Sleep 2023.03.08 Donovan

March 15, 2023

ID9682

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00:00And so without further introductions,
00:03it's really a pleasure to introduce our
00:07speaker today, Doctor Lucas Donovan,
00:10who is my former residency colleague
00:12from Beth Israel Deaconess in Boston
00:14and is a talented researcher like
00:16Drew Carey and LeBron James. Dr.
00:18Donovan was born in Cleveland, OH.
00:20He received his undergrad degree
00:23and his MD from Case Western before
00:25moving on to Beth Israel for residency
00:28training and his Sleep fellowship.
00:30And he was then recruited to
00:32University of Washington for pulmonary
00:33Critical Care Fellowship and has
00:35been there in faculty ever since.
00:36His current appointment is both at
00:38University of Washington at and at the VA
00:41of Puget Sound Healthcare System in Seattle.
00:43And Luke is, you know,
00:44he's deeply devoted to caring for
00:47the vulnerable veteran population,
00:48which has been a consistent
00:49focus of his work.
00:51His work is funded by the VA Health
00:53Services and Research and Development.
00:54Through the Career Development Awards as
00:57well as the prestigious Merit award and you,
01:00Luke has a unique combination of expertise.
01:02He's comfortable with basic science and
01:04all the way to implementation research.
01:07So he started his research career at
01:10Case Western with Doctor King and Stroll
01:12and looked at sleep apnea Physiology,
01:14ventilator control and then now focuses
01:16on sleep apnea among individuals with
01:19high comorbidity burden such as those
01:22COPD or opioid use disorder and.
01:25It does work in redesign of sleep
01:28apnea care delivery.
01:29And so his his current grants are
01:31focused on virtual sleep care and
01:33pragmatic approaches to weight loss
01:35and sleep apnea patients as well as
01:38pragmatic approaches to COPD care.
01:40And his work has been recognized by
01:42several different agencies and those
01:44prestigious ones in the last two years,
01:46just the last two years James
01:48scattered award for new investigator
01:50and also last year Joe Ray Wright
01:53Outstanding Science Award from the ETS.
01:55And so personal note Luke is a kind
01:57soul and a guy you want to run
01:59into at the sleep and a TS meetings
02:01and he's an outstanding.
02:02Speaker so I'm excited to hear his
02:05talk on reorganizing sleep apnea care,
02:07so please give a warm welcome to Luke.
02:12Alright, thank you so much.
02:14I really appreciate the opportunity
02:17to to speak to you all today
02:20and in particular my some of
02:22my colleagues from Beth Israel.
02:24I remember my time there very
02:27fondly and it's great to see
02:29some some familiar faces and look
02:32forward to a good good discussion.
02:35Can everyone see my slide?
02:39Should be the disclosure slide first.
02:43Excellent. Alright.
02:54This is Andre pointed out.
02:56Today I'm going to be talking primarily
02:59around reorganizing services for OSA,
03:02and in particular how we
03:04organize them towards the triple
03:06aim to achieve each of those,
03:10each of the triple names components.
03:15I have no relevant conflicts of interest,
03:17and it's important to note that
03:18my views do not represent the
03:19Department of Veterans Affairs.
03:243 objectives for today.
03:26First is to describe the challenges
03:28facing the delivery of care
03:30for obstructive sleep apnea.
03:31The second is to understand
03:33the existing opportunities and
03:34expand to expand services.
03:36And they're not overlapping limitations.
03:39Describe the role of the referral
03:42coordination in reorganizing care and if we,
03:44if we have time,
03:46also spend some time talking a
03:47little bit about a population
03:49health approach to managing care.
03:55So I'm sure you're all aware that
03:57OSC is an exceedingly common
03:59disorder affecting approximately
04:011 billion individuals worldwide,
04:0354 million adults in the United States.
04:05Treatment among many of these individuals
04:07is likely to improve symptoms,
04:09including quality of life,
04:11with improvement in other health related
04:13outcomes such as blood pressure.
04:18But OSA and its implications
04:20and management are not uniform.
04:22There's mark heterogeneity and it was a
04:24presentation in response to treatment.
04:26Including ratings of different
04:28symptom presentations,
04:29ranging from individuals with
04:30excessive daytime sleepiness
04:31to those with no symptoms.
04:33And there are important interactions
04:35with Common Core morbidities such
04:37as heart failure, stroke and COPD.
04:39And appropriate diagnostic and treatment
04:41approaches are going to differ based
04:44on those presenting characteristics.
04:48In addition to different
04:50differences in in presentation,
04:53there are also numerous treatment approaches,
04:54each with nuance selection criteria and
04:57standards for follow up and maintenance.
04:59And many of these procedures,
05:01particularly surgery as well as the
05:04the the fabrication and and and
05:06fitting of oral appliances require
05:08collaborations with other providers.
05:13And finally, there are additional
05:15administrative complexities
05:16in coordinating services.
05:17Even if you know what a patient needs,
05:19how do you deliver it and make it happen?
05:25These complexities have contributed to an
05:27approach to USA that is highly dependent
05:30on specialists and specialty care centers.
05:32More so than other common conditions.
05:34Specialists serve as the prime as the main
05:37provider of care for obstructive sleep apnea.
05:39And in the historical model,
05:42PCP's refer patients to specialists
05:45who see patients in person provide
05:48longitudinal care for the disorder,
05:50which primarily revolved
05:52around in person services.
05:55We've moved away from this a
05:57little bit with remote care,
05:59but in general the the primary approach
06:01within the United States is very,
06:03very much specialist driven.
06:08However, I think, I think there's a
06:10fair amount of of of agreement that
06:13this approach is not sustainable.
06:14There's a marked mismatch between the
06:16number of sleep providers in the US and
06:18the volume of patients who need services.
06:20Compounding this managed this
06:21mismatch is the fact that providers
06:23are not equally distributed.
06:24They're geographically clustered in urban
06:27areas as well as more affluent regions,
06:30widening disparities.
06:35We can distill our main challenges
06:37between the available resources to
06:39manage OSA and the worldwide burden
06:41of disease into two key barriers,
06:42one of geography and one of capacity.
06:47The goal of this talk is to how to is
06:50is to explore how to improve care in in
06:53a in recognition of these key barriers.
06:57Into ground and contextualizes our
07:00discussion. I would like to use
07:01the triple aim as the framework.
07:03So the triple aim was developed by the
07:05Institute for Healthcare Improvement
07:06about 15 years ago and serves as a
07:09widely used framework for all systems
07:10to use in order as they consider driving
07:13practice changes that are effective,
07:15sustainable and have far,
07:16far reaching impacts across the population.
07:19The core components of the AAA
07:21are to improve population health,
07:23improve patient experience of care
07:25and reduced per capita cost.
