At this point, there is little debate about the seriousness of sleep apnea. Experts agree that sleep apnea impacts vitality and makes medical and emotional problems worse. The problems associated with sleep apnea are often mistakenly explained away as the overwork and stress of everyday life.
The seriousness of sleep apnea is shared by 11.5 million Americans, both male and female, between 30 and 60 years of age—with more than 40 million Americans suffering from some form of chronic sleep disordered breathing.1,2 These disorders include narcolepsy, sleep apnea, and insomnia. Of the 11.5 million obstructive sleep apnea (OSA) sufferers, almost 3 million are diagnosed as moderate to severe.1
There are approximately 38,000 cardiovascular deaths annually attributed to OSA—and these figures include heart attack and stroke. To put this in perspective, Table 1 illustrates that sleep-disordered breathing is as common as diabetes and nearly as common as asthma in our population.
Table 1. Prevalence of sleep-disordered breathing compared to other chronic disorders in the United States.
High Blood Pressure: 25 to 30 million people
Asthma: 15 to 17 million people
COPD: 14 to 16 million people
Diabetes: 14 to 16 million people
Sleep-disordered Breathing:
12 to 18 million people
4% of middle-aged men
2% of middle-aged women
10% or more in geriatric populations
Heart failure: 4 to 6 million people
Source: personal correspondence, Darrell Drobnich, senior director, government affairs, National Sleep Foundation.
Do Physicians Get It?
When marketing services to physicians and the public, it is important to target your audience. Not so long ago it was presumed that sleep referrals came primarily from sleep specialists—pulmonologists, neurologists, or sleep centers. However, a recent study from a national clinical journal showed that the identified referral bases were primary care physicians, pulmonologists, and then otolaryngologists.
Are physicians today more aware of obstructive sleep apnea? Major medical research and publications on this topic are certainly prevalent. In addition, mainstream publications have featured this disorder as has sports TV regarding the prevalence of obstructive sleep apnea in present and former National Football League players. There has also been a proliferation of Web sites, blogs, and Internet chat or support groups for this disorder.
Quality of Life
Generally, the symptoms or reasons that lead sleep apnea sufferers to sleep practitioners or primary care physicians are feelings that impact quality of life (Table 2). Quality of life relates to how an OSA sufferer interacts with his world—while at work, driving, and socially. Looking at the sleep apnea patient and his quality of life is a relatively new area of research.
Table 2. Signs and Symptoms of Sleep Apnea
• Daytime sleepiness and fatigue
• Falling asleep during the day—at work
• Falling asleep while driving
• Frequent napping
• Restless Sleep
• Morning headaches
• Inability to wake up
• Frequent awakenings
• Mood or behavioral disorders
• Loss of energy
• Trouble concentrating
• Irritability, short temper
• Anxiety or depression
• Decreased libido
• Sexual problems
• Snoring
• Often interrupted by silence (apnea) then gasps
• Dyspnea
• Choking or gasping (snorts) during sleep
• Hypertension
• Nocturnal angina/arrhythmias
Mostly, researchers have used the Medical Outcome Study SF-36, which determines the impact of the disease burden on patients suffering from chronic disorders.3 The SF-36 Short Form was popular because it was brief, having only 36 questions in eight sectors, and it covered a broad range of health concepts. Those eight quality of life indices can be segmented into a physical component as well as a mental component (Table 3) with overlap.3,4
Research has found a significant relationship between the treatment of OSA and an improvement in the quality of life. In these various research studies, it has been concluded that in pretreatment (before the institution of CPAP therapy), there was a considerable decrease in the quality of life consistent with other patient populations suffering from a chronic illness.5 It was also shown that following CPAP these factors improved to the level of the general population within 3 months to 7 months, with significant improvement in vitality within 6 months. Long term (1 year to 18 months), there was significant improvement in not only vitality, but other areas such as the ability to function socially and physically.6,7
The evidence can pile up, but it is important for home care providers not to underestimate the ability of patients to comprehend their diagnoses and process the information. Many suppliers provide pamphlets or literature provided by outlets such as the National Sleep Foundation, or through their national buying groups. You may even wish to create your own informational materials, but this may prove to be a time- consuming and expensive process—unless the provider has the in-staff talent. If you wish to direct patients to the Internet for additional education, it is wise to provide a list of links that provide valuable and accurate information.
