The Clinician s Role in Educating Patients with Sleep Apnea Cindy Altman, RPSGT, R.EEG/EP T. Alegent Creighton Clinic/Omaha, NE Immediate Past President/BRPT
The Early Years in Sleep 1929 1930 1950 s 1968 1970 1972 1973 1974 1975 Brain waves (EEG) in humans Distinct EEG patterns in sleep Discovery of REM; repetitive sleep cycles Standardized Manual for sleep scoring First formal sleep clinic at Stanford Respiratory and cardiac monitors used New syndrome insomnia with sleep apnea Polysomnogram PSG coined BCBS California pays for PSG
Diagnosis and Treatment 1976 1981 1981 1981 1980 s 1993 2000 2001 + Obstructive Sleep Apnea Syndrome Long-term efficacy of tracheostomy proven First UPPP for OSA Sullivan et al devise first CPAP Maxillomandibular procedures developed 1 st major OSA population study published Association between OSA and HTN Relationship to CAD, heart failure, stroke diabetes, MVA, obesity, cancer
Sleep: An Unmet Public Health Problem Increase awareness of the burden of sleep loss and sleep disorders among the general public Expand awareness among health care professionals of the effects of sleep loss and sleep disorders through education and training Emphasize treatment, long-term patient care, and chronic disease management Institute of Medicine Report: Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem, 2006
Effects of Sleep Deprivation Cognitive impairment and memory loss Impaired moral judgment Irritability, hyperactivity, poor concentration Increased reaction time and decreased accuracy Impaired immune system Increased risk of Type 2 Diabetes Heart disease Obesity MVA and occupational injury
Prevalence of OSA (AHI 15) 1988-1994 2013 Men (30-49 y) 6% 10% (50-70 y) 14% 17% Women (30-49 y) 2% 3% (50-70 y) 7% 9% Am J Epidemiol. 2013; 177:1006 1014
Healthcare Utilization in OSA Sleep apnea is the 4th most expensive health condition in the United States Undiagnosed and untreated patients have at least twice the utilization and health care costs of those without sleep apnea Costs decrease significantly after diagnosis and treatment
Chronic Condition Any condition that requires ongoing adjustments by the affected person and interactions with the health care system Challenges to chronic care management Busy healthcare practitioners Limited tools to coordinate care Follow up failures Uninformed patients
Chronic Care Management Improves transition gaps in communication and follow up Significantly fewer admissions and readmissions Reduces the overall risk of disease Improves the outcomes of chronic disease care Greater improvements in general health and quality of life Diabetes and asthma management models
The Sleep Educator Concept 2006 ACCP Sleep Apnea Aftercare Consensus Conference 2007 Envisioning the Sleep Educator by R. Richard, P. Gay MD, P. Fry, RRT in Sleep Review Magazine 2009-2011 Becoming a Sleep Educator and other courses sponsored by ACCP
Moving the Concept Forward 2012 BRPT Clinical Sleep Educator Certificate Program 2012 AASM Innovation Care Delivery and Management Program for Patients with OSA 2014 CCSH Certification in Clinical Sleep Health The changing direction of healthcare and sleep medicine diagnosis and management
Definition of a Sleep Educator Healthcare worker Deep understanding of sleep disorders, treatments, and the importance of good sleep Review and analyze test results, treatments, and compliance data Use a variety of communication and teaching techniques to optimize patient education, selfmanagement, and community interactions Consider comorbidity issues in all interactions Work collaboratively with other healthcare providers
Goals of the Sleep Educator Improve patient and community education Positively impact patient outcomes and health Improve compliance treatments, interventions Reduce barriers to successful intervention and patient self-management Raise the understanding of sleep and sleep disorders with other healthcare professionals, patients, and the community Support interdisciplinary approach to diagnosis, management, and treatment of sleep disorders
Duties and Tasks Conduct individualized needs assessments Incorporate principles of adult teaching and learning to optimize treatment and compliance Follow concepts of health behavioral change models to enhance individualized patient instruction Provide tools and information to aid the patient in successful self management Consider comorbid conditions in all interactions Counsel patients on the consequences of non compliance Reinforce and recognize positive behaviors
Improving PAP Adherence 29-83% use PAP < 4hrs/night 1993 Study by Kribs, Pack, Kline et al Minimal use >4 hrs/night Optimal use >7 hrs/night Minimal criteria met on 50% of nights Optimal criteria met on 20% of nights 46% patients in study met minimum criteria Minimum Objective Compliance 4 hours/night; 5-7 nights per week (70% of nights)