07:27Experience of care is the aspect that we
07:31as clinicians are most accustomed to,
07:33and it's broken down into care that's safe,
07:36efficacious and patient centered.
07:40One thing to consider with the triple
07:42aim is that a single minded focus on
07:44just one of the aims components would
07:46lead to an unsatisfactory outcome.
07:48Our choices really need to be balanced.
07:51For instance,
07:52you could reduce per capita cost
07:54to 0 by providing no care,
07:56but this would come at the expense of
07:58population health and experience of care.
08:00Also,
08:00you could focus exclusively on
08:02maximizing patient experience and
08:04provide care of incredibly high cost to
08:06a vanishingly small number of patients.
08:09I would argue that's our default
08:11bias in healthcare,
08:12at least in the United States.
08:13And therefore,
08:14when when describing the benefits
08:16and downsides of strategies
08:17to redesigning OSA care,
08:19I'll be sure to address other
08:21considerations around population
08:22health and per capita cost.
08:25And finally, I would be remiss if
08:27I didn't mention the quadrupling,
08:29which has been an addendum to the AAA,
08:33which also considers staff
08:34well-being and experience.
08:39So as part of this talk,
08:40I'd like to discuss some of
08:41the available evidence based
08:42tools that are at our disposal,
08:43at our disposal to meet our
08:46needs and redesigning care,
08:47categorize these tools by the main barrier
08:50they overcome geography or capacity,
08:52although I think it's fair to
08:54say there's some overlap here.
08:55And this discussion will focus on 2 main
08:58strategies with the strongest evidence
08:59based to guide a nuanced discussion.
09:02And these are the, the,
09:04the pathways with the,
09:05these are the tools with the
09:07asterisks included and our ambulatory
09:09care pathways and the utilization
09:12of alternate care providers.
09:14These are the strategies where
09:15we have the most robust evidence
09:17stemming from multiple randomized
09:19control trials across a wide
09:21array of practice environments,
09:22and they offer comprehensive solutions.
09:26As part of this presentation,
09:27I'm going to focus on addressing the
09:29strengths and limitations of these of
09:31these approaches and how we reorganize
09:32them in light of the triplane.
09:36They're also a number of resources
09:38to to dig in, and particularly
09:40these other tools that I'm not going
09:42to mention such as remote visits
09:44and mail based tap dispensation,
09:46automated adherence monitoring and the like.
09:48And there's additional resources left
09:50hand corner you can review as well.
09:55First of all, I'm going to discuss in
09:57detail is the ambulatory care pathway.
09:59OSA is traditionally reliant on
10:01polysomnography, the gold standard
10:03for diagnosis and tailoring.
10:04Treatment of of OSA with PAP therapy,
10:08the ambulatory care pathway or
10:10home Pathway uses home sleep
10:12apnea testing to diagnose OSA and
10:14auto titrating path devices that
10:16automatically adjust pressure.
10:18I think this this paradigm is
10:19one with which this audience is
10:21very familiar and comfortable.
10:26Just in terms of describing it
10:28within the context of the triple aim,
10:30let's start off with
10:32experience and effectiveness.
10:33There have been, you know,
10:35about a half dozen of randomized
10:37trials that have been that have
10:38compared the effectiveness of an
10:40ambulatory to a lab based approach.
10:42And a full review of this literature is
10:44outside the scope of this presentation.
10:45But as evidence is demonstrated in
10:48existing guidelines and systematic reviews,
10:51the ambulatory care approach leads
10:53to comparable treatment decisions,
10:54PAP adherence and patient reported outcomes.
10:57In the available trials,
10:58and among patients who experience
11:00both pathways and crossover trial
11:02and were able to select a preference,
11:0575% said they preferred the
11:08ambulatory care pathway.
11:10However,
11:10there are potential downside
11:12stimulatory care pathway driven
11:14primarily by lower sensitivity of
11:15home sleep apnea testing devices and
11:17the inability of H Sats to and auto
11:19titrating PAP devices to distinguish
11:21central from destructive events.
11:23These considerations,
11:24like most randomized trials to limit
11:26enrollment to these populations and
11:29constrain their their populations to
11:32those with high pretest probability of OA,
11:36excluding individuals with conditions such
11:38as significant insomnia as well as those.
11:41Conditions such as heart failure and
11:43stroke that predispose to central events.
11:48So I think just to clarify,
11:50these are areas where we have
11:52gaps in evidence around the the,
11:53the the superiority of
11:55the lab based approach.
11:57They aren't necessarily areas we
11:59have strong evidence of meaning
12:01of the superiority for a lab
12:03based approach for meaningful
12:05patient centered outcomes which
12:06I think is a notable distinction.
12:11With regard to other
12:12elements of the triple lane,
12:14the ambulatory care pathway presents
12:16notable potential and observed
12:19advantages for population health.
12:20Ambulatory care pathways allow a system
12:23to overcome geographic barriers due
12:25to easier scalability as well as.
12:30Reduced requirement for.
12:33For capital improvements,
12:36they're also patients who can't
12:38easily sleep away from home for a
12:41night because they're taking care of
12:43young children or ill family members.
12:45Umm, and potentially because of
12:48this lower patient care burden
12:50and and latent preferences,
12:52you tend to see lower dropout in
12:54the in the ambulatory care arms
12:57of the randomized trials that
12:59compared both approaches.
13:01Finally,
13:01the lower complexity of the
13:03ambulatory care pathway is
13:05facilitated the management of OSA
13:07among alternate care providers,
13:09as we'll discuss next.
13:11With regard to per capita costs,
13:12the randomized trials that have
13:15assessed costs are 25 to 57% lower
13:18cost in the ambulatory care pathway.
13:24Now we're going to move on to capacity
13:26and the use of alternate care providers
13:28is an area of great interest.
13:30Alternate care provider here just to
13:32define its use is a catch all term for
13:35OSA care delivered by non specialists
13:37including primary care providers,
13:39registered nurses and respiratory therapists
13:41and this care can be delivered on their
13:44primary care specialty care settings.
13:48Similar to the ambulatory care pathway,
13:50we have a wealth of randomized trials,
13:52nearly a dozen now,
13:54that have been performed
13:55testing primary care providers,
13:57registered nurses or respiratory
13:58therapists relative to sleep specialists.
14:01These trials primarily focused on various
14:03points along the OA diagnostic pathway,
14:05with some beginning with patients
14:08with suspected OSA pre diagnosis
14:10and others enrolling patients.
14:12With with known OSA,
14:14while Complete view review of the literature
14:16is is is a bit beyond the scope of this talk.
