How to Make Your Patient With Sleep Apnea a Super User of Positive Airway Pressure Therapy

During these sessions, the PA provides education about sleep apnea and treatment. Thirty-minute follow-up clinic appointments are reserved for downloading CPAP data, providing interpretation, and educating patients to maximize PAP therapy and become super users. The remaining clinic sessions are run by 3 sleep fellows under the supervision of the sleep physicians. During all visits, providers encourage patients to maintain good sleep hygiene. Nonadherent patients are scheduled to be seen in a separate clinic session during which the RT troubleshoots and corrects PAP machine and mask-related problems.

Setting up the CPAP group classes and follow-up clinics required adding an FTE RT at a cost of $44,000 to $48,000 per year. By recruiting an FTE PA starting at GS-12 and $75,542 instead of another board-certified sleep physician, VAMC Detroit was able to provide increased access to patient care (8 clinics) at sizable financial savings (estimate, $75,000/y). A 0.5 FTE clinical psychologist provided cognitive behavioral therapy for insomnia and PAP therapy nonadherence and helped achieve the initiative’s goals.

The sleep center projects that the overall cost-effectiveness of these initiatives in terms of admission rates, life expectancy, and productivity would not be dissimilar to that reported in the peer-reviewed literature, as noted earlier. The center’s upcoming research projects will provide more data specific to its population. Educating patients requires that only motivated providers give patients instructions during a 30-minute follow-up clinic visit—there is no additional expense. This model of intensive care can be adopted at other VAMCs.

Conclusion

Maximizing PAP machine use is a unique approach that stimulates veterans to attain the highest level of adherence. This approach is based on clinical observation and patient encounters, and treatment recommendations over 8 years.

Showing enthusiasm with patients is crucial. Enthusiasm is contagious. Clinicians who are also PAP machine users should let patients know of their PAP super-user status and add that many others have attained this status, too. The benefits of optimal treatment are reviewed with patients: increased energy, lower risk of cardiovascular disease, lower blood pressure, better insulin sensitivity, and overall reduced mortality. Some patients have difficulty using the nasal mask and chin strap and understanding and adhering to PAP therapy. These impediments can be overcome with further education and follow-up. Sleep clinic clinicians take the time to show patients how to use the machine’s self-adherence check and leak functions. Patients can then monitor their progress daily.

To motivate patients, clinicians should set expectations early, invest time in providing education at follow-up; be diligent with respect to mask fitting and download evaluation. Sleep clinic providers should also speak the veterans’ language, create a self-fulfilling prophesy for success, and schedule a follow-up sleep clinic appointment if a patient is not fulfilling the Medicare adherence criterion of 4 hours’ nightly use for 70% of nights over 30 days.

PAP therapy coaching and persistent education with provider contact and enthusiasm can improve adherence. Encouragement and praise can help patients exceed Medicare’s minimum PAP therapy criterion and improve their overall PAP experience. The sleep team should tell patients they are proud of their accomplishments with such a difficult treatment. Being genuine and caring and showing concern about their evaluation, treatment, and follow-up is important. This helps reduce their OSA-related morbidity, lessen their depression, and improves their daily well-being and quality of life.

“The variation in responses to CPAP and acceptance of CPAP suggest that focused interventions, rather than one-size-fits-all interventions, may have a greater effect on the overall outcome of CPAP adherence,” wrote Weaver and Sawyer.⁴⁶

Finally, one cannot equate spending on veteran care with spending in other areas of the national budget. The real cost of not giving veterans appropriate care will be a loss of trust, given that the overarching mission is “to care for him who shall have borne the battle and for his widow and his orphan.”