Sleep Apnea Research Jon H. Lemke, Ph.D. Chief Biostatistician Jordan Brautigam, MHA Business Analyst Business Intelligence Center Genesis Health System 2016 Genesis Research Summit June 8, 2016 Adler Education Center Genesis Medical Center, Davenport (East Campus)
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Sleep Apnea Research Outline Study Purpose and Goals Study Design Outcomes Impact on Patient Care 5/25/2016 Lemke, GHS Business Intelligence Center 3
National Perspective ALL 41 Institutes in NIH claim diagnosis and treatment of sleep apnea is crucial to their mission. The Joint Commission issues an Alert Friday June 26, 2015 Incidence of Sentinel Events have an abundance of potential sleep apnea patients. Recommend screening patients for sleep apnea upon admission to the hospital to identify patients at greater risk for sentinel adverse events. At Genesis we have been doing this since November 2012. Sleep disordered breathing has a different footprint on across ALL major diagnostic categories. 5/25/2016 Lemke, GHS Business Intelligence Center 4
Anesthesiologist Perspective “Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea” (2006) Focus: “Patients with OSA who may be at increased risk for perioperative morbidity and mortality because of potential difficulty in maintaining a patent airway”(1082). Recommendations: “Anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of perioperative management”(1084). “A physical examination should include an evaluation of the airway, nasopharyngeal characteristics, neck circumference, tonsil size…”(1084). “The consultants agree that perioperative use of CPAP or NIPPV may improve the perioperative condition of patients who they believe are at increased risk from OSA…”(1084). “Because of their propensity for airway collapse and sleep deprivation, patients at increased perioperative risk from OSA are especially susceptible to the respiratory depressant and airway effects of sedatives, opioids, and inhaled anesthetics” (1085). 5/25/2016 Lemke, GHS Business Intelligence Center 5
Selected Previous Research Undiagnosed and Untreated Sleep Apnea patients with knee or hip replacement were 9 times more likely to have unplanned visits to ICU. Gupta R, Parvizi, J, Hanssen A, Gay P. Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study. Mayo Clin Proc. 2001;76:897-905. 32% increase (from 37% to 49%) of Left Ventricular Ejection Fraction (LVEF) after one month of PAP use; results reversed after one week without PAP. Bradley T, Floras J. Sleep Apnea and Heart Failure: Part 1: Obstructive Sleep Apnea. Circulation 2003;107:1671-1678. Schneider Trucking with comprehensive diagnosis and treatment had 74% reduction in accidents and 91% reduction in hospitalizations. Lazar RA. An Emerging Standard of Care Requiring Commercial Driver Screening for Sleep Apnea: Practical Considerations and Risk Management Strategies for the Trucking Industry. White Paper Published August 1, 2007. 5/25/2016 Lemke, GHS Business Intelligence Center 6
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Sleep Apnea Risk Groups 2. Dx-Nonadherent 1. Dx-Adherent 3. No Dx-Likely Sleep Apnea 4. No Dx-Unlikely to have Sleep Apnea 4/13/2016 Lemke, GHS Business Intelligence Center 8
Caveats Biases exist in this screening as we primarily depend upon what the patient tells us. We are only analyzing those that come to the hospital, and cannot compare them to those that are not hospitalized. In these analyses the focus is entirely on the “Inpatient” encounters. Changes in demographics of the population, access to care, definitions and documentation are changing who is a hospitalized “Inpatient”. Some inpatients are screened by self report at one GMC site, transferred and then observed at another GMC site. Several of these slides focus on the first 2.0 years of encounters. 4/13/2016 Lemke, GHS Business Intelligence Center 9
