Sleep 2023.03.08 DonovanMarch 15, 2023
To CiteDCA Citation Guide
- 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.
- 08:00you 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.
- 11:10there 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.
- 13:01the 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.
- 14:57despite relatively strong evidence
- 14:58for comparable outcomes with
- 15:00alternate care providers,
- 15:01there are potential downsides
- 15:03and limitations and evidence.
- 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.
- 15:29Similar 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.
- 20:26And 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?
- 47:02there 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.
- 53:28It'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.