Change your philosophy about CPAP!

[Sheriff Buford]

Sherriff, do you listen to Pugsy?" --SleepyCPAP

Pugs has a 2 by 4 made especially for me and with my name on it. I know she keeps it next to her keyboard and has threatened to "come lookin' for me" in Texas. I told her to let me know and I'd put out an "all points bulletin" for a lady with a cpap machine in the back (maybe several) and a couple of pug-nose dogs in the front seat with her.

I have stared-down a loaded gun twice in my life (once, I even heard the gun cocked... sheesh)... but I fear that 2 by 4 more...

Sheriff

[jdm2857]

Are you familiar with the phrase "thank you ma'am, may I please have another?"?

[chunkyfrog]

Picking on a man who is likely to be packing heat?
As it stands, hours of use is all we've got, even though the minimum numbers are sorrowfully low,
and the intent can be easily subverted by an angry, selfish person trying not to lose his CDL.
Of course, insurance companies could greatly increase effective use (and their bottom line) by demanding full-data AUTO machines,
(with software and data guidance), comprehensive patient education, and unlimited mask trials for the first 6 months.
Peering into our therapy numbers could be too invasive, and possibly illegal.
The cpap paradigm definitely needs some tweaking.

[forthguy]

It gives me some hope, forthguy, to hear that in at least one place the process is taking advantage of the new technology and getting unstuck from the old ways! Do you have any idea what helped things shift where you are? Did anyone talk to you about the shift? Knowing that might make a difference where I live.

Well, I have Kaiser in Northern California, and for them I'm pretty sure it's all about efficiency. My personal process was pretty quick, but I think it's because my facility in Vallejo may be one of the smaller full-service Kaiser facilities in the area. From what others have posted, the processes are very similar at the larger facilities, but the timeframes are longer. Janknitz has posted several explanations like the following, which seems to about sum it up:

Why then, do you think, does Kaiser have a very aggressive program to diagnose and treat OSA? Kaiser really pushes its primary care physicians to recognize the signs of OSA and send their patients for diagnosis. In my regional Kaiser facility, they test around 100 people a week, and I am guessing but I think they diagnose about 50- 75 people EACH WEEK. Mind you that Kaiser doesn't even charge a co-pay for the sleep testing, diagnosis and treatment--only for the machine and supplies (Kaiser is its own DME, although Crapria is the supplier). And believe me--based on the size of my co-pay--Kaiser isn't making any profit on my 20%.

Kaiser determines what they will cover based on EVIDENCE-BASED medicine. And the evidence in sleep medicine shows that a if a person with OSA is properly treated, more expensive illnesses like heart disease, stroke, diabetes, and motor vehicle accidents can be PREVENTED or greatly reduced. So Kaiser is being penny wise and pound wise--treating OSA pays off in reduced downstream medical costs.

I don't know it to be a fact, but that explanation seems perfectly logical to me. Kaiser has an incentive to keep its members from suffering from OSA, because of the larger impact on their bottom line. If they're going to do that, they need to process their members efficiently. Even though my timeline was shorter than others have experienced, the base process remains the same: in-home sleep test using a WatchPAT, issuance of a loaner auto machine for in-home titration, and data review and issuance of a permanent machine.

(The larger facilities, like Santa Rosa, actually lay out their process on their websites.)

[djhall]

Hooray for finally getting the point: effective treatment leads to better health. Hours of use isn't what to look for anymore, the data from data-capable machines is worth looking at to determine effectiveness! ... Why is more time on CPAP (or whatever PAP mode of therapy) still the measure?

Personally, I didn't take this as a proposal that AHI's should be used to determine compliance. I took it as a proposal that follow up focus should shift from simply ensuring compliance hours to a detailed analysis of the effectiveness of the treatment (including the reasons for non-compliance if present) rather than caring only about compliance hours without looking carefully at AHI, leaks, etc. to try to figure out if the treatment could be more effective and/or better tolerated by the patient.

