Cost Savings from Reduced Hospitalizations with Use of Home Noninvasive Ventilation for COPD.

BACKGROUND: Although evidence suggests significant clinical benefits of home noninvasive ventilation (NIV) for management of severe chronic obstructive pulmonary disease (COPD), economic analyses supporting the use of this technology are lacking. OBJECTIVES: To evaluate the economic impact of adopting home NIV, as part of a multifaceted intervention program, for severe COPD. METHODS: An economic model was developed to calculate savings associated with the use of Advanced NIV (averaged volume assured pressure support with autoexpiratory positive airway pressure; Trilogy100, Philips Respironics, Inc., Murrysville, PA) versus either no NIV or a respiratory assist device with bilevel pressure capacity in patients with severe COPD from two distinct perspectives: the hospital and the payer. The model examined hospital savings over 90 days and payer savings over 3 years. The number of patients with severe COPD eligible for home Advanced NIV was user-defined. Clinical and cost data were obtained from a quality improvement program and published reports. Scenario analyses calculated savings for hospitals and payers covering different COPD patient cohort sizes. RESULTS: The hospital base case (250 patients) revealed cumulative savings of $402,981 and $449,101 over 30 and 90 days, respectively, for Advanced NIV versus both comparators. For the payer base case (100,000 patients), 3-year cumulative savings with Advanced NIV were $326 million versus no NIV and $1.04 billion versus respiratory assist device. CONCLUSIONS: This model concluded that adoption of home Advanced NIV with averaged volume assured pressure support with autoexpiratory positive airway pressure, as part of a multifaceted intervention program, presents an opportunity for hospitals to reduce COPD readmission-related costs and for payers to reduce costs associated with managing patients with severe COPD on the basis of reduced admissions.

An electrocardiogram-based analysis evaluating sleep quality in patients with obstructive sleep apnea.

OBJECTIVE: The study compares polysomnography (PSG) and cardiopulmonary coupling (CPC) sleep quality variables in patients with (1) obstructive sleep apnea (OSA) and (2) successful and unsuccessful continuous positive airway pressure (CPAP) response. PATIENTS/METHODS: PSGs from 50 subjects (32 F/18 M; mean age 48.4 ± 12.29 years; BMI 34.28 ± 9.33) were evaluated. OSA patients were grouped by no (n = 16), mild (n = 13), and moderate to severe (n = 20) OSA (apnea-hypopnea index (AHI) ≤ 5, >5-15, >15 events/h, respectively). Outcome sleep quality variables were sleep stages in non-rapid eye movement, rapid eye movement sleep, and high (HFC), low (LFC), very low-frequency coupling (VLFC), and elevated LFC broad band (e-LFCBB). An AHI ≤ 5 events/h and HFC ≥ 50 % indicated a successful CPAP response. CPC analysis extracts heart rate variability and QRS amplitude change that corresponds to respiration. CPC-generated spectrograms represent sleep dynamics from calculated coherence product and cross-power of both time series datasets. RESULTS: T tests differentiated no and moderate to severe OSA groups by REM % (p = 0.003), HFC (p = 0.007), VLFC (p = 0.007), and LFC/HFC ratio (p = 0.038) variables. The successful CPAP therapy group (n = 16) had more HFC (p = 0.003), less LFC (p = 0.003), and e-LFCBB (p = 0.029) compared to the unsuccessful CPAP therapy group (n = 8). PSG sleep quality measures, except the higher arousal index (p = 0.038) in the unsuccessful CPAP group, did not differ between the successful and unsuccessful CPAP groups. HFC ≥ 50 % showed high sensitivity (77.8 %) and specificity (88.9 %) in identifying successful CPAP therapy. CONCLUSIONS: PSG and CPC measures differentiated no from moderate to severe OSA groups and HFC ≥ 50 % discriminated successful from unsuccessful CPAP therapy. The HFC ≥ 50 % cutoff showed clinical value in identifying sleep quality disturbance among CPAP users.