14:20There I think we can summarize by saying the
14:24trials to date have either shown superior,
14:27comparable or not inferior outcomes
14:29and patient reported outcomes such
14:32as sleepiness and in all but one
14:34of these trials showed comparable
14:36or non inferior package insurance.
14:39The only trial demonstrates superior
14:41outcomes with sleep specialist care
14:43was doctor Pendharkar's trial from
14:452019 from 2019 that found greater CPAP
14:48adherence among patients with severe OSA.
14:51Were cared for by sleep specialists
14:54relative to restaurant therapists.
14:56However,
14:57despite relatively strong evidence
14:58for comparable outcomes with
15:00alternate care providers,
15:01there are potential downsides
15:03and limitations and evidence.
15:05First,
15:05the existing trials did not explore
15:07the full spectrum of patients.
15:09They were generally limited
15:10to those with patients,
15:11those patients with excessive
15:12daytime sleepiness and few sleep and
15:15non sleep related comorbidities.
15:16Another general limitation
15:17is that there are many,
15:19many trials focused on PAP as a treatment,
15:22solely limiting our understanding around
15:25the success with alternative non PAP.
15:27Treatments.
15:29Similar to evidence around
15:31altercare pathways.
15:32It's worth reiterating this that
15:33these gaps in evidence are not based
15:36necessarily and strong evidence of
15:38superiority for specialist LED care,
15:40but not but rather our our gaps
15:42in in evidence.
15:43You know,
15:44there may be situations where
15:45specialists truly are superior,
15:47but they have not been proven in
15:50randomized control trials based on
15:53meaningful patient centered outcomes.
15:55And these scenarios are are are
15:57ripe for exploration and research.
16:01With regard to population
16:02health and per capita costs,
16:04there are clear benefits
16:05for alternate care providers
16:07relative to sleep specialists.
16:09There are 19 times as many
16:11primary care providers,
16:1220 times as many restorated therapists,
16:14and two and 500 times as
16:17many registered nurses.
16:18And in terms of per capita costs
16:20in the average cost of care
16:22per patient were $250 to six
16:24$860.00 less for those managed
16:26by alternative care providers.
16:31So based on this, on our review this far,
16:33there are some key takeaways and
16:35military care pathways and alternate
16:37care providers each provide
16:39opportunities to improve population
16:41reach and reduce production costs.
16:43Current limitations and evidence
16:45around the effectiveness for both
16:47alternate care providers and the
16:48ambulatory care model include those
16:50with atypical presentations of OSA,
16:53nearly those without excessive
16:55daytime sleepiness and those
16:56at elevated risk for central
16:58sleep apnea or hypoventilation.
17:00So clearly A1 size fits all
17:02approach is not going to work.
17:06And the main question that I think
17:08we need to wrestle with is how do
17:10we reorganize appropriate care
17:11in light of these limitations?
17:16He modeled the utilizing animal in
17:18in aligning patients with appropriate
17:20services is stepped care model.
17:23Step Care model assumes that there are
17:25limits and specialized personnel and
17:26resources and aims to align patients
17:28to the appropriate treatments and
17:29based on their needs in an effort to
17:32preserve capacity and patient outcomes.
17:35Septier models categorize patients
17:37based on disease characteristics and
17:39stratify patients to higher or lower
17:41complexity based on those characteristics.
17:43This model has been used extensively in
17:46other conditions in particular and it's
17:49used extensively in mental health and
17:51has been utilized in the delivery of.
17:53Meant for installing.
17:56Another another model that comes to
17:58mind is 1 geared primarily towards
18:00overcoming the barrier of geography
18:01and that is the hub and spoke model.
18:03And in this model,
18:05centralized hubs with specialized
18:06expertise partner with smaller
18:08and less specialized folks.
18:09These arrangements already exist for
18:11many health systems and a variety of
18:13specialties and there's a well developed
18:14hub and spoke model for Sleep Medicine
18:16within the Department of Veterans Affairs.
18:18And this arrangement,
18:20sleep specialist clinics and laboratories
18:22are the natural hubs given their access
18:25to specialized equipment and staff.
18:27And spokes would correspond to
18:28primary care settings or other
18:30geographically disseminated sites
18:32for alternate care providers.
18:34By consolidating the high
18:36cost specialized services,
18:38hub and spoke models tend to use
18:40resources more efficiently on the
18:42established relationships between spokes,
18:44and hubs allow for natural points
18:46of referral when patients that
18:48spokes need higher level of care.
18:51He had been the telemedicine further
18:53supports the reach of these hub and spoke
18:56relationships and limits the reliance
18:58on a strict geographic relationship,
19:01although in person services such as
19:03PSG will still definitely play a role.
19:10So how do we integrate these models and
19:12align with what we know about alternate care
19:15providers and ambulatory care pathways?
19:16This was a question that several colleagues
19:19and I wrestled with in a review article
19:22from a few years ago in in chest.
19:24We decided that a reasonable starting
19:26point would be based on current
19:28evidence limitations around the
19:30effectiveness for ambulatory care
19:31pathways and alternate care providers.
19:34We anticipate that lower complexity services,
19:37you know, those provided by alternative
19:38care providers and those provided.
19:40Through the ambulatory care pathway
19:41would be most appropriate for those at
19:44high pretest probability of OSA who are
19:46concerned for comorbid sleep disorders
19:48and lower risk for hypoventilation and
19:50hyperventilation and central sleep apnea.
19:53Those meeting these criteria would
19:55be more appropriate.
19:56Those not meeting these criteria
19:58would be more appropriate for higher
20:00complexity care that was driven by
20:03specialists and laboratory care pathways.
20:05Acknowledging that there's
20:07longitudinal changes over time,
20:08we anticipate that patients needs will
20:11change across their their experience
20:14of care and those initially who
20:17who need higher higher complexity
20:19care may be more appropriate for
20:21lower complexity care over time.
20:24Umm.
20:26And Please note that this is just
20:28really a starting place based on the
20:30the available evidence and should
20:31be subject to change based on new
20:34evidence and individual health system
20:36resources as well as capabilities.
20:41But I think a main, uh,
20:43latent question that's posed
20:44in this this new paradigm is,
20:47is how do we coordinate these transitions?
20:49You know it, I think it's it.
20:51It may be reasonable enough
20:53to set up a a pathway,
20:56but how do we manage when
20:57pathways need to change?
21:01Because we previously used to
21:03have a linear one way path,
21:05everyone went to a specialist and
21:06that was it and the specialist kind of
21:09managed everything from there on out.
21:10We just had a train on the
21:11tracks and it barreled along.
21:12Now we have traffic.
21:15Sharing specialists between alternate
21:17care providers and sleep specialists
21:19will almost certainly be a part
21:21of any comprehensive strategy,
21:22and we need to find ways to
21:24manage that traffic.