CPAP Treatment Lowers Costs PAP adherence resulted in significant reduction in physician claims and hospital stays PAP treatment associated with reduction in use of healthcare services PAP treatment reduced health care costs, disability costs, and missed workdays
Interventions Increase Usage Pattern of treatment established during the 1 st week Extended hospital stay, education, home visits Group cognitive behavioral therapy Individual provider education Peer buddies Combination short and long term interventions Goal to promote CPAP adherence to prevent comorbidities and enhance quality of life
Emerging Findings Need more research to determine what works best Group education + individual instruction from provider increased adherence at 1 month 3.5 vs 3.1 hr/day and 67.2% vs 62.1% of nights used Buddy peer support increased adherence at 3 months 5.2 vs 4.0 hr/day Review of 17 studies with 1070 participants 0.59 hrs/day increased adherence with education and encouragement 85 /100 failed over 4-12 weeks in control groups 46/100 failed in cognitive behavior groups
Case Management-One Story Improved adherence to PAP from 10% to 90% Classroom format for insomnia CBT -89% subjective improvement; reduced insomnia medication; 25% reduction in primary care office visits 1 yr after program Primary care physician survey: 100% reported closedloop, sleep program reduced time spent managing sleep disorders 88% patients reported case management program improved care over physician (sleep or primary care physician) management
Self-Management Programs Successful with other chronic illnesses Address patient access to information Continuity and coordination of care across specialties Availability and type of services Symptom management Key to effectiveness and efficiency in care of chronic disease Set goals, problem solve, and follow through Incorporate healthier choices
Focus on Patient-Centered Care 50% Medicare patients have 5+ chronic diseases 2 primary care MDs and 5 different specialists yearly 1/3 of hospital patients do not receive instructions on symptoms to watch for or who to contact after discharge 1/3 of patients indicate test results or medical records not available at clinic appointment; MD does not know that a doctor had already ordered a test they ordered MDs thought patients knew diagnosis, only 57% said they did
Patient s Burden of Treatment Confusion about treatment-what, how, why Challenges using treatment-side effects, bed partner Emotional factors-family tension, sleep deprivation Limitations-roles and activities can t go Financial challenges-testing, office visits, treatment Delivery of care-confusion, changing providers Navigating the healthcare system Fear of managing treatment at home Failure to understand condition and consequences
Benefits of Patient Education Improves patient s ability to manage chronic disorder Options to choose healthier lifestyles and prevention Increases satisfaction with care Decreases provider s risk of liability Promotes patient-centered care Increases treatment adherence, decreases complications More efficient and cost-effective long-term care Improves continuity of care Promotes independence in activities of daily living
The Time Is Right Focus on the value of sleep and healthy life Chronic nature of OSA and sleep disorders Decreasing physician reimbursement Move toward OCST diagnosis and management Outcomes-based medicine CHF, asthma, diabetes education-improved outcomes, quality of life, and reduced costs Interdisciplinary coordination and care
Knowledge: Sleep Over the Lifespan Describe normal sleep architecture, quantity, quality Identify factors contributing to variations in normal sleep Identify and recognize pathophysiology, epidemiology, and clinical presentation of abnormal sleep
Clinical Evaluation/Management Correlate and document sleep and medical history Identify comorbid conditions and impact on patient Assess and explain evaluation and management tools Evaluate treatment and therapy
Patient and Family Communication and Education Provide education to patient and family Understand and explain the importance of sleep hygiene Encourage and promote patient selfassessment and self-management
Program Maintenance and Administration Develop multidisciplinary programs Manage performance improvement and quality Promote sleep disorders as a public health issue
Scope of Practice A clinical sleep educator does NOT diagnose, treat, or provide any such services prohibited by law or scope of practice Scope of practice is dependent on licensure and other regulatory oversight Licensure and regulations vary by state and profession Work collaboratively with a sleep team
Patient education should be optimally delivered as part of a multidisciplinary chronic disease management team including the sleep physician, the referring provider, and allied health care providers. AASM Clinical Guideline for Evaluation, Management and Long-Term Care of OSA in Adults 2009