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
Video Teleconference
Wireless modem data transmission
Store and forward
Phone or video teleconference
Initial In-person or video teleconference evaluation
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
Video Teleconference
Wireless modem data transmission
Store and forward
Phone or video teleconference
Initial In-person or video teleconference evaluation
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
Wireless modem transmission of PAP data
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 + $$ incentive (n=40)
Web-based access (n=46)
3 month Visit (n=45)
3 month Visit (n=39)
Does giving patients access to their PAP data improve treatment use?
Kuna ST et al. Sleep 2015; 38: 1229-36
Total (n=136)
Usual care(n=52)
Web only(n=45)
Web+$$(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 ($$) groups compared to
Usual Care group at one week and 3 months
Kuna ST et al. Sleep 2015; 38: 1229-36
1 2 3 4 5 6 7
Weeks
2.0
3.0
4.0
6.0
7.0
Mean (SD) hours of use per week over 3 monthsAv
erag
e ho
urs
of u
se p
er w
eek
5.0
8 9 10 11 12
Web onlyWeb + $$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
Kuna ST et al. Sleep 2015; 38: 1229-36
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
Kuna ST et al. Sleep 2015; 38: 1229-36
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
Kuna ST et al. Sleep 2015; 38: 1229-36
Phone enrollment(N=60)
Video tele- conference (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
Fields B et al. Sleep (in press)
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
Fields B et al. Sleep (in press)
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)
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
Wireless modem transmission of PAP data
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
Fields B et al. Sleep (in press)
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
Fields B et al. Sleep (in press)