21:25In centers that have expanded the role
21:27of primary care providers and sleep,
21:29sleep services deliveries.
21:30Primary care providers feel
21:32comfortable managing the USA,
21:34but often are unsure about the
21:36optimal next steps in escalating
21:37care and who to talk to based on
21:40work done by Doctor Pendharkar.
21:42And for this reason,
21:43it seems logical that specialists,
21:45especially care teams,
21:46would serve as the natural point of
21:48coordination during who needs what when?
21:51But how do we avoid the pitfalls
21:53of the specialist dependent system?
21:54How do we how do we arrange and
21:58coordinate care without burdening our our?
22:01Or scare specialist supply?
22:03And how can we coordinate care
22:05in a way that promotes the AAA?
22:11So while it might not
22:13answer all these questions,
22:14our RV center's recent experience
22:17and referral Coordination
22:18initiative provides some valuable
22:20insight about how to optimize,
22:22especially care coordination.
22:23And I'm going to spend a few
22:25minutes talking about our
22:26experience and our evaluation.
22:31In the Department of Veterans Affairs,
22:33if you spent time in the VA,
22:34you probably know what an E consult is.
22:36Umm, and we've we've essentially
22:38incorporated specialists into the
22:40coordination and collaboration
22:41with primary care providers as part
22:43of the console system for years.
22:45And this occurred as a divergence from
22:48the reliance on synchronous visits,
22:51you know, in person visits where
22:53you're face to face with a patient
22:56or face to face via telehealth.
22:58You know the IT avoids a reliance,
23:00and there was synchronized visits that
23:02require a fair amount of coordination
23:05to set up that initial consultation.
23:07So in the Econsult model,
23:08primary care providers bring the patient
23:10to the attention of a specialist
23:13specialist reviews the patients chart
23:15asynchronously and alerts a separate
23:17group of administrative staff to
23:18schedule the next steps and management.
23:22This process is great,
23:23it gets patients to where they need to go,
23:25but it has limitations.
23:27First, at the specialist level,
23:29this part,
23:30this process requires a fair amount of time.
23:32We estimated it took about 25
23:34minutes per sleep console,
23:36which is a lot considering the
23:38existing positive specialists and
23:40existing limitations on their time.
23:43The second issue is that although we
23:45saved some administrative time by not
23:46having to schedule the patients into a
23:48synchronous visit with the specialist,
23:49there's still some need for
23:51scheduling the ultimate service,
23:53and this problem is by and large.
23:56You know the a lack of scheduling
23:59personnel who are familiar with
24:02this this specialized service.
24:04You know,
24:05frequently they use a utilized
24:07schedulers who who may schedule
24:09across multiple specialties across
24:11primary care and specialty care.
24:13And there's a lack of clarity
24:15around scheduling priority,
24:17lack of ability to communicate with
24:19patients about their next steps and
24:21specifically what needs to be done.
24:28So as a result this, this,
24:30this form of specialist directed
24:33coordination has some problems and
24:35up to 50% of patients referred for
24:37specialist services don't receive them.
24:39Less than 10% of patients were contacted
24:42to scheduled within a week and patients
24:44are increasingly referred outside of
24:46the VA system resulting in additional
24:48duplicative testing and delays.
24:53Now these issues with specialty care
24:55coordination are not unique to sleep and
24:57they're not unique to the VA A recent
24:59comprehensive review of of referral,
25:01especially care referrals within the
25:03within the Duke system found that less
25:06than 35% of of referrals from primary
25:09especially care led to service delivery.
25:12There's a lot of people who fall out,
25:14fall through their cracks.
25:17And this issue played out across
25:19multiple specialties in the
25:20VA across the last 10 years,
25:22capturing the attention of of leadership.
25:24And in 2017 and 2018,
25:26the director of VA's then director of access,
25:30Doctor Susan Kirsch, and Doctor David O,
25:33who's a pulmonologist and my
25:35mentor at the Seattle HRD,
25:37began discussing how to discuss
25:39how to how to address this gap.
25:41And the goal was to overcome limited
25:43specialist time and coordination.
25:45And they had two main strategies.
25:47To meet this need,
25:48the first was to create an integrated
25:51practice unit to coordinate
25:53specially care transitions.
25:55And the second was to incorporate alternate
25:57care providers to offload specialists.
26:01So what's an integrated practice unit?
26:03The concept of an integrated practice
26:05unit is really one of team based
26:07care that works together to achieve
26:09patients longitudinal needs centered
26:11around a common set of conditions.
26:13There are four main steps to
26:15developing an integrated practice unit.
26:17First, you'd have to define the comp,
26:19the the condition and the problem,
26:21map the patients process to meet those needs,
26:25create a multidisciplinary team
26:27to meet that need with a shared
26:30group of norms and structures.
26:32And is your outcomes to ensure
26:33that the needs are met,
26:34make sure that you're you're
26:35you're doing what you what you
26:37think you should be doing.
26:41What resulted out of this process
26:43was the referral coordination model,
26:45which is an integrated practice
26:48unit to managing referrals between
26:50especially primary and specialty care.
26:53In this system, nurses manage referrals
26:55using dishes and support tools,
26:56collaborate with dedicated administrative
26:58staff to arrange next steps,
27:00and engage specialists only as needed.
27:04So here I'd like to contrast the new
27:06system referral coordination with the
27:08traditional system kind of side by side
27:11instead of siloed discrete systems
27:13for decision making coordination.
27:15Referral Coordination team takes
27:17collective responsibility for patient care.
27:20Specialists are moved out of series and
27:22moved into an as needed role instead
27:24specialists being involved in each referral.
27:28Nurses take the first stab at E
27:30consultation using a decision support tool.
27:37Before I go any further,
27:38I want to highlight the critical
27:40importance of this decision support
27:42tool and illustrate that it's
27:44it's really not something that
27:47can be done quickly or easily.
27:49To facilitate the the nurses decision
27:51making within our context within
27:52our center a well vetted decision
27:54support tools critical and the key
27:56and it's the key to kind of sharing
27:58specialty care knowledge between
28:00the specialist and press and and
28:03takes a lot of work our our center
28:06approach this the the creation
28:08of this decision support tool in
28:09a collaborative fashion prior to
28:11deploying referral coordination
28:13our director of Sleep Medicine
28:15Doctor Brian Palin work extensively
28:16with Larry Fernandez the chief.
28:18For coordination nurse and the
28:20referral coordination team.
28:22They met weekly for for I think
28:24it was about 3 year,
28:25four months vetting the tool and
28:28ensuring shared decision making and
28:29this turned into a living document
28:32over time and we adapted it as we went,
28:34as as we,
28:35as we identified areas where what
28:36we thought we were communicating
28:39wasn't necessarily communicated.
