Sleep Apnoea – new approaches to managing the burgeoning national caseload

John StradlingEmeritus Professor of respiratory Medicine

Oxford University

Conflict of interests statement – I do some consulting work for ResMed UK

Outline of presentation

• What is sleep apnoea and why is it an important disease?

• What is the current patient pathway?

• Why is there a crisis in sleep apnoea services?

• What needs to change?

• What new solutions are out there?

• Other areas in sleep apnoea management that could benefit from new technology

What is sleep apnoea and why is it an important disease?

• Sleep apnoea - breathing repeatedly stops during sleep producing major adverse physiological changes, but SLEEPINESS is the dominant symptom

• Patients with this condition stop breathing often hundreds of time a night, of which they are not aware, and as a consequence suffer from unexplained daytime sleepiness

• Of major concern is that this sleepiness leads to a myriad of deleterious consequences, of which falling asleep driving is one of the most concerning

• There is an extraordinarily effective treatment called continuous positive airway pressure (CPAP) which patients use most nights, for most of the night

• This treatment abolishes the symptoms and has been strongly endorsed by NICE (TA139)

Each fatal accidents cost the community nearly £2 million pounds (DofT figure)

What is sleep apnoea and why is it an important disease?

• Sleep apnoea - breathing repeatedly stops during sleep producing major adverse physiological changes, but SLEEPINESS is the dominant symptom

• Patients with this condition stop breathing often hundreds of time a night, of which they are not aware, and as a consequence suffer from unexplained daytime sleepiness

• Of major concern is that this sleepiness leads to a myriad of deleterious consequences, of which falling asleep driving is one of the most concerning

• There is an extraordinarily effective treatment called continuous positive airway pressure (CPAP) which patients use most nights, for most of the night

• This treatment abolishes the symptoms and has been strongly endorsed by NICE (TA139)

CPAP

Compliance with CPAP is better than with anti-

hypertensives and asthma

therapy

What is sleep apnoea and why is it an important disease?• Sleep apnoea - breathing repeatedly stops during sleep producing major adverse physiological

changes, but SLEEPINESS is the dominant symptom

• Patients with this condition stop breathing often hundreds of time a night, of which they are not aware, and as a consequence suffer from unexplained daytime sleepiness

• Of major concern is that this sleepiness leads to a myriad of deleterious consequences, of which falling asleep driving is one of the most concerning

• There is an extraordinarily effective treatment called continuous positive airway pressure (CPAP) which patients use most nights, for most of the night

• This treatment abolishes the symptoms andhas been strongly endorsed by NICEhttp://www.nice.org.uk/guidance/ta139

• NICE has recommended fast tracking vocational drivers following an initiative by the OSA partnership, to try and ensure such patients are diagnosed, treated and back on the road within 4 weeks. http://cks.nice.org.uk/obstructive-sleep-apnoea-syndrome#!scenario

Current patient pathway

GP suspects sleep apnoea

Referral to hospital sleep unit

Sleep study and outpatient assessment

Put on CPAP if indicated

Immediate follow up

+ extra appointments if needed

Annual follow up

Why is there a crisis in sleep apnoea services?

• Sleep apnoea is common. Sleep apnoea, benefitting from treatment with CPAP, affects about 2% of the adult population

• This equates to about a million people, and the best estimate of patients currently on CPAP is 230,000

• This means that there are still 770,000 patients undiagnosed

• It is recommended that all patients on CPAP are followed, at least annually to ensure treatment remains efficacious and all problems are solved to ensure good compliance, (NICE, IMPRESS (BTS), ARTP, BLF)

• Routine follow-up alone of current patients would thus lead to 230,000 outpatient appointments a year, which at a cost of £120 per appointment would cost the country £28 million!

• We are victims of our own success and services are now overwhelmed

April 2015 9,700

Figures from the Oxford Sleep Clinic

What needs to change?

