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

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© 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

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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

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© 2017 ResMed I

Bilevel device portfolio

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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

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© 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

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© 2017 ResMed I

Signs to look for during sleep consultation

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• 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

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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

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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

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• 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

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© 2017 ResMed I

Evaluation of auto bilevel algorithm to treat pressure

intolerance in Obstructive Sleep Apnea

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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

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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

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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

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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

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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

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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

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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