Reducing heart failure re-admissions by enhancing sleep apnea treatment adherence

描述(由申请人提供)：重新入院对患者来说可能是毁灭性的，并为医疗保健系统带来巨大的经济负担。2013年，最近实施的联邦医疗保险医院再入院减少计划对2225家医院处以2.27亿美元的罚款。医疗保险一直专注于心力衰竭的诊断，因为它是最常见的入院原因之一，并且是所有医疗诊断中再入院率最高的。越来越多的研究表明，睡眠呼吸暂停是心力衰竭再次入院的主要预测因素；50%-80%的心力衰竭患者存在睡眠呼吸暂停。此外，宾夕法尼亚大学睡眠中心收集的初步研究表明，睡眠呼吸暂停的正压(PAP)治疗与显著降低再入院率有关。然而，使用PAP治疗睡眠呼吸暂停的依从性很差，只有30%-40%的患者有足够的使用时间。这一发现使研究人员得出结论，最近出院的心力衰竭患者由于不遵守PAP，再次入院的风险增加。医院面临的这个主要问题的潜在解决方案可以在AirCareLabs系统中找到。它提供了一种综合护理方法，包括远程医疗和视频会议功能，通过基于平板电脑的通信提供，在出院期间迅速启动并在家中继续。研究小组建议修改这一系统，通过无线实时监测脉搏血氧饱和度和PAP依从性，以及额外的教育内容，以显著降低开始PAP治疗的心力衰竭患者出院后第一个月的再住院率。关键创新包括患者能够在家中接受夜间PAP帮助(值得注意的是，目前患者无法获得)，以及一种财务模式，在这种模式下，应用的成本由医疗系统支付，因为它试图避免联邦医疗保险处罚，从而绕过限制睡眠呼吸暂停领域创新的有限的按服务收费的方法。拟议的项目包括第一阶段内容，包括修改AirCareLab系统以整合无线脉搏血氧仪数据、结构化访谈以确定解决患者护理问题的最佳治疗方法、开发供患者在家中通过AirCareLab系统获取的教育材料，以及在20名研究参与者中进行试点临床研究。第二阶段包括进一步提炼血氧仪数据并与PAP设备数据整合以创建解释性风险分类算法，以及对240名受试者进行大型随机对照试验以确认疗效。如果成功，该项目将创建一种新的可扩展模型，可以大幅降低心力衰竭的再次住院率。

DESCRIPTION (provided by applicant): Hospital re-admission can be devastating for patients and carries significant financial burdens for health care systems. In 2013, the recently implemented Medicare Hospital Readmissions Reduction Program imposed $227 million in penalties on 2,225 hospitals. Medicare has focused on heart failure diagnoses because it is one of the most common causes of admission and has the highest re-admission rate of any medical diagnosis. A growing body of research suggests that sleep apnea is a major predictor of heart failure re-admission; it is present in 50-80 percent of heart failure patients. Furthermore, preliminary research gathered by the University of Pennsylvania Sleep Center suggests that positive airway pressure (PAP) treatment of sleep apnea is associated with significantly reduced re-admission rates. However, adherence to sleep apnea treatment with PAP is poor, with only 30-40 percent of patients having adequate hours of use. This finding has led the study investigators to conclude that patients with heart failure recently discharged from the hospital are at increased risk of re-admission due to non-adherence with PAP. A potential solution for this major problem facing hospitals can be found in the AirCareLabs system. It offers an integrated care approach that includes telemedicine with video conferencing features delivered via tablet based communication that is initiated promptly in the peri-discharge period and continued at home. The study team proposes modifying this system for targeted care of sleep apnea patients through wireless real-time monitoring of pulse oximetry and PAP adherence, along with additional educational content, in order to significantly reduce readmission rates during the first month post discharge for patients with heart failure that are starting PAP therapy Key innovations include the ability for patients to receive at-home, night-time assistance with their PAP (remarkably, this is currently unavailable to patients), and a financial model in which costs for the application are covered by the health system as it seeks to avoid Medicare penalties, thus bypassing the limited fee-for-service approach that has curtailed innovation in the sleep apnea field. The proposed project includes a Phase I component that consists of modifying the AirCareLab system to integrate wireless pulse oximetry data, structured interviews to identify the optimal treatment approach to resolve patient care concerns, development of educational material for patients to access at home via the AirCareLab system, and a pilot clinical study in 20 study participants. The Phase II component includes further refining the oximetry data and integrating with PAP device data to create interpretive risk classification algorithms, and a large randomized controlled trial of 240 subjects to confirm efficacy. If successful, this project will create a new scalable model which can substantially reduce hospital readmission rates for heart failure.