In his career as a respiratory therapist, gary Roberson, RRT, has heard every excuse in the book for noncompliance with continuous positive airway pressure (CPAP) therapy.

“My mask is uncomfortable.”

“I can’t tolerate the pressure.”

“There is no way I can sleep with this.”

Obstructive sleep apnea, the primary reason for CPAP use, must be controlled because there is no cure. Yet studies show that patients on CPAP therapy who are noncompliant (industry standards set anything under 4 hours as noncompliance) and who are self-monitoring substantially overestimate the time they spend on therapy. Whatever the reason for the inflated evaluation—a genuine error, a desire to please, or wanting to be perceived as compliant—patients are not getting the therapy they need.

As supervisor of the Augusta Medical Center (AMC) Care Home Medical respiratory services program in Fishersville, Va, Roberson says that new e-monitoring devices have the potential to alter many concerns about compliance. One system available relies on a magnetic-stripe card similar to those commonly used in modern hotels as room keys. The card records compliance data from the CPAP machine, such as when and for how long the machine was used. Then the patient mails the card back to the HME dealer, or the dealer picks up the card from the patient.

Another available device, the one used by Roberson’s facility since November 2001, collects data and then uses a modem and the patient’s telephone line to transmit the data to a central computer server where authorized health care providers can access the data using their desktop computers. The entire process is automatic, with little required of the patient except to use the therapy.

“With the system that we use, the DME dealer is considered the administrator of the program,” Roberson says. “We register the patient’s demographics into the software in order to assign a CPAP unit and a separate modem by serial number. We identify the authorized users who can view the patient information, which often is our own clinical staff of [respiratory therapists].”

Sleep laboratories and physicians also may be authorized users. In this password-protected program, the central server that receives data from the compliance monitor’s modem tracks only serial numbers. The server, which is maintained by the vendor, has no patient information. Only when Roberson or his staff recall the information are the serial numbers matched with patient names to create a usable report. These safeguards assure patient confidentiality as well as data accuracy.

“This system gives us another tool to prove compliance and to monitor patients’ outcomes,” Roberson says.

Patient Acceptance is Critical
According to Roberson, studies show that the first 1 to 2 weeks of CPAP therapy are crucial. If a patient is compliant during that time period, he or she is more likely to have successful long-term usage and favorable clinical outcomes from the therapy, he says. Of prime importance during those first 2 weeks is monitoring and correlating clinical assessments, which include patient progress and tolerance of the therapy. E-monitoring is one helpful component of assuring that the patient is compliant.

Another plus for e-monitoring is that patients are much more accepting of CPAP therapy with e-monitoring, Roberson says. “[Patients] want to try it to see if they can get a benefit, because they have felt so bad for so long, and have not had quality sleep,” he says.

That patient enthusiasm gives Roberson and his 25 full-time employees the opportunity to do more in-depth teaching about the machine and the disease process. This, in turn, results in a higher compliance rate because patients understand how they are being helped.

Finally, physicians are becoming more aware that the long-term effects of untreated sleep apnea can be another motivation for patients to be compliant.

The simplicity and nonintrusive nature of the monitoring system used by Care Home Medical make it relatively easy for most patients to understand. The CPAP unit delivers the prescribed therapy. The compliance monitoring modem device, about the size of a small box of chocolates, connects to the back of the CPAP unit.

The modem operates on four AA batteries that give it an average battery life of 18 months and also make it a data storage unit. A backup memory feature ensures that data is preserved in case of power or battery failure.

If the patient does not have a phone line connected to the modem continuously, the modem stores information until the patient hooks it up to a phone line and activates it to download the information by pressing a button.

Where the device is connected to a phone line continuously, it transmits automatically at 3 am by a silent dial modem that takes 45 seconds for a download. The device can share a phone line with a phone and it does not interfere with calls coming in except at 3 am when it transmits for less than a minute.

Compliance data collected and transmitted in this manner is exceptionally accurate, because in order for the CPAP system to log a period of time of usage, it has to sense back pressure, created when the patient exhales against the system. “If a patient were to turn the unit on and let it run without applying the mask, it would log zero hours,” Roberson says. “With this system we can sit at our desks and monitor a patient nearly daily. We chose the system because of the timeliness of the information.”

Compliance vs Reimbursement
His experience has been that insurance companies in Virginia will approve a 2-month rental period rather than purchasing the equipment immediately. This effectively provides a 2-month monitoring period during which Care Home Medical can identify any mask problems the patient may have and can evaluate how the patient responds to CPAP therapy.

Will compliance eventually become a benchmark for reimbursement? Is there a pending danger of noncompliant patients eventually being denied care because they refuse to stay with their therapy? Roberson believes there is a potential for that to happen, although there is not a large HMO influence in the Shenandoah Valley.

In anticipation of such requirements, before the company implements a compliance program, the patient completes a questionnaire that documents his or her subjective responses. “We tried to structure it so that equipment issues were covered, we could get an actual compliance meter reading off their equipment, and then we included clinical questions to correlate improvement in symptoms after initiating CPAP therapy,” Roberson says.

He cautions, however, that compliance monitoring may tell only part of the story. It must be viewed in conjunction with clinical data, he says, citing as an example a patient who is 100% compliant but still demonstrates daytime fatigue and reduction in energy levels. “If we do not clinically correlate those symptoms, we may not stumble across that information,” he says. “In this case the patient may need a change in pressure. Then we submit the information from both the clinical component and the e-compliance monitor, which is available to any insurance company that would want it. But a compliant patient not getting better cannot be a reason for an insurance company to deny service, because other clinical factors may exist.”

E-monitoring may also have the potential to shift liability. If it is documented that a patient has been noncompliant over an extended period, and the insurance company makes the decision to discontinue reimbursement on that basis, it could relieve the insurance company of responsibility. If this sort of information becomes a requirement, e-monitoring may benefit HME dealers significantly by reducing the amount of time it takes them to collect data.

“Compliance monitoring has not necessarily changed the way we do business outside of the provision and setup of the additional equipment, but it has given us a useful tool to validate patients’ subjective response to compliance questions,” Roberson says. “We now have an accurate record of daily usage by actual time of day that is virtually foolproof as opposed to a compliance hour meter that only provides total hours used over time. The additional information helps us and the physician to better understand and precisely report how compliant the patient actually is with their prescribed therapy. This clearer picture allows for more informed decision making. That is the beauty of the compliance system.”

Judy Wade is a contributing writer for Dealer/Provider.