28:43In the next few minutes,
28:44I want to show you a review the
28:46findings of our comprehensive
28:48evaluation and referral coordination.
28:50Essentially, we wanted to know if the
28:53referral coordination delivered on the AAA.
28:56And so we comprehensively assess
28:58the impacts on timeliness,
28:59patient experience, quality,
29:00costs and staff experience.
29:04First, our analysis focused
29:06on communist and access.
29:08We looked at data from May 2018.
29:09Referral coordination
29:11started until December 2019,
29:13which is chosen to avoid confounding
29:15from the COVID-19 pandemic.
29:17During this time,
29:19we rolled out four coordination
29:21alongside the traditional system
29:22and patients received other
29:24traditional or referral full
29:26coordination based on provider
29:28availability at the time of triage.
29:30And so patients who went down
29:32the the traditional path,
29:33they continued using our traditional
29:36methods for scheduling and
29:38the patients in the referral
29:40coordination path they went into
29:42this referral coordination team.
29:43We given concerns that there might be some.
29:48Uh, differences in who lands
29:50into one group or the other.
29:52Although it was pretty much quasi random,
29:55we did match within biweekly time
29:57periods based on propensity score,
29:59including patient characteristics
30:00affecting that were thought to affect
30:03Council complexity as well as access.
30:08Overall, we saw marked benefits to RCI
30:10in terms of timeliness of appointments,
30:12timeliness of scheduling and we
30:13saw fewer patients needing to be
30:15referred outside of the system.
30:17The results were very similar when we look
30:19beyond the propensity matched population
30:22and they were essentially the same.
30:29We also conducted surveys with patients
30:31who are randomly selected from each arm,
30:33assessing whether they agreed their
30:35care and contact were timely and
30:37whether they knew what the next steps
30:39in their in their care were and whether
30:41they were treated with respect.
30:42Overall, for coordination of
30:44patients and the referral,
30:46coordination were more likely than
30:47patients in the traditional system
30:49to agree with each of these prompts.
30:53We then compare the traditional
30:56system and for coordination.
30:58Head to head in terms of quality,
31:00we looked directly at those referred
31:03for initial OA evaluation and testing
31:05compared to traditional system versus
31:074 coordination to assess the quality
31:09of sleep study orders compared
31:12objectively with the ASM guidelines and
31:16in addition to the overall patients.
31:19Overall we wanted to look at patients who
31:23were looked at in independently by nurses,
31:27you know those for whom they did not.
31:29Ask for help from a specialist.
31:31Relative to comparable patients,
31:33propensity matched within who who had
31:36consultation done by specialists themselves.
31:42In the overall sample,
31:44our our our main interests were H sats
31:48with a potential contraindication.
31:50As as defined by the 2017 and
31:53some guidelines and overall we
31:55saw well it was relatively rare
31:57that we had home tests with the
32:00potential confident indication.
32:01There were fewer in the referral
32:04Coordination group which participate
32:06which was borne out when we
32:10tested this hypothesis formally.
32:13And there was about the adjusted risk
32:17ratio was about .5 for guideline
32:18for those referred for guideline
32:20discordant test and those completing
32:23the guideline discordant test.
32:28And the propensity matched subsample
32:30of of those those sleep study orders
32:34that were done independently by nurses
32:37or independently by specialists.
32:39We saw comparable proportions of
32:42individuals with a potentially
32:44contraindicated home sleep apnea
32:46test order and as well as potentially
32:48inappropriate home sleep apnea test order,
32:51namely those with those with those ASM
32:55contraindications plus those that lacked
32:57a a symptom that would indicate high risk.
33:04And here you can see when we tested the
33:07potentially county Contra indicated orders
33:10and potentially inappropriate orders,
33:12we did not see a difference across groups
33:15in the propensity matched subsample.
33:18But if anything, there was,
33:21you know, potentially would
33:23favor the four coordination,
33:25although there was no significant difference.
33:33One critical aspect that we we looked
33:35at was staff time as well as as a as
33:39an introduction to looking at cost.
33:41And as we deployed,
33:43there were four coordination and
33:44we surveyed specialists as well as
33:46nurses about the time they spent
33:49performing E Councils and surveyed
33:51administrative staff members around the
33:53time they spend scheduling services.
33:55We then compare these time estimates
33:58to objective productivity and the
34:00number of consults completed and
34:02scheduled by each type of staff member.
34:04Overall, with report for coordination,
34:07specialist spent 16 minutes less per consult.
34:1125 minutes to 9 minutes.
34:14But as you can see here,
34:16there was actually more time overall
34:18devoted to consultation because
34:20we we added nurses and the nurses
34:24spent 36 minutes per consult.
34:26Overall, MSA time was relatively similar.
34:30So he spent 20 more collective minutes
34:33of of time from from staff members,
34:37but overall there is really not
34:39much difference in terms of of of
34:42overall cost due to the the the
34:45difference in cost per unit time
34:48for nurses relative to specialist.
34:51When we incorporated lower
34:53community care costs as well,
34:55there there there wasn't much in
34:56terms of a difference between the two,
34:59between the two groups in two groups in
35:01terms of overall costs when we employed
35:05our pretty healthy confidence intervals.
35:13In addition to overall
35:15cost just for for triage,
35:16we also wanted to take a more global
35:20view of the value of specialist time.
35:23So we as we as we mentioned 6,
35:26there's 16 minutes less spent by
35:29specialist on each referral in the
35:31referral coordination and in the
35:34referral coordination program.
35:35And based on this reclaim time,
35:39there's potential value there.
35:40We estimate that if you turn that time.
35:44Uh, into more visits for every
35:46thousand referrals that went to the
35:49referral coordination initiative
35:51versus versus our traditional approach.
35:53You could do up to 800 new
35:56encounters with the value of that
35:59care estimated about $70,000.
36:02And just in terms of what has happened
36:05since we've implemented this program,
36:07we've had,
36:08we've we've been able to dramatically
36:10increase the number of video visits
36:12we we perform and the number of sleep
36:14tests that we're able to accommodate.
36:20And finally, I just want to briefly
36:21touch on our qualitative work.
36:23We conducted interviews among RCI
36:26team members, SLEEP specialists,
36:28one of our respirate therapists
36:30who was involved in the RA program.
36:32As well as 16 referring providers,
36:36pretty much primary care providers.
36:39And our qualitative interviews,
36:43they they they touched on a number
36:45of themes including efficiency,
36:47patient access and experience,
36:48staff well-being, satisfaction,
36:49sharing, especially care,
36:51knowledge, nurse autonomy,
36:53as well as coordination and communication.
36:57I'm just going to talk
36:58about a few of these staff.
