optimizing treatment and compliance in the osa patient the ......optimizing treatment and compliance...

Optimizing Treatment and Compliance in the OSA Patient – The Mask is the Key”

Emerson Kerr RRT, RPSGT

Objectives

• Recognize how patient-driven design can lead to compliance

• Recognize how the technical features of a mask can lead to compliance

• Describe the importance of adherence to therapy

Sympathetic Activation

Wakefulness

Sleep

Arousal & Hyperventilation

O2 & CO2

Sympathetic Activation

Airway Patency Compensation

Airway Collapse

Decreased

Compensation

O2 & CO2

Increased RR

Increased mental

activity

Increased BP

Increased HR

Increased release

of glucose

What if your PCA pump had epinephrine instead of morphine or fentanyl?

“The pattern of adherence is established early, within the first week of treatment, and predicts long-term use.”

Terri E. Weaver and Ronald R. Grunstein "Adherence to Continuous Positive Airway Pressure Therapy", Proceedings of the American Thoracic Society, Vol. 5, No. 2 (2008), pp. 173-178

Medical definition of adherence (compliance)

Adherence

• Degree to which a patient follows medical advice

• Usually refers to medication compliance

• Can also refer to the use of:

• Medical appliances

• Advice on lifestyle management

• Attending counseling

6

Nonadherence to long-term therapies

• Noncompliance compromises treatment outcomes1 • Decreases quality of life

• Increases financial burden on society

• Patient nonadherence studies • 90% do not follow physician’s orders2

• 33 – 50% with chronic illness do not take prescribed medications

• 70 – 80% will comply to lifestyle change3

7

1. FirstWord Intelligence Report, Digital Technologies to Boost Patient Compliance, September 2010

2. Moriskey, Donald E. Adherence or Compliance Behavior, eNotes.com,

3. Jin et al, Factors Affecting Therapeutic Compliance: A Review from the Patient’s Perspective, Therapeutic Clinical Risk Management, February 2008

Improving peoples lives through

meaningful innovation...

A mask is more than just an interface between your patient and their device, it has the power to engage and motivate them on their journey to a healthy lifestyle.

Putting the patient first Building a successful mask starts with understanding the pain points of your patients:

• ease-of-use • noise • excessive leaks • cumbersome equipment • pressure intolerance • discomfort • red marks on the face

The Hospital Experience

Mask rotation

11

Schallom M, Cracchiolo L, Falker A. Pressure ulcer incidence in patients wearing nasal-oral versus full-face noninvasive ventilation masks. American Journal of Critical Care Medicine. 2015;24(4):349-356.

• Decreases skin breakdown by varying the pressure points on the skin.

12

CPAP therapy adherence

How is OSA treatment adherence defined? • > 4 hours of use, >70% of time1

• Based on this definition, Kribbs et al, described that 54% could be inconsistent users1

• Despite comfort changes in therapy, adherence has not increased through the years with only 46% using their devices3

• Patient adherence to therapy is not ideal but similar to maintenance medications2

1 Kribbs, et al., Objective Measurement of Patterns of Nasal CPAP Use by Patients with OSA. American Review of Respiratory Disease 1993:147 No. 4

2.Weaver, et al., Night-to-Night Variability in CPAP Use Over the First Three Months of Treatment. Sleep 1993:20(4):278-283

3.Wolkove, N.et al, Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea, Can Respir J Vol 15 No 7 October 2008

Higher CPAP usage associated with lower symptoms, improved daytime functioning and quality of life

Weaver TE, Maislin G, Dinges DF, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep 2007;30:711-719. Stradling and Davies, Sleep, 2000

Why > 4 hours of use?

ESS = Epworth Sleepiness scale

Epworth Sleepiness Scale (ESS), Multiple Sleep Latency Test (MSLT), and Functional Outcomes of Sleep Questionnaire (FOSQ).

Poor CPAP adherence -Patients at risk

• Unrelated to adherence • Disease severity • Age • Prescribed PAP pressures

• Claustrophobia has been consistently predictive of poor adherence1

• Adults with reduced nasal cross-sectional area

• Persons expressing low belief in ability to use CPAP and/or unable to identify reasons for using CPAP or outcome expectation

• Persons who experience difficulties with CPAP at initial exposure or have a negative experience with CPAP during early home treatment period2

.

1.Aloia, M.S. et al, Predicting Treatment Adherence in Obstructive Sleep Apnea Using Principles of Behavior, J Clin Sleep Med 2005 2. Sawyer AM et al, A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2011 Dec;15(6):343-56.

Criteria when selecting a patient interface

Patient morphology

Patient medical

condition and pathology

Patient personal

preferences

Patient psychosocial

issues

Pillow mask

+ Minimal contact and Lightweight

- Nostril discomfort

- Pressure restrictions

- Tubing torque

Traditional nasal mask

+ Seal and Stability

- Large footprint

- Claustrophobia

- Nasal bridge discomfort and/or Red marks

Patient’s emotional & clinical challenges

The right mask is crucial to PAP success

• The selection of the appropriate patient interface is a major factor in PAP therapy success1,2

• The selection of the appropriate patient interface in the early stages of therapy can result in long-term adherence1

• A mask or interface that fits properly and meets the needs of the patient is an important consideration when discussing CPAP adherence.

1. Massie & Hart CHEST 2003; 123:1112–1118, 2.Antonelli M et al. Eur Respir J (Suppl) 2003; 42:65S-71S

Interface needs

• Patients want • Comfort • Stability • Appeal • Simplicity

• Prevent red marks, discomfort or irritation in the nostrils or on the nose bridge2

• Allow wide field of vision to wear glasses, read or watch TV

1.2015 User Preference Questionnaire, data on file.; 2.Mask does not directly contact the bridge of the nose or nostrils.

Probing questions… • Toss and turn during the night? • Like to read or watch TV before falling asleep? • Sleep on your stomach? • Wear a traditional nasal mask because your CPAP pressure is too high for a pillows mask? • Wear a pillows mask because you don’t like anything on your nose? • Not want to scare your kids or pets when you have your CPAP mask on? • Want to kiss your wife goodnight like you used to before CPAP?

7 July 9, 2014 PI Confidential

- Pressure Restrictions - Nostril Discomfort - Jetting - Tubing Torque

+ Minimal Size + Lightweight

- Nasal Bridge Discomfort / Red Marks - Larger Footprint - Intimidation Factor

+ Seal/Stability + Comfort

Traditional Pillows Mask

Traditional Nasal Mask

Strategic Intent Resolving the Tradeoff

• The most common mistake is overtightening the headgear. The headgear should fit loose and comfortable.

• Skin bulges around the mask or red marks on your face: loosen the headgear.

• Straps on the ears: adjust the crown headgear strap

• Leaks around the nose: adjust the top and/or crown straps

• Leaks at the sides of the mouth: adjust the bottom headgear straps

• Reseating: slowly pull mask away with both hands and then reseal oral piece just before nasal piece and it will auto seal. Demo to clinicians – seeing is believing.

• Under the nose irritation: may occur but should resolve within one to two days. Explain that this is a bit similar to a new pair of shoes and you will quickly get used to it.

• “Air grazing”: working on solution, try crown strap

Troubleshooting

Review Again…Medical definition of adherence (compliance)

Adherence

• Degree to which a patient follows medical advice

• Usually refers to medication compliance

• Can also refer to the use of:

• Medical appliances

• Advice on lifestyle management

• Attending counseling

22

The digital age has changed the way we live, communicate and conduct business


2. Dolan, Brian, Survey:45 percent of doctors have iPADs, Mobihealthnews.com, April 2012

• 70% of Americans play online computer or video games

• 33% of Americans use social media and online sites to research health issues

• 40% of physicians believe that mobile health technologies

• 88% of physicians support patients monitoring their own health at home

• 74% of physicians already own a tablet or Smartphone1,2

23

Patient involvement • Physicians effectively

communicate with patients through mobile technology

• Reminding patients to go for tests

• Reminding patients of appointments

• Collection/transmission of data from home care clinician1

> Via tablet

> Via Smartphone


24

Patient involvement • Internet-based social networks • 36% value other consumer’s

knowledge prior to making healthcare decisions

• Social networks can: • Enable communication and

collaborations

• Maintain the flow of information in the healthcare space

• Increase compliance to therapies > Environment to offer support and

encouragement


25

CPAP therapy adherence • How is OSA treatment

adherence defined?

• > 4 hours of use, >70% of time (Kribbs1)

• Studies show patient adherence to therapy is not ideal but similar to maintenance medications2

• Kribbs found that 54% could be inconsistent users1

1 Kribbs, et al., Objective Measurement of Patterns of Nasal CPAP Use by Patients with OSA. American Review of Respiratory Disease 1997:147 No. 4

2 Weaver, et al., Night-to-Night Variability in CPAP Use Over the First Three Months of Treatment. Sleep 1993:20(4):278-283

Compliance Meter

26

Medicare’s definition of compliance:

Adherence to therapy is defined as use of PAP ≥ 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.*

* Reference LCD for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L11528)

27

Medicare compliance physician follow-up

• Continued coverage of a PAP device (CPAP or BiPAP) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating physician must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy.

• Documentation of clinical benefit is demonstrated by:

1. Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,

2. Objective evidence of adherence to use of the PAP device, reviewed by the treating physician.*

* Reference LCD for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L11528)

28

• Aggravates:

• High blood pressure

• Heart disease

• Blood sugar problems

• Significantly increases risk of stroke

OSA

Diabetes

Cardiovascular Disease

Atrial Fibrillation HTN

Stroke

Hui et al, Prevalence of Sleep Disordered Breathing and Continuous Positive airway Pressure Compliance, Chest, Sept 2002.

29

Consequences of non-adherence to CPAP therapy for the OSA patient

CPAP non-adherence •Hindrance to CPAP

compliance

• Poor patient education

• Poor understanding of the disease management process

• Supportive interventions enhance the use of CPAP therapy by 0.59 hours/night1

1. Donepudi et al., Touch Point Care and Advanced Monitoring Technologies Improves Compliance Rate of CPAP Usage, Abstract 1300, APSS 2012.

30

Mobile applications for compliance • Power of the mobile

application in healthcare • Not only reminder tools • Increase communication • Increase education

• Centered around disease management • Medication tracking • Drug recalls • Healthcare costs • Record management


31

Compliance and technology

• Touch point care and advanced monitoring technologies

• 626 patients using Medicare compliance criteria

• 88.5% compliance rate


Conclusion… “Engaging patients in their own disease management process and utilizing the newest technologies to monitor therapy greatly improves CPAP adherence”

32

Compliance rate study

Self-management systems Value to the clinician and the patient

• Reinforces PAP usage with immediate feedback

• Develops PAP usage goals

• Answers questions/troubleshooting

• Coaches for therapy guidance

• Motivates enhancement therapy

• Offers positive reinforcement

• Supports community

• Offers reminders

33

Thank You

optimizing treatment and compliance in the osa patient the ......optimizing treatment and compliance...

Documents