rapidly evolving models of care for patients with osa samuel t. kuna, md center for sleep and...

Rapidly Evolving Models of Care for Patients with OSA

Samuel T. Kuna, MDCenter for Sleep and Respiratory Neurobiology

University of Pennsylvania and

Sleep Medicine Section

Crpl Michael J Crescenz VAMC

Philadelphia, PA

Outline

• Application of emerging telehealth technologies to the diagnosis and management of patients with OSA

• Recent evidence showing the effectiveness of telemedicine management of patients with OSA

• Providing patients with web-based access to their PAP results improves adherence

• Development of a VA-based web platform (REVAMP) that will allow Veterans with OSA to be diagnosed and managed without having to come to a sleep center

Veterans Integrated Service Network (VISN 04)

AutoPAP treatment

AutoPAP treatment

In-lab PSGHome sleep

study

CPAP treatment

Clinic FU

Initial In-person evaluation

Split PSGNon-OSA

Non-OSA

OSA management at the Crescenz Veterans Affairs Medical Center

Diagnostic PSG

PSG / HST

Long-term FU

Telemedicine – the delivery of clinical services at a distance, using communication technologies that allow physical separation of practitioner and patient while evaluating and managing health issues.

Telemedicine – definition

PractitionerPatient

Any communication modality that allows the physical separation of patient

and practitioner

Teleconsultation

Clinical Video (Real Time) Telehealth Exchanging health services or education live via videoconference

Home TelehealthTransmission of medical data for diagnosis or disease management

Store and Forward TelehealthAcquires and stores clinical information (e.g. data, image, sound, video, etc.) that is then forwarded to (or retrieved by) another site for clinical evaluation

Telehealth modalities

• Increase access to healthcare information• Increase access to care (primary and specialty

services)• Decrease cost of care (reduce hospitalizations,

ER visits)• Improve healthcare for medically underserved

populations• Standardize care• Expand the healthcare workforce through

“virtual” education and training

Anticipated promises of telehealth/ telemedicine to patients and practitioners

AutoCPAP treatment

AutoCPAP treatment

In-lab PSGHome sleep

study

CPAP treatment

Clinic FU

Split PSG

Application of telehealth technologies for diagnosis and management of OSA

Diagnostic PSG

Video Teleconference

Store and forward of wireless data

Store and forward

Phone or video teleconference

Initial In-person or video teleconference evaluation

PSG / HST

Video teleconferencing program to deliver cognitive behavioral therapy for insomnia

This is where we are going!

AutoCPAP treatment

AutoCPAP treatment

In-lab PSGHome sleep study - DVD

CPAP treatment

Clinic FU

Split PSG

Telemedicine pathway for remote management of OSA

Diagnostic PSG


Wireless modem data transmission

Store and forward



PSG / HST

Some monitors used for home testing

Portable testing is just one part of an ambulatory clinical pathway for the

chronic management of OSA patients!

HST

AutoCPAP treatment

AutoCPAP treatment

In-lab PSGHome sleep study - DVD

CPAP treatment

Clinic FU

Split PSG

Telemedicine pathway for remote management of OSA

Diagnostic PSG


Wireless modem data transmission

Store and forward



PSG / HST

Wireless modem transmission of PAP data

Home PAP unit Manufacturer’s website

Event detection by PAP machine

Berry et al. Sleep 2012; 30:361-7

Diff

eren

ce A

HI A

ED

– A

HI

PS

G

Average AHI AED and AHI PSG

Apnea-Hypopnea Index

PAP with wireless modem at home

PAP data sent to manufacturer server

MANAGEMENT ACTIONS

PAP data entered into EMR (CPRS)

Data sent to patient via Secure Messaging

Review data with patient during clinic visit

Adjust PAP settingsPhone follow-up

Authorize home visit by DME therapist

Provider reviews data on website

STORE FORWARD


The amount of data can be overwhelming!

