A PNEA S CREENING FOR D IABETES P ATIENTS Sensible. Simple. Effective. Reaching out to more patients.

R EASONS TO I NTEGRATE AN A PNEA S CREENING P ROGRAM  Increasing Prevalence o 24%- Nearly one quarter of U.S. men suffer from some form of sleep disordered breathing (SDB).  International Diabetes Federation Recommendations OSA should be considered in the assessment of all patients with Type II Diabetes.  Improving Patient Care o Early detection & treatment reduces risk of disease & death related to other serious health conditions, such as: Type II Diabetes Hypertension Congestive Heart Failure Stroke New England Journal of Medicine. 1993; 328; Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12.

D IABETES & A PNEA Evidence indicates that the presence of one disease may trigger biological mechanisms that increase risk of the other. OSA Hypoxia & Sleep Fragmentation (Alters Glucose Metabolism) Stress Response (Alters Leptin Levels ; Increases Insulin Resistance) Glucose Intolerance/ Type II Diabetes Autonomic Neuropathy (Alters Ventilatory Control During Sleep) Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: Pagel, et. al. Supplement to The Journal of Family Practice. August 2008 ; Vol 57, No 8. D IABETES & A PNEA S CREENING S HOULD G O H AND IN H AND

Link Between Diabetes & SDB o 58% of Type II Diabetics have some form of sleep disordered breathing (SDB) Health Concerns o Both Diabetes & Apnea significantly increase risk of cardiovascular disease & death Treatment Concerns o Apnea negatively impacts glucose tolerance, insulin resistance & increased risk of metabolic syndrome  Leads to difficulties with diabetes management Richard; Gay & Farrell. The Economics of Sleep-Disordered Breathing. RT: June Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12 S LEEP D ISORDERED B REATHING (SDB) IN THE D IABETIC P OPULATION

Improves Factors Related to Diabetes o Improves glycemic control o Improved insulin sensitivity and leptin levels o Reduces Sympathetic Activation o A key factor in regulation of glucose & fat metabolism, as well as systemic inflammation. – Biological mechanisms thought to contribute to insulin resistance. Reduces Cardiovascular Risk o Significantly decreases blood pressure (BP) o Improves Heart Function o Decreases # of new cardiovascular events & arrhythmias Improves Overall Patient Outcomes o Reduces morbidity & mortality associated with cardiovascular events & stroke o Patients using positive airway pressure have better Epworth Sleepiness Scale & Health-Related Quality of Life scores. Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12 Richard; Gay & Farrell. The Economics of Sleep-Disordered Breathing. RT: June T REATING A PNEA

E CONOMIC I MPACT OF U NDIAGNOSED A PNEA  $3.4 billion Yearly estimate of the medical costs of untreated OSA in the U.S.  $15.9 billion Collision costs directly attributable to OSA in  $5 billion Yearly loss of productivity attributable to Apnea-related fatigue.  Other Indirect Costs E.g. higher insurance, production, & consumer costs Higher incidence of work-related accidents  Non-Financial Burden Increased incidence of disability Diminished quality of life for affected. Richard; Gay & Farrell. The Economics of Sleep-Disordered Breathing. RT: June Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: 2-12 SDB P LACES S UBSTANTIAL E CONOMIC B URDEN ON THE U.S.

R EASONS FOR A PNEA S CREENING  SDB is Largely Undiagnosed Over 28 million Americans suffer from OSA, yet 20 million go undiagnosed & untreated.  Increased Health Risks SDB is associated with a range of comorbid conditions.  Significant Financial & Disability Burden Untreated SDB places substantial burden on both individuals & society. Logan, et. al. J Hypertens Dec;19(12): Jahaveri, et. al. Circulation. 1998;97: Basetti & Aldrich. Sleep Mar 15;22(2): Finkel, et. al. Sleep Review July-Aug Shaw, et. al. Diabetes Research & Clinical Practice. 2008; 81: SCREENING IDENTIFIES PATIENTS THAT WOULD NOT SEEK TREATMENT OTHERWISE.

P ROBLEMS WITH C OMMON S CREENING M ETHODS o Subjective o Not specific i.e. high # of false-positives - Leads to unnecessary testing & delayed Dx for those with severe apnea o Cannot indicate type/severity of SDB o Not Validated for Diabetic Population Questionnaires In-lab Polysomnography (PSG) o Costly o Impractical for Screening Population is too large o Can Take Days or Weeks to Receive Results o Higher refusal/drop-out rates Finkel, et. al.. Sleep Review July-Aug Magalang, et. al. Chest 2003; 124; STOP Questionnaire; A Tool to Screen Patients for Obstructive Sleep Apnea. Chung, et. al.. Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104:1081–93.

M ETA - ANALYSIS OF OSA Q UESTIONNAIRES Study Pooled Study n FN Rate Ease of Use, 0-3 Test Accuracy, by Diagnostic Odds Ratio (DOR)* Summary Recommendations ** Berlin Questionnaire Poor-Excellent May have role in screening for severe OSA, Unacceptable FN rate BMI alone Poor Unacceptable FN rate Epworth Sleepiness Scale Poor Unacceptable FN rate STOP Questionnaire Poor Unacceptable FN rate STOP-BANG Average- Excellent Excellent screening test for severe OSA, unacceptable FN rate for Dx of OSA *DOR combines data on sensitivity and specificity to give an indication of a test’s ability to rule in or rule out a condition. **Summary recommendations developed for preoperative use. S CREENING T EST R ELIABILITY & S UMMARY R ECOMMENDATIONS Many of the most commonly used screening questionnaires have poor predictive values, esp. for mild to moderate cases. Derived from Ramachandran, et. Al. Anesthesiology, V 110, No 4, Apr 2009

T HE S.O.S. A PPROACH  Subjective Screen o Use questionnaire (e.g. STOP-BANG; Berlin) to screen everyone The population at risk is often large and will often include many patients with low risk. A much smaller subgroup with very high risk will require expedient intervention.  Objective Screen o Oximetry (e.g. SatScreen) devices are widely used because of affordability, high predictive value, & minimal patient impact. Identifies the high risk subgroup. “S.O.S.” Subjective Objective Screening Research shows a combination approach can be the most feasible & effective method Hwang, et. al. Chest 2008; 133;

Patents High resolution oximetry with digital pattern analysis & recognition SatScreen  Oximetry screening o FDA cleared acquisition, analysis & reporting software Patient Safety Connection Center  Oximetry & HST software management platform P ATIENT S AFETY, I NC T ECHNOLOGY B REAKTHROUGHS

W HY S AT S CREEN ? Most oximetry software only report raw data, ODI & O2 ranges. Accurate & Cost-Effective Results in Minutes Easy to Read Green to red indices for important information Indicates Arousal Failure & Hypoventilation Syndromes Indicative of more serious SDB & may require a different treatment approach Highlights Frequency of Events & Severity of O 2 Desaturations Bloch. Chest 2003; 124; ASA Task Force. Anesthesiology 2006; 104:1081–93. Madani. Advance for Respiratory Care and Sleep Medicine. Posted on January 7, 2009.

G ET S TARTED Define your protocol for at risk patients Determine your Screening Protocol Gather your team & assign responsibilities Practice Guidelines If patient is identified as at risk, follow ASA guidelines or preferred protocol Develop discharge instructions / plan Questions? We want to help you make your organization’s OSA screening program a success. Please contact us at: