Ramping Up for the Future of Sleep Emerging Trends Focus on Diagnosis to Treatment Models

• Mar 01, 2007

By Ron F. Richard, Senior VP of Strategic Marketing Initiatives, ResMed Corp.; Rebecca Olson, RRT, Clinical and Sales Manager, Oxygen One; and Jill Spellman, RRT, RCP, President, Oxygen One

Recently the industry reached a CPAP milestone. In 2006, CPAP celebrated its 25th anniversary as an approved treatment for obstructive sleep apnea. It’s hard to believe that CPAP has been around this long, and how much the devices and masks have changed.

The pioneer, often referred to as the founder of CPAP, Dr. Colin Sullivan, used off-the-shelf parts such as pool pumps and anesthesia masks literally glued to the patients’ faces to generate positive pressure to offset the symptoms of loud snoring and sleep suffocation syndrome.

After 25 years on the market, CPAP is recognized as the gold standard for treating sleep-disordered breathing conditions. But even after all these years, and despite the estimated 4 million patients receiving treatment, the industry still struggles with the classification of the condition. Some still debate that sleep-disordered breathing (SDB) is an acute condition and is curable. Others recognize that patients use CPAP for years, and the nature of the condition would convince them that it is a chronic and perhaps lifelong treatment.

As the sleep market matures, a positive step for the industry would be to finally agree and publicly recognize that sleep apnea is a chronic condition that warrants changes in the following areas.

Education
Patients need to be aware of the issues related to the condition, such as links of untreated SDB to cardiovascular disease, stroke, diabetes and occupational accidents and decreased productivity, that will affect their quality of life. Much like other chronic conditions such as diabetes, the industry should establish “sleep educators” who specialize in the longitudinal support of sleep disorder patients in the area of mask fitting, humidification, complex sleep apnea, diet and exercise.

Reimbursement
Payors are working closely with self-insured groups to gain insight as to what programs are working and how to motivate employees to get treatment for chronic conditions as it improves productivity and decreases expenses directly related to untreated SDB. Payors are beginning to gather data on various models being used to effectively diagnose and treat SDB. This information may lead to higher use of portable diagnostics and sleep screening as well as unattended titration as a means of controlling costs while offering clinically relevant solutions.

In a recent report, the following information was made available to the industry from Health and Human Services:
With the increased use in sleep, one can guess that the scrutiny being placed on this sector by the Centers for Medicare & Medicaid Services (CMS) and private payors will only increase. The best advice for sleep providers is to collect data from patients that document improvements in outcomes, highlight patient satisfaction and the services provided apart from the equipment, and present this to payors when renewing or bidding on contracts.

Continuity of Care
Many HMEs and sleep centers are developing follow-up programs for their patients who are being treated for a variety of sleep conditions. Asking subjective information regarding response to treatment, side effects from treatment, and addressing subjectively reported compliance issues gives providers insight into patient attitudes and motivations.

Contacting the patient within a couple of days from the start of therapy and continuing every two weeks as necessary allows for early intervention if patient issues arise. Developing a CPAP management program with the patient, setting goals for therapy and educating on health care repercussions of noncompliance or nontreatment allows the patients to make educated and informed decisions about their care. In addition, the use of a mask-fit guarantee program, supply reminders, mask-fit features, daily diaries and quarterly newsletters let companies willing to take advantage of them provide a service above what is expected to a patient population that appreciates the support and effort.

Compliance Monitoring
In light of increased scrutiny in reimbursement, increased business competition and the increasing trend of patient follow-up programs, HMEs and sleep centers have a strong incentive to provide and gather objective data to prove the efficacy of treatment and patients’ adherences to treatment. The old paradigm of simply calling a patient and asking questions is no longer an option to ensure quality and safe treatment for SDB.

Furthermore, patients notoriously overstate how many hours per night and how many nights per week they are using CPAP. This may or may not be intentional, but patients who do not use CPAP every night for a regular number of hours typically do not know how to answer questions regarding compliance. The use of CPAP devices that give compliance data has shown a way of comparing objective compliance with subjective beliefs.

Verifying the hours run and asking subjective questions is the easiest part of managing a CPAP patient’s treatment program. Providing a quality CPAP management program takes more work, time and clinical expertise. CPAP units in which mask fit and efficacy are not measured and observed only provide pressure with the impression of treatment. CPAP is useless if it is not clinically proved to work.

Some companies use the downloading features on CPAP systems to verify efficacy after therapy begins (usually after 30 days), to confirm the need for an adjustment in pressure (through a trial of auto-PAP), to determine when the patient’s current form of therapy needs to be reassessed, and to assist the physician in deciding if a repeat polysomnography is necessary. To accurately interpret these downloads and confidently determine how to proceed in a patient’s care, this takes a dedicated team of clinical specialists who have a true passion for SDB patients.

Downloaded objective data combined with subjective information regarding patient comfort and attitude afford CPAP management programs the opportunity to verify, confirm and continue compliance through continued patient support, education and clinical proof of efficacy. Being able to substantiate the efficacy of treatment with clinical evidence can provide HMEs and sleep centers a competitive advantage against other companies by distinguishing them as a provider of quality care. This can also serve to protect reimbursement now and in the future.

The Next Five Years
Based on feedback from leading industry resources, the sleep market will consistently grow from between 17 and 20 percent over the next three to five years. Moderate increases were also noted in terms of adding additional sleep beds over the next 24 months to accommodate the rise in sleep studies. Expect a leveling off as the market adjusts to changes in reimbursement and the shift to portable monitoring and unattended home-based titration models.

This trend is not unlike the changes seen in the pulmonary function markets from the late 1970s through the 1980s, whereby simple lower-cost spirometry testing took place outside the hospital, and only the sicker patients actually were tested on more sophisticated PFT systems.

Screening for obstructive and restrictive lung disease and providing early detection of these diseases has had a dramatic impact on health care costs, education and patient management. This shift is currently occurring in sleep markets based on improvements in portable technology, increased market demands, increased awareness in the public, and cuts in reimbursement on the in-lab diagnostic side of the business. To date, positive pressure treatment has proved, for the dollars spent, that it provides the best return for the payor and patient, compared to rival technologies.

In summary, patients suffering from SDB will require better follow-up and support to encourage them to stay compliant with their treatment, or they will seek other options to manage their condition. Thus, any improvements to help the patients better care for themselves and engage in a way of self-managing their condition will prove to be a wise investment in the future of health care. This will mean educating the patients about the condition and potential harmful effect it can have, not only on themselves but also their families, and in the case of a traffic accident, the lives of others.

The market is demanding improvements in all areas of health care, and high-growth areas such as sleep will come under a microscope in the near future to control costs while maintaining quality care. Thus, effective management of SDB as a chronic condition will require a multitiered approach, encouraging providers to enlist tools such as telemonitoring, automated patient management systems, replacement of routine supplies and scheduling in-office visits.

This article originally appeared in the Respiratory Management March/April 2007 issue of HME Business.