To further boost compliance, nothing is better than supplier follow-up. Repeated telephone contact during the early phase of treatment will head off problems, correct miscommunications, and provide that personal level of customer service and reassurance.
Epworth Scale and FOSQ
In 1991, the Epworth Sleepiness Scale (ESS) was introduced and validated.8 This scale was designed to give physicians a simple means to determine patient-perceived sleepiness ratings. Patients rate themselves in varying degrees during normal activities. In scoring the questionnaire, the higher the score, the greater the risk for sleep apnea. Patients are asked to rate themselves from 0 to 3 as follows:
0=Would Never Doze
1=Slight Chance of Dozing
2=Moderate Chance of Dozing
3= High Chance of Dozing
A score of 6 or less indicates a person that does not experience excessive sleepiness, but a score above 6 indicates a propensity for some form of sleep-disordered breathing. The beauty of the test or survey is its simplicity. It takes less than 5 minutes to complete and gives patients an immediate visual representation of their problem. The Functional Outcomes of Sleep Questionnaire (FOSQ) examined sleep apnea on a broader scope.9 This self-administered test used 30 questions and was a quality of life questionnaire designed and validated specifically for people with sleep disorders. It has proven so valuable that it has been incorporated in CPAP devices, and many companies hand it to patients as a compliance function—and as a means to gauge improvement. In either case, it can be useful in justifying the need for a sleep study and follow-up.
Compliance: What the Research Says
By Vernon R. Pertelle, MBA, RRT, CCM Vernon R. Pertelle
It has been shown that the type and degree of patient education can affect the extent of patient compliance for any specific medical condition.1 Compliance monitoring and the programs that have been produced to achieve this allow those involved in patient support to determine if the interventions they have in place are working. Subsequently, there have been a number of studies that have researched the effect of patient education on CPAP compliance. The majority of these studies have shown that any extra effort to support and assist those new to CPAP has increased compliance. Hoy et al2 showed in a randomized controlled trial that intensive support in the form of CPAP education for patient and partner, and additional nights in the sleep facility significantly increased CPAP usage (3.8 to 5.4 hours). A randomized clinical trial has shown that the simplest intervention will increase patient compliance. In this study, the group of patients that received printed literature explaining the benefits of CPAP use and guidelines used their prescribed CPAP machines for an average of 7.1 hours per night. This compared to the control group that received no information and used their units for an average of 4.4 hours per night.3 Clinic sessions that are designed to educate and encourage patient compliance significantly increase patient compliance to CPAP.4 Russo-Magno et al5 found that in older male patients with OSA, compliance with CPAP therapy is associated with attendance at a patient CPAP education and support group. Resolution of symptoms with therapy also appears to be associated with enhanced compliance. Sin et al6 assessed long-term compliance rates of patients treated in a group CPAP program consisting of consistent follow-up, troubleshooting, and regular feedback to both patients and physicians. From this study, it was determined that this type of program can achieve CPAP compliance rates of >85% over 6 months. In all of the above-mentioned studies, it is apparent that the more patients can be made aware of the benefits from CPAP treatment, the better. We conducted a systematic review of studies that have been published in peer-reviewed medical journals regarding patients treated with CPAP and factors associated with compliance. The evidence shows that in many patients, there are no significant differences in compliance at 2 weeks, 4 weeks, 3 months, and 6 months. Thus, there is no evidence that supports monitoring compliance beyond 1 month in the absence of patients’ complaints of symptoms. Vernon R. Pertelle, MBA, RRT, CCM, is national respiratory manager, Apria Healthcare, Lake Forest, Calif. |
Editor’s Note: Article references are available online at www.hhcdealer.com.
Alan S. Cross, MHA, RRT, is president of C&C Homecare Inc, Bradenton, Fla. Cross has been a speaker/presenter for the Florida Association of Medical Equipment Services, The Florida International Medical Expo, and Medtrade. He can be reached via email: cchomecare@aol.com.
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