I saw the Sleep folks yesterday. My clinic is associated with a teaching hospital so I have been interviewed by three different residents/fellows and a regular RT so far. My visit is always closed with brief consultation with the Honcho. It has been an interesting experience.
I had been concerned about the integrity of my sleep study 2 years ago and the Fellow that interviewed me yesterday (a tiny, very bright Filipino Chinese lady) had me all ready to go for a second titration study but the Honcho seemed to kibosh that. My problem ended up being my 48 day compliance record. They dumped the card and found that I had averaged 8.42 hours of compliance over the 48 days with zero days below 6 hours.
They said - “We never, ever see that!”. The average was a little high because of a few naps and several Saturday sleep-in marathons but I probably do get 8+ per day on the PAP. The problem is that I don’t feel that much better, at least yet. I am very much overweight (embarrassed to report exactly how much), have some arthritis and other inflammation problems etc. so I can not point specifically to the PAP and pressure but I remain a little skeptical but I think I missed a chance at a second titration because of my good compliance numbers. The fellow reviewed my sleep study and said my AHI was 7 (wonderment on my part) Apneas cleared at 8 (my prescribed pressure) and snores cleared at 10 (“why didn’t they prescribe 10?” her question but now mine too?). They left the machine at 8. She also speculated about UARS but that ended up going no further. The low AHI answers the questions I had about the ENT’s amazement at me being prescribed at all. I did not see the saturation levels but I’ll bet they were low. I need to get a copy of my study but they seem to be reluctant to provide it. I’ll kick up more of a fuss to get it eventually.
I was able to get a script for an APAP but there is no chance in the world my insurance will spring for it with those compliance numbers so, if I am going to do it I will have to use my own $$.
Several questions:
1. Are those compliance #s really that exceptional?
2. Are my concerns realistic (in your experience) or do the compliance #s say it’s working?
3. Should I spring for the APAP and resulting data access? I can afford it, more or less, but there are other places I could spend that $$ or I could hang on to it.
4. If I spring for the APAP should I wait on the Remstar M? (I currently have Remstar Pro not the 2), go for the current Remstar? (save on the humidifier) or go for the Resmed Vantage? The RT recommended the Resmed seeming to think the algorithm was better. I got two scripts because of my desire to not buy another humidifier.
5. What about notching up my pressure to 10 on my own?
Final comment in this windy post – they were astonished at my level of engagement, knowledge and compliance. That is because of what I have learned here. Thanks.
David
Doctor Visit Story – Long with ?s
4 posts
• Page 1 of 1
Doctor Visit Story – Long with ?s
O.G.S.D.K.
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Guest
Regarding compliance, the statistics are pretty dismal:
It is known that the CPAP compliance rate is significantly higher in Europe than in North America (80% vs 46% at 3 months). Also, fewer patients abandon CPAP in Europe than in the United States (5%-19% vs 19%-37%). In addition to cultural differences, perhaps Europe provides overall better patient support. Several studies have confirmed that more intensive support, and also simple follow-up measures, increases CPAP compliance rates.
Hoy et al compared CPAP compliance using standard support and an intensive educational program including nursing support. As expected, the average CPAP use was significantly higher (5.4 hours vs 3.8 hours per night) in the intensive support group. The authors estimated the additional cost for the intensive support at $1,500 per patient. Obviously, the full cost-benefit of such intensive support needs to be further evaluated.
The first studies investigating CPAP compliance were based on patient self-reports. The reported compliance ranged from 63% to 90% (nights device used). However, the first study to measure objective CPAP compliance noted a compliance of 68% with an average effective CPAP use of 4.28 ± 1.03 hours per night. In the often-quoted study by Kribbs et al, 76% of patients reported a use in excess of actual use and only 46% met the criteria for regular users. However, in a European study, 75% of patients met those criteria.
After a CPAP trial, 70% to 80% of patients accept CPAP and 5% to 37% of those will eventually abandon CPAP.*
*CPAP Compliance by Tony Sicenica, MD, and Lewis R. Kline, MD
It is known that the CPAP compliance rate is significantly higher in Europe than in North America (80% vs 46% at 3 months). Also, fewer patients abandon CPAP in Europe than in the United States (5%-19% vs 19%-37%). In addition to cultural differences, perhaps Europe provides overall better patient support. Several studies have confirmed that more intensive support, and also simple follow-up measures, increases CPAP compliance rates.
Hoy et al compared CPAP compliance using standard support and an intensive educational program including nursing support. As expected, the average CPAP use was significantly higher (5.4 hours vs 3.8 hours per night) in the intensive support group. The authors estimated the additional cost for the intensive support at $1,500 per patient. Obviously, the full cost-benefit of such intensive support needs to be further evaluated.
