Got Compliance? Strategies for adherence to PAP therapy

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Got Compliance?Strategies for adherence to PAP
therapy
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Objectives

• Review the benefits of PAP therapy compliance
• Review potential consequences of untreated
  obstructive sleep apnea (OSA)
• Discuss potential barriers to PAP therapy
• Identify possible solutions for barriers to PAP
  therapy
• Discuss data management and methods to monitor
  patient compliance to therapy

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What is the prevalence of sleep disordered
breathing (SDB)?

• Impacts about 20 million American adults
• Prevalence similar to that of asthma
• 1 in 4 adults suffer from SDB
• 85-90 are undiagnosed and untreated
• Impacts all walks of life, ages, and gender
• Obstructive sleep apnea (OSA) most common

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OSA therapy

• For most OSA patients, continuous positive airway
  pressure (CPAP) is generally the preferred
  treatment
• 70 - 80 of patients utilize CPAP therapy with a
  nasal mask1

1 Frost Sullivan, Sleep Apnea Models, 2001
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Goals of positive airway pressure (PAP) therapy

• Short Term
• Maintain open airway
• Improve quality of sleep
• Alleviate daytime symptoms
• Sleepiness
• Moodiness/impaired concentration/memory loss
• Morning headache

Marin, JM et. al Lancet 2005 3651046 - 1053
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Goals of positive airway pressure (PAP) therapy

• Long Term

• Reduce mortality and morbidity
• Decrease cardiovascular consequences
• Reduce sleepiness
• Improve quality of life

Marin, JM et. al Lancet 2005 3651046 - 1053
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OSA therapy

• The efficacy of CPAP has been validated and
  studies have shown a relationship between the
  amount of time a patient uses CPAP and clinical
  outcomes
• Despite its efficacy in treating OSA, nearly 50
  percent of patients are non-compliant with
  therapy within the first few months1

1Kribbs, N., and et al. Objective measurement of
patterns of nasal CPAP use by patients with
obstructive sleep apnea. Am Rev Respir Dis
1993147887-895.
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Consequences of untreated OSA
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Consequences of untreated OSA

• Short-Term
• Automotive accidents
• Excessive sleepiness
• Decreased quality of life
• Long-Term
• Cardiovascular disease
• Arrhythmias
• Stroke
• Impaired glucose tolerance

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Consequences of untreated OSA

• In US, more than 40,000 deaths and 6 million
  injuries occur from motor vehicle accidents every
  year1
• Sleep-related accidents comprise 15-20 of all
  motor vehicle crashes2

1 US Census Bureau. Statistical Abstract of the
United States. 119th end. 1999, No. 225 (146) and
No. 1041 (645) 2 Young, T., Blustein, J., Finn,
L., et al. Sleep Apnea, Sleepiness, and Driving
Risk. Am J Respir Crit Care Med 19941501463-73
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Potential barriers to PAP therapy

• Compliance and Acceptance of OSA Therapy

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Early intervention may improve compliance

• Skipping CPAP for two or more nights within the
  first week of treatment signals potential
  non-adherence and emphasizes the need for close
  follow-up during this period of time1
• The first week to month of home therapy appears
  to be the most critical phase for intervention
  and securing long-term compliance

1 Weaver, TE and Grunstein, RR. Proc Am Thorac
Soc 20085173-178.
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CPAP therapy adherence

• How is OSA treatment adherence defined?
• gt 4 hours of use, gt70 of time (Kribbs1)
• Studies show patient adherence to therapy is not
  ideal
• Kribbs found that 54 could be inconsistent
  users1
• Weaver found 47 inconsistent users2

1 Kribbs, et al., Objective Measurement of
Patterns of Nasal CPAP Use by Patients with OSA.
American Review of Respiratory Disease 1997147
No. 4 2 Weaver, et al., Night-to-Night
Variability in CPAP Use Over the First Three
Months of Treatment. Sleep 199320(4)278-283
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Ensure patients receive effective therapy

• Look for
• Acceptance
• Tolerance
• Response
• Enhance patient education
• Proactive in addressing non-tolerance and
  non-response

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What are reasons for non-compliance?

