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Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio.

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Presentation on theme: "Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio."— Presentation transcript:

1 Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio Ospedaliero di Sesto San Giovanni @AForesi 1

2 full hub/spoke/satellite service @AForesi 2

3 @AForesi 3

4 SpecialitàStrutture di degenzaServizi senza posti letto Bacino Max Min* Bacino Max Min* Pneumologia0,8 0,4? * (x milioni di abitanti) Bozza Decreto su “Definizione degli standard qualitatitivi, strutturali, tecnologici, e quantitativi relativi all’assistenza ospedaliera…” 9 Luglio 2014 @AForesi 4

5 Sleep Medicine is a very prevalent disorders with effective treatments that change patients lives Sleep Unit with polisomnograpy needs higly specialised personnel and complicated technology. Sleep technology is a rapidly growing, advancing, and evolving field Sleep Medicine is chronic care management discipline, not a diagnostic one @AForesi 5

6 @AForesi 6

7 Classification of Sleep Disorders - ICSD-2 Thorpy MJ - Neurotherapeutics (2012) 9:687–701 @AForesi 7

8 Patologie sonno-correlate di maggiore interesse pneumologico OSA(S) BPCO Overlap syndrome Apnee centrali CSR-CSA S. obesità-ipoventilazione (OHS) DRS in corso di patologie neuromuscolari o restrittive toraciche @AForesi 8

9 Functions and obligations of primary care and sleep units with respect to the handling of patients with OSA, or suspected of having OSA Martínez-García M.A. – Breathe Review 2010 @AForesi 9

10 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 10

11 risk factors commonly associated with OSA: obesity, gender (more common in men than women), age (more common in older age), hypertension and diabetes. @AForesi 11

12 Percent of UK hospitals delivering each service ARTP Working Groups on Standards of Care and Recommendations for Lung Function Departments (2007) @AForesi 12

13 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 13

14 OSAS: Sonnolenza o fatica? Su 197 soggetti : Astenia : 62% Fatica : 57% Stanchezza : 61% Sonnolenza : 47% Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest 2000;118:372–9

15 Cosa fare per inquadrare il paziente Scala della sonnolenza di Epwort (ESS) Scala di autovalutazione della Fatica (FAS) Questionario SWIFT? Questionario di valutazione funzionale del sonno

16 Ann Intern Med. 2014;161:210-220.

17 Masa JF, et al. Effectiveness of home single-channel nasal pressure for sleep apnea diagnosis. SLEEP 2014 @AForesi 17

18 AUCs from ROC curves for the manual and automatic HNP home single-channel nasal pressure scorings, based on AHI polysomnographic cutoff points @AForesi 18 Masa JF, et al. Effectiveness of home single-channel nasal pressure for sleep apnea diagnosis. SLEEP 2014

19 A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care Chai-Coetzer C.L. - Thorax 2011;66:213-219 @AForesi 19 157 pts aged 25-70 years attending their primary care physician for any reason patients with AHI 30 performance of the OSA50 screening

20 @AForesi 20 When GPs take an active role in screening and referral pathways then this is beneficial to the patient, the GP and the sleep clinic BLF 2014

21 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 21

22 Up to 80 per cent of people with OSA have not been diagnosed BLF 2014

23 @AForesi 23 BLF 2014 timely access to diagnostic services

24 Ann Intern Med. 2014;161:210-220. doi:10.7326/M12-3187

25 Night-to-night variability of apnea-hypopnea index in individuals having 2 in-laboratory polysomnograms Respir Care 2010;55(9):1196–1212 @AForesi 25 PSG

26 Respiratory polygraphy in sleep apnoea diagnosis SWISS MED WKLY 2007;137:97–102 · @AForesi 26

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28 Phenotypes of patients with mild to moderate OSA as confirmed by cluster analysis 1184 consecutive patients AHI of 5-30/h, collected over 24 months REM predominant OSA, 44.6% non-REM predominant OSA, 18.9% supine predominant OSA, 61.9% intermittent OSA, 12.4% Joosten SAJoosten SA, et al. Respirology. 2012 Jan;17(1):99-107Respirology. @AForesi 28

