Compliance Issues in Home CPAP Therapy. Joseph Lewarski, BS, RRT, FAARC

Transcription

1 Compliance Issues in Home CPAP Therapy Joseph Lewarski, BS, RRT, FAARC

2 Obstructive Sleep Apnea Syndrome OSA 1 st recognized over 30 years ago 1981 Sullivan publishes small study in Lancet¹ Late 80s, early 90s population based studies suggest high prevalence of OSA in adults² 1 Sullivan CE, et al. Reversal of obstructive sleep apnoea by continuous positive airway pressure applies through the nares. Lancet 1981 Apr 18;1(8225): Young T, et al. Epidemiology of Obstructive Sleep Apnea: A population health perspective. Am J Respir Crit Care Med Vol 165:

3 Growth in CPAP Use in the US: Medicare Data Medicare CPAP Spending $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $

4 CPAP Therapy Evidence CPAP for the management of OSA Abundance of studies and anecdotal data supporting the efficacy of CPAP in treating the physiologic symptoms of OSA Two major papers & guidelines from the AASM Gay P, Weaver T, Loube D Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. SLEEP 2006;29(3): Kushida CA, et al. Practice parameters for the use of continuous & bi-level positive airway pressure devices to treat adults with sleep related disorders. SLEEP 2006;29(3):

5 Defining CPAP Compliance There is currently no standard definition of compliance Kribbs,, et al, Am Rev Respir Dis 1993;147: defined compliance as 4 hrs/night 70% nights 60% of the patients reported nightly use but only 46% objectively met the usage criteria Sin, et al, Chest 2002;121: Used a range from 2.5 to 4.5 hrs/night Measured compliance from 93% to 78% depending on definition Patient education and close follow-up improved compliance Other studies have used as low as 2 hrs/night as the definition of compliance

6 Patient Education & Follow-up Drivers of Compliance Systematic education programs improve patient compliance Organized, consistent training programs are effective tools for improving patient compliance Close follow-up of CPAP use and problems by trained health care providers Especially important in the first few weeks of the therapy Long term CPAP compliance is establish in the first few months of therapy At least one study (Weaver, et al, Sleep 1997;20:278-83) 83) suggests long term CPAP compliance patterns are established in the first week of treatment Other studies suggest that compliance and usage behavior in the first weeks and months predicts long term behavior

7 Patient Education & Follow-up Address side effects quickly; compliance drops if not corrected Many side effects manifest in the first weeks and left untreated, may result in discontinuation of tx Interface and pressure related complaints are most common Objective monitoring of CPAP use Patient report usage information is not accurate or reliable. Patients often over-report report use by hrs/night Objective monitoring tools (i.e., hour meter, download technologies) are needed to provide accurate compliance data

8 Role of the Technology: PAP Generators There is very little published level-1 1 evidence to support the role of novel pressure devices and bi-level over standard CPAP 2 level-1 1 RCT showed no compliance improvement of bi-level vs. CPAP 1,2 Anecdotally, there may be some benefit of bi-level for some patients with very high pressure needs 1 Gay, et al. Sleep 2003;26(7): Reeves-Hoche, et al. Am J Respir Crit Care Med 1995;151:

9 Role of Technology: Humidity Evidence supports added humidity (heated) improves CPAP compliance 3 of 4 RCT demonstrated improved compliance with heated humidity Few studies compared heated vs. non-heated or different heated and/or non-heated devices (i.e., small, integrated heaters vs. large, free-standing) Sin, et al used passive, non-heated humidity for the majority of patients and claims very high compliance

10 Role of Technology: CPAP Interfaces Anecdotally, the interface plays a major role in CPAP compliance Little objective, scientific data exists to guide interface selection Dozens of interfaces may promote frequent and unsuccessful changes There is little scientific data demonstrating the efficacy or outcomes associated with any particular interface 2 Small studies to compare oral CPAP device to traditional mask. Khanna,, et al. Sleep Med Jul;4(4): & Anderson, et al Sleep 2003 Sep;26(6): study compared nasal pillows to a mask. Massie, et al. Chest 2003 Apr;123(4):1112-8

11 Clinic vs. home setup Patient Training: Location All patient education & training is important and promotes compliance Evidence supports group, clinic and home setup/training No studies support that one point of care is better than others (i.e., home training is better than clinic) Anecdotal data suggests clinic or outpatient setting may be highly effective for many patients Less distractions than home setting

12 AASM Practice Parameters: Standards CPAP is indicated for the treatment of moderate to severe OSA CPAP is indicated for improving self-reported sleepiness in patients with OSA CPAP should be objectively monitored to help assure utilization Close follow up of PAP usage and problems in patients with OSA by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems, if needed. This is especially important in the first few weeks of PAP use

13 AASM Practice Parameters: Standards The addition of heated humidification is indicated to improve CPAP utilization The addition of a systematic educational program is indicated to improve PAP utilization CPAP & BPAP therapy are safe; side effects and adverse events are mainly minor and reversible

14 ACCP Sleep Institute Consensus Conference-Sept 2006 Consensus Conference on the aftercare of patients with OSA Care of patients with OSA is dysfunctional Payment is weighted toward diagnosis, not effective treatment and management Research is limited and more is needed Consensus paper to be published in CHEST in 2007

15 Summary Patient education, monitoring and regular intervention/support play a major role in CPAP user compliance Early and effective patient training & support influences long-term compliance Patients with subjective symptom relief are more likely to remain compliant More research is needed to define clinically effective compliance Appropriate payment method is necessary for patient training and follow-up