V.A. policy on sleep studies? Other ways to detect apnea?
Question:
On Thu, 03 Mar 2005 13:28:12 -0500, Tom Devlin <tomdev…@ameritech.net> wrote: >Well sure, this sort of thing is a moving target. Kate, who had a >thoroughly botched UPPP, seems to be doing fine with an AutoSet >Spirit. >But I’m still going to obstinately continue to suggest that people >who’ve had a UPPP might not be the best candidates for AutoPAPs.
That could well be true, but considering that one of the bad outcomes of UPPP is tissue damage in certain locations, I suspect that problems could happen with any form of xPAP. >We >can argue about the reasons, you seem to have your own theories, but I >simply can’t ignore the fact that a night in the sleep lab would be a >good idea for anyone who doesn’t seem to be getting the expected >results from an AutoPAP. Especially if they’ve had a UPPP.
I don’t disagree with the concept of getting another study done, but I don’t necessarily think that one can jump to the conclusion of blaming the type of equipment >And I’m going to continue to mention snoring until I find something >better to blame this on. Feel free to continue to correct me. <g> >Tom
– .andy To email, substitute .nospam with .gl
Response:
"Tiger Lily" <m…@privacy.com> wrote: >> I would, especially if it’s been a while since your last titration. My >> pressure’s gone up about 1Cm/year. >interesting…….. i have to say the same thing as well……. that’s why >i’m so thrilled with my AutoPAP………… it makes the changes for me
I’m doing my own adjusting. My DeVilbiss 9001D lets you go in .5Cm steps, it’s nice for fine tuning. >occassionally the setting drops back down to the first Rx’d level, but that >doesn’t stay for very long………
That might be due to body position or depth of sleep, it would be interesting to try to figure out which (if either). Tom
Response:
Andy Hall <an…@hall.nospam> wrote: >>That may be cause and effect. A UPPP eliminates snoring, a major >>trigger for any AutoPAP. >It’s one of the triggers, and in the past a significant one on some >early autotitrating machines.
There used to be a well-conected poster on sleepnet named Perry, he was a "tough case" for AutoPAPs and manufacturers used to send him equipment to test. He said that, once you got past all the "patent language", snoring was still the primary trigger for most AutoPAPs. IIRC, He also said the unit most likely to work for people who’d had a UPPP was the DeVilbviss AutoAdjust LT. According to someone here, Joe Guilford (the cpapman), said that Respironics had hired the fellow who’d developed that machine to design the REMstar Auto, that could very well explain Quick’s findings. >On the newer ones, and as algorithms have been updated, the major >sensing is based on flow limitation detected from the change in shape >of the flow/pressure curve over a period of time.
Well sure, this sort of thing is a moving target. Kate, who had a thoroughly botched UPPP, seems to be doing fine with an AutoSet Spirit. But I’m still going to obstinately continue to suggest that people who’ve had a UPPP might not be the best candidates for AutoPAPs. We can argue about the reasons, you seem to have your own theories, but I simply can’t ignore the fact that a night in the sleep lab would be a good idea for anyone who doesn’t seem to be getting the expected results from an AutoPAP. Especially if they’ve had a UPPP. And I’m going to continue to mention snoring until I find something better to blame this on. Feel free to continue to correct me. <g> Tom
Response:
>Dan: >I’m a bit confused by your closing statement. First, Norm basically said >Andy was incorrect in his comments because of his generalizations. You >sternly took Norm to task for that. Now you say "it is not possible to >generalise." You can’t have it both ways.
No, this is another case of people reading what they wanted to read rather that what was actually said. I was very careful not to make generalisations but to point out there are geographical differences in diagnosis and treatment for reasons that are clinical, fashionable, economic and so on. The important things are the rates of effective diagnosis and outcomes of treatment. >You are also wrong in your generalization about BiPAP being described only >for OSA patients who also have cardiac or respiratory problems. Despite your >"contacts with six CPAP companies you are incorrect. I was prescribed BiPAP >treatment and I do not have cardiac or respiratory problems.
