amerigas / penn occupational sleep medicine program€¦ · amerigas / penn occupational sleep...
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Jean Tyrell, RN
AmeriGas / Penn Occupational Sleep Medicine Program
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The Science• Basic sleep/circadian biology
Contributing Factors• Provide an understanding about different sleep disorders that impact the
workplace
What Employers Can Do• In depth review of the common sleep disorder—obstructive sleep apnea
& impact on health care outcomes
Learning Objectives
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• Primer in sleep/circadian biology
• Sleep problems in the workplace
• What is sleep apnea?
• Impact of Sleep problems in transportation
• A novel program to address sleep apnea
Today’s Discussion
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• Alertness in morning following major sleep episode• Become “sleepy” after lunch (1:00-3:00 PM)
• (siesta time)• Alertness then returns even if individual does not sleep• Early evening becomes forbidden time for sleep• Sleepy again in late evening• Sleep efficiency impaired if try to sleep at “alert clock times”
• CLOCK SETS TIME WINDOW FOR SLEEP
Consequences of Interaction Between Sleep and Circadian Systems
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Time of Occurrence of Fall-Asleep Crashes in Individuals Age 16-25 Years
(Pack A, et al, Accid Anal Prev 27:769, 1995)
0
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0:00
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22:0
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Time of Day
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rash
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Time of Occurrence of Fall-Asleep Crashes in Individuals Over 65 Years
(Pack A, et al, Accid Anal Prev 27:769, 1995)
05
10152025303540
0:00
2:00
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Time of Day
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• Chronic insufficient sleep
• Shift-work sleep disorders
• Insomnia
• Obstructive sleep apnea
Sleep Problems in the Workplace
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Chronic Insufficient Sleep
Van Dongen et al., 2004
But you don’t realize that you are getting worse.
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• Shift-work sleep disorder– Difficult to sleep at “incorrect” circadian time
• Insomnia– Chronic difficulty initiating and sustaining sleep
Shift Work and Insomnia
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• In a typical good sleeper, the cost of lost productivity was approximately $1,293 per employee per year
• Insomnia: $3,156 (↑144%)• Insufficient Sleep: $2,796 (↑116%)• At-risk: $2,319 (↑79%)
• Significant productivity lost due to• Time management• Mental and interpersonal demands• Output demands• Physical job demands
The Cost of Sleep Lost
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• At the individual level
• At the group level
• At the system level
How to Address This?
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• What is Sleep Apnea?
Obstructive Sleep Apnea
AWAKE ASLEEP
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Life with Sleep Apnea
worse with weight gain
APNEAS, HYPOPNEAS(observed by others)SnoringChokingGasping LOW OXYGEN
ADRENALINE
AROUSALS
• Hypertension• Heart disease• Stroke• Pre‐diabetes• Death
• ↓produc vity• Absenteeism• Sleepiness
• ↑Crash risk
• ↓ mood, memory, concentration, attention
• ↑ reaction time
• Morning headache
• Impotence
DAYTIME
LONG‐TERM
NIGHTTIME
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We Have a Growing Problem
051015202530
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Source: Centers for Disease Control
Percen
t who are obese
As obesity becomesmore common,
so does sleep apnea
Prevalence of moderate‐to‐severe apnea
Men Women
1994 (Young et al) (state employees) 4% 2%
2007‐2010 (Peppard et al)
30‐49 years 10% 3%
50‐70 years 17% 9%
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In-Lab Sleep Study (Polysomnography)
• Brain waves
• Eye movement
• Chin, leg muscles
• Chest and abdomen effort
• Airflow, snoring
• Oxygen level
85% of cases remain undiagnosed
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Ambulatory Sleep Study (Home Sleep Test)
• Chest and abdomen effort
• Airflow, snoring
• Oxygen level
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• Continuous Positive Airway Pressure (CPAP)
Is Sleep Apnea Treatable?
http://www.sleepwise.com.au/images/D912193040.gifhttp://www.resmed.com/uk/images/cpap_treatment.jpg
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Effects of CPAP on Sleep and Oxygen Levels
Without CPAP• Sleep fragmentation• No N3, REM• Low oxygen saturation
With CPAP• Sleep consolidation• REM rebound• Slow wave sleep achieved• Oxygen saturation restored
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In Addition to Eliminating Breathing Pauses During Sleep and Improving Oxygen Level,
What are the Benefits of CPAP?
