Sleep Apnea Research Jon H. Lemke, Ph.D. Chief Biostatistician - - PowerPoint PPT Presentation

Sleep Apnea Research

Jon H. Lemke, Ph.D. Chief Biostatistician Jordan Brautigam, MHA Business Analyst Business Intelligence Center Genesis Health System

2016 Genesis Research Summit June 8, 2016 Adler Education Center Genesis Medical Center, Davenport (East Campus)

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Sleep Apnea Research Outline

 Study Purpose and Goals  Study Design  Outcomes  Impact on Patient Care

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National Perspective

 ALL 41 Institutes in NIH claim diagnosis and treatment of sleep apnea is crucial to their mission.  The Joint Commission issues an Alert Friday June 26, 2015

 Incidence of Sentinel Events have an abundance of potential sleep apnea patients.  Recommend screening patients for sleep apnea upon admission to the hospital to identify patients at greater risk for sentinel adverse events.

 At Genesis we have been doing this since November 2012. Sleep disordered breathing has a different footprint on across ALL major diagnostic categories.

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Anesthesiologist Perspective

“Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea” (2006)

 Focus: “Patients with OSA who may be at increased risk for perioperative morbidity and mortality because of potential difficulty in maintaining a patent airway”(1082).  Recommendations: “Anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of perioperative management”(1084).  “A physical examination should include an evaluation of the airway, nasopharyngeal characteristics, neck circumference, tonsil size…”(1084).  “The consultants agree that perioperative use of CPAP or NIPPV may improve the perioperative condition of patients who they believe are at increased risk from OSA…”(1084).  “Because of their propensity for airway collapse and sleep deprivation, patients at increased perioperative risk from OSA are especially susceptible to the respiratory depressant and airway effects of sedatives, opioids, and inhaled anesthetics” (1085).

Selected Previous Research

 Undiagnosed and Untreated Sleep Apnea patients with knee or hip replacement were 9 times more likely to have unplanned visits to ICU.

Gupta R, Parvizi, J, Hanssen A, Gay P. Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study. Mayo Clin Proc. 2001;76:897-905.  32% increase (from 37% to 49%) of Left Ventricular Ejection Fraction (LVEF) after one month of PAP use; results reversed after one week without PAP.

Bradley T, Floras J. Sleep Apnea and Heart Failure: Part 1: Obstructive Sleep Apnea. Circulation 2003;107:1671-1678.

 Schneider Trucking with comprehensive diagnosis and treatment had 74% reduction in accidents and 91% reduction in hospitalizations.

Lazar RA. An Emerging Standard of Care Requiring Commercial Driver Screening for Sleep Apnea: Practical Considerations and Risk Management Strategies for the Trucking Industry. White Paper Published August 1, 2007.

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Adherent - but

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Sleep Apnea Risk Groups

• 3. No Dx-Likely Sleep Apnea
• 4. No Dx-Unlikely to have Sleep Apnea
• 1. Dx-Adherent
• 2. Dx-Nonadherent

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Caveats

 Biases exist in this screening as we primarily depend upon what the patient tells us.  We are only analyzing those that come to the hospital, and cannot compare them to those that are not hospitalized. In these analyses the focus is entirely on the “Inpatient” encounters.  Changes in demographics of the population, access to

care, definitions and documentation are changing who is a hospitalized “Inpatient”.

 Some inpatients are screened by self report at one GMC site, transferred and then observed at another GMC site.  Several of these slides focus on the first 2.0 years of encounters.

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Competing Risks: Physician Documented Prevalences with MIDAS+ Cluster Ranking by Sleep Apnea Status

Sleep Apnea Risk Group

Arthroplasty Total Knee Heart Failure Septicemia PTCA Viral Pneumonia

Dx – Adherent 1st (8.2%) 4th (5.1%) 2nd (6.6%) 3rd (5.3%) 6th (4.6%) Dx – Nonadherent 6th (3.9%) 1st (6.9%) 2nd (6.9%) 3rd (5.7%) 4th (5.3%) No Dx – Likely 9th (2.5%) 4th (4.2%) 1st (6.7%) 2nd (5.6%) 3rd (5.3%) No Dx – Unlikely 2nd (5.4%) 5th (3.3%) 1st (6.1%) 4th (3.9%) 3rd (4.8%)

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Focus on 44,924 Acute Care Inpatients Sleep Apnea Status by Site

Sleep Apnea Risk Group Davenport Silvis Aledo DeWitt Total: Dx – Adherent 4,437 (12.6%) 687 (7.6%) 34 (10.3%) 25 (7.0%) 5,183 (11.5%) Dx – Nonadherent 4,334 (12.3%) 903 (10.0%) 44 (13.4%) 63 (17.7%) 5,344 (11.9%) No Dx – Likely 4,464 (12.7%) 997 (11.1%) 31 (9.4%) 47 (13.2%) 5,539 (12.3%) No Dx – Unlikely 22,012 (62.5%) 6,406 (71.2%) 220 (66.9%) 220 (62.0%) 28,858 (64.2%) Total 35,247 (100%) 8,993 (100%) 213 (100%) 255 (100%) 44,924 (100%)

