Sleep Apnea Screening for ASCs

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Stephanie Wasek: We all hear about the impact of overweight and obese patients on the population and healthcare system; obstructive sleep apnea (OSA) is just one of the conditions associated with these patients. How prevalent is this problem in ASCs?

Dr. Steve Burton: According to the National Sleep Foundation Report on Sleep Apnea, approximately 18 million people suffer from sleep apnea daily. Approximately 12 percent to 15 percent of the surgical population has sleep apnea. That’s 10 percent of men and post-menopausal women. It’s as common as diabetes or asthma; however, eight in 10 are undiagnosed or untreated. The balance of patients suffer from sleep apnea every day and don’t know why. It’s this high rate of unmanaged disease that presents the risk to ASCs. Stephanie Wasek: We all hear about the impact of overweight and obese patients on the population and healthcare system; obstructive sleep apnea (OSA) is just one of the conditions associated with these patients. How prevalent is this problem in ASCs?

Dr. Steve Burton: According to the National Sleep Foundation Report on Sleep Apnea, approximately 18 million people suffer from sleep apnea daily. Approximately 12 percent to 15 percent of the surgical population has sleep apnea. That’s 10 percent of men and post-menopausal women. It’s as common as diabetes or asthma; however, eight in 10 are undiagnosed or untreated. The balance of patients suffer from sleep apnea every day and don’t know why. It’s this high rate of unmanaged disease that presents the risk to ASCs. 

SW: With that many undiagnosed sleep apnea patients, it seems that surgical centers would be impacted by the problem.

SB: You’re right. It’s essential from a quality perspective to be aware of OSA, because apnea patients have twice the number of surgical complications when compared with non-apnea patients, and three times the number of severe complications — extubation problems, cardiac events, extended ICU admissions, and the like.

SW: So the solution you bring to the table is screening, at the ASC end, so the OSA can be identified and managed?

SB: The ASA proposed in May 2006 a four-point quality process to improve surgical outcomes and reduce the risk associated with apnea. The first step is to screen for apnea risk; patients determined as at-risk should undergo a sleep test, then start
treatment ASAP, and monitoring should be increased after surgery.

Ion Healthcare provides screening that takes care of all those steps except the post-op monitoring. But with our program, ASC staff know who has OSA and who therefore might benefit from increased monitoring.

SW: Why target ASCs?

SB: The ASC is a perfect place to address a market that’s tremendously underserved, and make a tremendously positive impact on the quality of life of this patient population. It also presents an outstanding opportunity for ASCs to be a part of the overall solution for improving the quality of life for millions of undiagnosed apnea patients. 

Undiagnosed sleep apnea patients present a multi-billion burden on the healthcare system. Getting a sleep apnea patient in treatment reduces the annual healthcare expenses for that patient by 50 percent.

In 2007, 1 million patients presented to sleep centers nationwide seeking a diagnosis, but it’s estimated that over 4 million patients with sleep apnea presented at ASCs. By finding sleep apnea patients at a rate that exceeds four times the rate discovered today, ASCs could literally save the overall healthcare system billions of dollars annually.
SW: How does the screening program work? What are the steps for surgeon, staff and patients?

SB: The facility and Ion work out an arrangement for space, with Ion setting up either in the ASC, contiguous to the building or near the center, depending on the physical space available. Ion provides its own staff and equipment to perform testing procedures that are all billable and reliably reimbursed.

The surgeon refers a patient at risk for sleep apnea to Ion for screening when scheduling the surgery. We like to try to screen the patients the day they’re posted, either in the surgeon’s office, at the ASC, or wherever it’s been determined it makes the most sense to locate the screening kiosk, which is
proprietary and fully HIPAA-compliant. It’s a touch-screen interface with wireless Internet, integrated printer and card reader.

Basically, the patient walks up to the kiosk and answers the apnea screening questions. If the screening shows high risk of OSA, we provide them with a home test that can be completed that night. The test we use is FDA-approved and published studies have found it to be as reliable and accurate as a PSG test conducted at a sleep lab. If the SNAP test reveals sleep apnea, Ion provides treatment options and helps the patient start managing the condition before the day of surgery.

Literally, then, within 24 to 48 hours of the surgery’s being scheduled, we can have patients screened,
diagnosed and treatment initiated. This gives the ASC staff advance notice so it can plan precautions and care for the patient. The national average for compliance with treatment for sleep apnea is around 50 percent; ours is around 80 percent. We involve patients early in a patient-friendly process, and engage them in more aftercare programs from day one, with compliance being our primary mission.

We also supply post-op care equipment to the surgery center so that, in case the patient forgets his CPAP, it’s on hand and the case doesn’t have to be cancelled. We in-service the ASC staff so they can feel comfortable with apnea patients and apply that in the recovery room.

SW: What are the ancillary benefits, outside patient care?

SB: You can include the surgery center’s pre-screening questions with the apnea screening, which reduces some of the burden on your nurses. The average ASC grabs a nurse between cases to make screening calls 24 to 48 hours pre-op — this lets you turn those screening calls into a nursing interview that is a clarification on points and a follow-up, so you can achieve a better screening rate. Instead of going through the whole patient history, you can drill in on the key points and make a 15-minute phone call five minutes. If you do that across 20 or 30 percent of patients, that’s a great time savings, and you can reallocate those nurses to patient care. Some claim that’s the best benefit of our program.

Insurance companies like you to find apnea; that goes a long way with them. You won’t drop your liability rates, but you do become a better coverage risk — by having a quality program like this in place, you’ll find yourself as more insurable.

We run this program as a true quality program with metrics that give you the ability to assess yourself. Quality reports are generated monthly, so you can measure outcomes and compliance and report those data to insurance carriers.

The Joint Commission last year floated the idea that any patient who undergoing surgery with anesthesia or analgesia in a Joint Commission-accredited facility would have to undergo sleep apnea screening. A lot of people felt they weren’t yet prepared to deal with that, and the Joint Commission backed off, but once it’s been out on the table, you know it’s coming. And ASCs will eventually be affected, too — you may as well lead the way and derive the benefits.

SW: Is there an economic benefit to the ASC as well?

SB: You can run this strictly as a quality program that Ion provides at no charge, but you can also derive economic benefits: The ASC and Ion form a joint-venture partnership and establish a new entity that performs the quality program; the surgical center partners can then participate in the revenues that are generated from the program The JV partnership lets ASCs enjoy a recurring revenue stream from their patient base without splitting inside resources. One and done is the traditional patient at a surgery center; the ASC then leaves the patient’s life forever. By screening for apnea at the facility, 10 percent of patients, the apnea patients, could become patients for life.

We bring the people, equipment and clinical process, and execute, manage and build it. The ASC gets a quality program, plus the economic benefit of participating in disease management for its patients. It’s a growing base of patients; the chance they would return to the ASC facility for their next surgical procedure is high. The local physician market is also more likely to support the ASCs that are seen as out front supporting quality.  From that perspective, it’s a high return on investment.

Dr. Burton is the founder of Ion Healthcare and a diplomate of the American Board of Sleep Medicine.

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