• Non-tolerance refers to problems that are mask,
  nasal, pressure/airflow or psychosocial in nature
• Inconsistent users can be identified in the first
  week of therapy using a data management system to
  review compliance
• Non-response is when a patient feels no benefit
  to using therapy. This may be uncovered when
  reviewing the Functional Outcomes of Sleep
  Questionnaire (FOSQ) within a data management
  system

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CPAP clinical pathway
OSA Diagnosis
Therapy Selection
Patient Education

• Helpful hints
• Ramp time
• Ramp start pressure
• Mask-off alarm
• Mask satisfaction/fit
• Humidification
• Flex technology

• Encore or phone-in reports

Patient Follow-up
Compliance Achieved?
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Monitoring for effective therapy
Non-Acceptance Non-Tolerance Non-Response
Effective Therapy
No
No Perceived Benefit
Psychosocial Concerns
Nasal Symptoms
Mask Issues
Pressure Issues
Compliance achieved?
Go to Bi-level Therapy
Interventions unsuccessful
Yes
or Auto-Adjusting Bi-level Therapy
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Possible solutions

• Strategies to improve
• PAP compliance

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Solutions for nasal symptoms

• Humidification adds moisture for patients
  receiving PAP therapy
• Cool humidifiers or heated humidifiers available
• Humidification may improve compliance by
  decreasing effects of
• Dry or runny nose
• Nose bleeds
• Mouth breathing/leak
• Reimbursement provided for humidification

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Solutions for nasal symptoms

• Other suggestions for overcoming dryness or
  discomfort include normal saline sprays, mouth
  washes or oral gels that may help to provide
  moisture to the mouth or nose by increasing
  hydration

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The right mask is crucial to PAP success

• A mask or interface that fits properly and meets
  the needs of the patient is an important
  consideration when discussing CPAP compliance
• There have been many changes in interface
  technology, and a wide variety of styles are
  currently available

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DID YOU KNOW?
Several medical studies show that the selection
of the appropriate patient interface is a major
issue in CPAP therapy success (1)
Your Choice is Crucial
Medical studies also show that the selection of
the correct interface in the early stages of
therapy can result in long term adherence (2 )
Timing is Crucial
Clifford A. Massie, PhD and Robert W. Hart, MD,
FCCP (CHEST 2003 12311121118) Antonelli M,
Pennisi MA, Conti GEur Respir J (Suppl) 2003
4265S-71S
1
2
Clifford A. Massie, PhD and Robert W. Hart, MD,
FCCP (CHEST 2003 12311121118) Kribbs et al. Am
Rev Resp Dis 93
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To optimize patient compliance and therapy
adherence, several criteria have to be taken into
consideration while selecting a patient interface
Patient medical condition and pathology
Patient morphology
Patient psychosocial issues
Patient personal preferences
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Patient Medical Condition and Pathology
New patients with no CPAP or BiPAP experience Compliant PAP user Mouth breathing patterns Facial muscular disease Clinical situation (chronic or acute)
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Patient Morphology Physical Characteristics
Nare narrowness and/or deviated nasal septum Symmetry of face, teeth, nose format, moustache, beard, Nose bridge pain, nose bridge scars, burns, deformation Skin sensitivities Eagle nose, Flat nose"," Narrow nose,...
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Patient Psychosocial Issues
Anxiety Feeling of Claustrophobia Self Image
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Patient Personal Preferences
Desire for improved visibility Dissatisfaction with aspects of standard alternatives Preference for less facial contact, less pressure points, bulk
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Pressure intolerance/trouble exhaling

• A typical complaint of sleep apnea patients using
  CPAP is that its uncomfortable or even difficult
  to exhale against the continuous positive
  pressure
• There have been many advances in technology to
  help patients adapt to CPAP therapy

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Solutions for pressure issues

• Ramp
• Allows for patient to fall asleep at a lower
  pressure and acclimate to pressure over time
• Can be adjusted based on pressure drop and length
  of time until patientis back at prescribed PAP
  pressure while falling asleep

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Solutions for pressure issues

• Comfort settings on exhalation
• Provide relief during exhalation phase to allow
  for improved comfort to CPAP therapy
• When to use
• Initial set up
• Pressure intolerance
• Difficulty with acclimation to PAP therapy

1 Aloia, et. al. Chest, June 2005 2 Rosenthal,
et. al Sleep, June, 2005
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Clinically validated comfort technology

• Study compared adherence, treatment outcomes and
  attitudes in patients treated with traditional
  CPAP versus patients treated on CPAP with flex
  technology
• Patients on flex technology had a significant
  improvement in adherence to therapy over a
  3-month period and demonstrated an increase in
  confidence in their ability to adhere to
  treatment1

1Aloia, MS., et al. Treatment adherence and
outcomes in flexible versus standard continuous
positive airway pressure therapy. Chest
2005127(6)2085-2093.
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Psychosocial concerns

