DOC WOULD NOT PRESCRIBE AUTO C-FLEX

Hey folks, no need for apologies. I've been to Australia many times, they have some very competent medical personnel there. I am very interested in their opinion on the issue. Meanwhile, as I said earlier, there have been many studies done on the subject in this country and I have provided just a few of the links in my earlier post.

My soon-to-ex sleep specialist contends that all the studies showing positive results for APAPs in comparison to CPAPs were funded by makers of APAPs.

With the XPAP technology developing rapidly, it may be best to look critically at studies that were done more than a few years ago.

fstanmyre wrote:Hey folks, no need for apologies. I've been to Australia many times, they have some very competent medical personnel there. I am very interested in their opinion on the issue. Meanwhile, as I said earlier, there have been many studies done on the subject in this country and I have provided just a few of the links in my earlier post.

Thanks Stan,

Yes there are some *outstanding* OSA researchers in Australia

Cheers

DSM

Anonymous wrote:dsm-- it is Fred (as signed in his post) not Stan.
Again, Fred, our apologies to you.

Opps, I missed this too.

Fred, sorry I have kept calling you Stan.

Cheers

Doug

gracie97 wrote:Tried to return the REMstar Pro 2 he’s renting to me for $500/month today, but the front desk staffer REFUSED to take it back, saying she’s not allowed to accept rental machines back without permission of the doctor.

I'm a little surprised I haven't read someone else questioning this. Is it common practice for a doctor to also act as a DME? Doesn't this scream conflict of interest to anyone but me?

And as if to validate my ticket:

Mr Tired wrote:Just got back from the doc. I asked him to change the prescription from c-flex to auto c-flex. He would not do it. He said the auto feature is unreliable & has not been perfected yet.

If he's also acting as the DME, could his doctor's real (even if subconscious) motive be that the APAP is more expensive than the CPAP, but the insurance company will only reimburse at the lower CPAP price, therefore reducing his margin of profit (as DME)?

That is an issue with DMEs having to supply the more expensive APAP machines if that's what the Rx calls for, but the insurance company only reimburses at the CPAP price. But if the doctor is also the DME, well...

In my case, my GP would write the Rx for APAP & then simply tell the DME "I don't care about your profit margin problem, I want him to have APAP!"

And oh, by the way RG,

• Do You know the difference between a doctor and God?
  God doesn't think he's a doctor.

Ya'all sleep well tonight...
Rol

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CPAPopedia Keywords Contained In This Post (Click For Definition): C-FLEX, CPAP, DME, Prescription, auto, APAP

Rol Yup.

Wish I could remember who posted about a funny cartoon he saw once. I think it might have been WillSucceed. Wish I could find the post. Anyway, went something like this:

Man walks into a doctor's office. Receptionist tells him, "Please have a seat. After the doctor is certain you've waited a sufficient amount of time to feel totally insignificant, he'll see you."

fstanmyre wrote:Hey folks, no need for apologies. I've been to Australia many times, they have some very competent medical personnel there. I am very interested in their opinion on the issue. Meanwhile, as I said earlier, there have been many studies done on the subject in this country and I have provided just a few of the links in my earlier post.

Fred,
as I mentioned to you via PM, I spoke to D (name & ph# as supplied to you) at the RNSH SS clinic yesterday. I raised the matter of AUTO studies -- D said that RNSH have no axe to grind and support no particular vendor, just patients, and that their issue is that the studies they have seen to date have been funded by Vendors and that most of these studies seem to concentrate on patients with low pressures (in the 10 region).

D said that the biggest problem they have is that whilst AUTOs seem to be the future, there are no independent studies done that they are aware of. So if you have any, please pass the sources on to D she will be more than appreciative if they stack up.

D also said that results with patients using AUTOs are inconsistent (that seems to be reflected in other peoples posts here). The inconsistencies seem to be more noticable among patients on high pressures (15-20).

There is also an issue in that with straight CPAP, the algorithms are simpler and well understood but with AUTOs there is a great variance between what Vendors implement and this raises concerns. D believes that vendors will iron these matters out in time.

In summary D said that they will be happy to recommend AUTO units once they (RNSH SS) clinic have more reliable information in regard to independent studies.

I hope this helps you prepare your call to D.

My hope from this thread, is that we get a better understanding of why some people in the industry may make the recommendations they do even if we don't like or want to hear them.

Cheers

DSM

Btw, you should tell "D" that there are piles of independent studies on auto vs cpap, I gave you just a few links using google. Trust D has access to Google in Australia?

Rested Gal wrote:

Wish I could remember who posted about a funny cartoon he saw once. I think it might have been WillSucceed. Wish I could find the post. Anyway, went something like this:

Man walks into a doctor's office. Receptionist tells him, "Please have a seat. After the doctor is certain you've waited a sufficient amount of time to feel totally insignificant, he'll see you."