29 Comparison of supine-only and REM-only OSA Gillman A et al. Sleep Medicine 13 (2012) 875–878 prevalence of supine-OSA varied from 23% (strict definition) to 63% (lenient definition); prevalence of REM-related OSA was 10% @AForesi 29

30 Sleep Med Clin 6;309–333;2011 @AForesi 30

31 PSG

32 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 32

33 A Clinical Decision Rule to Prioritize PSG in Patients with Suspected Sleep Apnea Rodsutti J; SLEEP 2004;27(4):694-9.

34 Reduction of AHI after automatic titration and manual titration in 491 patients Gao W et al. Sleep Breath (2012) 16:329–340

35 The CPAP after automatic titration and manual titration pressuredetermined by two titration methods involving 808 patients Gao W et al. Sleep Breath (2012) 16:329–340

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37 Residual sleepiness in obstructive sleep apnoea: phenotype and related symptoms Vernet C. et al. Eur Respir J 2011; 38: 98–105 @AForesi 37

38 CompSA has been reported to occur in 6% to 15% of CPAP-treated OSAS patients Can Respir J Vol 18 No 1 January/February 2011

39 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 39

40 Aderenza alla terapia con CPAP Aderenza alla terapia insufficiente se uso della CPAP inferiore a 4 ore/notte per il 70% (o meno) delle notti del periodo considerato A livello mondiale tra il 5 e 25% dei pazienti con OSAS rifiuta l’opzione del trattamento con CPAP o ne abbandona l’uso entro la prima settimana di trattamento Si stima che tra il l 12- 25% dei pazienti restanti abbandoni il trattamento entro i 3 anni dall’inizio. L’aderenza del paziente al trattamento con la CPAP è il principale fattore che determina l’efficienza del trattamento stesso

41 @AForesi 41 BLF 2014

42 An Official American Thoracic Society Statement: Continuous Positive Airway Pressure Adherence Tracking Systems. The Optimal Monitoring Strategies and Outcome Measures in Adults. Clinical algorithm for using continuous positive airway pressure adherence tracking systems. Published in: Richard J. Schwab; Safwan M. Badr; Lawrence J. Epstein; Peter C. Gay; David Gozal; Malcolm Kohler; Patrick Lévy; Atul Malhotra; Barbara A. Phillips; Ilene M. Rosen; Kingman P. Strohl; Patrick J. Strollo; Edward M. Weaver; Terri E. Weaver; Am J Respir Crit Care Med 188, 613-620.

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44 CPAP Adherence Factors RussellT. - Semin Respir Crit Care Med 2014;35:604–612.

45 subjective adherence was 85.1% and objective adherence was 64.5%. Respir Care 2013;58(9):1467–1473

46 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 46

47 In the United States, the Center for Medicare and Medicaid Services (CMS) requires at least one face-to-face contact between the 31st and 91st days of therapy with visual inspection of adherence data verifying use > 4 hours per night 70% of the time.

48 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 48

49 @AForesi 49 BLF 2014 “coping with the CPAP mountain”

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51 Prima Oggi Configurazione del modulo e abbinamento fra paziente e S/N Raccolta del consenso del paziente Chiamata del tecnico alla sede per attivare la telesorveglianza La soluzione tecnologica a domicilio

52 Schema di monitoraggio paziente OSAS

53 Patologie respiratorie nel sonno: modelli organizzativi Pre-test evaluation Screening/Referral Diagnosis Treatment Compliance/Adherence Follow-up Long term care Costs @AForesi 53

54 Full-night PSG for diagnosis and CPAP treatment of OSA are highly cost-effective are robust within the ranges of input parameter uncertainty. Diagnosis and treatment of OSA contributes to significant increases in patient quality of life and substantial reductions in the risk of motor vehicle collisions, heart attacks, and strokes. Pietzsch JB et al. SLEEP 2011;34(6):695-709.