The first studies investigating CPAP compliance were based on patient self-reports. The reported compliance ranged from 63% to 90% (nights device used). However, the first study to measure objective CPAP compliance noted a compliance of 68% with an average effective CPAP use of 4.28 ± 1.03 hours per night. In the often-quoted study by Kribbs et al, 76% of patients reported a use in excess of actual use and only 46% met the criteria for regular users. However, in a European study, 75% of patients met those criteria.
After a CPAP trial, 70% to 80% of patients accept CPAP and 5% to 37% of those will eventually abandon CPAP.*
*CPAP Compliance by Tony Sicenica, MD, and Lewis R. Kline, MD
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NightHawkeye
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Re: Doctor Visit Story – Long with ?s
David,
FWIW, you may be focusing too strongly on the worst case scenario of insurance not paying for the APAP. I'd recommend to you what I did. Focus on what you think is appropriate, and let that drive your decision. In my own case, I failed my sleep study so I was worse off than you with regards to insurance, at least initially. I decided to pursue what I thought was appropriate and requested an xPAP prescription. My physician wrote it without argument, but suggested that I would have to pay for it myself.
To me, the cost-to-benefit analysis was overwhelming, given the status of my health at the time. Fortunately, insurance paid 100% of the cost of the machine - no argument at all.
Is data monitoring worth it? In my opinion, that's a no-brainer. I can't imagine doing xPAP without monitoring. Choice of machine and method is up to you. I find Encore Pro quite useful.
Don't know about the need for APAP. In my case, it makes a lot of difference being able to spend much of the night at low pressures, but that doesn't seem to be necessary for a lot of folks. Plenty of people do just fine adjusting a CPAP on their own. Pick whichever way you're comfortable. APAP is not a magic bullet compared to CPAP. All APAP's can be set to CPAP mode if you prefer that though.
Hope this helps a little, David.
Regards,
Bill
FWIW, you may be focusing too strongly on the worst case scenario of insurance not paying for the APAP. I'd recommend to you what I did. Focus on what you think is appropriate, and let that drive your decision. In my own case, I failed my sleep study so I was worse off than you with regards to insurance, at least initially. I decided to pursue what I thought was appropriate and requested an xPAP prescription. My physician wrote it without argument, but suggested that I would have to pay for it myself.
To me, the cost-to-benefit analysis was overwhelming, given the status of my health at the time. Fortunately, insurance paid 100% of the cost of the machine - no argument at all.
Is data monitoring worth it? In my opinion, that's a no-brainer. I can't imagine doing xPAP without monitoring. Choice of machine and method is up to you. I find Encore Pro quite useful.
Don't know about the need for APAP. In my case, it makes a lot of difference being able to spend much of the night at low pressures, but that doesn't seem to be necessary for a lot of folks. Plenty of people do just fine adjusting a CPAP on their own. Pick whichever way you're comfortable. APAP is not a magic bullet compared to CPAP. All APAP's can be set to CPAP mode if you prefer that though.
Hope this helps a little, David.
Regards,
Bill
Thanks,
I reached the same conclusion re: insurance. I have HMO which is a little less flexible. I am not even sure how to approach it but I may give it try. I don't think the docs will go to bat for me, they seem to think everything is fine.
Since I have the script I will wait awhile. I am interested in the smaller machines like the Vantage or the new M since I plan to travel to Europe in the fall. Perhaps there will be useful feedback on the M by late summer.
It seems that my therapy is OK and I just need to show some patience. I may kick the pressure up a little to see if I feel better quicker but it may just take time. I do wish I could monitor but I can wait as well.
I think that more is better if I can get my hands on it affordably, or not. I can go straight CPAP, I can go sans C-Flex, I can go with humidifier but if I don't have APAP, C-Flex and humidifier it is a lot harder to add them..
We will see. Thanks for the feedback.
David
I reached the same conclusion re: insurance. I have HMO which is a little less flexible. I am not even sure how to approach it but I may give it try. I don't think the docs will go to bat for me, they seem to think everything is fine.
Since I have the script I will wait awhile. I am interested in the smaller machines like the Vantage or the new M since I plan to travel to Europe in the fall. Perhaps there will be useful feedback on the M by late summer.
It seems that my therapy is OK and I just need to show some patience. I may kick the pressure up a little to see if I feel better quicker but it may just take time. I do wish I could monitor but I can wait as well.
I think that more is better if I can get my hands on it affordably, or not. I can go straight CPAP, I can go sans C-Flex, I can go with humidifier but if I don't have APAP, C-Flex and humidifier it is a lot harder to add them..
We will see. Thanks for the feedback.
David
O.G.S.D.K.
4 posts
• Page 1 of 1