Ya, it was me. I have it on my fridge; still makes me laugh.

fstanmyre wrote:Btw, you should tell "D" that there are piles of independent studies on auto vs cpap, I gave you just a few links using google. Trust D has access to Google in Australia?

Fred,

Thanks for those links. I myself read them but I am in no way qualified to say if they are independant or Vendor funded or not. How does one know ?, How are *you* working that out ? - if you can validate their independance I am happy to email and hardcopy them to the RNSH SS clinic.

Cheers

DSM

PS: Any joy getting thru to D ?

PPS: I also located the original post I saw that raised questions about runaway pressures. It is a post in this thread ... viewtopic.php?t=2327&start=0

It is under the name Guest so I don't really know who wrote it. RG Do you know ?

If the below poster has *any* authority, then some interesting questions were raised.

>>>
Mike, I suspect the Remstar Auto likely addresses air-pressure responsive flow limitations as good as any AutoPAP. For all intents and purposes, the multiple controller approach is implemented by the other AutoPAP models as well. That is because they each: 1) must detect/differentiate sleep events, 2) provide different pressure response routines based on sleep events (versus a universal and indiscriminate pressure response routine for all detected events), and 3) Make a pressure response priority call when these differentiated sleep events either concur or simply overlap in pressure response time windows.

The 420e's tendency to over trigger on flow limitations is interesting. My first take was that this had to be a flaw or oversight. However, my second thought is that PB does not want to relinquish the real-time resources toward a more robust pressure-response "sanity checking" routine than they already have. Because the IFL1 can be turned off directly from the LCD control panel (whereas IFL2 cannot), PB is full aware of this particular response. Yet they opt not to relinquish it. Rather, they implicitly leave the assessment of possible IFL1 over triggering to human eyes. I'm sure they intended those eyes to be therapists' versus the end user. The first Remstar RG bought was from a woman who also experienced pressure runaway. The Spirit has experienced pressure runaway as well. The potential for APAP to pressure-runaway with under specific circumstances seems to be an Achilles Heel in my opinion.

My hunch is that PB would have to beef up physical resources to accomplish even more algorithmic tasks then they currently do. That implies the possibility of more accommodation for IPS, more heat transfer, more physical form factor at worst. At best it implies additional development cost to overhaul the design toward accomplishing quite a bit with the same real time constraints. More guesswork and pondering on my part than anything else, however. I would love to see all AutoPAPs capable of detecting and correcting pressure runaway scenarios. I think the 420e suffers IFL1-based pressure runaway so much because it is so very pressure aggressive with flow limitations.
<<<

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CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, auto

dsm, the "Guest" you quoted was -SWS as he explained in the post just under where he was accidentally "guested" in that topic. His authority (as far as I'm concerned) is a mind second to none in understanding how these machines work. He isn't a doctor, or cpap machine designer, if that's what you're asking.

I'd take anything -SWS says about how autopaps work to the bank. He has both a Respironics REMstar Auto (before they added C-Flex) and a Puritan Bennett 420E auto.

Fred, I'd say "D" in Australia is hanging her hat primarily on this particular link that you provided: American Academy of Sleep Medicine Review which looked at a great many studies of autopaps.

I've lifted a few excerpts from the AASM review that sound very much like what she has seen or heard about.

The Use of Auto-Titrating Continuous Positive Airway Pressure for Treatment of Adult Obstructive Sleep Apnea

An American Academy of Sleep Medicine Review
SLEEP, Vol. 25, No. 2, 2002

(website Page 10)
p. 157 "Part 5.8 Are there safety considerations in selecting patients for auto-CPAP titration or treatment?"

"While most studies did not exclude patients needing high CPAP levels (>14 cm H2O), the average treatment pressure in most studies was in the 8 to 12 cm H2O range. No study specifically addressed APAP efficacy in the group requiring high CPAP pressures."


(website Page 11) p. 158 "Part 6.0 Future Research"

"Review of the current literature has identified several issues that need more information. There is little or no data comparing the effectiveness of different APAP technologies."

"There is conflicting data about whether chronic treatment with APAP can increase acceptance of or adherence to positive pressure treatment. To date, no study has shown APAP improves patient outcomes."

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Of your links, this next one probably provides your best argument.

Your 4th link (actually third one, since link 2 & 3 were duplicates) went to this PDF article about a German study published in CHEST in 1998:

http://www.chestjournal.org/cgi/reprint/113/3/714

This study was cite #35 in the AASM review of studies.

