Our over-riding premise in this post assumes that turning a patient into a regular user of PAP improves health benefits and saves healthcare dollars. Although the first half of the statement is a given, the second half remains controversial as we discussed in Part I. A fair number of research studies show cost-savings emerge by increasing PAP use, but no analysis has ever been conducted, to my knowledge, factoring in the costs of the number of trips to the sleep lab. Thus, to be fair, the remainder of this post must be weighed in balance against the speculative theory more trips to the sleep lab are not so costly as to eat up all the other gains to be realized, both to the patient and insurers.
We’ll start with masks because as conventional wisdom goes, most sleep professionals and probably most patients perceive mask fit, mask leak, and mask comfort as the ultimate deal-breakers. Our clinical experience indicates pressurized air is the larger problem, and in fact the type of mode delivering the pressurized air also influences these mask issues. Nevertheless, as so many people are wedded to the belief in prioritizing mask issues, we’ll follow the lead.
There are so many nuances to mask issues, but a universal problem afflicts nearly all patients and that is how they cope with the experience of mask problems. As each patient individually navigates attempts at new masks (types or styles), the most immediate deal breakers are discomfort or pain. Now, imagine you are a patient sitting at home about to go to bed. Maybe you have succeeded in putting the mask on your face, attaching the headgear, connecting the tubing and then turning on the pressure. At this critical juncture, if you feel any discomfort or pain stemming from the mask, no matter on your face, nose, or head, it is quite common to simply remove the maskf. Whether you are sleep-related institutions or professionals such as DME companies, insurers or sleep doctors, it seems apparent a fair number of healthcare personnel in this field just do not realize how rapidly mask problems lead to immediate rejection from which many patients may never recover.
Think about the above scenario. The patient has completed all the necessary testing to proceed to the point of filling a prescription for the PAP device. They may have even felt comfortable with the mask at a titration sleep study as well as during the initial setup period working with the respiratory therapist or sleep technologist. But, now in the comfort of one’s home, the patient must replicate the experiences, presumably positive ones, previously encountered in the lab or DME facility. And, what happens if the mask fitting, comfort and placement cannot be replicated? What if the mask causes unexpected discomfort and pain? What happens next?
Take the simplest and often most common problem of improper mask fitting. This issue might seem implausible to you if you don’t have first-hand experience as a patient or a sleep professional regarding the application of masks, but guess what: anywhere from one-third to one-half are fitted with the wrong size of mask the first time they are attempting PAP therapy. Not only are the sizes frequently incorrect, but the actual mask selection is just not going to work for a new patient. How could there be so much error arising in these circumstances. The answer is just as a simple. Every person has quirks to his or her facial structure as well as specific sites of sensitivities regarding comfort and pain. In other words, for more than 50% of first-time PAP users, it may be nearly impossible to find the best mask, fit it properly and confirm it is the correct size.
With so much variability in just these early encounters with masks, is it any wonder so many OSA/UARS patients drop out of care so quickly. Even if they have tried these masks in one night of testing in the sleep lab, the rates of misfits and mis-sizing are preposterously high. Now imagine the scenario of home sleeping testing (HST), where the patient is never trying out the mask in a way to match the lab experience. Instead, they are fitted in a short encounter at the DME, and then the patient must go home and try it all out. Again, for someone with the capacity to easily work his or her way through the trials and tribulations of getting the mask to properly, the series of adjustments are no big deal. However, for someone with greater facial sensitivities or a lower threshold to pain or discomfort, the process is next to impossible.
Enter the role of the sleep lab. In this environment the individual repeatedly receives hands-on adjustments for all manner of mask difficulties, but most importantly, they receive repeated adjustments throughout the night and as necessary they return to the sleep lab a week, a month or few months after initiating PAP therapy and again go through repeated mask adjustments. Most regrettably, there are many sleep professionals and technologists who just do accept these premises. They are somehow persuaded that patients are fitted properly with the best mask the first night of the study and these issues of pain and discomfort would resolve in due course. Again, while these perspective do manifest among that proportion of the population where PAP therapy adaptation is relatively easy, these viewpoints are way off base among the more vulnerable or sensitive patients where even the potential to find the right mask the first go-round is remote.