• Behavioral approaches, such as Motivational
  Enhancement Therapy (MET), may benefit some
  patients who are struggling with psychosocial
  issues related to CPAP therapy1
• MET is a patient-centered counseling approach
  that focuses on the concerns and perspectives of
  the patient and his or her hesitancy about
  behavior change (i.e., using CPAP therapy) in a
  supportive, non-confrontational manner

1Aloia, MS., et al. Clinical management of poor
adherence to CPAP motivational enhancement.
Behav Sleep Med 20042205-222
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Goal of MET

• The main goal of MET is to increase the level of
  importance the patient places on changing his/her
  behavior within a supportive, non-judgmental
  environment
• Utilizing methods such as asking open-ended
  questions and reflexive listening, the clinician
  is able to help the patient to explore their
  feelings about therapy, the benefits, and
  potential roadblocks to compliance1

1Aloia, MS., et al. Clinical management of poor
adherence to CPAP motivational enhancement.
Behav Sleep Med 20042205-222
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No perceived benefit of therapy

• A patients perception of the benefit of symptoms
  following CPAP therapy, improvement in daily
  functioning, and positive social support may be
  related to initial acceptance and adherence to
  treatment1
• A patient may be more vulnerable to
  non-compliance if they do not have an
  understanding of the benefits of using CPAP
  therapy or the impact it could have on the
  patients quality of life

1Weaver, TE and Grunstein, RR. Adherence to
continuous positive airway pressure therapy the
challenge to effective treatment. Proc Am Thorac
Soc 20085173-178.
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FOSQ Questionnaire

• OSA specific quality of lifequestionnaire
• Assesses impact OSA on
• Activity level
• Vigilance
• Intimacy
• Productivity
• Social outcomes

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Plan your rescue strategy

• On average, 20-40 of patients abandon treatment1
• Roughly 50 of these patients can be converted to
  bi-level therapy and remain compliant for the
  long term2,3
• Consider implementing a bi-level rescue program

1 Engleman, H.M., and Wild, M.R., Sleep Medicine
Reviews 2003 7,181-99. 2 Szumstein, s., et
al., Sleep 1999, Abstract Supplement.3 Gay,
P.C., et al., Sleep 2005, Abstract Supplement.
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Data management and compliance monitoring
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CPAP Reports

• Humidification
• C-Flex
• Overall Daily Use

Confirmation of pressure setting
Quality of Life assessment
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CPAP REPORTS

• Trend Dates
• Data on report is based on these dates at the
  top of the report

• Average AHI
• Treat similar to sleep study standards
• If the AHI gt 5 with EDS or gt15 consistently you
  may want to address with patient MD

• Average Vibratory Snore Index
• Determines amount of snoring or airway movement
  with therapy
• Excessive snoring may negatively impact therapy

• Leak Information
• Acceptable leak based on pressure and mask being
  used
• High mask leaks may cause pressure levels to be
  inaccurate

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Blower hours vs. Breathing hours
Black line Ramp/Loss of therapy/ blower on no
breathing detected/ Match with QOL
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Data Management System

• Setting the standard for the best patient care

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Identification of compliance

• Advanced reporting tools
• Cross patient reporting capabilities
• Referring physician
• Insurance company
•  Therapy mode (cpap, bi-level, auto-cpap)
•  Mask type

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Advanced reporting

• Advance Reporting Data
• Mask aging
• Mask replacement

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Advanced reporting
Compare patient success rates with different masks

• Cross patient reporting capabilities
•   Referring physician
•  Insurance company
•   Therapy mode (cpap, bi-level, auto-cpap)
•   Mask type
• Humidification (passover, heated, none)

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Communication is key to success

• Ensure your patient understands the importance
  (and necessity) of providing usage data in order
  for you to identify possible barriers to
  compliance and to initiate appropriate
  interventions

Tip Ensure patients understand how you will be
collecting their usage data how and when do
they get the data card back to you?
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Rememberbe proactive and encourage questions

• There are a variety of reasons for
  non-compliance and may encompass problems with
  the mask, difficulty adjusting to the device,
  psychological issues or a combination of factors

Tip Some patients stop using their therapy
because of problems that could be easily
addressed in the sleep lab or during set-up
Encourage patients to ask questions!
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Summary

• There are many reasons why a patient may choose
  not to be compliant with CPAP therapy
• Your patients may experience none, one, or
  perhaps all of these, during the initial
  treatment period
• As a result, clinicians will likely need to
  utilize a variety of approaches very early in the
  treatment period when addressing these adherence
  issues with their patients

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Questions?

• Thank you for your time