Transcript Impact of Sleep Apnea on Hospital Admissions and Outcomes: 27,555 Inpatient Encounters of 19,044 Individuals Jon H.

Impact of Sleep Apnea on Hospital Admissions
and Outcomes: 27,555 Inpatient Encounters of
19,044 Individuals
Jon H. Lemke, Ph.D.
Chief Biostatistician
Business Intelligence Center
Genesis Health System
Genesis Sleep Apnea Registry: Principal Investigator
Genesis Research Summit Presentation
Davenport, IA
June 18, 2015
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Conclusions
 “Destiny is no matter of chance. It is a matter of choice. It
is not a thing to be waited for, it is a thing to be achieved.”
– William Jennings Bryan (1860-1925)
 Nonadherent and Probable sleep apnea patients’:
– reasons for being in the hospital are in no way similar to
those of the Adherent and Unlikely sleep apnea
patients.
– risks are greater for worse outcomes and longer stays
than Adherent and Unlikely sleep apnea patients.
 If each of you can be bold enough to motivate one person
to switch from a nonadherent or probable sleep apnea
patient to an adherent sleep apnea patient you will have
made a significant impact on their lives.
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Conclusions
 No ACO (Accountable Care Organization) will be successful
unless it aggressively diagnoses and treats sleep apnea.
Advantage goes to those that started before they became an
ACO.
 CMS Bundled payments start July 1 are for 90-day episodes of
care. Advantage go to Orthopedics given patients can be on
CPAP prior to elective knee and hip surgery. All can benefit
with 90-days instead of the traditional 30-days.
 Now there is even more opportunity for double dipping with
CMS Pay-for-Performance:
 Readmission Reduction Program
 Hospital Value Based Purchasing
 Hospital Acquired Condition Penalty
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Current Research Team Investigators
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Jon H. Lemke
Desyree Weakley
Stephen C. Rasmus
Vicki Loving
Tosha Allen
Mike Malloy
Alyssa Barkalow
Brian Dirksen
Mikel O’Klock
Neil Flynn
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Special Thanks
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Maja Zingmark
Chris Lynn
Dr. Claudy
Gina Gore
Candice Elias,
Tami Gumpert
Braxton Lancial
Lynn Colberg
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 Dianna Paustian
 Amanda Wesson
 Every Physician and
Every Nurse who has
had a frank discussion
about sleep apnea.
 All of the Sleep Techs
 All of the Respiratory
Techs
Lemke, GHS Business Intelligence Center
National Perspective
 ALL 41 Institutes in NIH claim diagnosis and treatment of
sleep apnea is crucial to their mission.
 Sleep disordered breathing is associated with health
conditions across ALL organ systems.
 Changing definitions and documentation are changing
who is an inpatient, outpatient, or observation patients;
and will be making it even more difficult to track patients
across hospitalizations by using different coding systems.
 Schneider Trucking with comprehensive diagnosis and
treatment had 74% reduction in accidents and 91%
reduction in hospitalizations (Lazar 2007).
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Sleep Apnea Risk Groups
2. Dx-Nonadherent
1. Dx-Adherent
3. No Dx-Probable Sleep Apnea
4. No Dx-Unlikely to have Sleep Apnea
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Methods
1) Inclusion: Genesis Medical Center first inpatient admission
screened for sleep apnea status since November 4, 2012.
[We do screen others on admission as well, but not for
these analyses.]
2) Classification: Each inpatient is classified relative to their
sleep apnea status at each admission (details soon). If
already screened, status is carried forward until there is
evidence of change.
3) Duration of Stay: Censored if patient expires, goes AMA, or
is transferred to another acute care facility.
4) Duration of Follow-up: Censored if patient expires, goes
AMA, is transferred to another acute care facility other than
a GMC facility or until November 3, 2014.
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Nonelective 6.44 times the Opportunities than Elective
Major Diagnostic
Category
Adherent
Nonadherent
Probable
Unlikely
Cases
Elective
803
477
409
3,892
5,581
Nonelective
2,250
2,430
3,279
14,015
21,974
All Encounters
3,053
2,907
3,688
17,907
27,555
Odds Ratios
SA Dx or Probable
vs. Unlikely
0.76
Less Likely to Have
(0.70 , 0.83)
Sleep Apnea
2.19
(1.87 , 2.57)
SA Dx vs. Probable
Adherent vs.