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Competing Risks: Physician Documented Prevalences with MIDAS+ Cluster Ranking by Sleep Apnea Status Sleep Apnea Risk Arthroplasty Viral Heart Failure Septicemia PTCA Total Knee Pneumonia Group 1 st 4 th 2 nd 3 rd 6 th Dx – Adherent (8.2%) (5.1%) (6.6%) (5.3%) (4.6%) 6 th 1 st 2 nd 3 rd 4 th Dx – Nonadherent (3.9%) (6.9%) (6.9%) (5.7%) (5.3%) 9 th 4 th 1 st 2 nd 3 rd No Dx – Likely (2.5%) (4.2%) (6.7%) (5.6%) (5.3%) 2 nd 5 th 1 st 4 th 3 rd No Dx – Unlikely (5.4%) (3.3%) (6.1%) (3.9%) (4.8%) 4/13/2016 Lemke, GHS Business Intelligence Center 12
Focus on 44,924 Acute Care Inpatients Sleep Apnea Status by Site Sleep Apnea Risk Davenport Silvis Aledo DeWitt Total: Group 4,437 687 34 25 5,183 Dx – Adherent (12.6%) (7.6%) (10.3%) (7.0%) (11.5%) 4,334 903 44 63 5,344 Dx – Nonadherent (12.3%) (10.0%) (13.4%) (17.7%) (11.9%) 4,464 997 31 47 5,539 No Dx – Likely (12.7%) (11.1%) (9.4%) (13.2%) (12.3%) 22,012 6,406 220 220 28,858 No Dx – Unlikely (62.5%) (71.2%) (66.9%) (62.0%) (64.2%) 35,247 8,993 213 255 44,924 Total (100%) (100%) (100%) (100%) (100%) 4/13/2016 Lemke, GHS Business Intelligence Center 13
Comparison of Sleep Apnea Risk Groups by Sex Dx of Sleep Apnea No Dx of Sleep Apnea Total (Group 1 + 2) (Group 3 + 4) Male 5,915 (27.9%) 15,320 (72.1%) 21,235 (100%) Female 4,612 (19.5%) 19,077 (80.5%) 23,689 (100%) Total 10,527 (23.4%) 34,397 (76.6%) 44,924 (100%) Dx-Adherent Dx-Nonadherent Total (Group 1) (Group 2) Male 3,068 (51.9%) 2,847 (48.1%) 5,915 (100%) Female 2,115 (45.9%) 2,497 (54.1%) 4,612 (100%) Total 5,183 (49.2%) 5,344 (50.8%) 10,527 (100%) No Dx – Likely No Dx – Unlikely Total (Group 3) (Group 4) Male 2,290 (19.3%) 9,586 (80.7%) 11,876 (100%) Female 2,072 (14.1%) 12,650 (85.9%) 14,722 (100%) Total 4,362 (16.4%) 22,236 (83.6%) 26,598 (100%) 4/13/2016 Lemke, GHS Business Intelligence Center 14
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Current Research Team Investigators Jon H. Lemke Desyree Weakley Stephen C. Rasmus Vicki Loving Tosha Allen Mike Malloy Brian Dirksen Mikel O’Klock Neil Flynn 9/25/2015 Lemke, GHS Business Intelligence Center 18
Special Thanks Maja Zingmark Lynn Colberg Hannah McAfoos Dianna Paustian Ryan Kelly Amanda Wesson Chris Lynn Every Physician and Every Nurse who has had Dr. Claudy a frank discussion about Gina Gore sleep apnea. Candice Elias All of the Sleep Techs Tami Gumpert All of the Respiratory Techs Braxton Lancial Alyssa Barkalow 9/25/2015 Lemke, GHS Business Intelligence Center 19
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Acute Inpatient Complications by Sleep Apnea Status 2013-2015 (18+) Excess 200.00 Sleep Apnea O:E Delta to 175.00 Status Ratio (O-E) Target 150.00 Adherent 1.04 24.9 115.5 125.00 Nonadherent 1.19 163.7 273.7 100.00 Observed Likely 1.38 258.6 346.5 75.00 per 1000 Unlikely 1.33 1111.0 1546.6 Expected 50.00 All 1.28 1558.1 2282.3 per 1000 25.00 0.00 5/25/2016 Lemke, GHS Business Intelligence Center 25
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Acute Inpatient Mortality by Sleep Apnea Status 2013-2015 (18+) Excess 3.00% Sleep Apnea O:E Delta to Status Ratio (O-E) 2.50% Target Adherent 0.88 -11.73 0.97 2.00% Nonadherent 0.98 -2.36 14.59 1.50% Observed Likely 0.89 -15.37 2.75 Percent 1.00% Unlikely 0.81 -127.02 -41.61 Expected All 0.85 -156.47 -23.29 0.50% Percent 0.00% 5/25/2016 Lemke, GHS Business Intelligence Center 30
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