from titration to follow up: improving outcomes with ......airfit f20 airfit n20 *90 day trial...
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From Titration to Follow Up:
Improving Outcomes with
Bilevel Therapy
© 2017 ResMed I
• Changing trends in the industry – guest speaker Rita Brooks!
• Identifying which patients should be titrated on S/VAuto mode in the lab
• When to consider transitioning patients to a VAuto device during a follow-up
• Using AirView to access patient reports
• Documentation requirements
• Marketing materials
Agenda
2
© 2017 ResMed I
Changing Market Dynamics – Rita Brooks
3
Insurers Want More Cost Effective Care• Emphasis shifting from diagnosis to disease-management
• In lab PSG reserved for more complex patients
• Treatment modality has to be effective and tolerated
The sleep technologist role is expanding• Utilizing more complex therapies
• Providing patient education
• Assisting patients to be adherent with therapy
• Involvement in follow-up and outcomes management
© 2017 ResMed I
Changing Market Dynamics – Rita Brooks
4
Grow your potential
• Expand your horizons - our roles are expanding!
• Learn new technologies
– Understand their applications
– Know how they will improve patient comfort and care, and improve patient outcomes
– Utilize technology to monitor and assist your patients to succeed!
© 2017 ResMed I
Changing Market Dynamics – Rita Brooks
5
We can make a difference!
• Advance your knowledge of sleep technology
• Understand sleep/wake disorders
• Know the effects of associated co-morbid conditions (cardiac
disease, pulmonary disorders and diabetes)
• Use the most appropriate therapeutic modality
• Get the titration right!
• Assist patients to adhere to their therapy
• Monitor adherence and assure patient comfort!
• Make adjustments / suggest alternatives to maximize adherence!
• Continue to learn - stay abreast of technology changes!
From Titration to Follow Up:
Improving Outcomes with
Bilevel Therapy
© 2017 ResMed I
You spend a lot of time titrating patients on CPAP/APAP
7
© 2017 ResMed I
But studies show that many CPAP/APAP users
are non-compliant
8
1. Terri E. Weaver and Ronald R. Grunstein “Adherence to Continuous Positive Airway Pressure Therapy” Proc
Am Thorac Soc Vol 5. pp 173-178, 2008.
When adherence is defined as greater than 4 hours of nightly
use, 46-83%1of patients with obstructive sleep apnea
have been reported to be non-adherent to treatment.
© 2017 ResMed I
Why are they non-compliant?
9
69%
69%
68%
56%
50%
16%
15%
12%
4%
3%
3%
3%
10%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Uncomfortable
Don't like wearing a mask
Hard to get used to
CPAP disturbs my sleep
Inconvenient
Bed Partner does not like it
Difficult with my lifestyle
I travel a lot
Don’t need it every night
High Cost
Sinus/Allergy/Nasal issues
Efficacy/not working anymore
Other
We can help with the
comfort issue!
n=96
Weigelt et al. Sleep 2010 Poster
© 2017 ResMed I
This high non-compliance rate indicates that certain
patients should be on a bilevel device
10
© 2017 ResMed I
Bilevel device portfolio
11
AirCurve 10 S AirCurve 10 VAuto AirCurve 10 ST-A AirCurve 10 ASV
For non-compliant OSA patients,
consider the S or VAuto mode
during titration.
© 2017 ResMed I
CPAP S
APAP VAuto
Algorithm comparisons
12
© 2017 ResMed I
AHI (events/hr)
Baseline = 61.4 +/- 25.9*
CPAP = 30.4 +/- 16.1**
Auto Bilevel = 4.6 +/- 4.9**
AHI (events/hr)
Baseline = 69.1+/- 29.1*
CPAP = 14.9 +/- 9.1**
Auto Bilevel = 4.2 +/- 3.3**
Efficacy of Bilevel-Auto treatment in OSA patients who are
intolerant or not responsive to CPAP
13
• Not responsive to CPAP during a full night titration.
Group A
• Intolerant of therapy during a full night titration.
