Practical methods to improve compliance with positive airway pressure devices.
By Jennifer D. James, RPSGT
Compliance with all therapy begins with the introduction. This is never more true than when dealing with sleep apnea patients. One must always remember that we are working with the most sleep-deprived portion of the population. These patients are often irritable, depressed, and overly anxious for any cure for their current state of misery. It is imperative that their first impression of CPAP be a positive one, for it will predict if they will actually utilize this treatment modality. Everyone has heard, “There is never a second chance to make a first impression.” Well, your role in making a patient’s first impression of CPAP a positive one may actually help save a life.
Compliance does not begin with the order to the durable medical equipment (DME) company. It does not begin when the therapist arrives to deliver the unit. Compliance begins when the patient arrives for a sleep study or, in many cases, in the physician’s office with the referral to the sleep center. Compliance starts with the feeling of hope that this may actually work, and that life may greatly improve, if the patient follows the treatment instructions.
Understanding equals better compliance
Before introducing therapy, the patient must fully understand the risks and side effects of untreated sleep apnea. According to the National Sleep Foundation, there is a 37% higher chance of heart attack or stroke associated with untreated apnea. The outcome is bleak and the alternatives few. We have to make patients understand that, even if CPAP is difficult to acclimate to, neurological and cardiac treatments are much more intensive and lack the ultimate hope for complete elimination with treatment. These worst-case scenarios (heart attack and stroke) can be the ultimate motivator for even the most noncompliant patient. Make sure patients understand what apnea is; how it impacts the heart rate, blood oxygen levels, and sleep cycle; and why snoring is an indication along with daytime sleepiness and frequent nocturnal urination.
Through understanding the entire process, patients begin to see how apnea can be treated. If patients arrive at the sleep center and have no idea why they are there, why the snoring is an issue, or why surgery may not be the first treatment option, then it falls to the technician to educate them. In my experience, technicians greatly increase the chance of a successful titration, if they offer patients a full explanation of apnea and CPAP, as well as a trial of the mask at a low setting before they attach even one electrode to the patient.
It is imperative in health care and, in life, to treat all persons with respect and dignity—even apnea patients who may be the ultimate challenge to this idea for hurried technicians. In the first few hours the patients are in the center, there is education to provide, explanations to offer, demonstrations of CPAP to give, and all of this should be done while the patients are still in their street clothing. Patients may have 100 questions, but they will be too intimidated once they are in their sleeping attire to ask them, which just may be the key to their acceptance of therapy.
In our sleep centers, all patients are given their demonstrations and explanations prior to changing into their sleep clothing and having electrodes attached. As a result of this simple change in procedure, we have noticed a marked improvement in successful split-night titrations and long-term compliance. Making time in the technician’s schedule for this most important step will increase compliance in the center and in the home.
When I was a technologist responsible for the data acquisition, I realized that the more I worked with patients prior to “lights out,” the easier my night was all the way around. There were fewer mask changes in the night, less anxiety, and more delta and REM rebound noted. The faster a patient falls asleep on 3 to 5 cm/H2O of pressure, the easier it becomes to titrate and reach therapeutic pressure. If patients have difficulty acclimating to the airway pressure and the interface in the center, it is going to be a problem for them to awaken feeling more rested or refreshed. The patients who do not get proper titration, for any reason, often feel as though they are no better with CPAP than without it. This will be a major hurdle for both the physician, who must interpret a less than stellar titration study, and for the DME company that must get this patient set up for home treatment. The DME’s therapist will be met with much resistance, and the patient will more than likely require more follow-up support than others.
Outside the laboratory
Once a patient has accepted the diagnosis and treatment recommendations, home care begins. A patient must feel a level of support and encouragement from the first contact with the DME company. The patient will need much instruction and also must be shown the many available units and interfaces. It is in this home care process that many patients, who may have been tolerant and compliant in the center, will refuse to commit to treatment.
As a technologist, I assumed that, if all went well during the polysomnograms, the patients would wear CPAP every time they slept without question. Before I began work at somniCare Inc, I was oblivious to the effort and commitment required on the part of the home care provider to ensure the best compliance possible.
Commitment to successful therapy must include all parties: the patient and the bed partner; the technologists and therapists involved in the diagnosis and treatment; and the physician. The role of succinct communication to all parties regarding outcomes and further needs of each individual case is key. I have witnessed CPAP/bilevel therapy save more than one marriage. Simply getting both bed partners in the same room greatly increases the chance for intimacy, which otherwise is impossible when one is on the couch or in the spare bedroom due to heroic snoring.
Overcoming the excuses
I have had patients tell me that they are not using their positive airway pressure device because the therapy is just not attractive or sexy. I quickly tell them that falling asleep during a play, a concert, a family reunion, or while driving is also not attractive in any way and may be life-threatening.
There can be many excuses for non-compliance, or lack of reported increase in functioning. However, a good therapist will not yield to excuses and will persist in looking for some means of eliminating the barrier between patient and therapy.