Correction: A quality improvement initiative for COPD patients: A cost analysis.

[This corrects the article DOI: 10.1371/journal.pone.0235040.].

Effects of the melatonin MT-1/MT-2 agonist ramelteon on daytime body temperature and sleep.

STUDY OBJECTIVES: A reduction in core temperature and an increase in the distal-proximal skin gradient (DPG) are reported to be associated with shorter sleep onset latencies (SOL) and better sleep quality. Ramelteon is a melatonin MT-1/MT-2 agonist approved for the treatment of insomnia. At night, ramelteon has been reported to shorten SOL. In the present study we tested the hypothesis that ramelteon would reduce core temperature, increase the DPG, as well as shorten SOL, reduce wakefulness after sleep onset (WASO), and increase total sleep time (TST) during a daytime sleep opportunity. DESIGN: Randomized, double-blind, placebo-controlled, cross-over design. Eight mg ramelteon or placebo was administered 2 h prior to a 4-h daytime sleep opportunity. SETTING: Sleep and chronobiology laboratory. PARTICIPANTS: Fourteen healthy adults (5 females), aged (23.2 +/- 4.2 y). MEASUREMENTS AND RESULTS: Primary outcome measures included core body temperature, the DPG and sleep physiology (minutes of total sleep time [TST], wake after sleep onset [WASO], and SOL). We also assessed as secondary outcomes, proximal and distal skin temperatures, sleep staging and subjective TST. Repeated measures ANOVA revealed ramelteon significantly reduced core temperature and increased the DPG (both P < 0.05). Furthermore, ramelteon reduced WASO and increased TST, and stages 1 and 2 sleep (all P < 0.05). The change in the DPG was negatively correlated with SOL in the ramelteon condition. CONCLUSIONS: Ramelteon improved daytime sleep, perhaps mechanistically in part by reducing core temperature and modulating skin temperature. These findings suggest that ramelteon may have promise for the treatment of insomnia associated with circadian misalignment due to circadian sleep disorders.

A quality improvement initiative for COPD patients: A cost analysis.

The objective of this analysis was to evaluate and report on the economic impact of implementing an integrated, quality, and operational improvement program on chronic obstructive pulmonary disease (COPD) care from acute through post-acute care settings. This initiative was established in a cohort of 12 hospitals in Alabama and sought to address COPD readmission through improved workflows pertaining to early diagnosis, efficient care transitions, and patient visibility across the entire care episode. Implementation of the initiative was influenced by lean principles, particularly cross-functional agreement of workflows to improve COPD care delivery and outcomes. A budget impact model was developed to calculate cost savings directly from objective data collected during this initiative. The model estimated payer annual savings over 5 years. Patients were classified for analysis based on whether or not they received noninvasive ventilation. Scenario analyses calculated savings for payers covering different COPD cohort sizes. The base case revealed annual per patient savings of $11,263 for patients treated through the quality improvement program versus traditional care. The model projected cumulative savings of $52 million over a 5-year period. Clinical incorporation of non-invasive ventilation (NIV) resulted in $20,535 annual savings per patient and projected $91 million over 5 years. We conclude that an integrated management program for COPD patients across the care continuum is associated with substantial cost savings and significantly reduced hospital readmissions.

Medical disorders and their effects on sleep.

Disturbances of sleep can be encountered in many medical disorders. Conversely, sleep impairment can adversely affect the symptoms of a variety of medical conditions, including respiratory, cardiac, gastrointestinal, renal, rheumatologic, and infectious disorders. More than one sleep pathology may be present in a particular patient, and these disorders may interact to increase the severity or prolong the duration of sleep disturbance.

Parasomnias and other sleep-related movement disorders.

