Treading a finer line on “The Patient Pathway”

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Having attended the British Sleep Society Anniversary Meeting in Edinburgh, SASA were invited by Judy Harris, OSA Project Manager at British Lung Foundation, to attend the Foundation’s OSA conference in Blackpool at the Hilton Hotel, Blackpool on Saturday 1st February 2014. The conference was directed at health care professionals who manage sleep services and commissioners of sleep and respiratory services and was attended by clinicians from all parts of the UK.

The Conference looked at the patient pathway for people with OSA and how this varied in different areas of the UK, examined where they are in terms of national standards and discussed ways to ensure the treatment of OSA remains a priority in the future.

The financial benefits of treating OSA are considerable. The cost of a fatal road traffic accident can be as much as £1.25 million (Department of Transport figures), whereas the cost of treating an OSA patient with CPAP is only £1,300.

Sleep clinics across the UK are all reporting a significant increase in patients being referred. It is predicted that the number of patients being diagnosed with OSA is likely to continue to rise. It is estimated that only 1/5 of those with OSA have been diagnosed so far. OSA is often linked to obesity and obesity trends are still rising.  Increasingly sleep clinics are overloaded and finding it hard to cope with the increased patient numbers.

Professor John Stradling, Professor of Respiratory Medicine, Oxford University, suggested that one solution might be for GPs to take on a greater role, just as they now do, for example, in the treatment of diabetic patients. He outlined several possible models that this greater GP involvement might take. Initial home sleep studies might be done by GPs with results then referred on to a sleep centre. Devices such as Grey Flash or Apnoea Link or other similar home sleep study devices might be used, perhaps by a group of GP surgeries working together in conjunction with their local sleep centre. Some such models have already been trialled in conjunction with the Oxford Sleep Centre.

Initial screening could be carried out by GPs. ESS (The Epworth Sleepiness Scale) is one commonly used method. Another is the STOP BANG screening tool devised by a Canadian anaesthetist .  A third screening method becoming more widely used is the Australian one referred to as: OSA – 50: 

Overweight                         If Yes  Score

men with waist over 40″                  3

women with waist over 35″

Snoring                                       3

Apnoeas                                     3

50 years or older                           2

Professor Stradling also posed the question whether certain groups should be screened for OSA. For example, those with particular conditions such as Type 2 diabetes, diabetic retinopathy or ischaemic heart disease or those who are professional drivers, such as bus, lorry or coach drivers.

Dr Maxine Hardinge from the Oxford Sleep Unit spoke about setting up a “One Stop Shop” for the assessment and diagnosis of OSA. The one stop shop approach had been trialled there in an effort to shorten the patient pathway from initial referral to final diagnosis and treatment. However, they found that having only one appointment was less successful for patients, who felt there was too much information to take in at one time, and they have now moved to a “two stop”system, with a follow up appointment being scheduled for 3 weeks after the initial appointment.

John O’Reilly, Consultant in Sleep and Respiratory Medicine at University Hospital, Aintree described the setting up of a sleep service. The Aintree development was designed to be used as a sleep lab at night and to be used for clinics during the day to make the most effective use of the space available. He also spoke of how cost effective the treatment for OSA is. The costs of treating a patient with PAP therapy are all front loaded, with the cost of CPAP treatment being cost effective after 2 years.

A number of speakers spoke about the management of OSA and the importance of ongoing support. The drop out rates for patients using CPAP vary considerably from centre to centre. It is very important that adequate support is available for new patients in the early stages of using CPAP. The first week of use is an important predictor of long term success. Some centres are now looking at using wireless technology, as this makes day by day monitoring possible, so that intervention can be done early if there are problems such as too many mask leaks or the machine not being used.

One speaker highlighted some of the problems their centre was encountering where patients had arrived from other centres, where ongoing support was not being given. Among the problems encountered were old or ill fitting masks, patients demotivated because of lack of timely support and patients who needed re-titration because of weight gain or weight loss.

Dr David Dawson Bradford described a service being offered by Phillips Respironics for the remote diagnosis of truck drivers.  MOST – management of sleep therapy . Drivers are offered a two nights home sleep study, followed by a clinic appointment where the sleep study is gone through with the patient and OSA and the use of a PAP device is explained.The patient is then fitted for a mask and given an auto-titrating PAP machine. Patients are followed up at 48 hours and then given a phone call at 1 week to go over the data.  There is further data recall at 4 weeks, 3 months and then 6 months,and a follow up clinic appointment at 6 weeks. This level of ongoing patient support should help to reduce the drop out rate for patients using PAP therapy.       

Ongoing support may be improved through the use of modern technology, such as remote monitoring. However, having staff available to assess the information may still present a problem.

Following a break, the Conference delegates broke up into 4 groups to continue  ‘The Patient Pathway’ discussion.

This was followed by a session looking at OSA minimum standards, led by representatives from England, Scotland, Northern Ireland and Wales.

Finally the conference closed with a panel of experts who put forward suggestions as to how to ensure OSA is made a priority within the NHS.   This is one area where the BLF have made great strides in raising awareness with Governments as well as the General Public.