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

描述（由申请人提供）：再次住院对患者来说可能是毁灭性的，并给卫生保健系统带来重大的经济负担。2013年，最近实施的医疗保险医院再入院减少计划对2225家医院施加了2.27亿美元的罚款。医疗保险一直关注心力衰竭的诊断，因为它是最常见的入院原因之一，也是所有医疗诊断中再次入院率最高的。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%的心力衰竭患者都有这种症状。此外，宾夕法尼亚大学睡眠中心收集的初步研究表明，气道正压通气（PAP）治疗睡眠呼吸暂停可显著降低再入院率。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坚持PAP治疗而再次入院的风险增加。在AirCareLabs系统中可以找到解决医院面临的这一主要问题的潜在解决方案。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，在出院期间迅速启动，并在家中继续。研究小组建议修改该系统，通过脉搏血氧仪和PAP依从性的无线实时监测，以及额外的教育内容，对睡眠呼吸暂停患者进行有针对性的护理，以显着降低开始PAP治疗的心力衰竭患者出院后第一个月的再入院率。关键的创新包括患者能够在家中接受夜间PAP辅助(值得注意的是，患者目前无法使用)，以及一种财务模式，在这种模式下，应用程序的成本由卫生系统承担，因为它试图避免医疗保险的处罚，从而绕过了限制睡眠呼吸暂停领域创新的按服务收费的有限方式。拟议的项目包括第一阶段的组成部分，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，开发患者通过AirCareLab系统在家访问的教育材料，以及20名研究参与者的试点临床研究。II期部分包括进一步完善血氧仪数据，并与PAP设备数据整合，以创建解释性风险分类算法，以及一项包含240名受试者的大型随机对照试验，以确认疗效。如果成功，这个项目将创建一个新的可扩展模式，可以大大降低心力衰竭的再入院率。

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.