37:00You know they discussed a lot around
37:03the impacts on nurses, autonomy and.
37:06Something that we noted is that
37:09while the nurses appreciated
37:12clear algorithmic criteria,
37:15that had its limits.
37:18You know, as one sleep specialist mentioned,
37:20initially we had hoped that the
37:22decision support tool was going
37:23to cover every eventuality,
37:24but then the toolkit became so exhaustive
37:26and so detailed that it becomes unusable.
37:29So the key, one of the key things that
37:31we found in this process was that.
37:34There needs to be a balance between
37:37detail and and just the pragmatic
37:40nature of of getting things done.
37:43And also of note,
37:45specialists mentioned that they were
37:47able to spend less time kind of echoing,
37:50reinforcing the our, our,
37:52our quantitative findings and primary
37:55care providers echoed what we found
37:59quantitatively around greater availability
38:01in terms of access to services.
38:08When it comes to a pretty high overview,
38:11we come to the conclusion that the
38:13referral coordination program at
38:14least based on our local experience.
38:17Gets us a little bit closer to the triplane
38:21and maybe a guide for for coordinating
38:24sleep care services going forward.
38:28We found that there was
38:29greater access to services,
38:31greater improved patient experience of
38:33care and similar per capita cost with
38:36the potential for greater healthcare
38:38system value for the reclaimed provider
38:41time and in general our interviews
38:44indicated a positive experience.
38:45So we can potentially speak
38:46to their quadrupling as well.
38:50However, globally within pro coordination,
38:54more work will need to be done to adapt
38:57the practices to contacts within the
39:00other specialties and other locations.
39:02the VA has worked on disseminating RCI
39:04across all specialties with the goal
39:06of adopting initially by June 2021.
39:08Harbor sites have been limited and
39:11their implementation across specialties
39:13with potential drivers including
39:15insufficient staffing and adequate
39:17information to guide patients around
39:19options like a clear guidance.
39:21These new sites where it's been
39:23rolled out in other specialties.
39:25And and and on that basis of those
39:29initial hurdles through the sale
39:32donor center of Innovation for health
39:34services research and development,
39:36we're actually leading a nationwide
39:38evaluation to better understand and meet
39:40these barriers to implementation more
39:42widely with RCI and other specialties.
39:49So thus far we've presented OSA care on the
39:52context of the default mode of provider
39:55delivered and recommended services,
39:57which I think is going to be the default
39:59mode for at least the foreseeable future.
40:01But before we close,
40:02I want to talk a little bit about an
40:06additional and and potential alternative
40:10approach that we could consider.
40:13The default mode to provide a
40:16recommended and referred services
40:18goes a little bit like this.
40:20A patient has a need for services,
40:22patients discuss their need with providers,
40:25provider orders the next the services
40:27to meet those needs and the health
40:30system delivers that services.
40:32However, for certain services,
40:34providers might just get in the way.
40:37You know it.
40:38We we may consider what's known
40:40as a population health approach.
40:44Where the health system proactively
40:45identifies the patients need.
40:47And deliver services directly to patients.
40:52And I think this is going to
40:53become more of a a,
40:55a model going forward as we seek to
40:58expand the population health reach
41:00of our effective interventions.
41:04One potential implication application
41:05in OSA is around weight loss.
41:08Obesity explains about 60% of OSA
41:10severity and lifestyle based weight
41:12loss interventions improve OSA severity
41:14and are currently recommended in
41:17guidelines for all patients with OSA
41:19and obesity at least to be offered.
41:22However, these these these guidelines
41:25are frequently not adhered to.
41:28And 33% of only about 33% of patients
41:32with OSA discuss weight loss with
41:35providers and less than 10% of of
41:37patients with OSA access lifestyle
41:38interventions even if they're available
41:40within their healthcare system.
41:44There were two reasons for this lack
41:46of reach and they include an adequate
41:48patient time and adequate provider time,
41:50distance from services they're frequently
41:53provided on site as well as the lack
41:56of flexibility in the way that we
41:58deliver those those interventions.
42:00And so that leads many patients did not
42:04receive these lifestyle based weight
42:05loss programs that are recommended.
42:10Umm and so one thing we've
42:11we've been thinking about is,
42:12is a population health approach
42:14to weight loss care in LA.
42:17And ideally if you're going to deliver
42:18things in a population health manner,
42:20an intervention would be remote and
42:23scalable and and luckily we have one
42:24of our close colleagues and doctor
42:26Ma from the University of Illinois,
42:28Chicago developed a remote self-directed
42:30weight loss program that compares
42:33favorably to in person services.
42:35Although the impact in OSA is
42:38unclear and when tested anonymously
42:40populations really leads to modest
42:43but detectable benefits to weight.
42:46These self-directed programs might
42:48be appropriate for patients with OSA
42:51as patients with OSA tend to be more
42:54engaged with weight loss relative to
42:56peers without us say and there are
42:59definite benefits to weight loss in
43:01terms of symptomatic improvements
43:03even from modest weight loss.
43:06And so with this background in mind,
43:08we're currently testing a population
43:10health approach to weight loss care.
43:13And recruiting patients nationwide
43:15within the VA,
43:17we proactively identify veterans with
43:19recently diagnosed to reconfirm OSA and
43:22obesity, invite them to participate.
43:24If they opt in,
43:25we randomize them to remote self-directed
43:27care with the weight loss center,
43:30with the self-directed weight loss
43:33intervention or usual usual care
43:35and then follow them up to over 24
43:39months looking at primary outcomes
43:40including sleep player quality
43:42of life measured by fosc.
43:43As well as some of the measured weight.
43:46Thus far we've randomized about
43:48550 veterans and should should
43:50hit our planned recruitment number
43:53by 696 by May of this year.
43:56Just another potential approach
43:58to meeting our patient,
43:59meeting the needs of our patients with those.
44:04So to recap, within Sleep Medicine
44:06we have evidence based tools to
44:08overcome barriers of geography and
44:10capacity and we have strategies
44:12that can integrate and coordinate
44:14care for these for these different
44:16options across the population,
44:18their care delivery models that are
44:20well developed and other in other
44:22conditions as well as within inner,
44:24inner emerging within OSA.
44:27Pro coordination can streamline appropriate
44:29referrals and navigate these transitions,
44:31and population health management
44:33may serve as a future way of
44:35reorganizing and improving,
44:36further improving access to services.
44:41However, there are some
44:42key unanswered questions.
44:44As alluded to earlier in the presentation,
44:46we don't have a lot of high quality
44:49experimental evidence to guide patient
44:51selection for these more complicated,
44:53complex pathways.
44:53As of yet, the there are no trials
44:57that really confirm the the the
45:00populations where we absolutely need
45:02PSG versus home sleep apnea test.