Group B
Results
Conclusion: CPAP titration significantly decreased AHI, but a further
significant reduction was obtained during Bilevel-Auto treatment in both groups.
J Clin Sleep Med 2015 Carlucci A et al. *=ns **= p<.0001
Main Headline Goes Here
© 2017 ResMed I
Identifying which patients should be titrated on
S/VAuto modes for greater comfort
14
© 2017 ResMed I
Signs to look for during sleep consultation
15
• Deviated septum
• Claustrophobia
• Allergies
• Asthma
• Failed CPAP in the past
• Tried CPAP therapy for three
months and failed, now needs a
new sleep test
© 2017 ResMed I
Signs to look out for during CPAP titration
16
Events persist at15 cm H2O
. 2 Women may need to be
switched to a lower
pressure due to their
increased pressure
sensitivity.
Patient
complains of
not being able
to exhale
despite EPR
feature. 1
Patient is not tolerating high
pressure settings1
• Arousals or micro arousals
• Can’t progress to REM sleep cycle
• Feels bloated or sensation of
swallowing air
1. Gay P et al. Sleep 20062. Kushida CA et al. J Clin Sleep Med 2008
© 2017 ResMed I
AASM titration guidelines for bilevel transition
17
Address mask and mouth leaks to confirm that they are not the reason the patient is uncomfortable.
The patient complains that he/she is uncomfortable or is intolerant of high CPAP pressures.
CPAP level is 15 cm H20 and respiratory disturbances continue.
AAST 2012
© 2017 ResMed I
A large hospital system in northern Kentucky
18
• Follow the AASM guidelines for
titrating and scripting bilevel.
• Mask leak is addressed
immediately.
• If the patient complains that the
pressure is too high, they can’t
exhale or they feel like they are
suffocating, immediately transition
to S/VAuto mode.
• If the patient is on or above a
pressure of 15cm H20, they are
transitioned to S/VAuto mode.
• Approximately 55% of patients are
scripted a VAuto or S bilevel device
from this location.
• Patient comfort comes first!
© 2017 ResMed I
Possible misconceptions about sleep bilevel devices
19
Misconception #1
Putting a patient on an Auto
device with comfort settings is as
effective as prescribing a VAuto
device.
Misconception #2
An S bilevel device provides the
same comfort level as a VAuto
device
© 2017 ResMed I
Difference between EPR and pressure support
20
© 2017 ResMed I
Evaluation of auto bilevel algorithm to treat pressure
intolerance in Obstructive Sleep Apnea
21
22 subjects with prior diagnosis of OSA who
failed CPAP due to pressure intolerance
slept on VAuto & S for 1 night each in the lab.
Starting mean AHI was 53.4 events/hr.
Results:
VAuto Mean AHI = 6.2
S Mean AHI = 8.3
Conclusion: Ratings for satisfaction with treatment, ease of
falling asleep, the ability to stay asleep, and how refreshed the
patient felt in the morning were all rated higher on the VAuto.
Sleep Breath 2011 Ball N et al.
Purpose: Evaluate auto bilevel mode (VAuto) against
standard bilevel mode (S).
Study Design:
•Prospective
•Randomized
•Double-blinded
•Cross-over
© 2014 ResMed I
Why bilevel therapy can be beneficial
22
Why?
• Greater comfort for the patient
• Auto-adjusting to deliver
efficacious therapy
• Higher pressure support (0-10)
• Includes both the VAuto & S
algorithms
AirCurve 10 VAuto is an auto-
adjusting bilevel that uses the
comfort of the AutoSet algorithm to
treat OSA patients who need greater
pressure support.
© 2017 ResMed I
Features and benefits of the AirCurve 10 VAuto
23
Integrated cellular
connectivity
Integrated
humidification
Advanced event
detectionTrigger and cycle
sensitivities
Remote assist
myAir
© 2017 ResMed I
When deciding to script an AirCurve VAuto…..
24
© 2016 ResMed - Company Confidential 2525
What about patients who are
set up on a CPAP/APAP
device, but are not tolerating
therapy?