Making matters worse are the various insurance policies that do not permit swift transitions to replace the current mask with different ones before the usual 90-day window for such transactions. Thus, only among DMEs or sleep centers that create their own home-grown loaner programs will these vulnerable or sensitive patients have the opportunity to quickly gain a 2nd or 3rd chance instead of rapidly rejecting PAP due to a poor fitting mask.
Imagine the patient who is a horrible mouth breather, but who also suffers from claustrophobia. Do you give them nasal pillows (NP) to prevent claustrophobia or a full face mask (FFM) to cover mouth breathing? In an ideal world the patient might consider both, alternating them for a period of time. But in the real world of healthcare, the scenario plays out very differently. In those with clear-cut claustrophobic responses, they will never agree to early use of FFM, and some won’t even try on these masks. So, they use the nasal pillows in the sleep lab and agree to start with NP at home. Then, in short order, they report horrible dry mouth and want a solution. They might briefly try a chinstrap, but this step also induces claustrophobia. The bottom line is that the patient is probably ultimately going to need the FFM, but how long will they continue to reject it due to their psychological distress, and at what point would they quit PAP therapy?
Again, the answer is the sleep lab, where all these various combinations can be tried out in the safety and security of an attended study, where the patient is eager to experiment under the guidance and hands-on coaching from the sleep tech. These encounters occur frequently at our sleep lab, and the success rate is high, because the patient has proceeded with the understanding nothing would be forced upon him or her. Rather, through trial and error with the help of an expert, the patient believes it’s worth a shot to solve the mask problem. To be sure, the patient has already attempted to solve these problems at home and has typically failed outright or produced extremely inconsistent results. They want to use PAP, but in their minds, they cannot achieve success. This frustration motivates them to return to the lab, where it seems like the most rational way to approach the problem. However, under current insurance guidelines, the patient’s efforts to return to the sleep lab could be blocked for weeks or months or forever (as is the case with certain patient-unfriendly insurers) at which point they quit PAP therapy. Just one more night in the sleep lab might have turned things around 180 degrees.
And, we’ve just started with mask fitting and touched on mouth breathing. The additional problems of mask leak, pain, comfort and sizing all flare up in vulnerable and sensitive patients. And, no matter how dedicated and diligent a DME company might be in attempting to address these problems, it is not a small proportion of patients where daytime appointments will lead to less than adequate solutions, after which the patient will quit. And, remember, every step of the way, if the “cure is worse than the disease,” the patient will not experience our ultimate benchmark, “sleeping better.” And, anything that prevents improvement in sleep quality or worse, something that aggravates existing poor sleep quality, will almost invariably lead to diminished motivation in this cohort of patients and sooner than later rejection of the treatment and refusal to engage in the treatment.
Turning to mask pain, discomfort and sizing issues, it remains one of the weakest links throughout all efforts to manage OSA/UARS patients. And, why shouldn’t it be? Placing something foreign and unnatural on your face and expecting it to be worn there all night long seems far fetched. If you are old enough or experienced enough to know what masks were like in the 1980s, you would be shocked upon learning what was expected of the patient. The discomfort, pain, and irritation occurred with virtually every mask. When I first attempted PAP in 1993, I used a nasal mask and recall waking up all night long to adjust it so as to eliminate the pain on my upper lip and the gums of my teeth. Even with all the great advances in mask technology, which reflect huge strides of progress, it remains exquisitely difficult to size patients with the right mask, even sometimes the right size of nasal pillows for specific nostril openings.