Yes and that’s fine. It’s common practice in the U.S. The point being made that this is not considered to be a medically necessary reason in many countries in Europe. Equally, you might argue that use of autotitrating equipment is not considered medically appropriate in certain healthcare environments in the U.S. Nobody has an issue with that. THe point is that treatment approaches do vary and there are lots of factors involved. As far as I am aware, Americans are not genetically different to Europeans, so there is no basis to assume that different regimes are more or less appropriate either way. They are simply different. >You and Andy >may be informed on OSA treatment in the UK and Ireland. But that >"expertise" does not extend to OSA therapy in the U.S.
Nobody has discussed this in terms of expertise at all. The point has simply been that there are different methods of treatment and diagnosis in use in different parts of the world and that clinical and other arguments can be made for all of them. — .andy To email, substitute .nospam with .gl
Response:
On Tue, 01 Mar 2005 12:06:36 GMT, normc <no…@socal.rr.com> wrote: >> It’s amazing how attitudes differ. >Sometimes one’s attitude results from the availability, or >lack thereof, of appropriate medical services.
Of course, and that was part of my point. – Hide quoted text — Show quoted text ->> I was talking to my specialist recently about this as well as reading >> the clinical guidelines that are supposed to be operated in the public >> sector. I also found an insurance company guideline (IIRC from >> Cigna?) >> It appears that generally the first option both here in the UK, and >> from what I see, the U.S. is to go for a single fixed pressure >> machine. Cost appears to be a big factor in that whether it be the >> government or the insurance company paying, they want the cheapest. >Your statement here is incomplete and, as a result, very >misleading. You make it sound like the cheapest equipment >is provided, without regard to its medical appropriateness. > That just isn’t so in the US, except for HMOs.
No, I haven’t made misleading statements at all. I did look at the policies of some insurance companies in the U.S. for some of the comments, but I haven’t suggested that this becomes a policy thing for all cases. I’m certainly aware that HMOs look on a cost basis, so in that sense may be looking for economies that don’t offer thje clinically best options. My point was that cost is a big issue wherever you are and with whatever scheme. It may be that the higher tier insurance companies appear to offer things without regard to cost, but ultimately nobody is writing bland cheques and it would be naive to assume that they are. I don’t think that we fundamentally disagree here, I am simply making the point that no medical care is given without some regard to cost. it may be buried, but it’s certainly there. >Medicare and insurance companies will pay for what is >medically required. Since an autopap is not usually >medically required, they won’t normally pay for it.
That is not a valid assumption at all. You describe the flow chart of certain clinical practise in parts of the U.S. In Europe it is quite common to prescribe autotitrating equipment as the next step if fixed pressure equipment causes the user problems of compliance. In that sense it is a medical choice and would be funded by public healthcare. I am well aware that the common view in the U.S is different, but that does not mean that one can make a sweeping statement that a given treatment technique is not medically necessary. The furthest that you can go is to say that it is typically not deemed medically necessary in a certain geography. >> Here in the UK in the public sector, the second step, if the patient >> has compliance difficulties but not any respiratory problems beyond >> OSA, an autotitrating machine is used. >This is an interesting qualification…. no respiratory >problems. Are you saying that some sort of respiratory >problems would keep you from using apap? If so, why?
No, it’s the opposite way around. Patients can have compliance issues if they have a single high fixed pressure set in an attempt to eliminate apnoea and hypopnoea events in as many scenarios as possible. In reality, they may well not need the high level of pressure all the time at all and there is plenty of evidence to suggest that improved compliance can be achieved if a lower pressure is used for a greater proportion of the time. The qualifier about respiratory issues needs to be added because there can be instances where either fixed or autoitration equipment is not appropriate and the patient medically needs bilevel equipment. My point was that here at least, bilevel equipment is typically not prescribed if the only issue that the patient has is compliance difficulties with a fixed pressure machine run at high pressure. It might be used if the issue is related to another respiratory condition. >What kind of compliance problem does an autopap eliminate?