This kind of commitment from all parties involved in the patient’s care will never come to fruition, if the means of home care is offering mask choices of only small, medium, or large. Everyone deserves to know what is available and to be listened to and helped, especially if this is why a home health provider is employed.
When I was introduced to the home health aspect of sleep medicine, I was stunned to realize that not all patients are delighted with positive airway pressure therapy as an option to untreated apnea. Soon after, I heard a statistic that 50% of patients prescribed a positive airway pressure device would refuse to wear it. I was shocked and knew that somniCare Inc accomplished a much higher rate of compliance and success than this dismal statistic. We pay attention to the patients’ needs first and everything else is secondary. There must be ample time allotted to thoroughly demonstrate and explain every single factor of home compliance. Anyone who claims to be able to successfully:
- explain CPAP and pressure setting,
- offer a demonstration,
- cover co-pay information,
- ensure Health Insurance Portability and Accountability Act (HIPAA) compliance,
- explain interface options,
- provide contact information in case of machine malfunction,
- go over infection control and effective cleaning,
- review the device warranties,
- discuss the number of interface changes allowed per calendar year by individual insurance restrictions,
- review any other options or special problems in less than 60 minutes, obviously skipped some vital steps toward compliance or was setting up CPAP for Colin Sullivan, MD, the Australian inventor of nasal CPAP therapy.
The human element
Compliance with therapy will never be 100% without human interaction. A video instruction is no substitute for a return demonstration and a word of encouragement from the therapist. More than one patient has hugged me and said that I helped contribute to their happiness and health. Having those involved in patient care also take on the role of “the encourager” is a key portion of patient compliance. Be the one who points out the marked reduction in dark circles under the eyes, the return of a smile, the decreased dependence on caffeine for stimulation, and the return of the plays, movies, and family reunions without fear of falling asleep and snoring in a social situation. The encourager is the one who asks and cares, and it is a role that should be taken up by all parties involved in the care of sleep apnea patients.
Dropping off a unit at a patient’s door, with a note reading “wear this,” will result in a continued dismal compliance rate among those prescribed therapy. It is the duty of every home care provider to develop a professional relationship with the patient. Without communication, how is the physician to know the patient’s response to home therapy, initially and throughout, while under the care of any individual home health care provider?
Medicare’s recent decision to begin competitive bidding practices with DME providers is one such undertaking that strongly enforces the accountability of those responsible for home health care. If an organization cannot successfully demonstrate strong follow-up practices, it will cease to be a competitor for referrals, as those failing will not be allowed to participate with health plan providers. It is apparent that insurance providers will demand consistent and thorough follow-up as a gold standard for reimbursement. It is a brilliant move, and one that will ensure quality versus quantity when selecting providers, especially those awarded nationwide insurance contracts.
When it comes to encouraging a patient to wear the interface and try CPAP therapy, those new to the sleep field will find little sympathy from the seasoned sleep veterans who had to help patients with treatment compliance back when there were only two kinds of CPAP units and only two kinds of masks. There was only one, very hot, full skullcap that served as gear to hold the mask. Nasal pillows and the required headgear to go with them had more Velcro than kindergarten tennis shoes.
Today, home units weigh as little as 1.5 pounds versus the 15 to 20 pound average in 1993. In addition, the units come with built-in heated humidifiers and ramping devices. There are more than 50 available resources online to help find any kind of interface for any kind of nose, mouth, or combination of the two. If technologists a decade ago could convince patients to wear CPAP and actually be excited about it, then today’s technologists and therapists should be able to achieve tremendous compliance with all the resources and devices now available.
There are many individual classifications of sleeping disorders; sleep apnea is but one. Through follow-up the therapist can not only help evaluate compliance with positive airway pressure, but also provide endless education regarding sleep hygiene and other sleep problems, which may contribute to a return of previously treated symptoms. Before the therapist contacts the referring physician, it is important to gather as much information as possible. Have the patient complete an Epworth Sleepiness Scale. Determine if there is an increase in self- reported somnolence, and if so, ask questions as to why. Inquire:
- Has there been a change in the work schedule?
- Are you experiencing any lifestyle changes, disruption to normal routine, or stress?
- Have you had a return of snoring or weight gain?
This information will greatly facilitate compliance and the communication to the physician will be infinitely appreciated. Simple education and further evaluation will only aid in lifelong positive sleep habits, and ultimately an increase in sleep awareness, and a more positive image of home therapy. It will require committed organizations, and nothing less should be expected.
Jennifer D. James, RPSGT, is director of sales and marketing for somniTech Inc, Overland Park, Kan. The author wishes to acknowledge Pam Gillis as the president and founder of somniTech Inc, somniCare Inc, and A-STEP- accredited somniSchool Inc. “We all are indebted to her generosity of spirit, and genuine concern for quality patient care.”