Establishing a Successful CPAP Compliance Program Presenter: Christina Olszewski

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Establishing a Successful CPAP Compliance
ProgramPresenter Christina Olszewski
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To achieve the impossible dream, try going to
sleep. Joan Klemper
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CPAP Compliance

• Internationally 5-50 of OSA reject CPAPs
  treatment option or discontinue use within the
  first week 1
• 12 to 25 of the remaining patients may be
  expected to have discontinued it use at 3 years
  1

• Englemen HM. Sleep Med Reviews. 2003 7,81-99

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CPAP Compliance, cont.

• When adherence is defined as gt 4 hours of nightly
  use, 46 to 83 of OSA patients have been
  reported to be non-adherent to treatment 2

• Weaver TE. Proc Am Thorac Soc. 2008 5,173-178.

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CPAP Compliance, cont.

• CMS defines adherence to therapy as use of CPAP
  for gt 4 hrs/night on 70 of nights during a
  consecutive 30 day period
• Objective evidence of adherence to the use of
  CPAP after 90 days

Source http//www.cms.hhs.gov/mcd/viewlcd.asp?lcd
id171lcd_version55showall
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CPAP Compliance Outcomes

• Improves health outcomes
• Improves QoL indicators
• Reduces healthcare utilization
• Has a positive impact on chronic conditions such
  as CHF, COPD or hypertension

Source Iioberes P. Chest. 2004126, 1241-1247
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Barriers to CPAP Compliance
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Equipment Related Barriers

• Complexity of therapy/device
• Improper mask fit
• Excessive mask leak
• Device noise
• Portability/Battery backup
• Hose length

Source Weaver TE. Proc Am Thorac Soc. 2008
5,173-178 Smith, C. Heart Lung, J Acute and
Crit Care,1998 27(2)99-108
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Therapy Related Barriers

• Adverse reactions that go unaddressed
• Nasal dryness or dry eyes
• Nasal congestion
• Skin irritation
• Bloody nose
• Expense of therapy
• Compliance decreases over time

Source PJ. Clin Chest Med 19981955 Smith, C.
Heart Lung, J Acute and Crit Care,1998
27(2)99-108
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Patient Related Barriers

• Health literacy
• Ambivalence
• Lack of family or other social support
• Patient economics
• Lack of reimbursement

Source Weaver, T. Sleep. 2003 26,727- 732
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Patient Related Barriers, cont.

• Psychological variables - claustrophobia
• Physical limitations
• Less severe factors/Little or no perceived
  benefit from therapy
• Use of prescription/non-prescriptions drugs or
  alcohol

Source HoyCJ. Am J Resp Crit Care Med, 1999159,
1096-1100
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Clinician Related Barriers

• Poor patient relationship
• Lack of clinician follow-up
• Expression of doubt concerning
  therapeutic potential or creating falsely
  elevated expectations

Source Weaver, T. Sleep. 2003 26,727- 732 Hui
DSC.Chest, 2000 117,1410-1416.
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Clinician Related Barriers, cont.

• Unwillingness to educate patient
• Lack of knowledge on patients medical history,
  and other medication a the patient may be
  taking

Source Weaver, T. Sleep. 2003 26,727- 732 Hui
DSC.Chest, 2000 117,1410-1416.
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Intervention
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Equipment/Therapy Interventions

• Heated humidification to relieve nasal dryness,
  running nose, nose bleeds
• Nasal spray
• CPAP modalities auto-titrating or bilevel
• Refit interface
• Change mask type

Source Weaver TE. Proc Am Thorac Soc. 2008
5,173-178.
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Equipment/Therapy Interventions, cont.

• Comfort features
• Lightweight
• Ramp
• Smaller footprint
• Quieter blower
• Battery backup
• Expiratory pressure relief

Source Weaver TE. Proc Am Thorac Soc. 2008
5,173-178.
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Patient/Clinician Intervention

• Family/social support
• Bed partners acceptance
• Suitable education and training on equipment
• Literacy
• Language

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Patient/Clinician Intervention, cont.

