Funding Focus

Having a Follow-Up Plan Helps Foster Compliance

• By Kelly Riley
• Jul 01, 2009

In the last issue, “Capturing Compliance Creates More than Cash,” the discussion revolved around the need for providers to collect their own patient PAP compliance rates and then benchmark against themselves on a quarter-to-quarter basis, and then against other providers.

Given the latest CMS mandates for objective adherence monitoring data, this should not prove such a daunting task. It will, on the other hand, arm you with data to show whether your organization is truly a quality sleep provider, an average provider, or even a below-average provider. While there could be other metrics to define a best practice, measuring patient outcomes should be at the top of the list. Time and time again, increased compliance to therapy leads to optimal patient outcomes.

CMS has placed the bar for PAP compliance as usage of four plus hours over 70 percent of nights within any consecutive 30- day period. While certainly not meeting the test of scientific validity, it offers a place to start. CMS is aware of the scientific data that acknowledges CPAP as effective therapy for OSA. Compliance, however, is often suboptimal. Numerous studies estimate that 50 percent of patients recommended for therapy are noncompliant one year later.

“Numerous studies estimate that 50 percent of patients are noncompliant one year later.”

One of the most important components related to compliance success is the implementation of a consistent and well-defined follow-up program.

Start by placing patients into categories based on risk of compliance failure, given several proven factors. (See last month’s column regarding negative and positive factors that affect compliance rates). For example, patients set up on PAP who report a lack of daytime sleepiness, presence of nasal obstruction, or claustrophobia would fall into the “high risk of failure” category and warrant extra attention. At the other end of the spectrum, patients who report increased daytime sleepiness and have higher apnea hypopnea index (AHI) require a standard level of follow-up.

One study suggests that a patient’s attitude toward treatment after seven days on CPAP predict later adherence. This study, as well as several others, would suggest that the timing of patient follow-up post initial application of PAP is important. If you are waiting until 30 days have elapsed to provide patient follow-up, you are missing opportunities.

While patient follow-up questionnaires routinely ask questions related to skin irritation, mask cleaning and machine use, they often miss some key metrics that can provide evidence of future success or failure.

In a poster presented at this year’s AASM conference in Seattle, researchers from Madigan Army Medical Center in Tacoma,Wash. said that asking OSA patients on CPAP therapy about continued snoring could serve as a rapid, effective assessment tool in helping providers identify individuals who would benefit from further evaluation to enhance compliance.

In another study, researchers at the Institute for Sleep/Wake Disorders at Hackensack University Medical Center in N.J., found that a significant number of patients reported intolerance and poor compliance to therapy if the last meal was consumed less than one hour prior to usage of CPAP. Education on the time of the last meal prior to sleep could foster compliance.

Other components of an effective follow-up plan include:

• The patient’s involvement in his/her own treatment.
• A support network available for the patient.
• Education provided by a health care team that includes consistent follow-up, troubleshooting and regular feedback to both patients and physicians.

Utilization of these components has helped providers increase their compliance rate to greater than 85 percent over six months.

Methodologies for tracking PAP compliance and patient follow-up are often based on the size of your patient population base. These tools can range from highly sophisticated call centers and voice response units, to your own internal direct mail or e-mail campaign. Most PAP manufacturers have great tools to use as part of your patient reminder and follow-up process. Whatever tool you implement, be sure to measure the effectiveness to see if you need to consider moving to a more sophisticated system.

Remember the old adage, “People do what you inspect, not what you expect.” Letting patients know that you will continue to monitor their compliance and that their numbers count toward your numbers, will in many cases instill in them more ownership of the entire process.

References: Differential Pretreatment Predictors of Initial and Long-Term CPAP Adherence, Glidewell RN, Orr WC Sin don D et al. Long-Term Compliance Rates to Continuous Positive Airway Pressure in Obstructive Sleep Apnea: a Population-Based Study. Chest (United States) 2002; 121(2): 430-435.

This article originally appeared in the Respiratory Management July/August 2009 issue of HME Business.