APNEA SCREENING FOR DIABETES PATIENTS

Sensible. Simple. Effective.Reaching out to more patients.

REASONS TO INTEGRATE AN APNEA SCREENING PROGRAM

Increasing Prevalence o 24%-

Nearly one quarter of U.S. men suffer from some form of sleep disordered breathing (SDB).

International Diabetes Federation Recommendations

OSA should be considered in the assessment of all patients with Type II Diabetes.

Improving Patient Careo Early detection & treatment

reduces risk of disease & death related to other serious health conditions, such as:• Type II Diabetes• Hypertension• Congestive Heart Failure• Stroke

New England Journal of Medicine. 1993; 328; 1230-1235.Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12.

DIABETES & APNEA

Evidence indicates

that the presence of

one disease may

trigger biological

mechanisms that

increase risk of the

other.

OSA

Hypoxia & Sleep Fragmentation (Alters Glucose

Metabolism)

Stress Response (Alters Leptin Levels ;

Increases Insulin Resistance)

Glucose Intolerance/

Type II Diabetes

Autonomic Neuropathy (Alters Ventilatory

Control During Sleep)

Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12.Pagel, et. al. Supplement to The Journal of Family Practice. August 2008 ; Vol 57, No 8.

DIABETES & APNEA SCREENING SHOULD GO HAND IN HAND

Link Between Diabetes & SDBo 58% of Type II Diabetics have some form of sleep disordered breathing (SDB)

Health Concernso Both Diabetes & Apnea significantly increase risk of cardiovascular disease

& death

Treatment Concernso Apnea negatively impacts glucose tolerance, insulin resistance & increased

risk of metabolic syndrome Leads to difficulties with diabetes management

Richard; Gay & Farrell. The Economics of Sleep-Disordered Breathing. RT: June 2006.Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12

SLEEP DISORDERED BREATHING (SDB) IN THE DIABETIC POPULATION

Improves Factors Related to Diabeteso Improves glycemic control

o Improved insulin sensitivity and leptin levels

o Reduces Sympathetic Activation

o A key factor in regulation of glucose & fat metabolism, as well as systemic inflammation. – Biological mechanisms thought to contribute to insulin resistance.

Reduces Cardiovascular Risk o Significantly decreases blood pressure (BP)

o Improves Heart Function

o Decreases # of new cardiovascular events & arrhythmias

Improves Overall Patient Outcomeso Reduces morbidity & mortality associated with cardiovascular events & stroke

o Patients using positive airway pressure have better Epworth Sleepiness Scale & Health-Related Quality of Life scores.

Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12Richard; Gay & Farrell. The Economics of Sleep-Disordered Breathing. RT: June 2006.

TREATING APNEA

ECONOMIC IMPACT OF UNDIAGNOSED APNEA

$3.4 billion Yearly estimate of the medical costs of untreated OSA in the U.S.

$15.9 billionCollision costs directly attributable to OSA in 2000.

$5 billion Yearly loss of productivity attributable to Apnea-related fatigue.

Other Indirect Costs • E.g. higher insurance, production, &

consumer costs• Higher incidence of work-related accidents

Non-Financial BurdenIncreased incidence of disabilityDiminished quality of life for affected.

Richard; Gay & Farrell. The Economics of Sleep-Disordered Breathing. RT: June 2006.Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12

SDB PLACES SUBSTANTIAL ECONOMIC BURDEN ON THE U.S.

REASONS FOR APNEA SCREENING

SDB is Largely UndiagnosedOver 28 million Americans suffer from OSA, yet 20 million go undiagnosed & untreated.

Increased Health RisksSDB is associated with a range of comorbid conditions.

Significant Financial & Disability Burden Untreated SDB places substantial burden on both individuals & society.

Logan, et. al. J Hypertens. 2001 Dec;19(12):2271-7.Jahaveri, et. al. Circulation. 1998;97:2154-2159Basetti & Aldrich. Sleep. 1999 Mar 15;22(2):217-23.Finkel, et. al. Sleep Review July-Aug 2006. Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12.