Parasomnias are common clinical complaints. Formal sleep evaluation including PSG is indicated for parasomnias that are violent and potentially injurious; disruptive to the bed partner or other household members; accompanied by excessive daytime sleepiness; or associated with medical,psychiatric, or neurologic symptoms or findings [2]. Multiple sleep latency testing should be considered for patients who have complaints of excessive daytime sleepiness. An extensive history, including medical, neurologic,psychiatric, and sleep disorder, and a review of medication, alcohol, illicit drug use, and family history of parasomnias, may provide useful clues. Distinguishing between a parasomnia and a seizure may be difficult as both can present as recurrent, stereotypical behaviors. Evaluation may be aided by an expanded EEG montage during overnight PSG studies.

Monitoring respiration during sleep.

Monitoring of respiration during sleep allows the assessment of physiologic variables that are required to characterize SRBD events. The patency of the upper airway, the pattern of breathing, oxygenation, and ventilation usually can be inferred from simultaneous measurements of airflow, respiratory effort, thoracic volume, and blood gases. As new techniques of respiratory monitoring emerge, the respiratory therapist and sleep technologist must be familiar with the advantages and shortcomings of each modality.

Monitoring respiration during sleep.

The sleep-related breathing disorders have been categorized in various ways. The most basic schema divides them into obstructive or central apneic events. An American Academy of Sleep Medicine (AASM) Task Force Report published in 1999 defined four separate syndromes associated with abnormal respiratory events during sleep among adults, namely, obstructive sleep apnea-hypopnea syndrome (OSAHS), central sleep apnea-hypopnea syndrome, Cheyne-Stokes breathing syndrome, and sleep hypoventilation syndrome. In this classification, the upper airway resistance syndrome was not regarded as a distinct syndrome; instead, respiratory event-related arousals (RERAs) were considered part of the syndrome of OSAHS.

Medical treatment of obstructive sleep apnea.

A variety of treatment options are available for the treatment of obstructive sleep apnea in addition to positive pressure therapy and surgery. These modes of treatment might be employed in patients who cannot tolerate positive pressure therapy despite aggressive measures to improve compliance. These options include weight reduction, sleep hygiene, positional therapy, and oxygen therapy. Some of the options are still experimental and include pharyngeal muscle and hypoglossal nerve stimulators. A variety of pharmacological agents have also been used. The mechanisms by which these drugs improve sleep-disordered breathing include increasing ventilatory drive and upper airway muscle tone, reducing the amount of rapid eye movement (REM) sleep, and enhancing daytime wakefulness.

Heatstroke and other heat-related illnesses.

Preview Victims of high heat and humidity may be young and healthy or old and debilitated. In either case, severe heatstroke may present a life-threatening situation if treatment is delayed. In this article, the authors examine the various therapeutic options, including physical cooling methods and supportive measures. They also describe therapy for the less serious summer ailments of heat edema, heat cramps, and heat syncope.

Pulmonary hypertension and cor pulmonale in COPD.

Pulmonary artery hypertension (PAH) is the primary cardiovascular complication encountered in chronic obstructive pulmonary disease (COPD). Cor pulmonale can range clinically from mild changes in right ventricular function to frank right heart failure. The prevalence of PAH increases as COPD worsens, and the development of PAH and cor pulmonale appears to affect survival of patients with COPD. Potential causes proposed to explain the development of PAH in COPD include gas exchange abnormalities, destruction of the pulmonary vascular bed, alterations in respiratory mechanics, changes in intrinsic pulmonary vessel tone, and increased blood viscosity. Standard clinical evaluation, including history, physical examination, spirometry, electrocardiography, and chest radiography, is generally inadequate in identifying right ventricular dysfunction. Noninvasive techniques, such as echocardiography, radionuclide ventriculography, and magnetic resonance imaging, have largely replaced invasive pulmonary artery catheterization in the initial assessment of cor pulmonale. The goals of therapy consist of attenuation of PAH, enhancement of right ventricular function, alleviation of clinical symptoms, and improvement in survival. The agents that have been most extensively evaluated for these purposes include oxygen, vasodilators, theophylline, and inotropic medications.