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Sleep Apnea Research
Jon H. Lemke, Ph.D. Chief Biostatistician
Jordan Brautigam, MHA Business Analyst
Business Intelligence Center Genesis Health System
2016 Genesis Research Summit June 8, 2016
Adler Education Center Genesis Medical Center, Davenport (East Campus)
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Sleep Apnea Research Outline
Study Purpose and Goals
Study Design
Outcomes
Impact on Patient Care
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National Perspective ALL 41 Institutes in NIH claim diagnosis and treatment of
sleep apnea is crucial to their mission.
The Joint Commission issues an Alert Friday June 26, 2015
Incidence of Sentinel Events have an abundance of potential sleep apnea patients.
Recommend screening patients for sleep apnea upon admission to the hospital to identify patients at greater risk for sentinel adverse events.
At Genesis we have been doing this since November 2012. Sleep disordered breathing has a different footprint on across ALL major diagnostic categories.
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Anesthesiologist Perspective “Practice Guidelines for the Perioperative Management of Patients
with Obstructive Sleep Apnea” (2006)
Focus: “Patients with OSA who may be at increased risk for perioperative morbidity and mortality because of potential difficulty in maintaining a patent airway”(1082).
Recommendations: “Anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of perioperative management”(1084).
“A physical examination should include an evaluation of the airway, nasopharyngeal characteristics, neck circumference, tonsil size…”(1084).
“The consultants agree that perioperative use of CPAP or NIPPV may improve the perioperative condition of patients who they believe are at increased risk from OSA…”(1084).
“Because of their propensity for airway collapse and sleep deprivation, patients at increased perioperative risk from OSA are especially susceptible to the respiratory depressant and airway effects of sedatives, opioids, and inhaled anesthetics” (1085).
Selected Previous Research Undiagnosed and Untreated Sleep Apnea patients with
knee or hip replacement were 9 times more likely to have unplanned visits to ICU.
Gupta R, Parvizi, J, Hanssen A, Gay P. Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study. Mayo Clin Proc. 2001;76:897-905.
32% increase (from 37% to 49%) of Left Ventricular Ejection Fraction (LVEF) after one month of PAP use; results reversed after one week without PAP.
Bradley T, Floras J. Sleep Apnea and Heart Failure: Part 1: Obstructive Sleep Apnea. Circulation 2003;107:1671-1678.
Schneider Trucking with comprehensive diagnosis and treatment had 74% reduction in accidents and 91% reduction in hospitalizations.
Lazar RA. An Emerging Standard of Care Requiring Commercial Driver Screening for Sleep Apnea: Practical Considerations and Risk Management Strategies for the Trucking Industry. White Paper Published August 1, 2007.
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Adherent - but
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Sleep Apnea Risk Groups
3. No Dx-Likely Sleep Apnea
4. No Dx-Unlikely to have Sleep Apnea
1. Dx-Adherent
2. Dx-Nonadherent
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Caveats Biases exist in this screening as we primarily depend upon
what the patient tells us.
We are only analyzing those that come to the hospital, and cannot compare them to those that are not hospitalized. In these analyses the focus is entirely on the “Inpatient” encounters.
Changes in demographics of the population, access to care, definitions and documentation are changing who is a hospitalized “Inpatient”.
Some inpatients are screened by self report at one GMC site, transferred and then observed at another GMC site.
Several of these slides focus on the first 2.0 years of encounters.