When staff running sleep units are asked -

“what is the biggest load that impacts on your service?”

It is the routine follow-ups, interim patient phone calls, and emails etc. that crush the service

These are mainly relatively simple problem solving, providing information, replacement masks, broken kit etc

Without this service load of relatively ‘simple’ tasks they could concentrate on the more skilled activities within the sleep unit.

What new solutions are out there?

Centralised call centres benefitting from:

• Economies of scale• Recruiting issues, larger staff pool buffers holidays/sick leave etc• High standard approach to all patients and their problems across the country• Staff training becomes a continuous activity within the call centre• Can help both large and small services, delivering the same service to patients• Full range of replacement kit, rapid response times to send out• Extended working hours• Comprehensive database allowing rapid identification of who is calling and their

details

Country-wide service provided by a company in cooperation with the sleep unit

Several such services already in operation, but currently low take-up by NHS – perverse incentives limit this avenue

What new solutions are out there?

Telemonitoring:-

When a patient rings up with a problem, instantly being able to interrogate their CPAP machine would allow most problems to be solved there and then

CPAP machines monitor:• Usage – i.e. how much is the patient using the treatment• Mask leak – a common problem that can be addressed• Residual sleep apnoea – is the system working• Any machine faults – might explain the patient’s problem

This used to require patient attendance at the clinic to collect this informationThen there were data cards that could be sent back in the post

Now this can be done remotely via wireless/mobile phone technology

Provides instant information to the person answering the call

The settings on the machine (e.g. pressure) can be adjusted remotely as well

Immediate follow up of patients recently starting CPAP

The first few days following the introduction of CPAP are critical

• Patterns of usage are set within the first week

• Important to identify early ‘failing’ patients

Good

Not very good

Printouts from ResMed AirViewTM, part of ResMed Air Solutions

Display of patients recently starting CPAPPrintouts from ResMed AirViewTM, part of ResMed Air Solutions

Current ResMed CPAP machine with built in Wireless communications

Example of a Unit adopting telemonitoring• Sleep Clinic, 1 consultant and 4 clinicians• 500 new CPAP set-ups/year, 2,000 on CPAP already• Overload, failing to meet 18 week treatment target• “There was no scope for extra staff to cope with

rapidly increasing demand” Claire Goulden

Introduced AirView TM, part of ResMed Air Solutions in October 2014

• They were able to replace current routine follow-ups with targeted phone

calls, or appointments, only for those who needed this input• They were able to quickly identify new patients experiencing problems and

spend more time on them• Far fewer outpatient appointments and thus far less patient inconvenience• Time saved allowed time to be spent with more complex patients, such as

those needing NIV

They had full management support for what was clearly a better system

Other areas in sleep apnoea management that could benefit from new technologyGiven that OSA is:-

• Very common • Under-diagnosed• For which there is a highly effective treatment• Been around a long while (cf hypertension, diabetes)

It should and will become much more a primary care issue

Simple home screening equipment - now fully accepted for sleep apnoea diagnosis

Needs simple, reliable devices

Results need to be easily available to a variety of clinicians, GPs, consultants, sleep nurses, sleep technicians involved in the patients’ care

Home sleep apnoea diagnosis – e.g. ApneaLink™Air

• Can be uploaded to the cloud so that other clinicians in any location can see the data instantly

• This facility would be particularly appropriate when the GP does the sleep study and the consultant needs to see the sleep study when assessing the patient later

Abbreviated summary page to help with referral decisions

Full data display for the sleep centre clinician

ResMed ApneaLink™Air - results

Conclusions

Sleep services are in crisis, they need new ways of working to solve the ever increasing numbers of patients starting CPAP and requiring follow-up

The best solution requires large centralised call centres and CPAP machines equipped with wireless technology

Sleep apnoea is underdiagnosed and waiting lists for diagnostic services are growing

Home sleep studies by GPs, with wireless technology for transmitting the results to the sleep centre, provides a solution