• Cognitive behavioral therapy, motivational
  enhancement therapy
• Rapid response to difficulties

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Long Term CPAP Compliance
A CPAP program consisting of consistent
follow-up, troubleshooting, and regular feedback
to both patients and physicians can achieve CPAP
compliance rates ofgt 85 over 6 months

• Source Sin DD. CHEST 2002 121430435

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Therapist-Driven Compliance Program
Respiratory therapy-driven PAP compliance program
results in a high compliance rate with emphasis
being on early and consistent follow-up
Source Basile J. www.rcjournal.com/abstracts/2004
/?idOF-04-08020Basile
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Compliance Program Options

• Homecare/DME therapist-driven programs
• Physician/Sleep Lab follow-up programs
• Support meetings
• AWAKE meetings, CPAP clinics
• Internet programs
• Outsource, to a company specializing in CPAP
  follow-up

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Reduce Payer Expense

• Reduce claims associated to patients diagnosed
  with OSA by 50 (1)
• Reduce cost associated with the management and
  treatment of OSA co-morbidities by 50(1)

• Richard RF. RT for Decision Makers in Resp Care.
  Jun 200664

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Reduce Payer Expense

• Studies also show that patients having OSA
  typically go undiagnosed for up to 10 years with
  steadily increased use of healthcare resources
  (2)
• Co-morbidities associated with OSA(2)
• Diabetes
• High Blood Pressure or Hypertension (HTN)
• Heart Disease

• Pagel JF. J Am B Fam Med, 200720(4)392-398

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Effectiveness of PAP Therapy

• A meta-analysis of applicable studies
  demonstrated that consistent evidence exists
  showing that treatment of OSA with continuous
  positive airway pressure (CPAP) therapy leads to
  significant improvement in daytime sleepiness and
  quality of life measures as well as reduced
  diastolic and systolic blood pressure.

Source Pagel JF. J AM Board Fam Med.
200720(4)392-398
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Effectiveness of PAP Therapy, cont.

• In OSA patients, there is reduced hospitalization
  with cardiovascular and pulmonary disease in OSA
  patients on nasal CPAP treatment.

CPAP Users Non-Users
Hospital Days 2 Years Prior 413 days 54 days
Hospital days 2 Years Post 137 days 188 days
Source Pagel JF. J AM Board Fam Med.
200720(4)392-398
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Compliance Program

• Improve patients success PAP therapy
• Maintain customer loyalty
• Establish future supply revenue
• Create future referral business/relationshipswith
  sleep labs and physicians

Source Kribbs NB. Am Rev Respir Dis.
1993,147(4)887-95
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Compliance Program Example
5-7 day Benchmarking data established and profile built. Initial concerns identified.
30 day Sleepiness Witnessed Apnea Monitoring , Weight and BMI Assessment, continued education and concerns identified
60 day Sleepiness Witnessed Apnea Monitoring , Weight and BMI Assessment, continued education
90 day Sleepiness Witnessed Apnea Monitoring , Weight and BMI Assessment, continued education
180 day Sleepiness Witnessed Apnea Monitoring , Weight and BMI Assessment, continued education
270 day Sleepiness Witnessed Apnea Monitoring , Weight and BMI Assessment, continued education
360 day Sleepiness Witnessed Apnea Monitoring , Weight and BMI Assessment, continued education
Note The information is provided solely for
illustrative purposes and is not intended as a
suggestion for implementation.
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Compliance Program, cont

• Why this ProtocolCritical 1st Days
• Failure to comply with treatment has been
  reported to be as high as 50, with patients
  typically abandoning therapy during the first 2
  to 4 weeks of treatment. -- Zozula R, Rosen
  R.

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Compliance Program

• In the study, 39 of the initial patients were
  still using CPAP after 1 year. Those patients
  who manifested good compliance during the first
  week of treatment continued using CPAP for the
  entire first year. Hours of use the first week
  was correlated to hours of use the first year.
  -- Leon Rosenthal, et al.

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Compliance Program

• Patient education, close follow-up and
  intervention appear to improve long-term
  tolerance. -- Anstead M, Phillips B, Buch K

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Empathy - Understanding with Compassion

• You are not alone
• The patients personal sleep care advisor
  understands the drastic lifestyle change they
  will endure.
• Many patients have faced and overcome the same
  challenges
• Help them locate online resources and local AWAKE
  meetings

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Education

• Disease state
• What is their diagnosis
• How severe is their OSA
• How will it impact their lives
• What are the potential co-morbidities
• What should they expect

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Education, cont.