"Use of Conventional and Self-Adjusting Nasal Continuous Positive Airway Pressure for Treatment of Severe Obstructive Sleep Apnea Syndrome*

A Comparative Study

Martin Konermann, MD; Bernd M. Sanner, MD; Martin Vyleta, MD; Frank Laschewski, MD; Juergen Groetz, MD; Alexander Sturm, MD; and Walter Zidek, MD"

"Conclusion: Self-adjusting nCPAP demonstrates the same reliability in suppression of respiratory disturbances as fixed-mask pressure therapy. Sleep quality is slightly superior, patient compliance is highly significantly better. (CHEST 1998; 113:714-18)"

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However, if "D" is, indeed, relying heavily on the AASM review, the three AASM reviewers had some quibbles with the German study.

The AASM's comments about the German study included this (website Page 9) :

p. 156 "5.7 What is the evidence that auto-CPAP will increase acceptance or utilization with positive pressure treatment when used as long-term treatment for OSA?"

"Konermann et al. (35) also used a parallel design in which patients were randomized to fixed CPAP or APAP in-lab titration followed by a three-to-six-month treatment period using the same mode of positive pressure. Adherence was determined over that period. The number of nights per week with >4 hours use was greater in the APAP group (APAP: 6.5±0.4 vs. CPAP: 5.7±0.7 night per week). The mean nightly duration of use did not differ (5.6±2.5 with CPAP vs. 5.9±1.6 with APAP), and the fixed CPAP and APAP groups were well matched. However, the exact details of the timing of when adherence monitoring occurred were not provided. Thus, one cannot determine if adherence was sampled at equivalent times in the two groups. The APAP group had more slow wave sleep on the initial treatment night. This group may have responded better on average to positive pressure and thus potentially might be more adherent. Furthermore, it was not documented that the small difference in adherence resulted in any difference in outcomes."
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I wonder if the three people preparing the AASM report were not just a tiny bit biased against autopap? I don't quite see why they came up with this comment about the German study (emphasis mine):

"The APAP group had more slow wave sleep on the initial treatment night. This group may have responded better on average to positive pressure and thus potentially might be more adherent."

Seems to me an equally plausible comment could have been stated like this (my words, not the AASM reviewers' words!): "An increase in slow wave sleep on the initial treatment night of the APAP group may have demonstrated better treatment and thus might have made that group more adherent."

At any rate, Fred, thought you might want to be forewarned about whether the AASM review was the right kind of ammunition or not for a chat with "D".

I'm a believer in autopap, but if a person is going to butt heads over "studies" with a sleep professional who may be relying on the American Academy of Sleep Medicine's review of other studies, I'm afraid that link won't get you very far.

P.S. About this link:
http://ajrccm.atsjournals.org/cgi/conte ... 163/6/1295

Patric Lévy and Jean-Louis Pépin (the authors) are consultants to Mallinckrodt.

Mallinckrodt is associated with Puritan Bennett - manufacturers of the Goodknight cpap, autopap, and bi-level machines. There would be a vendor sponsored connection in that study.

RG

Excellent detective work. I am still wondering then about the runaway pressure problem SWS spoke of.

Fred, do you have any comments on this aspect of the thread seeing as this issue was where you stepped in it

Cheers

DSM

I asked him to change the prescription from c-flex to auto c-flex. He would not do it.
Mr Tired

Mr. Tired,

Curious about whether you've made any decisions about this situation yet?

I tried yet again to return my CPAP to sleep doctor today -- this time he was really helpful and charming (a first for him), so I wound up walking out with it yet again.

He scoffed a bit when I talked about how I wanted a machine that would reduce pressure as possible: "Your pressure is only 7!" (I don't care: It's still work to breath out against it, and when I'm asleep, I want to be resting as much as possible.)

From what I've been told, returning the CPAP would be tantamount to parting company. In ways, that sounds really win/win. But there's one catch: He seems to appreciate the full spectrum of my sleep disorders. And because I fear (for good reason) becoming disabled with these problems and because he seems to be very reputable (in spite of his sleazy rental tactics), he could come in handy.

My PCP has written a prescription that should be good for an auto for me, so all that is stopping me is just managing to return the CPAP.

It irritates me that the doctor and his clinic are so PUSHY about this: If APAPs are no worse than CPAPs, I think they should just humor me and not try to coerce me into having a CPAP. That they won't do that strikes me as part of the dominating nature of that provider which is really chafing in various other ways.

Mr. Tired & Gracie97 - I think you're just threatening to cut into your doctor's profits.

Note a quote from me in an earlier post on this thread. I wrote: "I'm a little surprised I haven't read someone else questioning this. Is it common practice for a doctor to also act as a DME? Doesn't this scream conflict of interest to anyone but me?"

And then: "If he's also acting as the DME, could his doctor's real (even if subconscious) motive be that the APAP is more expensive than the CPAP, but the insurance company will only reimburse at the lower CPAP price, therefore reducing his margin of profit (as DME)?"

I'm still mystified that we don't see an uproar over what appears to me to be a classic conflict of interest. I think Mr. Tired's & gracie97's experiences are a perfect example of why this should be ringing all kinds of ethics bells.

Am I just being paranoid?

Rol