• CPAP lowers:• health care costs1, 2,3
• disability claims3
• absenteeism3
• workplace turnover4
• crash risk6
• blood pressure7,8
• CPAP improves • quality of life5
• alertness6
• performance on driving simulator6
•1Albarrak, Sleep, 2005•2Ronald, Sleep Res Online, 1998•3Hoffman, JOEM, 2010•4Osterberg, Schneider Trucking, Sleep Apnea Trucking Conference, 2010•5Sanner, Eur Respir J, 2000•6Tregear, Sleep, 2010•7Haentjens, Archives Int Med, 2007•8Bazzano, Hypertension, 2007
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How Do We Know Patients Are Using CPAP?
MONITORING SYSTEMS REPORTED DATA
SD cards
Remote/wireless
Hours of use
Pressure level
Residual Apnea‐Hypopnea Index (AHI)
Mask leak
Issues can be addressed in “real” time
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• Major crashes indicate impact of insufficient sleep, diurnal
time and sleep apnea
Impact on Transportation
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Metro North Train Crash
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Driver of train did not adjust speed. Speeding at 82 MPH in a 30 MPH curve
Driver stated he was “stupefied”
Train derailed – 4 dead, 82 injured
Driver has now been diagnosed with severe obstructive sleep apnea
Metro North Rail Crash
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Tracy Morgan Crash
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Driver of Wal-Mart truck struck the rear of limo Tracy Morgan was in
Driver had been awake for more than 24 hours
Had been driving for 9 hours, 37 minutes
Was speeding at 65 MPH through work area (45 MPH limit)
Comedian killed – Tracy Morgan seriously injured
Tracy Morgan Crash
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Train Crash at O’Hare Airport
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Driver fell asleep – train went up escalator
Occurred at 2:52 AM – circadian low
No deaths or serious injuries
32 minor injuries
O’Hare Rail Crash
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Awake @ the Wheel
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• Approx 6,500 drivers throughout all 50 states
• ‘Bobtail’ trucks used to ship Propane
• Propane is highly explosive and flammable, making a Bobtail accident especially devastating
AmeriGas - A Leader in Safety Initiatives
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• Sleep impacts safety, productivity, health care costs
• Department of Transportation (DOT) physical• BMI assessment• Time impact on the business with our drivers out of the truck if sleep apnea
testing was required
• Benefit coverage impact• New hires were ineligible for coverage• Cost prohibitive even for current EE’s/recertification
Business Issue
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• Target new hires with telehealth program in available states
• Speed to virtual assessment – ipad• @ home sleep study
• Follow-up & support
• Direct contract with UPenn Sleep Medicine Department
Sleep Apnea Program - UPenn
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• Equipment/user failures• EE/Patient was not using the at home test correctly
• Durable medical equipment network & support can be challenging
• Health plans struggled with the pre-cert process• EE’s in the program vs. Other EE’s/Dependents who were not part of program
• Some employees need additional “convincing” the importance of what we are providing for them:
• Health + Your Job = Your Livelihood
Lessons Learned
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• Secondary internal review of all Commercial Driver License (CDL) occupational exam notes, focusing on risk of sleep disordered breathing
• At risk drivers must undergo sleep testing• Diagnosed drivers must begin CPAP therapy and achieve
minimum Department of Transportation (DOT) compliance before CDL is granted or recognized by AmeriGas• 4+ hours on at least 70% of nights over the last 30 days prior to the
exam
AmeriGas’ Pre-Penn Sleep Program
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• Mandatory for all new hires in pilot states• 5-state pilot scope; expansion to 14 states in 2016• Future expansion to all 50 states
• Telemedicine Visits and Home Sleep Tests by mail• Auto-adjusting PAP therapy with ongoing Care Management