• Equipment
• How it works
• How to inspect and replace when required
• What support is available to ensure the patients
  success in therapy.

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Empowerment Patients need to take part in
Therapy

• Make it important to the patient
• It is not about just being sleepy
• One can not just caffeine way through it
• They control their own success
• Provide the tools they need to be successful

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Coaching

• Personal relationship
• Help the patient by being consistent with your
  interaction
• Ability to maintain and manage inbound patient
  questions and concerns
• Provides goals and resolutions to patients
  ongoing challenges with PAP Therapy

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Promoting Positive Business

• Establish solid patient loyalty
• Provide clinical efficiencies
• Create future referral business/relationshipswith
  sleep labs and physicians

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Critical Period

• The first week of CPAP use has been identified as
  critical period for long term adherence.
• Create a compliance program that helps guide and
  support a patient through this period.

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The Patient Experience
Reassured Experienced Competent Comfortable Em
powered Relieved Calm
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References

1. CMS CPAP Policy. http//www.cms.hhs.gov/mcd/viewlc
   d.asp?lcd_id171lcd_version55showall
2. Englemen HM. Improving CPAP use Patient with the
   sleep apnea/hypopnea syndrome. Sleep Med
   Reviews.20037,81-99.
3. Ioberes P. Predictive Factors of Quality-of-Life
   Improvement and Continuous Positive Airway
   Pressure Use in Patients With Sleep
   Apnea-Hypopnea Syndrome. Chest.
   20041261241-1247.
4. Weaver T. Self-efficacy in sleep apnea. Sleep.
   200326,727-732.
5. McArdle N. Long term use of CPAP therapy for
   sleep apnea/hypopnea syndrome. Am J Resp Med.
   1999 159,1108-1114.
6. Sin DD. Long-term Compliance Rates to Continuous
   Positive Airway Pressure in Obstructive Sleep
   Apnea. CHEST. 2002121430435.
7. Aloia MS. Treatment Adherence and Outcomes in
   Flexible vs Standard Continuous Positive Airway
   Pressure Therapy . Behavioral Sleep Med.
   20075,89-104

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References

• Weaver TE. Adherence to Continuous Positive
  Airway Pressure Therapy. Proc Am Thorac Soc.
  20085, 173-178.
• Basile J. Respiratory therapist-driven compliance
  program for initiation and delivery of positive
  airway pressure therapy. www.rcjournal.com/abstrac
  ts/2004/?idOF-04-08020Basile
• Ebell MH, et al. Strength of recommendation
  taxonomy (SORT) a patient-centered approach to
  grading evidence in the medical literature. Am
  Fam Physician. 2004 69 549-57.
• Kapur V, Blough DK, Sandblom RE, et al. The
  medical cost of undiagnosed sleep apnea. Sleep
  1999 22 Suppl 6 749.
• Banno K, et al. Healthcare utilization in women
  with obstructive sleep apnea syndrome two years
  after diagnosis and treatment. Sleep 2006
  29(10) 1307
• Giles T, et al. Continuous positive airways
  pressure for obstructive sleep apnoea in adults.
  Cochrane Database Syst Rev 2006(1) CD001106
• Kribbs NB et al. Objective Measurement of
  Patterns of Nasal CPAP Use by Patients with
  Obstructive Sleep Apnea. Am Rev Respir Dis.
  1993,147(4)887-95

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References

• Albarrak M, et al. Utilization of healthcare
  resources in obstructive sleep apnea syndrome a
  5 year follow-up study in men using C-pap. Sleep
  200528(10) 1306-11.
• Hands G. CPAP for OSA is cost effective. Thorax
  2006 61999.
• Richard RF. The Economics of Sleep-Disordered
  Breathing. RT for Decision Makers in Resp Care.
  Jun 200664
• Pagel JF. Obstructive Sleep Apnea in Primacy
  Care Evidence-based Practice. J AM Board Fam
  Med. 200720(4)392-398
• Smith, C. CPAP Patients and caregivers learning
  needs and barriers to use. Heart Lung, J Acute
  and Critical Care, 119827(2)99-108.
• Hui DSC. Effects of augmented CPAP education and
  support on compliance and outcome on a Chinese
  population. Chest, 2000 117,1410-1416.