Telemedicine-based proactive patient management during positive airway pressure therapy

Continuous positive airway pressure (CPAP) is the most effective treatment for obstructive sleep apnoea (OSA) and is mandated by current guidelines [1]. However, the benefits of treatment cannot be realised if patients do not adhere to prescribed therapy.

A number of different approaches to improve compliance with CPAP therapy have been assessed in clinical trials, including patient education [2‐5], peer support [6, 7], behavioural interventions [3, 4], clinical support [8] and choice of equipment [9‐12]. In addition, features of the healthcare system and service/treatment delivery can have an impact on adherence [13]. Despite this, health stakeholders have not traditionally focussed on addressing adherence issues, and there are relatively few data on interventions to improve adherence, which in turn could improve patient outcomes [13].

Regular follow-up by clinicians and objective assessment of device data have been suggested to be essential in facilitating good compliance with CPAP therapy for OSA [14]. However, current management of CPAP compliance is reactive. Patients who are experiencing challenges or difficulties during CPAP therapy have to contact their healthcare provider to request assistance. Alternatively, less motivated patients might just stop using therapy altogether if there is a problem, or if they perceive there to be a problem.

Telemedicine is a term used to describe the use of information and communications technology to deliver healthcare at a distance [15]. It also offers the opportunity to provide quality care without dramatically escalating healthcare costs [16]. It is especially suited to the management of chronic diseases that require long-term monitoring to ensure successful therapy [17]. Having remote access to CPAP therapy data creates an opportunity for healthcare professionals to intervene proactively and provide appropriate support to individual patients with the aim of having them continue to use PAP therapy. Remote data are useful for tracking CPAP adherence and can also provide information on mask leak and residual apnoea–hypopnoea index (AHI), but there are few data on how use of these systems impacts on outcomes in OSA patients [18].

This study used data from a large German homecare provider to investigate the impact of a proactive patient management programme supported by remote access to PAP therapy data on therapy termination compared with standard care.

Study data were obtained from ResMed Germany Healthcare, a German homecare provider. German data protection law allows for the use of such data, if anonymised, for scientific purposes. Therefore, patient informed consent was not necessary in this study.

A total of 3401 patients who were managed using the proactive strategy and 3401 matched patients receiving standard care were included in the analysis. There were no significant differences between the matched groups at baseline (Table 1).

The results of this study showed that a telemedicine-based proactive strategy for the management of patients receiving PAP therapy reduced the rate of therapy termination over time, irrespective of gender, device used and the type of insurance. The finding that the proactive strategy was effective irrespective of the type of PAP device used might suggest that therapy acceptability (e. g. interface comfort) may play a bigger role than the type of device being used. Interestingly, the positive effects of proactive care were seen in all age groups except those aged <40 years. One possible explanation for this may be that the youngest patients are more comfortable with using information technology to better inform themselves about their condition.

To the best of our knowledge, this study is the first to investigate the impact of a telemedicine-based strategy on long-term continuation of PAP therapy. The main outcome measure in many previous studies has been compliance in terms of hours of device usage per night, and there is a lack of data on therapy termination rates. The majority of these studies have focussed only on CPAP in patients with OSA, used a variety of different telemedicine-based strategies, and reported inconsistent results. In addition, the majority were small, single-centre and/or short-term studies [19‐24].

Interface problems and side effects are the most common causes of CPAP intolerance and an important potential benefit of telemedicine-based strategies is early identification of these issues and the implementation of strategies to resolve them in a timely fashion. Other benefits of telemonitoring strategies have been reported, such as reduced labour time for healthcare staff, allowing the same levels of adherence and efficacy to be achieved with fewer staff resources [17, 25]. This is important in the context of a projected increase in the number of patients presenting with sleep-disordered breathing due to the aging population and the growing rates of comorbidities such as obesity and diabetes that will increase demand for already stretched healthcare services. The ability to utilise telemedicine to provide patient-focussed, proactive and intensive management of patients using PAP therapy facilitates the management of large patient populations, as well as significantly improving therapy continuation rates and usage. Telemedicine also appears to be a cost effective strategy for managing CPAP treatment in patients with OSA [16].

Improved patient engagement is another potential advantage of telemedicine strategies, which in turn could contribute to additional gains in terms of PAP adherence and outcomes. The positive impact of patient involvement in therapy was highlighted in a recent study which showed that providing patients with web-based access to their personal PAP usage data increased device usage in the first week of therapy and over 3 months of follow-up compared with usual care [26].

According to the World Health Organisation (WHO), it is important that health systems evolve to meet new challenges [13]. The introduction of new technologies, such as telemedicine, is one way in which healthcare systems and providers can advance patient care. In the case of PAP therapy this could contribute to better adherence and improved patient outcomes. WHO has also recognised that interventions targeted at improving adherence should provide a significant positive return on investment via prevention of adverse health outcomes, and that there are also economic benefits associated with improved quality of life, including reductions in indirect costs and increased productivity [13]. In the context of CPAP therapy for OSA, the importance of increasing adherence has also been recognised by a Cochrane review that emphasised the need for new strategies to promote CPAP compliance [27].

One of the main limitations of this analysis is the lack of specific data on device usage in the standard care group. Thus, we report therapy termination rates rather than device usage hours, which made comparison with existing data more difficult. However, it could be argued that therapy termination is the most important endpoint to assess because once a patient stops therapy getting them to restart is likely to be difficult. In contrast, reduced usage provides a cue for intervention, and there is always the possibility that hours of device use will increase. Another potential limitation is that the ability to accurately determine therapy termination is different in the two groups – it is very obvious when patients in the proactive strategy group stop PAP therapy based on device data received, but therapy termination might be less obvious in the standard care group for whom the requirement for a homecare provider visit may be the only indicator of therapy problems or termination. Interrogation of big data allows inclusion of a very large population of patients treated in routine clinical practice. However, databases created for administrative, rather than scientific, purposes do not include a full set of clinical data. In the current analysis, this means that we had no data on clinical features, insomnia and other factors that might have influenced the outcomes under study. Furthermore, these are observational data and therefore do not provide proof for a causative relationship between the intervention (proactive care) and the outcome (reduced therapy termination). Data from randomised clinical trials are needed to more clearly elucidate the effects of a telemedicine-based proactive management strategy on PAP therapy termination rates. In addition, future research should further investigate the potential of telemonitoring-guided proactive care on additional endpoints, including device usage, resource use and healthcare professional time requirements.

This analysis of a large population of PAP therapy users in Germany showed that the long-term rate of therapy termination was significantly lower in patients managed using a telemedicine-based proactive management strategy compared with standard care. This association was observed in both men and women, across a wide range of patient ages, for all PAP devices and in patients with public or private insurance. Implementation of telemedicine-based strategies has the potential to improve adherence and patient outcomes and may allow more efficient allocation of scarce healthcare resources. Randomized, controlled clinical trials are needed to further assess both therapy termination rates and device usage, which would complement our large data set from routine clinical practice.