Already described. >> Private patients can opt for >> this at the outset, since they will be paying for the equipment >> anyway. The public sector doesn’t look beyond the end of its nose in >> terms of the saving that can be made through not requiring titration >> studies or as many followups; but purely at the equipment cost. >That model fits your view, but it doesn’t fit mine or many >others. If I am having a sleep related problem, I have no >expectation of being able to solve it with an apap machine. > Too many possible variables.
That’s really your issue. For many people, this is a good solution and is in wide use in other geographies. One of the points is that the technology can deal with some of the large number of variables. If you aren’t comfortable with that, then it’s no problem. Go with what works for you. >I have every expectation of a far better opportunity of >solving the problem with a PSG. And that’s why insurance >companies and Medicare in the US pay for PSGs. AAMOF, >Medicate requires a two night study. >But I’ll have to say, if I couldn’t get the best, I’d take >whatever I could get. >HMOs in the US are notorious for not providing adequate and >appropriate medical services, for many things, including >apnea. They are the ones that promote autopaps, in order to >increase their profits, or as you say, "..the savings that >can be made.." I don’t want any cost cutting. I want the best.
This is all fine and if you are able to get that kind of treatment, good luck. Ultimately somebody pays and that ends up being you and others. There are different approaches to diagnosis. For example, here the common practice in all sectors is to screen and diagnose SDBs first on the simple basis that they need treating anyway. Then if there are other issues, other tests including PSGs can be done. One of the points about this is that if a PSG is done with a severe apnoea patient and they are then treated for it, the sleep architecture and information from a PSG are going to change anyway, necessitating repeat of the test. It’s a matter of clinical opinion and methodology and the important thing is the outcome. There are certainly savings that can be made by using technology, but there is no basis for treating them as a second best approach when the outcome is the same. I don’t like cost cutting in medicine either, but I do look carefully at diagnostic and treatment methods. If there are methods to achieve the same outcome at lower cost or with less patient inconvenience, then it’s reasonable to consider them. >> In continental Europe, it is much more common to start with >> autotitrating equipment because there is a longer term view taken of >> the budget aspects and in any case such a machine can always be set to >> a fixed pressure. >Are we supposed to take your word for all the statements you >make without any support. For all I know, you may have a >vivid imagination, or just a great urge to get people to see >things your way.
It’s up to you. I don’t really care. If you would like clinical references, I will happily post them for you. I have no urge to persuade people to think one way or another. It doesn’t matter to me. I am simply poionting out that there are geographical variations in treatments and approaches to diagnosis and that one can’t really say that one is better than the other without looking at the outcome. >> Bilevel machines are quite rarely used here, and usually only when >> medically indicated, e.g. the patient has some additional respiratory >> disease, heart failure and so on; very rarely because of CPAP >> compliance issues due to pressure. >I won’t believe this without something other than your >casual statement. Exactly how does a bipap affect >respiratory disease, heart failure, and so on.
That’s up to you. I tend not to make casual statements unless I make it clear that that’s what it is. Take a look at http://www.sign.ac.uk/pdf/sign73.pdf sections 4.3.1 to 4.3.3 >> AIUI, and comment here, in the U.S. a bilevel machine is usually the >> second choice after fixed pressure even for compliance issues? >Indeed. At least you got that right.
