy Foldvary-Schaefer, DO, a specialist in Cleveland Clinic’s Sleep Disorders Center. Medical training for sleep disorders has historically been low, so sleep isn’t always top of mind for primary care providers who have to cover many topics during patient checkups.

“The latest statistics indicate that medical students get about an hour's worth of exposure to sleep medicine during their training,” says Foldvary-Schaefer. “Yet sleep medicine is a booming field. We know that sleep disorders and chronic sleep loss have numerous adverse health consequences. Sleep is foundational to health and wellness. Every cell in every organ of the body needs sleep for repair and restoration.”

Impetus for the app arose as a result of a collaboration between the health system’s Sleep Disorders Center and a donor who sought to promote awareness after her partner, who suffered from undiagnosed sleep apnea, died in his sleep. Originally piloted for the iPhone operating system, Sleep by Cleveland Clinic now is also available for Android devices.

How it works

To engage with the app, users click to a welcome screen, then follow prompts that explain why sleep is important and request demographic and medical information — age, race, sex, height and weight, activity levels, and work shift hours, as well as information about sleep habits and sleep disorders. Based on that information, the app assigns a Cleveland Clinic sleep apnea probability score, which has been validated by polysomnography (Katzan, 2016); an insomnia severity index score (Morin, 2011); and the shift work disorder (SWD) instrument (Barger, 2012).

Educational material also is available so users can read more about any of these issues and find out how to connect to a sleep disorders clinic near them. They are encouraged to discuss their results with their healthcare provider. Cleveland Clinic clinicians whose patients elected to send results to MyChart should be able to view them in the patient’s electronic medical record.

Sleep by Cleveland Clinic was launched in 2021. Used in conjunction with donor-supported CME activities for clinicians, the app aims not just to educate patients but to expand awareness among providers so that they may recognize risks and refer patients, when appropriate, for testing.

Data collection

App users are informed that their data may be used for research, but information collected is deidentified and not connected to medical records. The first wave of data showed relatively high numbers of users at risk for severe OSA and for shift work disorder.

“People who don't have any problem at all might not be interested in using the app,” says Dr. Foldvary-Schaer. “That's probably why we see such a high risk in some of these disorders."

Among unexpected results, she says, was that “67% of these people report sleeping the recommended number of hours that they're supposed to for their age, because we know that 40% of adult Americans don’t.”

The app uses multiple metrics to determine how much a person is sleeping. Questions include what hours the user sleeps on weekdays, on weekends or days off, and whether they nap. “We calculated total sleep based on work and non-work days and naps and provide an estimate of average sleep duration for the person's age,” she says. “So their risk assessment is based on more than a single number of hours of estimated sleep.”

While the assessments aren’t infallible — some who show high risk for OSA have tested normal or mildly abnormal in follow-up studies — the sleep apnea questionnaire, developed by Cleveland Clinic experts, performs better than other instruments in the field, says Dr. Foldvary-Schaefer. The most common apnea screening tool is the STOP-BANG, which assigns one point each to users if they snore, experience daytime tiredness, have been observed having apnea, have high blood pressure, have a body mass index (BMI) over 35, are age 50 or older, have a neck circumference over 16 inches, and are male gender. Scores range from zero to eight.

“The Cleveland Clinic Sleep Apnea Probability Score (SAPS) incorporates the same instruments, excluding neck circumference, because it doesn't add value beyond BMI,” says Dr. Foldvary-Schaefer. “A regression model generates a probability score based on your age, BMI and gender in addition to the responses to the sleep questions. The probability ranges from zero to 100. So we're able to provide a likelihood of having sleep apnea instead of saying ‘high risk.’ It's more refined estimate that has been validated against polysomnography.”

For clinicians

The benefit of the more nuanced probability score can be considered on an individual basis, adds Dr. Foldvary-Schaefer.

“If a person has a probability of only 20% of having significant sleep apnea, that doesn't sound like a lot. But if that patient has heart failure, 20% might be enough to order a sleep test,” she says. “So the provider may consider that probability in the context of comorbidities and sleep apnea symptom severity. It can help them decide whether that patient needs testing.

"Similarly, you can have a young person who has 50% probability because they've got a very high BMI and maybe they snore," she adds. "But in the absence of other comorbidities, the decision to proceed or not with testing rests more on what the person has to gain or lose by getting a diagnosis and on the patient's preference.”

Researchers may consider other uses for the app, such as in screening for clinical trials.

“This could be used in many different capacities, but it was really intended to offer access to adults interested in screening themselves for sleep disorder risk,” says Dr. Foldvary-Schaefer. “Despite how common these disorders are, and how much we talk about them, probably 90% of people in the U.S. with OSA don't know they have it. So there's still a lot of work to do, given the enumerable medical and psychosocial consequences of untreated sleep disorders.”