Impact of modem-based monitoring on PAP adherence in patients with OSA

• Patients with OSA (AHI > 15) prescribed autoPAP were randomized to standard care or telephone contact in the first month based on modem-transmitted PAP data

• Outcomes: PAP adherence after 3 mo, subjective sleep quality, and side effects

Fox et al. Sleep 35: 477-81, 2012

Sharing wireless PAP data with the patient

Home PAP unit Manufacturer’s website

Patient website Patient

Websites for patients on PAP therapy

Mobile app and web-based systems providing patients with personalized feedback allowing them to take an active role in their sleep apnea therapy. These portals will allow patients to: –View equipment guides and educational

videos about sleep apnea–Patients set custom goals and

monitor their progress –Receive feedback on treatment–Troubleshoot common problems

195 patients with newly diagnosed OSA (AHI ≥ 15)

Randomized (n=139)

Usual care (n=53)

3 month Visit (n=52)

Web-based access + $$ incentive (n=40)

Web-based access (n=46)



Does giving patients access to their PAP data improve treatment use?

Kuna ST et al. Sleep 2015; 38: 1229-36

Total (n=136)

Usual care(n=52)

Web only(n=45)

Web+$$(n=39) P-value

First week 5.6 (2.9) 4.7 (3.3) 6.3 (2.5) 5.9 (2.5) < 0.0001

3 months 4.5 (3.2) 3.8 (3.3) 5.0 (3.2) 4.8 (3.0) < 0.0001

Mean (SD) daily hours of PAP use in first week and over 3 months

Increased PAP use in the Web Only and Web+Financial Incentive ($$) groups compared to

Usual Care group at one week and 3 months


1 2 3 4 5 6 7

Weeks

2.0

3.0

4.0

6.0

7.0

Mean (SD) hours of use per week over 3 monthsAv

erag

e ho

urs

of u

se p

er w

eek

5.0

8 9 10 11 12

Web onlyWeb + $$Usual care

1 2 3 4 5

2.0

3.0

4.0

6.0

7.0

Mean (SD) hours of use per week over 3 monthsA

vera

ge u

se p

er w

eek

(hr)

5.0


Days

Per

cent

age

of s

ubje

cts Web only

Web + FI

Percentage of patients accessing the website each day to view their PAP data


Web-based access - Lessons learned

• Patients’ web-based access to PAP adherence improves average daily hours of PAP use over the first 3 months of treatment

• Addition of a financial incentive in the first week of PAP treatment to web-based access to PAP results does not result in improved use compared to web-based access alone

• While web-based access to PAP results improves long term PAP adherence, it does not prevent the gradual decline in adherence over time

• Additional strategies are needed to help patients sustain their initial pattern of adherence


Phone enrollment(N=60)

Video teleconference (N=28)

Home sleep test(N=28)

APAP ordered(N=19)

OSA negative

(N=9)

1-mo and 3-mo video teleconference

FU (N=14)

In-person visit(N=28)

Home sleep test(N=27)

APAP ordered(N=21)

OSA negative

(N=4)

1-mo and 3-mo In-person FU

(N=20)

Video teleconference vs in-person care: Protocol

Fields B et al. Sleep (in press)

VariableIn-Person

Care (n=19)Telemedicine Care (n=15)

P Value

FOSQ 0.89 ± 0.59 2.57 ± 0.69 0.067

CES-D -4.31 ± 1.73 -6.51 ± 2.03 0.413

ESS -3.56 ± 1.13 -4.22 ± 1.31 0.702

SF-12, physical 2.08 ± 1.54 0.86 ± 1.83 0.611

SF-12, mental 0.73 ± 1.78 9.26 ± 2.09 0.003

Working Alliance Index (WAI) 1.70 ± 1.50 5.93 ± 1.77 0.074

Client Satisfaction (CSQ-8) 0.013 ± 0.48 -0.31 ± 0.57 0.665

Video teleconference vs in-person care: Functional outcomes and satisfaction


PAP adherence variable

In-person (mean ± SE;

N = 20)

Telemedicine (mean ± SE;

