Sleep Diagnosis and Therapy

Official Publication of the American Sleep and Breathing Academy

Cost Effectiveness of CPAP Therapy for the Patients with Obstructive Sleep Apnea

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Obstructive Sleep apneas is a common disorder characterized by recurrent collapse of the upper airway during sleep and is associated with an increased risk of motor vehicle crashes., and other problems. Most common treatment for OSA is CPAP therapy even though dental appliance can be a useful adjunct. But CPAP therapy is expensive and needs to be used possibly for life time. But is it cost effective as a whole for the general population?

1. Direct Cost of the Sleep Studies:

Direct cost effectiveness of the cpap therapy vs HST followed by Autopap therapy. Medicare Payment: 2014 shows the following: SG study (95810) was 618.08 dollars, while the cost of CPAP
Titration study (95811) was 648.38 dollars. And the total cost of the sleep study for one patient was 1266.46 dollars. In contrast, HST (2012) cost from Medicare was 183.80 dollars. With a saving
of 1082.66 per patient studied. In addition there are direct health care cost form the associated conditons . eg, cardiovascular disease, diabetes, depression, work-related injuries and motor vehicle crashes. While the direct costs of all this is not available in USA there are studies which are available form the studies done in Australia(A)

2. Indirect Costs:

We have to calculate the indirect savings for the specific treatment. As we know from the earlier model that OSA causes increased motor vehicle crashes. Using Markov model the costs and quality of life gained can be calculated accounting for the gains from the reduced motor vehicle crashes (MVC). When quality of life, costs of therapy and MVC outcome are considered CPAP therapy for patients with OSA is economically attractive. The treatment of CPAP reduced MVC by a factor of approximately 7 (odds ratio of MVC with CPAP compared to no CPAP.0.15 (C.I 0.10-0.22) from the meta analysis study1

The other indirect costs related to sleep apnea include: Work related injuries, including production disturbance, legal investigation, human capital, travel, and funerals. Also we should
include costs related to motor vehicle crashes: long term care, work force/labor disruption, quality of life., legal costs, repairs, towing, travel delays, administration , police and property damage.2

Health Care Utilization:

Untreated OSA leads to multiple medical problems such as hypertension, cardiovascular disease, injuries, and mood disorders that potentially increase medical care utilization. Kapur3 evaluated 238 adult patients with OSA who were members of HMO matched to 476 control subjects. They compared the direct cost of patients with and without sleep apnea during and prior to the diagnosis. Mean medical costs of patients with OSA were signifi cantly greater ($ 2720) than those of matched controls ($1384).

Also remember the treatment of OSA with CPAP also produces signifi cant cardiovascular and metabolic benefi ts. In one study it showed that treatment may reduce cardiovascular and pulmonary disease costs by $ 2800 per year.4

In addition the cost effectiveness of the cpap has been compared to dental devices and life style advice for adults. On average, CPAP was associated with higher cost and Quality –adjusted life-year (QALY) compared to dental devices or life style . In the case base case analysis the incremental cost effectiveness of ratio (ICER) for CPAP compared to dental devices was around
4,000 pounds per QALY (2005-06 prices). The probability that CPAP is more cost effective than
dental devices or life style advice at a threshold value of 20,000 pounds per QALY was 0.78 for
men and 0.80 for women. Sensitivity analysis shows that ICER for CPAP consistently fell below
20,00 pounds per QALY gained. The model suggested that CPAP is more effective compared to dental devices and life style advice for adults with moderate or sever symptomatic OSAHS and is reflected in NICE guidelines.5

Health Care Utilization:

Cost effectiveness is usually assessed by the incremental cost effectiveness ratio (ICER).,which is the ratio of incremental cost and incremental change in quality adjusted life years (QALY) that follows from the adoption of a treatment (CPAP Vs No CPAP). In general ICER of $ 50,000.00 per
QALY is considered to be cost effective.