45:05Similarly, we we don't know exactly.
45:09From the patients who absolutely
45:12need specialists relative
45:13to alternate care providers.
45:15And where the where the actual
45:18impacts of redesign systems
45:19on care on a global level.
45:21You know what do we do for reach
45:23when we integrate both these
45:25systems within and and are able to
45:27manage the the transitions within
45:29a referral coordination pathway.
45:31How do we most effectively train the
45:34alternate care providers and what are
45:36the long term impacts on patients
45:39trust and satisfaction as we move
45:41away from highly specialized. One way St.
45:44to a more collaborative model.
45:48And what are the settings in which
45:50population health management?
45:51Where we, where we?
45:54Avoid these issues around these
45:58requirements that providers identify.
46:01The issues, make the order all that.
46:04Where can we integrate population
46:07health approaches that meet the needs
46:09of patients in a more streamlined
46:11fashion and where is it actually effective?
46:13Right now,
46:14we don't know where it is effective.
46:18And finally, I think a pretty major
46:22question is how do we pay for all of this?
46:26It should be apparent from the the
46:28discussion that integrated health
46:29systems like VA or Kaiser would be
46:31well suited to this kind of model
46:33given their health systems incentives.
46:35Such a model becomes trickier and
46:38in in systems that rely on fee
46:42for service for reimbursement.
46:44Particularly when you start
46:46talking about incorporating non,
46:47non providers into the delivery of care,
46:50how do they bill for their
46:52services and how do we,
46:53how do we align what they're doing
46:56with traditional scopes of practice
46:59out in in other organizations?
47:01However,
47:02there are some opportunities along
47:04the in the in the near distant future
47:07in the form of bundle payments
47:09and more value based purchasing
47:12which is becoming more and more.
47:14More and more of the standard
47:16across the industry,
47:17things like accountable care organizations
47:19as well as value based contracts,
47:21we may see those become increasingly
47:24increasingly available and available to
47:28reimburse you know strategies such as these.
47:35So with that, I just wanted to
47:38close by saying redesign processes
47:40for care is not going to be easy.
47:42There's a mountain of work ahead
47:43of us that we need to climb.
47:45However, by using existing
47:46evidence as well as frameworks,
47:48we can create a path forward
47:50that aligns with our values.
47:52By using these frameworks
47:53and focusing on our values,
47:55we can rigorously test these assumptions
47:58and approaches that are being that are
48:00going to be necessary to move this
48:02closer to fully addressing the population.
48:04It's gonna say and maximizing well-being.
48:07There's a lot of people I need
48:09to think and including mentors,
48:12collaborators, my institutions,
48:14as well as the Sleep
48:16Medicine providers within.
48:17BA isn't 20.
48:19And with that,
48:20I will take your questions.
48:23Great. Thank you. Look for a great
48:26talk and the 20,000 foot view all the
48:30way down to individual view on this.
48:32There are a couple of questions in the chat
48:35and so we'll start with Doctor Eric Heckman.
48:37And so Eric is asking a question or
48:40you want to ask your own question,
48:42Eric, why don't you do that
48:43instead of me reading yours?
48:45Sure, happy to. Great
48:47talk, Lucas. My my question is,
48:49you know outside of the VA there's
48:51like overly onerous amount of
48:54documentation that has in my opinion
48:55at least it has to happen proposed
48:57sleep study and for Valve with CPAP
48:59that seems to be a persistent barrier
49:01in in getting less specialized providers
49:04to take ownership and the OSA pathway.
49:07So how do you foresee kind of
49:09breaking through this logjam that
49:11seems to be a barrier to adopting any
49:12model for sleep apnea therapy that
49:14that doesn't keep the specialist?
49:17It's the central cog. Absolutely.
49:19That's a great question.
49:20I think a a key key limitation in
49:23in in innovation and in expanding
49:26population health is just the sheer
49:28administrative burden and and I I don't
49:31have a a very easy answer to that but I
49:34think as a field we collectively need to.
49:38Encourage payers to recognize where
49:41the value of Sleep Medicine services
49:44lies and and how to pay for that value
49:48the payers there's always going to
49:51be you know well I I think we all in
49:53this in this room would would would
49:55would want payers to pay more for sleep
49:57care services than they currently do.
49:59I think that's our our our our
50:01particular event they they do
50:03have there are limitations and and
50:06how much they can pay but.
50:08How they allocate those resources
50:11towards meeting the needs of the
50:13patients is is up for is up for
50:16debate and in terms of how do they
50:19allocate resources to to provide
50:21benefit across the population.
50:23Those are those are questions that
50:25that I think need to be had.
50:27I think currently you know they the
50:30the limitations that care relies on.
50:33Whether or not you have a sleep
50:36provider who's willing to fill
50:38out all the documentation and in
50:41certain jurisdictions are you able
50:42to your your your ability to get
50:44sleep care relies on your ability
50:46to spend the night in a sleep lab.
50:49Even if you and the sleep provider
50:51don't think you need to.
50:52We need to you know kind of challenge
50:55that paradigm and instead work with
50:58payers to to reimburse care based
51:00on patients likelihood of benefit.
51:03You know there's there's going
51:04to need to be a line somewhere.
51:05At least in a fee for service
51:08environment and that's how it's done.
51:10Now if we consider more value
51:12based purchasing.
51:13You know if you provide a healthcare
51:15system a certain amount of funds
51:17to to manage a given population
51:19then the healthcare system itself
51:21can figure out how to you know use
51:24their their their resources to
51:26to manage the population at hand.
51:28And that's where value based
51:30purchasing will really become a a
51:33really become helpful I'm I'm biased.
51:36Was that when I was just going to admit
51:37it just based on where I work in the VA?
51:40But there are limitations as well
51:42and I think there are large policy
51:45and implementation discussions
51:47that that need to be had.
51:50So I'm I'm not sure that I'm necessarily
51:52the one to have those conversations but.
51:56I think. Thanks, Luke.
51:57Good question, Eric.
51:58Thank you. So Doctor Robert
51:59Thomas has another question.
52:01So I'll meet you Robert.
52:03Hopefully your hand is not numb
52:04holding it up for so long.
52:12Ohh hey look hey long time no see.
52:14It's good to see you. For this audience,
52:18Lucas are very special fellow he.
52:22He really was the only fellow.
52:23I did not have to explain
52:25what high lutein was.
52:27If you go and look at his pub Med
52:28publications, you will see that he has
52:30done some seminal work in this area.
52:32So that was nice anyway so.
52:37You know, I mean, no,
52:38I'm looking in as much as I can
52:41in China and India to try to.
52:44Get him off the ground in terms of.