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Competing Risks: Physician Documented Prevalences with MIDAS+ Cluster Ranking
by Sleep Apnea Status
Sleep Apnea Risk Group
Arthroplasty Total Knee
Heart Failure Septicemia PTCA Viral
Pneumonia
Dx – Adherent 1st
(8.2%) 4th
(5.1%) 2nd
(6.6%) 3rd
(5.3%) 6th
(4.6%)
Dx – Nonadherent 6th
(3.9%) 1st
(6.9%) 2nd
(6.9%) 3rd
(5.7%) 4th
(5.3%)
No Dx – Likely 9th
(2.5%) 4th
(4.2%) 1st
(6.7%) 2nd
(5.6%) 3rd
(5.3%)
No Dx – Unlikely 2nd
(5.4%) 5th
(3.3%) 1st
(6.1%) 4th
(3.9%) 3rd
(4.8%)
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Focus on 44,924 Acute Care Inpatients Sleep Apnea Status by Site
Sleep Apnea Risk Group
Davenport Silvis Aledo DeWitt Total:
Dx – Adherent 4,437
(12.6%) 687
(7.6%) 34
(10.3%) 25
(7.0%) 5,183
(11.5%)
Dx – Nonadherent 4,334
(12.3%) 903
(10.0%) 44
(13.4%) 63
(17.7%) 5,344
(11.9%)
No Dx – Likely 4,464
(12.7%) 997
(11.1%) 31
(9.4%) 47
(13.2%) 5,539
(12.3%)
No Dx – Unlikely 22,012 (62.5%)
6,406 (71.2%)
220 (66.9%)
220 (62.0%)
28,858 (64.2%)
Total 35,247 (100%)
8,993 (100%)
213 (100%)
255 (100%)
44,924 (100%)
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Comparison of Sleep Apnea Risk Groups by Sex Dx of Sleep Apnea
(Group 1 + 2)
No Dx of Sleep Apnea
(Group 3 + 4)
Total
Male 5,915 (27.9%) 15,320 (72.1%) 21,235 (100%)
Female 4,612 (19.5%) 19,077 (80.5%) 23,689 (100%)
Total 10,527 (23.4%) 34,397 (76.6%) 44,924 (100%)
Dx-Adherent
(Group 1)
Dx-Nonadherent
(Group 2)
Total
Male 3,068 (51.9%) 2,847 (48.1%) 5,915 (100%)
Female 2,115 (45.9%) 2,497 (54.1%) 4,612 (100%)
Total 5,183 (49.2%) 5,344 (50.8%) 10,527 (100%)
No Dx – Likely
(Group 3)
No Dx – Unlikely
(Group 4)
Total
Male 2,290 (19.3%) 9,586 (80.7%) 11,876 (100%)
Female 2,072 (14.1%) 12,650 (85.9%) 14,722 (100%)
Total 4,362 (16.4%) 22,236 (83.6%) 26,598 (100%)
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Current Research Team Investigators
Jon H. Lemke
Desyree Weakley
Stephen C. Rasmus
Vicki Loving
Tosha Allen
Mike Malloy
Brian Dirksen
Mikel O’Klock
Neil Flynn
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Special Thanks Maja Zingmark
Hannah McAfoos
Ryan Kelly
Chris Lynn
Dr. Claudy
Gina Gore
Candice Elias
Tami Gumpert
Braxton Lancial
Alyssa Barkalow
Lynn Colberg
Dianna Paustian
Amanda Wesson
Every Physician and Every Nurse who has had a frank discussion about sleep apnea.
All of the Sleep Techs
All of the Respiratory Techs
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Acute Inpatient Complications by Sleep Apnea Status 2013-2015 (18+)
0.00
25.00
50.00
75.00
100.00
125.00
150.00
175.00
200.00
Observedper 1000
Expectedper 1000
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Sleep Apnea Status
O:E Ratio
Delta (O-E)
Excess to
Target
Adherent 1.04 24.9 115.5
Nonadherent 1.19 163.7 273.7
Likely 1.38 258.6 346.5
Unlikely 1.33 1111.0 1546.6
All 1.28 1558.1 2282.3
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Acute Inpatient Mortality by Sleep Apnea Status 2013-2015 (18+)
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
ObservedPercent
ExpectedPercent
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Sleep Apnea Status
O:E Ratio
Delta (O-E)
Excess to
Target
Adherent 0.88 -11.73 0.97
Nonadherent 0.98 -2.36 14.59
Likely 0.89 -15.37 2.75
Unlikely 0.81 -127.02 -41.61
All 0.85 -156.47 -23.29
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Sleep Apnea Status with Maximum O:E Ratio by Most Frequent MDC
System/Disease Complications Mortality ALOS Readmission
Circulatory Unlikely Likely Nonadherent Nonadherent
Musculoskeletal Likely Likely Likely Likely
Respiratory Likely Nonadherent Likely Adherent
Digestive Likely Nonadherent Likely Likely
Infectious and Parasitic
Likely Nonadherent Likely Adherent
Nervous System Nonadherent Nonadherent Nonadherent Unlikely
Kidney and Urinary Tract
Nonadherent Nonadherent Likely Nonadherent
Endocrine, Nutr., Metabolic
Adherent Likely Unlikely Unlikely
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Conclusions Benefits of No Diagnosis or Nonadherence?
More likely to visit the hospital for nonelective reasons
More likely to stay longer
More like to have complications
More likely to code
More likely to have an unplanned visit to the ICU
More likely to die in the hospital
More likely to get inpatient status benefits
Hmm, and for everyone?
Higher motor vehicle insurance premiums
Higher healthcare insurance premiums
Unnecessary loss of friends and family 5/25/2016 Lemke, GHS Business Intelligence Center 36
Conclusions You must know the sleep apnea status of each
patient to anticipate complications, rapid responses, code blues, unplanned ICU transfers, serious safety events, sentinal events, … .
In peer reviews of cases it is crucial to ask about a patients sleep apnea status.
Expect the unexpected for people with untreated sleep apnea!
The success of any ACO is dependent upon how well the health system deals with sleep apnea!
Be grateful to each person with sleep apnea who is an adherent CPAP user!
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