Main Headline Goes Here
© 2017 ResMed I
Transitioning a pressure-intolerant
CPAP/APAP patient to a VAuto device during
follow-up
26
© 2017 ResMed I 27
WHEN?
Identify non-compliant patients when
they come in for their follow-up
appointment
HOW?
Determine the most comfortable
device for the patient
ACTION?
Document the reasons for the switch
and consider scripting a bilevel
device for the patient
Time to identify pressure-intolerant CPAP users
© 2017 ResMed I
WHEN?
28
Medicare Guidelines State:
Patient is required to have a follow-up with their
Physician between days 30-90
Do not need a new sleep test to switch a patient
from E0601 to E0740
Based on CMS guidelines. Before filing any claims, it is the provider’s sole responsibility to verify current requirements and policies with the payor.
© 2017 ResMed I
How do you view patient reports?
29 *Patient identity and data are fictional.
© 2017 ResMed I
Ways to identify potential VAuto patients
30
Low usage
Residual
events
occurring (AHI
continues to
be high)
Verbal
discomfort
Experiencing
headaches
© 2017 ResMed I
What documentation is required?
31
Physician needs to
document the
following in the
patient’s medical
records.
Pressure
*Ineffective is defined as documented failure to meet therapeutic goals using a HCPCS code E0601 device during the titration portion of a facility-based study or during home use
despite optimal therapy (i.e. proper mask selection and fitting and appropriate pressure settings).page 4
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/PAP_DocCvg_Factsheet_ICN905064.pdf
https://www.cgsmedicare.com/jc/pubs/news/2010/0810/cope12752.html
*
Disclaimer: This is general reimbursement information only. It is not legal advice, nor is it advice about how to code, complete or submit any particular claim for payment.
Although we supply this information to the best of our current knowledge, it is always the provider’s responsibility to determine and submit appropriate codes, charges, modifiers
and bills for the services that were rendered. This information is provided as is, and all coding and reimbursement information is subject to change without notice.
Mask
© 2017 ResMed I
Documentation through AirView reports
32
*The patient’s leak needs to be under
control: well below 24 l/min cap.
*Pressure settings and comfort
features may have been adjusted
*Low usage indicates that the patient
may be pressure-intolerant
© 2017 ResMed I
Scripting an AirCurve VAuto
33
AirFit N20AirFit F20
*90 day trial
restarts once
the new device
is dispensed
Disclaimer: This is general reimbursement information only. It is not legal advice, nor is it advice about how to code, complete or submit any particular claim for payment.
Although we supply this information to the best of our current knowledge, it is always the provider’s responsibility to determine and submit appropriate codes, charges, modifiers
and bills for the services that were rendered. This information is provided as is, and all coding and reimbursement information is subject to change without notice.
© 2017 ResMed I
Bilevel transition overview
34
1
Follow Up Visit:
Patient complains of
pressure intolerance
or you notice signs
of intolerance in
therapy report.
32
Document:
1. Mask leak is under
control
2. Comfort settings and
lower pressure setting
have failed to make
therapy tolerable or
effective.
Consider Scripting
the patient an
AirCurve VAuto device
for greater patient
comfort and send
transition
documentation to the
patient’s HME.
© 2017 ResMed I
Sleep Lab Bilevel Marketing Materials
35
AirCurve 10 Fact
Sheet 1017630AirView Stamp
1019835
Sleep Lab Titration
Guide 1013904NEW VERSION COMING
SOON!
Script Note Pad
(50 Sheets)
1015938
AirView Report Guide
1017594Air Solutions
Troubleshooting
Guide 1019624
N20 Fitting Template
1019537
F20 Fitting Template
1031823
© 2017 ResMed I
Reimbursement Marketing Materials
36
Reimbursement Fast
Facts CPAP and
Bilevel 1013493
Medicare Policy for
Treatment of OSA 1013248
Reimbursement support available:
Online: resmed.com/reimbursement
Hotline: 800-424-0737, ext. 2
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