and mandatory compliance monitoring via wireless modem data• Non-compliant drivers are immediately removed from the truck until
compliance is regained
The AmeriGas/Penn Sleep Pilot Program Goes Well Beyond Federal Guidelines
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Penn Sleep Providers Must Assess Risk Differently Compared to the Traditional Clinical Patient Encounter
• Patients frequently deny symptoms to avoid diagnosis
• Confirmed data on comorbidities is obtained from CDL exam notes
• Unless Provider can rule OUT risk with high confidence, home sleep test will be ordered
INITIAL TELEMEDICINE CONSULTATION WITH PENN SLEEP PROVIDER
INITIAL TELEMEDICINE CONSULTATION WITH PENN SLEEP PROVIDER
HOME SLEEP TEST
HOME SLEEP TEST
CLEAREDCLEARED
~40% CLEARED WITHOUT TEST~40% CLEARED WITHOUT TEST
ORDERED FOR ~60%ORDERED FOR ~60%
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• High initial failure rate due to intentional patient tampering or refusal to wear device
• Negative test results with high pre-test probability results in in-lab PSG, OR repeat HST using telemedicine chain of custody protocol
Home Sleep Testing Has Additional Challenges in a Mandatory Program
Successful Initial HSTs:
Failed Initial HSTs:
70%
30%
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• Intentional tampering on the initial HST is a surprisingly accurate predictor of a positive diagnosis for sleep disordered breathing
Patients Who Fail Initial HST Are More Likely to Show OSA on Second HST
Initial HST, OSA+
Initial HST, no OSA
Second HST, OSA+
Second HST, no OSA
34% no OSA
14% no OSA
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RESIDUAL AHI
RESIDUAL AHI
The Care Team Proactively Coordinates All Activity to Enhance the Patient Experience
PRE‐CERTIFICATIONS
PRE‐CERTIFICATIONSSLEEP TECHNOLOGISTS
SLEEP TECHNOLOGISTSDURABLE MEDICAL
EQUIPMENT PROVIDERS
DURABLE MEDICAL
EQUIPMENT PROVIDERS
CPAP MACHINESCPAP MACHINES
DOT PROVIDERSDOT PROVIDERSSUPPLY REFILLSSUPPLY REFILLS
HOME SLEEP TEST DEVICES
HOME SLEEP TEST DEVICES
SLEEP PHYSICIANSLEEP PHYSICIAN
IN‐LAB POLYSOMNOGRAPHY
TESTING
IN‐LAB POLYSOMNOGRAPHY
TESTING
CLINICAL STAFFCLINICAL STAFF
COMPLIANCE REQUIREMENTSCOMPLIANCE
REQUIREMENTS
MASK LEAKMASK LEAK
PENN SLEEP CARE TEAM
PENN SLEEP CARE TEAM
Patient NeedPatient Need
ResolutionResolution
Proactive Compliance Outreach
Proactive Compliance Outreach
HAPPY AND COMPLIANT PATIENT
HAPPY AND COMPLIANT PATIENT
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Results – First 12 Months
167 Screened
• Initial consultation via telemedicine
•97 had HST ordered
•69 cleared without HST
•1 had recent HST
84 HST Complete
• 50 OSA +
• 34 OSA ‐
44 CPAP
• 35 actively on PAP (several terminations; 1 patient lost significant weight now OSA‐)
• 33 are 30+ days (2 <30 days)
35 in Care Mgt
•All 30+ day patients are 100% compliant
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Health Care Financial Impact
Service Cost
Average Cost/Driver(Initial Consult, HST, OSA & Follow‐up, 1 yr Case Management)
$580
84 drivers $48,720
Average Sleep Lab Cost $2,500
72 drivers $210,000
Net Savings to Health Cost ($161,280)
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• Mandatory programs will encounter resistance from many patients in the population…– Proactive patient management is crucial!
• Compliance to therapy can be impacted from very first encounter with the patient… – Centralized coordination of care significantly and positively
impacts the patient experience!
Things We Learned
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• Awareness/Education• Understand your population & work schedules• Provide opportunities to educate EE’s on tips for better sleep/time
management• Address the 24/7/365 culture without sacrificing productivity• Take advantage of the wearable device trend
• Assessment & Program Support• Partner w/3rd party vendors to assess & gather sleep data• Digital/Telehealth coaching support
What Employers Can Do
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• Questions?
Thank You For Your Attention!
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Q&A
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Thank you.