52:47Interesting. Some of the issue.
52:48It's far worse out there in terms
52:50of resource and needs and so on.
52:53And one thing which always struck me is that.
52:55The best.
52:58Workforce and they are essentially
53:00blocked from providing.
53:02Any kind of care or sleep technologist.
53:05Because they have the exact
53:07skills which are needed for.
53:09A lot of sleep management,
53:10but especially apnea.
53:13And it would be such a great segue for them,
53:15right, if you do two or three years at night.
53:18You know,
53:18and then you move partly into the day,
53:20and then you move mostly into the day.
53:24They are cheaper than those
53:25practitioners and nurses.
53:26They make a decent living.
53:28But.
53:28It's a real career path for them
53:30rather than getting burnt out and
53:32then try and do something else.
53:34And I think the ASM probably can.
53:37You know, SMAC can probably address that.
53:40It'll take a bit of.
53:42Time and effort,
53:43but it's such a readily available
53:45workforce which is being wasted.
53:47Another point I'd like to
53:48make is that sleep care,
53:50one of the reasons why I think we are.
53:52Going behind the systems haven't really
53:55sprung into place to solve problems
53:57is that there's no punishment, right?
54:00We can provide really poor care
54:01and there's no punishment.
54:03We are not part of any mandatory thing like,
54:06you know, checking potassium A1C.
54:10Oh, you know, bone density,
54:11etcetera, etcetera.
54:12There's no punishment for really,
54:13really poor sleep care.
54:15We are not part of any.
54:16Obligatory part of any guideline.
54:20No, you may in the A DSS, yeah,
54:23you may think of sleep apnea.
54:24Sleep apnea, sorry, obviously just says,
54:26yeah, things are really bad.
54:28You could do something about it,
54:29but we are sure it'll help you, et cetera.
54:31So there's no punishment,
54:33and much of US medical care anyway revolves
54:37around avoiding punishment you take.
54:41Readmissions as an example,
54:43a hospitals are doing anything to
54:45avoid readmission penalties, right?
54:46So system gets developed,
54:48what to do, etcetera.
54:49But sleep?
54:49There's no punishment.
54:52Advocating for punishment.
54:53Robert, thank you. But, but I guess
54:56that'll get a feel forward.
54:58It's not a bad thing, you know.
54:59Six months wait time.
55:01Fine, no problem. You know,
55:02alright, alright, alright. So,
55:04so Luke, a couple of comments I think,
55:06just want to make sure we have time for
55:08any other questions that they creep up.
55:19Any comments, Luke? Oh, sorry,
55:22sorry. I thought you were
55:22waiting for other questions.
55:23Yeah, I think the so the,
55:24the the notion of of of punishment
55:27is definitely one that's you know
55:29is is you mentioned it's used
55:31in other other areas such as,
55:32you know readmission penalties.
55:36It's not necessarily a.
55:38The the only way to achieve value
55:43based care you know there's other
55:45other options as as as we've discussed
55:48you know you know more capitated
55:50models where you have a certain set
55:52of money to take care of a population
55:54and then the the health system
55:56itself makes makes decisions around
55:58how to how to allocate that care
55:59and and and and prioritize services.
56:02But you know certainly I think I
56:04think we can all agree that we
56:06need to create metrics and and
56:07and and follow metrics that align
56:09with our our values and.
56:11And and and benefits to the patients
56:13and I think those those need to
56:15be thought out very carefully.
56:17I think there's there's been you know
56:18with regard to the readmission penalty,
56:21I think there's there's there's a
56:22lot of debate as to whether or not
56:23that's really the the right metric.
56:24And then so I think if we as we
56:28consider those those options and
56:29Sleep Medicine we need to be really,
56:32really attuned to focusing that there
56:34really patient centered outcomes.
56:36Yeah. So. So, so look I'm going to
56:39jump on that wagon for just a second.
56:41And just talk a little bit about value.
56:44Yeah, how do we define it?
56:45Because depending on how you define it,
56:47you could actually cause harm
56:49to the system and the individual
56:52humans that we're trying to help.
56:55Versus, you know, creating a benefit.
56:57And so one example I can think of
56:59is if you ask certain practices
57:02to measure certain outcomes,
57:04they may not have the capacity to do that.
57:05So you're going to lose a bunch of
57:08small practitioners or individual
57:09practitioners who are still out there.
57:12And then the healthcare becomes
57:13a Walmart of healthcare where
57:15you have large healthcare systems
57:17who are dominating the landscape.
57:18And so how do we define the value?
57:22I'm sure it's a big question,
57:24last minute but.
57:24How do you define value?
57:26What are some of the patients
57:28that are outcomes that are
57:29critical and who gets to do
57:31that? Yeah well I think
57:34you know symptoms are you know really
57:37where the you know where the the most
57:41meaningful patient centered outcomes are at
57:42least with the the the management of OSA.
57:45And so I think there are inherent
57:47limitations in in the measurement of
57:49symptoms but how do we how do we measure
57:52that in a pragmatic and universal way.
57:56I think that's that's really important
57:57because the last thing you want to
57:59do is create a a rule that you'll
58:00only be reimbursed if your parent.
58:02If your patients have good outcomes
58:04in terms of symptoms and then you
58:07only include you know, you, you, you,
58:10you gain the system by, you know,
58:13focusing your your your panel on.
58:16On patients who are more likely
58:18to fill out those those surveys.
58:21So I think we need to you know
58:23carefully consider that.
58:24I think in general I would focus on
58:29throughput for you know meeting patients
58:31needs and and delivering care that
58:33we know is is going to be effective.
58:36You know have you delivered a CPAP to a
58:38good number of of of of patients have
58:40we are we able to you know support
58:43their their adherence among patients.
58:45You appear to be deriving a benefit
58:50from therapy and I think we,
58:53we need to really be thoughtful
58:56and considerate as we, as we,
58:58as we have debates like these around how
59:02we define value and how we implement it.
59:05Certainly there's,
59:06there's a,
59:07there's a simple solution and and that
59:09simple solution is going to be likely wrong.
59:11But I think collectively I'm,
59:13I have faith that we'll be able to.
59:15To come up with a system that that
59:18approaches value for our patients
59:19and and I and I would argue that
59:22in that discussion we need to make
59:23sure that patients are present.
59:27Yeah, absolutely.
59:28Very good. All right.
59:30Well, thank you very much,
59:31Luke, and thank you very much,
59:33everyone and for making
59:35this a successful series.
59:36I think on the initial slide
59:38before the conference started,
59:40in the last three years,
59:41we've had 1800 participants with the
59:44average of 80 to 90 participants per session.
59:47So thank you all for making that happen
59:50and we'll see you guys next week.
59:52Thank you.