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57 Future of sleep medicine Budgetary constraints on the health care system make it unlikely that we will see any significant expansion of facility-based PSG resources Regional Networks to organise services and management strategies at a regional level Shifting from a focus on diagnostic testing to chronic disease management Focus on quality outcomes of care moving towards a patient-centered and outcomes-based delivery model @AForesi 57

58 Building a new model of Sleep-Lab Provide for diagnosis and treatment for all sleep disorders Balanced capability for in-laboratory and in- home sleep studies Define set of outcomes (OSA) sleep apnea symptoms, ESS, FOSQ, Fatigue, PAP compliance, blood pressure, HbA1C (for diabetics), and medication use @AForesi 58

59 @AForesi 59 Lack of awareness of OSA amongst the general population Lack of undergraduate training for medical and dentistry students Lack of recognition of the key symptoms by general practitioners Lack of widespread screening based on the key symptoms Possible referral bias towards middle-aged overweight men amongst general practitioners Lack of standardised, accredited training for sleep medicine health care professionals Lack of standardised, specified service provision People not coming forward: not thinking there is a problem; embarrassment; fear of losing driving licence; not knowing there is treatment Barriers to treatment include: BLF 2014

60 Brooks R, Trimble M. The future of sleep technology:report from an American Association of Sleep Technologists summit meeting. J Clin Sleep Med 2014;10(5):589-593.

61 CPAP France 500,000 UK 330,000 Italy 120,000-140,000

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63 Sleep Medicine is chronic care management discipline, not a diagnostic one @AForesi 63

64 Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio Ospedaliero di Sesto San Giovanni @AForesi 64

65 Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio Ospedaliero di Sesto San Giovanni @AForesi 65

66 Hanes et al. / Research in Social and Administrative Pharmacy j (2014) 1–16 @AForesi 66

67 @AForesi 67 treating 500 patients for five years prevents one fatal accident, 75 injury accidents, and 224 property damage accidents, and that £5.3 million would be saved, with an estimated treatment cost of £0.4 million (12.3 times return on investment). BLF 2014

68 Hanes et al. / Research in Social and Administrative Pharmacy j (2014) 1–16 @AForesi 68 1. Referral standards 2. Diagnostic and treatment standards 3. Patient review standards 5. Driving issues

69 1. There is a rise in demand for services 2. There is variation in service provision between and within nations in the UK 3. There is a growing “follow up mountain” of people on treatment 4. There is a need to develop ways to influence and support the commissioning / planning process BLF 2014

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73 Alonderis A, Barbe F, Bonsignore M, Calverley P, De BW, Diefenbach K, et al. Medico-legal implications of sleep apnoea syndrome: driving license regulations in Europe. Sleep Med 2008;9(4):362-75.

74 The Canadian Medical Association recommends that if a physician believes their patient has a sleep disorder, and the patient refuses a sleep study or refuses to comply with treatment, the patient should not drive any type of motor vehicle Canadian Medical Association. Determining medical fitness to operate motor vehicles: CMA driver's guide. 7th ed. Ottawa: Canadian Medical Association; 2006.

75 The Canadian Sleep Society is finalizing a position paper on level III sleep studies. This is expected to be published in the Canadian Respiratory Journal but the date of publication is not yet known [Personal communication, Dr. Helen Driver, Canadian Sleep Society, June 21, 2010].

76 Summary of cost analysis studies

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78 PSG

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84 focus in sleep medicine is shifting from procedures to outcomes. This will require that the sleep center team integrate with other medical professionals, including primary care physicians, otolaryngologists, behavioral specialists, and dentists

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90 Sleepdisordered breathing is a common public health problem that affects an estimated 10% of 30- to 49- year-old men; 17% of 50- to 70-year-old men; 3% of 30- to 49-year-old women; and 9% of 50- to 70-year-old women

91 Can Respir J Vol 20 No 4 July/August 2013 Key potential care gaps

92 ASA / NATA web page : http://www.sleep.org.au/membersarea/accre ditation (last accessed 24-6-13)

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