The Cost-Effectiveness of Telehealth versus In-Person PAP Set-Up for Patients with Sleep Apnea

Introduction: Telehealth has been widely integrated into healthcare systems during the COVID-19 pandemic and is here to stay. At the Greater Los Angeles VA Healthcare System (GLA-VAHS), for patients newly diagnosed with sleep apnea pre-pandemic, the majority of initial positive airway pressure (PAP) set-ups and education was done in person. During the pandemic, this process was transitioned to telehealth using video/phone and PAP machines were mailed out to patients. The cost effectiveness of telehealth integration has not been well characterized. As part of a larger study examining the overall efficacy of telehealth versus in-person PAP set-up, we performed a cost analysis of these two modalities at the GLA-VAHS. Methods: We performed a cost analysis of telehealth versus in-person set-up of PAP for patients newly diagnosed with sleep apnea at GLAVAHS between March and October 2021 (n = 2,662 PAP set-ups). There was an average of 16 PAP set-ups per day with 11 set-ups (68.75%) via telehealth and 5 set-ups (31.25%) in person. We used a bottom-up analysis which includes only variable direct costs and factors out the high costs of healthcare infrastructure. Results: At GLA-VAHS, the cost of telehealth PAP set-up was $98.87 per patient and in-person PAP set-up was $49.85 per patient. For telehealth set-ups, there was an additional cost of mailing the PAP machine and more respiratory therapist (RT) time spent on educating patients compared to in-person set-ups (31.2% more RT time). After initial PAP set-up, a larger subset of patients required additional troubleshooting help from RTs about proper PAP use after telehealth compared to in-person set-ups (5% versus 1%). Conclusion: Telehealth PAP setups were nearly two times the cost of in-person PAP set-ups at GLA-VAHS due to the cost of mailing the PAP machine, more RT time spent on education, and a higher rate of troubleshooting. While the costs of telehealth implementation is one factor, one must also consider the benefits of telehealth including ability to capture more patients and higher patient satisfaction which may outweigh these costs. There are opportunities for institutions to alleviate bottlenecks with telehealth use such as supplemental educational materials about PAP use ahead of set-ups or scripting RT and patient dialogue when familiarizing patients with a PAP machine. In addition, as providers and patients become more familiar with interfacing with telehealth, efficiency with use of these systems is likely to improve and reduce costs in the long run.

SLEEPY IN THE MOUNTAINS

Introduction: Central sleep apnea (CSA) is a rare disorder caused by a reduction of airflow and ventilatory effort during sleep. CSA is rarely idiopathic and associated with medical conditions including heart failure, opioid medications, treatment emergent and high-altitude periodic breathing. At higher altitudes, hypoxemia induces periodic breathing with periods of deep and rapid breathing alternating with central apnea. Patients with high-altitude periodic breathing experience fragmented sleep, poor sleep quality, excessive daytime sleepiness, morning headaches and witnessed apnea. We discuss a patient with obstructive sleep apnea (OSA) who developed new-onset central sleep apnea after relocating to a higher altitude location. Report of Cases: A 75-year-old male with a history of moderate obstructive sleep apnea well controlled on CPAP for eight years, with no known cardiovascular or pulmonary disease, presented with new-onset excessive daytime sleepiness. He had recently relocated to an area in the Colorado mountains (7000 ft elevation) from his previous home in Los Angeles (sea level). His residual apneahypopnea index (r-AHI) displayed on his CPAP machine increased to 7-14/ hr from his normal of 1-2/hr after his relocation. Review of his compliance data revealed his central apnea index was elevated, contributing to his high r-AHI. A one-night nocturnal oximeter was mailed to the patient to use while on CPAP. Data revealed oxygen desaturation to less than 88% for about 2 hours of the night, worse during the early morning hours. The patient was advised to undergo a polysomnography and adaptive servo-ventilation titration if significant central sleep apnea was present. The patient declined due to concern about the COVID-19 pandemic. Supplemental nocturnal oxygen was initiated at 2L/min with normalization of the r-AHI. Conclusion: Patients with OSA who experience worsening symptoms or increased r-AHI despite excellent compliance with PAP therapy should be considered for repeat polysomnography or titration study. While it is expected that high-altitude central sleep apnea will improve with acclimatization, nocturnal supplemental oxygen in addition to PAP therapy is indicated for patients with high-altitude central sleep apnea to diminish hypoxemia and improve residual AHI and sleep quality.

THE COST OF IN-PERSON VERSUS TELEHEALTH PAP INITIATION FOR PATIENTS WITH SLEEP APNEA

Introduction: Telehealth has been widely integrated into healthcare systems during the COVID-19 pandemic and is likely to remain a part of routine clinical care. At the VA Greater Los Angeles Healthcare System (VAGLAHS), positive airway pressure (PAP) set-up visits transitioned from in person to telehealth for newly diagnosed sleep apnea patients during the pandemic. The telehealth pathway included mailing of PAP machines to patients with follow-up video/phone education by respiratory therapists (RTs). As part of a larger study examining the clinical outcomes resulting from telehealth versus in-person PAP initiation, we performed a cost analysis of these two treatment pathways within VAGLAHS. Methods: We examined the total variable direct cost of telehealth versus in-person PAP initiation for patients newly diagnosed with sleep apnea at VAGLAHS between March and October 2021 (n = 2,662 PAP set-ups) using a bottom-up analysis. There was an average of 16 PAP set-ups per day with 11 set-ups (68.7%) via telehealth and 5 set-ups (31.3%) in person. Results: The total variable direct cost of telehealth PAP initiation was $98.87 per patient. The total variable direct cost of in-person PAP initiation was $50.58 per patient. For telehealth, there was an additional cost of mailing the PAP machine and 31.2% more RT time spent on educating patients compared to the in-person pathway. After the initial PAP set-up visit, a larger subset of patients required additional troubleshooting help from RTs about proper PAP use after telehealth compared to in-person set-ups (5% versus 1%). Conclusion: The telehealth PAP initiation pathway was nearly two times the cost of in-person PAP initiation. This resulted from the additional cost of mailing the PAP machine, more RT time spent on education, and a greater need for troubleshooting after the visit. Telehealth visits may need to be supplemented by written educational materials or web-based resources to reduce the need for additional support after the initial visit.

THE IMPACT OF THE COVID-19 EPIDEMIC ON THE NUMBER OF VISITORS IN SELECTED PROTECTED AREAS IN THE CZECH REPUBLIC

Visitor monitoring has been taking place in many protected areas of the Czech Republic for many years. This provides nature conservationists with knowledge about the impact of visitors on the objects of protection of these areas. The 2020 COVID-19 epidemic and related government measures disrupted current long-term attendance trends in many localities. Based on several case studies, the text illustrates how the epidemic and the measures taken specifically affected the number of visitors to Czech protected areas. © 2022 Public Recreation and Landscape Protection - With Environment Hand in Hand? Proceedings of the 13th Conference. All rights reserved.