SCREENING IDENTIFIES PATIENTS THAT WOULD NOT SEEK TREATMENT OTHERWISE.

PROBLEMS WITH COMMON SCREENING METHODS

o Subjective

o Not specific i.e. high # of false-positives - Leads to unnecessary testing & delayed Dx for those with severe apnea

o Cannot indicate type/severity of SDB

o Not Validated for Diabetic Population

QuestionnairesIn-lab Polysomnography (PSG)

o Costly

o Impractical for ScreeningPopulation is too large

o Can Take Days or Weeks to Receive Results

o Higher refusal/drop-out rates

Finkel, et. al.. Sleep Review July-Aug 2006. Magalang, et. al. Chest 2003; 124; 1694-1701.STOP Questionnaire; A Tool to Screen Patients for Obstructive Sleep Apnea. Chung, et. al.. Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104:1081–93.

META-ANALYSIS OF OSA QUESTIONNAIRES

StudyPooled Study n

FN RateEase of Use, 0-3

Test Accuracy, by Diagnostic Odds Ratio

(DOR)*

Summary Recommendati

ons**

Berlin Questionnaire

692 .081-.0382 1 Poor-Excellent

May have role in screening for severe OSA, Unacceptable FN rate

BMI alone 4060.228 - 0.298

0 Poor Unacceptable FN rate

Epworth Sleepiness Scale

46 0.714 1 Poor Unacceptable FN rate

STOP Questionnaire

1770.205 - 0.344

1 Poor Unacceptable FN rate

STOP-BANG 177 0.0 - 0.164 2Average-Excellent

Excellent screening test for severe OSA, unacceptable FN rate for Dx of OSA

*DOR combines data on sensitivity and specificity to give an indication of a test’s ability to rule in or rule out a condition.**Summary recommendations developed for preoperative use.

SCREENING TEST RELIABILITY & SUMMARY RECOMMENDATIONS

Many of the most

commonly used

screening

questionnaires have

poor predictive

values, esp. for mild

to moderate cases.

Derived from Ramachandran, et. Al. Anesthesiology, V 110, No 4, Apr 2009

THE S.O.S. APPROACH

Subjective Screen

o Use questionnaire (e.g. STOP-BANG; Berlin) to screen everyone

• The population at risk is often large and will often include many patients with low risk.

A much smaller subgroup with very high risk will require expedient intervention.

Objective Screeno Oximetry (e.g. SatScreen) devices are widely used

because of affordability, high predictive value, & minimal patient impact. • Identifies the high risk subgroup.

“S.O.S.”Subjective Objective Screening

Research shows a combination approach can be the most feasible & effective method

Hwang, et. al. Chest 2008; 133; 1128-1134. 

Patents High resolution oximetry with digital pattern analysis & recognition

SatScreen Oximetry screening

o FDA cleared acquisition, analysis & reporting software

Patient Safety Connection Center Oximetry & HST software management platform

PATIENT SAFETY, INCTECHNOLOGY

BREAKTHROUGHS

WHY SATSCREEN?

Most oximetry software only report raw data, ODI & O2 ranges.

Accurate & Cost-Effective

Results in Minutes

Easy to ReadGreen to red indices for important information

Indicates Arousal Failure & Hypoventilation Syndromes

Indicative of more serious SDB & may require a different treatment approach

Highlights Frequency of Events & Severity of O2 Desaturations

Bloch. Chest 2003; 124; 1628-1630. ASA Task Force. Anesthesiology 2006; 104:1081–93.Madani. Advance for Respiratory Care and Sleep Medicine. Posted on

January 7, 2009.

GET STARTED

Define your protocol for at risk patientsDetermine your Screening Protocol

Gather your team & assign responsibilities

Practice GuidelinesIf patient is identified as at risk, follow ASA guidelines or preferred protocol

Develop discharge instructions / plan

Questions?

We want to help you make your organization’s OSA screening program a success.

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support@patientsafetyinc.com