I get many things right and can provide references as appropriate. The issue is one of having an open mind that there are different approaches to diagnosis and treatment and that part of this is based on standardised clinical practices which vary by geography/ — .andy To email, substitute .nospam with .gl
Response:
"normc" <com> wrote in message com… > Let’s see… how much did your apap cost you <g>? > Unfortunately they are pretty tough to get on Medicare or > other insurance here in the U.S. There has to be a medical > necessity/reason. TTBOMK, not having to make doctor and > clinic visits for further tests and machine adjustments > don’t quality for these requirements. So you mostly have to > pay for them yourself, which I certainly can’t afford. > I suppose if you live in the boonies, doctor and clinic > visits could be a problem, but it sure isn’t a problem for me.
you get sleep studies done!!! it takes me 2 years as a non-urgent to get a sleep study done….. and once they have done ONE sleep study………… well, good luck on getting another sleep study………. i did go back to the sleep Dr for a referral for a sleep study then there was my insurance….. they wouldn’t pay for a mask and hose but they would pay for a complete XPAP up to $2,000 i got the AutoPAP with 2 masks for $2,180 …………. looks like the DME supplier knows how to play the game too……….. sigh……… at least it was paid for…… i won’t go back though…… i will stick with it and pay the extra that is needed to have it…………… kate
Response:
"h.sanders" <h.sand…@comcast.net> wrote in message
news:Qc-dnZt5Aav8ILnfRVn-3A@comcast.com… – Hide quoted text — Show quoted text -> "D. Smyth" <dannospa…@eircom.net> wrote in message > news:d02d7k$4l0$1@reader01.news.esat.net… >> (SNIP) >> I may be able to help here. Although in Ireland I am somewhat familiar > with >> what happens in the UK. >> >> It’s amazing how attitudes differ. >> > Sometimes one’s attitude results from the availability, or lack >> > thereof, >> > of appropriate medical services. >> >> I was talking to my specialist recently about this as well as reading >> >> the clinical guidelines that are supposed to be operated in the public >> >> sector. I also found an insurance company guideline (IIRC from >> >> Cigna?) >> >> It appears that generally the first option both here in the UK, and >> >> from what I see, the U.S. is to go for a single fixed pressure >> >> machine. Cost appears to be a big factor in that whether it be the >> >> government or the insurance company paying, they want the cheapest. >> > Your statement here is incomplete and, as a result, very misleading. > You >> > make it sound like the cheapest equipment is provided, without regard >> > to >> > its medical appropriateness. That just isn’t so in the US, except for >> > HMOs. >> Must agree with Andy here. First choice for a public patient in either >> the >> UK or Ireland is a fixed pressure machine. Absolutelt no doubt about >> that. >> > Medicare and insurance companies will pay for what is medically > required. >> > Since an autopap is not usually medically required, they won’t normally >> > pay for it. >> >> Here in the UK in the public sector, the second step, if the patient >> >> has compliance difficulties but not any respiratory problems beyond >> >> OSA, an autotitrating machine is used. >> > This is an interesting qualification…. no respiratory problems. Are > you >> > saying that some sort of respiratory problems would keep you from using >> > apap? If so, why? >> Problems such as COPD or similar, heart failure etc will stop a patient >> using a fixed pressure machine. They will be unable to exhale against the >> fixed pressure. There can also be problems with the force of a fixed >> pressure machine, relating directly to their condition. >> > What kind of compliance problem does an autopap eliminate? >> As above. Also with patient requiring high pressure. >> >> Private patients can opt for >> >> this at the outset, since they will be paying for the equipment >> >> anyway. The public sector doesn’t look beyond the end of its nose in >> >> terms of the saving that can be made through not requiring titration >> >> studies or as many followups; but purely at the equipment cost. >> > That model fits your view, but it doesn’t fit mine or many others. If >> > I >> > am having a sleep related problem, I have no expectation of being able > to >> > solve it with an apap machine. Too many possible variables. >> I am also one of many who can solve my OSA problem with a fixed pressure >> machine., >> > I have every expectation of a far better opportunity of solving the >> > problem with a PSG. And that’s why insurance companies and Medicare in >> > the US pay for PSGs. AAMOF, Medicate requires a two night study. >> > But I’ll have to say, if I couldn’t get the best, I’d take whatever I >> > could get. >> The introduction of auto titrating machines is having a major effect on >> hopital stay times on this side of the pond. It’s really a case of using >> technology to minimise hospital stays. >> > HMOs in the US are notorious for not providing adequate and appropriate >> > medical services, for many things, including apnea. They are the ones >> > that promote autopaps, in order to increase their profits, or as you > say, >> > "..the savings that can be made.." I don’t want any cost cutting. I > want >> > the best. >> What is the best ? A recent study reported on the NAPS site showed that >> three forms of titration, the traditional overnight hospital stay (with >> monitoring etc), the use of a formula (in the past used by technicians, > with >> data from the original sleep study) and an autotitrating machine used in > the >> patients home produced, pretty much, the same result. >> >> In continental Europe, it is much more common to start with >> >> autotitrating equipment because there is a longer term view taken of >> >> the budget aspects and in any case such a machine can always be set to >> >> a fixed pressure. >> > Are we supposed to take your word for all the statements you make > without >> > any support. For all I know, you may have a vivid imagination, or just > a >> > great urge to get people to see things your way. >> Again, I side with Andy. Figures from Belgium (2001) indicate a 2 month > wait >> from referral to commencement of treatment for OSA. This compares to >> anything up to 3 years in the UK, and up to 2 years in Ireland. The > Belgians >> use auto titrating machines in the main, usually in the patients home for >> titration purposes. >> >> Bilevel machines are quite rarely used here, and usually only when >> >> medically indicated, e.g. the patient has some additional respiratory >> >> disease, heart failure and so on; very rarely because of CPAP >> >> compliance issues due to pressure. >> > I won’t believe this without something other than your casual >> > statement. >> > Exactly how does a bipap affect respiratory disease, heart failure, and > so >> > on. >> Not a casual statement by any means. I am in regular contact with 6 >> different CPAP companies. Bi Level PAP comes under the heading of non >> invasive ventillation (rather than OSA PAP). The companies (all of them) >> tell me that Bi Level PAP is only prescribed for patients with other >> respiratory or cardiac problems in addition yo OSA. My own sleep > specialist >> also confirmed this. >> >> AIUI, and comment here, in the U.S. a bilevel machine is usually the >> >> second choice after fixed pressure even for compliance issues? >> In Ireland auto titrating machines are the second choice for compliance >> issues. Bi Level is not prescribed for OSA alone. >> > Indeed. At least you got that right. >> I think he got pretty much everything right. >> In the UK, the National Health Trust (for public patients) grant an >> amount >> of funds to each sleep clinic on an annual basis. This is to cover >> running >> costs, also the cost of purchasing all PAP machines, masks, filters, >> hoses >> etc. They are then responsible for ‘maintaining’ their existing and new >> patients, not the CPAP company. The ongoing maintenence cost can knock a > big >> hole in any new funding received, so a clinic that is very efficient and >> treats a lot of patients is actually penalised by ’short funding’. Not a >> very fair system, which is why the clinics look for ‘value’ when > purchasing >> machines. There are many cases of patients being diagnosed with OSA, >> being >> titrated, and then being told to come back in 6 months time when the > clinic >> hope to have machines available. There are also cases of non compliant >> patients having their CPAP machine taken back by the clinic, >> reconditioned >> and given to a new patient. >> In Ireland, whether you are a public or private patient you must either >> purchase or rent your machine. One exception are patients who hold >> Medical >> Cards which come under 2 categories. Those who have low incomes (and I > mean >> low) and those over 70 years of age. In these cases the Health Services >> Executive pick up the tab for whatever machine is prescribed, also all >> maintenence costs (the CPAP companies handle the paperwork on behalf of > the >> patient). For everyone else the choice is to purchase or rent. In the >> case >> of rental, the cost (or part of it) can be recouped from the state. If > your >> medical (drugs etc) plus CPAP rental exceeds ?85 ($96 or