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Comparison of Sleep Apnea Risk Groups by Sex

Dx of Sleep Apnea (Group 1 + 2) No Dx of Sleep Apnea (Group 3 + 4) Total Male

5,915 (27.9%) 15,320 (72.1%) 21,235 (100%)

Female

4,612 (19.5%) 19,077 (80.5%) 23,689 (100%)

Total

10,527 (23.4%) 34,397 (76.6%) 44,924 (100%)

Dx-Adherent (Group 1) Dx-Nonadherent (Group 2) Total Male

3,068 (51.9%) 2,847 (48.1%) 5,915 (100%)

Female

2,115 (45.9%) 2,497 (54.1%) 4,612 (100%)

Total

5,183 (49.2%) 5,344 (50.8%) 10,527 (100%)

No Dx – Likely (Group 3) No Dx – Unlikely (Group 4) Total Male

2,290 (19.3%) 9,586 (80.7%) 11,876 (100%)

Female

2,072 (14.1%) 12,650 (85.9%) 14,722 (100%)

Total

4,362 (16.4%) 22,236 (83.6%) 26,598 (100%)

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Current Research Team Investigators

• Jon H. Lemke
• Desyree Weakley
• Stephen C. Rasmus
• Vicki Loving
• Tosha Allen
• Mike Malloy
• Brian Dirksen
• Mikel O’Klock
• Neil Flynn

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Special Thanks

• Maja Zingmark
• Hannah McAfoos
• Ryan Kelly
• Chris Lynn
• Dr. Claudy
• Gina Gore
• Candice Elias
• Tami Gumpert
• Braxton Lancial
• Alyssa Barkalow
• Lynn Colberg
• Dianna Paustian
• Amanda Wesson
• Every Physician and

Every Nurse who has had a frank discussion about sleep apnea.

• All of the Sleep Techs
• All of the Respiratory

Techs

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Acute Inpatient Complications by Sleep Apnea Status 2013-2015 (18+)

0.00 25.00 50.00 75.00 100.00 125.00 150.00 175.00 200.00 Observed per 1000 Expected per 1000

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Sleep Apnea Status O:E Ratio Delta (O-E) Excess to Target Adherent 1.04 24.9 115.5 Nonadherent 1.19 163.7 273.7 Likely 1.38 258.6 346.5 Unlikely 1.33 1111.0 1546.6 All 1.28 1558.1 2282.3

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Acute Inpatient Mortality by Sleep Apnea Status 2013-2015 (18+)

0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% Observed Percent Expected Percent

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Sleep Apnea Status O:E Ratio Delta (O-E) Excess to Target Adherent 0.88

• 11.73

0.97 Nonadherent 0.98

• 2.36

14.59 Likely 0.89

• 15.37

2.75 Unlikely 0.81

• 127.02 -41.61

All 0.85

• 156.47 -23.29

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Sleep Apnea Status with Maximum O:E Ratio by Most Frequent MDC

System/Disease Complications Mortality ALOS Readmission Circulatory Unlikely Likely Nonadherent Nonadherent Musculoskeletal Likely Likely Likely Likely Respiratory Likely Nonadherent Likely Adherent Digestive Likely Nonadherent Likely Likely Infectious and Parasitic Likely Nonadherent Likely Adherent Nervous System Nonadherent Nonadherent Nonadherent Unlikely Kidney and Urinary Tract Nonadherent Nonadherent Likely Nonadherent Endocrine, Nutr., Metabolic Adherent Likely Unlikely Unlikely

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Conclusions

 Benefits of No Diagnosis or Nonadherence?

 More likely to visit the hospital for nonelective reasons  More likely to stay longer  More like to have complications  More likely to code  More likely to have an unplanned visit to the ICU  More likely to die in the hospital  More likely to get inpatient status benefits

 Hmm, and for everyone?

 Higher motor vehicle insurance premiums  Higher healthcare insurance premiums  Unnecessary loss of friends and family

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Conclusions

 You must know the sleep apnea status of each patient to anticipate complications, rapid responses, code blues, unplanned ICU transfers, serious safety events, sentinal events, … .  In peer reviews of cases it is crucial to ask about a patients sleep apnea status.  Expect the unexpected for people with untreated sleep apnea!  The success of any ACO is dependent upon how well the health system deals with sleep apnea!  Be grateful to each person with sleep apnea who is an adherent CPAP user!

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