We would all like for these issues to be like rocket science. Not even close. And, therefore, it requires the patients’ presence in the sleep lab for the implementation of very subtle adjustments to headgear and mask fit. A particular popular approach among my sleep techs is to teach patients how to spread laugh lines on their cheeks to smooth out the skin, doing one side at a time, and then placing the mask cushion. This technique may eliminate leak in patients suffering intractable leak problems. Another one is the proper use of REMZzzs mask liners, a widely under-utilized add-on that relieves pain and discomfort in a large segment of vulnerable and sensitive patients. Yet, it is very easy for these types of patients to exhibit difficulties in hand or eye coordination to properly fit the mask liners. Another area of common concern is the in-betweener, where the individual goes back and forth between medium and small or between medium and large sizes of any style of mask. Even in the sleep lab, this sizing issue may prove very difficult to resolve, yet it is in the sleep lab environment where the greatest chances of success are to be discovered.
To give you an idea of how difficult these tasks are in the absence of the sleep lab, I recently asked a few of my techs to predict which size of the Airfit Touch (F20) (FFM with the foam cushion) would be the right fit for me. Not only did I receive various suggestion for different sizes, but I also received specific comments about the likelihood of my being an in-betweener. My techs were only a little surprised when I informed them it was the large size that not only felt the most comfortable but also had completely eliminated the recent leak issues I’d been experiencing. Yet, the majority of techs presumed I would have had the greatest success with the medium size.
When I see second opinion patients, the most common problem is the failure of the previous sleep center consider a trial of advanced PAP, even just a bilevel trial, let alone ABPAP or ASV. And, we’ll talk later about this obsession with CPAP, but the second most common finding that diminished their chances to succeed were related types of obsessions with mask styles. Currently, it has become fashionable to declare that full face masks do not work well or that they cause side-effects or other problems in using PAP. Most of these sentiments fall into the categories of anecdotal evidence or weakly designed research studies, either of which lead sleep professionals to develop conventional and highly entrenched “wisdom.” I know of many sleep doctors and DME professionals who virtually refuse to let their patients even try out FFMs. We have worked with hundreds of second opinion patients who were stunned when we informed them of the existence of a mask that covered the nose and mouth. They expressed equal parts disappointment and anger directed at the prior sleep professionals who had not given them the opportunity to consider this option. Many of these patients found great relief moving from nasal pillows or nasal masks to the FFM. We have even published a paper on this phenomenon, describing in detail how over several months or longer patients transition from less invasive to more invasive masks based on the desire for better and more consistent results.
This rigidity to stick with one mask style is rife within the sleep community and flares up in various spots, including sleep technologists who have favorite masks, sleep doctors who insist they know what’s best for every patient, and DMEs often caught in the middle when they cannot convince the sleep center to let the patient try something new and different in mask types. Of course, these problems can occur in the reverse direction, wherein some DMEs hold fast to certain types of masks and brands due to cost factors or other preferences. Every mask type and style has its own strengths and weaknesses, but the explosion of variety in masks may actually not be all that it’s cracked up to be if these sleep professionals do not take advantage of all these options for their patients.
Our center is named Maimonides Sleep Arts & Sciences for a reason, being that many PAP patients (what we affectionately called “Pappers”) are just too finicky to be able to gain a consistent response without our taking them through the “art” of mask sizing and fitting. To reiterate, you cannot get this level of care in any other place except a night time experience in the sleep lab or in some cases a daytime experience with a PAP-NAP. While I certainly believe in the genuine and sincere good intentions of all members of the sleep medicine community, it’s simply impossible to expect to solve these mask issues in brief daytime encounters for a very sizeable number of cases. Yet, this approach is exactly what insurance companies are adopting by throwing up barriers that prevent patients from returning to the sleep lab.
So much of these issues revolve around the belief that patients should just be able to figures things our or they just need to try harder to figure things. And, I am not debating here that there is a large proportion of patients that easily figure these issues. Such individuals in general are more well-adjusted, individualistic and in possession of a can-do attitude. They exhibited what’s known as a very high degree of “self-efficacy.” These posts are not about these sorts of patients. Vulnerable and sensitive patients are quite different. Not only would we see them as being more dependent than independent in personality style, but in many there simply is not the dexterity or common sense to solve these problems.
