Seguimiento clinico del paciente con CPAP: u?lidad de la telemedicina Clinical follow- up of pa.ent treated by CPAP: use of telemedicine

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1 Seguimiento clinico del paciente con CPAP: u?lidad de la telemedicina Clinical follow- up of pa.ent treated by CPAP: use of telemedicine Prof P.Escourrou Centre de Médecine du Sommeil Hôpital Béclère, Clamart, France

2 Background Over the past ten years, there has been a significant growth in the number of people tested for OSA. This can be arributed to a number of different factors. greater awareness of sleep disorders, including OSA, in the general popula?on. expanding popula?on of elderly and obese popula?ons. These factors have resulted in increased tes?ng and treatment for OSA which payers have experienced as an increase in spending for sleep disorders.

3 New policies to cut costs of diagnosis and treatment of sleep disorders. Use of ambulatory sleep tes?ng to diagnose OSA in place of in- center polysomnography. Use of Auto- PAP to?trate the pa?ent in place of an in- center PAP?tra?on. Use of primary care and na?onal providers of ambulatory diagnosis in place of local board cer?fied sleep physician providers. Use of na?onal Home Care Providers chains in place of local HCP. Stricter control on the use of CPAP.

4 Place for telemedicine of SDB in Europe? Telemedicine for diagnosis? Telemedicine for treatment and follow- up? How to bill for telemedicine? Telemedicine program for other applica?ons than OSA?

5 Management of Obstruc?ve Sleep Apnea in Europe I.Fietze, Sleep Medicine 2011, on behalf of the COST Ac?on B26 Group

6 Management of Obstruc?ve Sleep Apnea in Europe I.Fietze, Sleep Medicine 2011, on behalf of the COST Ac?on B26 Group There is no concensus on the diagnos?c procedure in Europe: ambulatory or in hospital/center There is consensus (90.5%) on the necessity for CPAP therapy follow- up But reimbursement only takes place in 14/19 countries (73.7%). Aher?tra?on, the follow- up intervals within the first half- year to year vary extensively. Some?mes,the exper?se of the arending physician is required

7 Telemedicine for Diagnosis of OSA J F Masa, Thorax 2011 ROC for Home Resp Polygraphy Vs. In lab PSG Cost of telema6c HRP vs non- telema6c HRP in % of in lab PSG

8 CPAP treatment: The clinical path clinics Pa6ent Treatment Follow- up Reimbursement Linked to use (minimal compliance) Home care Providers Sleep Specialist Diagnosis Prescrip.on Health care organisa?on Med Device Manufacturers

9 Reference Treatment : CPAP Con?nuous Posi?ve Airway Pressure Efficient treatment requires more than 3hrs of use/night The first 3 months are crucial for the long- term compliance

10 Telemedicine of CPAP treatment in France: Nb of pa?ents with CPAP: > Cost of treatment: 414 millions euros (2009) Increase between 2007 and 2009: 40% Indica?ons for CPAP: AHI > 30/h(PG) or respiratory arousals>10/h (PSG) Treatment follow- up: HCP covered by Social Security CPAP device, mask and maintenance Educa?on 2 home visits/yr and report transmission to physician Rate: 20 /week i.e /year Star?ng october 1 st 2013 : mandatory teleobservance transmired to «Caisse Na?onale d Assurance Maladie» mean 3h/night/28 days

11 Information flow

12 objectives Set up an interoperable telemedicine system for the follow-up of patients with sleep apnea syndrome. Combine data from Continuous Positive Airway Pressure devices, and clinical patient data, into the e-health sleep record. Develop technical and clinical alerts based on the data to trigger ia technical interventions or a clinic visit. Improve patient compliance via an interactive training tool targetting patient education about CPAP use Study the health economic impacts of telemonitored CPAP devices and of the telemonitoring services.

13 Consor?um Consor6um: - Réseau Morphée (Sleep Health Network) - Assistance Publique- Hôpitaux de Paris - Resmed (manufacturer) - Philips Respironics (manufacturer) - Orkyn (Home care provider) - Santéos (Informa?on system) - Adverbia - Acsen?s Associate Members: - DGCIS (Ministry of Industry) - ARS (Agence Régionale de Santé) - SFRMS (société de Recherche sur le Sommeil) - Pa?ents groups: FFAIR, Sommeil et Santé

14 Medico- economical evalua?on Design :Randomized Control Trial J 0 No tele- monitoring 200 pts OSAS randomisa?on Tele- monitoring 100 pts 100pts Primary end- point: compliance/ night at 3 months Secondary end- points: Comparison of costs Residual somnolence Residual AHI with CPAP M1 Home visit alerts Daily monitoring Par.cipants: 12 sleep centers in Paris region Home visit adjustments Home visit Clinic adjustements Clinic M3 PSG Compliance

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17 Developping exper?se Revised care pathways: berer communica?on between health care professionals, improved reac?vity and berer alloca?on of ressources Telefollow- up: technical/medical alarms ini?al follow- up: 3 months annual follow- up: periodic transmission Increasing pa?ent autonomy via improved pa?ent educa?on

18 A generalizable solu?on Na?onal deployment : capitalisa?on and mutualisa?on For the same sleep disease: OSAS other HCP, other prescribers Service Plaqorm: Home Telediagnosis : Polygraphy, Polysomnography Teleexper?se: help for diagnosis and follow- up Teletreatment: serngs of the Medical Device

19 A generalizable solu?on For other diseases at home: Non- invasive Ven?la?on Heart Failure Renal dialysis Telemedicine in Europe COPD, Hypertension medico- economical study: MAST Thérapeu?c Educa?on : «serious game»

20 The problems Local reglementa?on: ARS autorisa?on in France payment of the HCP and the Health Professionnals Integra?on to device specific sohware already in use: need for industry partnerships

21 The future New care pathways Development of new jobs: i.e: management of automa?cally generated alerts HCP, HP Development of «Proac?ve Connected» Pa?ents Modifica?on of pa?ent- doctor rela?onship Importance of direct human contact (home,clinics)