[DiverCTHunter]

Helloooo to everyone still stuck on hours-of-use: please wake up and time warp back from the good old days when you warmed up your car in the driveway for a set amount of time before driving your rented movie back to Blockbuster Video ("please be kind and rewind")! I'm guessing most Docs and DMEs watch digital at home, and do the rental online or on screen from the comfort of their couch. These are intelligent, willing-to-embrace technology adults, whose training and protocols at work don't match what is in all other areas of their lives. Digital electronics improve more quickly than medical education, apparently.

Emphasis added for effect.

I'm in medical IT and I can count the number of intelligent, willing-to-embrace-technology doctors I've met on one hand

[Pugsy]

I'm in medical IT and I can count the number of intelligent, willing-to-embrace-technology doctors I've met on one hand

I am out of the field now but still have some contact and I don't know that I can count above one hand on those that I know.
Not my official sleep doctor for sure...about as much personality as a toad. I don't care if I never see him again. Not a bad doc from what I hear but just so "blah".
Now his PA....worth her weight in gold and then some. We never discussed hours of use...we discussed how I felt and then discussed the reports I had brought with me. Since I had bought my machine out of pocket they didn't even care about hours of use....they had no idea how many hours I used it and in fact didn't ask.

I will refrain from getting up on the soapbox. Pretty much what I think has already been said here.
I do think that brick machines should not exist at all. I think it borders on malpractice to prescribe a treatment and not have some sore to measure or evaluation tool to look at if there is a problem beyond "hours of use". Hours of use is useless IMHO.
Too many other things can mess with people and their sleep and how they feel.
No, not everyone will want to monitor their data or in fact need to but I think it should be there available just in case.
Better to have it and not need it than need it and not have it.
Whenever the medical profession and the insurance companies (which ever one was the driving force behind this 4 hour thing) got together to set the compliance standard by hours of use they sure missed the boat.
Typical bureaucracy though...no one has any common sense.

[archangle]

Actually, I think the current 4 hour per night 70% of the nights for 30 days out of the first 90 days "compliance" standard is good for what it's intended for.

It says you can't get a CPAP machine, not use it, and expect insurance to keep paying for it. It gives the patient, doctor, and DME incentive to get the patient to actually use it.

If it's being used for something like truck driver regulatory compliance, there's value there. I think for most drivers, if they go to the effort to wear it for 4 hours a night, they'll adjust to CPAP eventually.

The idea of requiring a specific AHI is a bad idea in my opinion. If someone goes from an AHI of 90 to an AHI of 20, they're probably a lot better off. Also, AHI doesn't take the severity of events into account. An AHI of 20 may mean that the patient has 20 full obstructive apneas an hour that are 100% non breathing for 2 minutes each time. It could also mean 20 events an hour that are 11 seconds long.

The sad thing is that "dumb 4 hour" compliance is used as a measure of "success" by incompetent or lazy doctors and other "professionals." They really should review a few nights of in home data, including event count, type, duration, and airflow graphs.

I really wish the insurance companies would start requiring some sort of yearly data check. Take a few nights of full data, including airflow, send it to some central repository where it gets reviewed. You could probably have a computer program that rapidly clears 90% of the patients by looking for low AHI, no long apneas, etc. Then flag the remainder for a quick review by a human with minimal training, with a process for feeding the information to a more qualified person if something needs further evaluation.

[caffeinatedcfo]

Sleep I agree - the use of APAP devices could greatly improve quality of life for patients. I had to wait for my sleep study first, but luckily that was only a couple of weeks for me. A couple of days later, my PCP had the report which confirmed severe OSA. I was immediately referred to a sleep doc - again a short wait but luckily only two weeks. Sleep doc immediately wrote a script for APAP machine because he checked and the sleep center was backed up for a month to do my titration study. It took me a couple weeks to get the right pressure and mask, but I was well on my way to good sleep before my formal pressure study.