Just the other day, I saw a patient who was furious with every key sleep professional in our care, including me, my staff, his DME company and the insurance company. All the problems revolved around mask replacement issues. Somehow no one had every explained to her the difference between a mask and mask cushion. The patient kept receiving mask cushions in the mail on a monthly basis, but she could not figure out what do with them and repeatedly contacted all relevant parties demanding she receive a new mask. It turned out that we only needed to show her how to pop the current cushion off the hard mask system and then seat the new cushion on in its place.
The above example is not designed to suggest someone needs to go to the sleep lab to learn how to replace mask cushions. This patient, however, had come to us from another facility, had been failing on CPAP for years, and was never accurately diagnosed and effectively treated for a leg jerk disorder, all of which required her presence in the sleep lab, where we showed her the option of the full face mask. The FFM helped her respond much better to pressurized air, and the new PAP mode (ABPAP) was much more comfortable and efficacious. We failed her though in not showing her the cushion replacement technique on the night she was in the lab.
Ultimately, we return to common sense and dexterity issues that are so critical to the success of vulnerable and sensitive patients. It may seem expensive and inefficient to resort to the sleep lab for these types of patients, but if the premise proves accurate that not using a PAP machine is almost always more expensive in the long-run compared to letting patient’s health problems worsen, then the sleep lab currently is the place to invest a great deal of time, effort and resources to place these dependent types patients onto the right treatment pathways. Still to hop on board this “sleep lab track” requires considerable negotiations with insurance carriers, although surprisingly or not, an institution such as Medicare has made the process extremely accessible as no prior authorizations are required.
Nonetheless, one of largest of all the barriers would be found among insurers applying prior authorization schemes to maneuver patients away from the sleep lab, which we believe results in inferior outcomes for the vulnerable and sensitive patients we have been discussing. The most obvious ways in which patients suffer, of course, is merely the delaying process that frequently occurs in dealing with insurance personnel. With these delays, patients’ frustrations mount and eventually some quit therapy altogether and in the process give up on the idea of ever being able to use a PAP machine. Even larger negative influences on patients are the various authorization hoops to jump through, which not only add to the delay but often lead to new and greater frustrations.
Take the example of a chinstrap. It’s very reasonable to assume that a patient with mask leak and mouth breathing problems might see great improvements with a chinstrap, which is why these add-ons are a popular remedy prescribed for many patients. But, if you’ve never worked directly with patients to fit and prescribe a chinstrap, then you may not be aware of how much time, effort and nuanced adjustments are needed to get things right. Even among my own techs, there are occasional battles where one tech started the patient on a non-adjustable chinstrap and then a few weeks or months later the patient is seen again in clinic or in the lab, and it seems clearer that the adjustable chinstrap is the better option.
Many more chinstraps are available nowadays, but there remain several fitting problems, not the least of which is determining whether a patient must use the chinstrap under the mask (atypical) or over the mask and headgear (traditional location). Just this single change could yield monumental differences. Yet, there are a proportion of cases where the chinstrap either proves irritating or painful or induces claustrophobia if it is worn outside the mask, and only after the patient learns how to apply the chinstrap first and then seats the mask atop will optimal results ensue. Though this dimension of care may seem straightforward, in fact learning how to apply chinstraps correctly, how to clean chinstraps, and how to readjust them night after night to secure a proper and comfortable fit takes more time in vulnerable and sensitive patients, which is why they must return to the sleep lab to learn all these steps.
Finally, if we return to our ultimate question of whether an insurer is acting rationally, you will see in the next post how we must attempt to traverse through these various administrative hoops to eventually secure a spot for a patient in the sleep lab to work on all the numerous and subtle obstacles that prevent them from achieving optimal responses to PAP. The question thus arises as to whether the insurer’s authorization schemes are truly an effective way to help patients move forward?