But what is the impact of cpap treatment on financial health of the nation?. This also has been addressed in NHS study. Markov model was constructed to assess the cost effectiveness of the CPAP compared with no treatment. The model depicted 55 years old patient with severe OSAHS as defi ned by AHI > 30/hour and Epsworth Sleepiness scale of >12 for a period of 14 years. NICE considers that a technology that has a cost effectiveness of < 20,000.00 pounds per QALY potentially affords an effective use of NHS resources. The use of CPAP over 14 years is therefore expected to afford the NHS a cost effective technology since, after 2 years of treatment with CPAP, the cost per QALY gained is < 10,000 and after 13 years CPAP becomes dominant.6 Treatment of OSAS reversed the trend of increasing health care utilization seen prior to diagnosis. Preexisting ischemic heart disease results in a negative impact on health care utilization. CPAP results in long term health benefit, as measured by the use of health care services.7

The CPAP is also cost effective in american context where they used Markov model and found that ICER of CPAP was found to be 3354 dollars per QALY.7

CPAP compares very favorably with many medical treatments; Use of cholesterol lowering medications in the primary prevention of cardiovascular events -$ 54,000-,400,000 /QALY
gained : Biologic agents in the treatment of rheumatoid arthritis-$ 30,500/QALY.8

Recent Developments:

In the last few years due to the exponential growth of sleep related medical expenses the
insurance companies have started giving hassles to the physicians to get pre authorization to conduct sleep studies and cpap therapy. However, most of the health Insurances do cover home sleep
testing and do not need pre-authorization which is good for initial screening. While it is their goal to make profi t for their shareholders, the goal of physicians should be to be the patient advocate. In the long run the medical expense for the sleep related testing and treatment is cost effective and should not be denied or postponed in the name of “ Un – necessary test” or “ pre authorization –required” by the health insurers.9 Regulatory authorities should take note of cost effectiveness of CPAP therapy and ensure that the health insurers do comply sleep services as covered services. And also when the patients continue to have symptoms like excessive drowsiness, or fatigue, it is right thing to do CPAP re –titration of the patient in the Laboratory even though many Insurance companies routinely reject for the Authorization process to control the costs and increase the revenue for the shareholders and the executive’s . This has to be watched by the Professional society‘s like AASM or ACCP.

As for patients, not to mention sleep labs, the importance of quality cannot be overemphasized. “You might never know that a sleep study has been incorrectly scored–until it’s too late, until a patient realizes they’ve been misdiagnosed,” Morin emphasizes. She says that quality scoring should never be rushed or timed against a stopwatch.”Rushing this process sends the message that costefficiency is more important than patient care,” she explains. “This is definitely not the message anyone wants to send.” Employing a reputable and industry-recognized scoring service is not only an excellent way to ensure the efficient scoring of data, but also a way to gain access to experts, thus decreasing time and increasing efficiencies. And this, says Morin, means the needs of patients are being recognized, met and respected.

 

References

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    166(9): 977–984
  2. Hillman DR,Murphy AS, Antic R, Pezzullo L: 2006. The economic cost of sleep disorders. Sleep 29(3): 299–305
  3. Kapur V, Blough DK, Sandblom RE, Hert R, de Maine JB, Sullivan SD, Psaty BM. (1999). The medical cost of undiagnosed sleep apnea. Sleep 22 (6) 749–755
  4. Peker Y, Hedner J, Johansson A, Bende. Reduced hospitalization with cardiovascular and pulmonary disease in obstructive sleep apnea patients on nasal CPAP treatment. Sleep 1997 Aug; 20 (8); 645–653
  5. Weatherly HL, Griffi n SC, Mc Daid C, et al: An economic analysis of continuous positive airway pressure for the treatment of obstructive sleep apnea hypopnea syndrome.
    Int J Technol Asses Health Care 2009 Jan 25(1) 26–34.
  6. Guest JF, Helter MT, Morga A and Stradling JR: Cost effectiveness of using continuous positive airway pressure on the treatment of severe obstructive sleep apnea/ hypopnea syndrome in the UK. Thorax 2008: 63: 860–865.
  7. Albarrak M, Banno K, Sabbagh AA, Delaive K, Walid R, Manfreda J, Kryger MH. Utilization of health care resources in obstructive sleep apnea syndrome: a 5 year follow up study in men using CPAP. Sleep 2005 Oct 28 (10) 1306–1311
  8. Prosser LA, Stinnett AA, Goldman PA, Williams LW, Hunnink MG, Goldman L, Weinstein MC (2000). Cost effectiveness of cholesterol lowering therapies according to selected patient characteristics. Ann Inter Med 132 (10) 769–779.
  9. Bendix J: Curing the prior authorization headache. Medical economics. Oct 10, 2013.