Nonadherent
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1.82
(1.54 , 2.15)
More Likely to Have a Diagnosis
of Sleep Apnea
More Likely to be Adherent
Lemke, GHS Business Intelligence Center
Sleep Apnea Status by Major Diagnostic Categories with
at least 24 Cases and 3 Cases per Status
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Sleep Apnea Status by Major Diagnostic Categories with
at least 24 Cases and 3 Cases per Status
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Endocrine, Nutritional & Metabolic: 225 Opportunities for Improvement
Major Diagnostic
Category
Adherent
Nonadherent
Probable
Unlikely
Cases
Endocrine,
Nutritional
& Metabolic
179
98
127
605
1,009
Else
2,874
2,809
3,561
17,302
26,546
All Encounters
3,053
2,907
3,688
17,907
27,555
Odds Ratios
SA Dx or Probable
vs. Unlikely
1.25
More Likely to Have
(1.05 , 1.48)
Sleep Apnea
SA Dx vs.
Probable
Adherent vs.
Nonadherent
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1.37
(1.03 , 1.83)
1.79
(1.28 , 2.51)
More Likely to Have a Diagnosis
of Sleep Apnea
More Likely to be Adherent
Lemke, GHS Business Intelligence Center
Sleep of
Apnea
Status
by those
Major
Diagnostic
Categories
Percent
Probables
among
with
Some Indication
of Sleepwith
Apnea
at least 24 Cases and 3 Cases per Status
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Musculoskeletal System: 772 Opportunities for Improvement
Major Diagnostic
Category
Adherent
Nonadherent
Probable
Unlikely
Cases
Musculoskeletal
System
534
386
386
3042
4,348
Else
2519
2521
3302
14865
2519
All Encounters
3053
2907
3688
17,907
27,555
Odds Ratios
SA Dx or Probable
vs. Unlikely
0.81
Less Likely to Have
(0.70 , 0.84)
Sleep Apnea
SA Dx vs.
Probable
Adherent vs.
Nonadherent
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1.56
(1.32 , 1.85)
1.38
(1.14 , 1.67)
More Likely to Have a Diagnosis
of Sleep Apnea
More Likely to be Adherent
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Syndromes with Sleep Apnea
Syndrome Z
Sleep Apnea + Metabolic Syndrome
After 3 months of CPAP-treatment the
patients had a reduction in blood pressure,
glycated hemoglobin, triglycerides, LDL, total
cholesterol and BMI (Soneja et. al. 2012)
Overlapping Syndrome
Sleep Apnea + COPD
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Severity of Illness Prior (P) and With
(W) the Two Midnight Rule
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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Extreme
Major
Moderate
Mild
Lemke, GHS Business Intelligence Center
Severity of Illness Comparative Analysis under
Sleep Apnea Status with Two Midnight Rule
Severity of Illness
PRIOR
Adherent
MILD
MODERATE
MAJOR
EXTREME
Total
206
(14.1%)
480
(32.8%)
540
(36.9%)
237
(16.2%)
1463
0.81
CI (0.68 , 1.18)
0.87
CI (0.86 , 1.26)
1.04
CI (0.80 , 1.32)
P-VALUE
0.9055
WITH
Adherent
202
(12.8%)
555
(35.3%)
566
(36.9%)
249
(15.8%)
1572
PRIOR
Nonadherent
& Probable
450
(16.1%)
939
(33.6%)
939
(33.6%)
468
(16.7%)
2796
1.14
CI (1.02 , 1.46)
WITH
Nonadherent
& Probable
507
(13.6%)
1.31
CI (1.10 , 1.43)
1139
(30.5%)
1368
(36.6%)
1.18
CI (1.01 , 1.41)
722
(19.3%)
P-VALUE
0.00006
3736
Risk of Mortality Prior (P) and With
(W) the Two Midnight Rule
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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Extreme
Major
Moderate
Mild
Lemke, GHS Business Intelligence Center
Risk of Mortality Comparative Analysis under
Sleep Apnea Status with Two Midnight Rule
Risk of Mortality
PRIOR
Adherent
MILD
MODERATE
MAJOR
EXTREME
Total
581
(39.7%)
366
(25.0%)
329
(22.5%)
187
(12.8%)
1463
0.97
CI (0.83 , 1.22)
1.04
CI (0.89 , 1.21)
1.02
CI (0.75 , 1.29)
P-VALUE
0.8572
WITH
Adherent
630
(40.1%)
375
(23.9%)
362
(23.0%)
205
(13.0%)
1572
PRIOR
Nonadherent
& Probable
1041
(37.2%)
715
(25.6%)
660
(23.6%)
380
(13.6%)
2796
1.27
CI (1.03, 1.35)
WITH
Nonadherent
& Probable
1246
(33.6%)
1.29
CI (1.05, 1.37)
936
(25.1%)
909
(24.3%)
1.42
CI (1.10 , 1.59)
643
(17.3%)
P-VALUE
0.00001
3734
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