N = 16)P value

% days with device usage 54 ± 8 65 ± 8 0.493

% days ≥ 4 hours 39 ± 8 47 ± 9 0.493

Use, hours (all days) 2.9 ± 0.6 3.7 ± 0.6 0.301

Use, hours (days used) 4.5 ± 0.5 5.1 ± 0.5 0.426

Video teleconference vs in-person care: PAP adherence


Isetta V, et al. Thorax (in press)

Baseline visitCPAP titration and training

Control group (70)Standard CPAP follow-up

Face-to-face visits at month 1 and 3Extra contacts by phone

Telemedicine group (69)CPAP follow-up at distanceTelevisits at month 1 and 3

Extra contacts by e-mailWeb tool support

At 6 months:CPAP adherence, QoL, cost

effectiveness139 included in ITT analysis123 included in PP analysis

Cost-effectiveness of telemedicine management of sleep apnea

Cost-effectiveness of telemedicine management of sleep apnea

Isetta V, et al. Thorax (in press)

A personalized, interactive website for Veterans with OSA that promotes self-management by providing feedback on test results, PAP treatment, and response to treatment

Remote Veteran Apnea Management Portal

• Increase access to care for Veterans with OSA• Standardize care across the Veterans Health

Administration• Obtain patient centered outcomes and PAP data• Improve cost effectiveness of OSA management

Goals of REVAMP


Manufacturers’ websites

REVAMP website

Patient

Practitioner

Features of REVAMP’s patient portal

• Intake and follow-up questionnaires to evaluate patients and track clinical outcomes

• Videos and educational materials• Frequently Asked Questions for self-management• Graphical displays of PAP results • Secure messaging• Sends reminder text and e-mail messages to the

patient

Features of REVAMP’s practitioner portal

• Create new patient accounts • Select tasks to be completed by patient• Monitor patient’s completed and upcoming tasks• Review patient’s questionnaire responses• Questionnaire responses autofill progress notes• Interface with VA electronic medical record

Electronic Medical Record

Wireless PAP Data

Standardized history and sleep study collection

Patient centered outcomes

REVAMP provides standardized, patient outcome based management of OSA

Time to Leap Into Telemedicine?

Barriers to implementing telemedicine into routine practice

Telemedicine Parity LawPartial Parity LawProposal Parity BillNo Parity legislative Activity

Sleep telemedicine – a promising but unproven future

• Provides a scalable, cost effective alternative to in-laboratory management of patients with OSA

• Web-based applications will increase patient access to care, improve PAP adherence and promote patient self-management

• The combination of clinical video teleconferencing, home sleep testing and wireless transmission of PAP data will allow patients with OSA to obtain care without coming to a sleep center

Rapidly Evolving Models of Care for Patients with OSA

Samuel T. Kuna, MDCenter for Sleep and Respiratory Neurobiology

University of Pennsylvania and

Sleep Medicine Section

Crpl Michael J Crescenz VAMC

Philadelphia, PA

• 14/15 participants mentioned “convenience” of telemedicine.

• 14/15 participants had no prior exposure to telehealth visits.

• 15/15 agreed: “The quality and content of telehealth visits are comparable to in-person visits.”

• 1/15 was concerned about confidentiality (“who is getting the information”)

Video teleconference vs in-person OSA management: End of study phone calls


Well, I don’t think it was really any different. I mean, like I said, he was right there. We were talking face-to-face over the video. The only difference between talking over the video versus talking to a doctor actually in the office is, you know, they are there, in the office.

I don’t think it [in-person visit] would’ve made any difference. It was more convenient for me to do it this way than for me to have driven all the way to the hospital. It was much more convenient for me.

I think it’s just a great idea and a great study all the way around. With the fact that they can, you know, monitor your sleep patterns remotely with the wireless router. And you wouldn’t have to go to the clinic, you know, every six months, once a year, they can do it

right from the house.

[I] would have been more comfortable actually being in a room with the doctor…the video visit was OK, too.More things may have come to mind

[in-person]…being it [telehealth visit] was more convenient, it was worth that little bit I might have missed

discussing, you know.

Video teleconference vs in-person management: End of study phone calls


rapidly evolving models of care for patients with osa samuel t. kuna, md center for sleep and...

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