1. Impact of Sleep Apnea on Hospital Admissions and Outcomes: 27,555 Inpatient Encounters of 19,044 Individuals Jon H. Lemke, Ph.D. Chief Biostatistician Business Intelligence Center Genesis Health System Genesis Sleep Apnea Registry: Principal Investigator Genesis Research Summit Presentation Davenport, IA June 18, 2015

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3. Conclusions  “Destiny is no matter of chance. It is a matter of choice. It is not a thing to be waited for, it is a thing to be achieved.” – William Jennings Bryan (1860-1925)  Nonadherent and Probable sleep apnea patients’: – reasons for being in the hospital are in no way similar to those of the Adherent and Unlikely sleep apnea patients. – risks are greater for worse outcomes and longer stays than Adherent and Unlikely sleep apnea patients.  If each of you can be bold enough to motivate one person to switch from a nonadherent or probable sleep apnea patient to an adherent sleep apnea patient you will have made a significant impact on their lives. 6/18/2015Lemke, GHS Business Intelligence Center

4. Conclusions  No ACO (Accountable Care Organization) will be successful unless it aggressively diagnoses and treats sleep apnea. Advantage goes to those that started before they became an ACO.  CMS Bundled payments start July 1 are for 90-day episodes of care. Advantage go to Orthopedics given patients can be on CPAP prior to elective knee and hip surgery. All can benefit with 90-days instead of the traditional 30-days.  Now there is even more opportunity for double dipping with CMS Pay-for-Performance:  Readmission Reduction Program  Hospital Value Based Purchasing  Hospital Acquired Condition Penalty 6/18/2015Lemke, GHS Business Intelligence Center

5. Current Research Team Investigators  Jon H. Lemke  Desyree Weakley  Stephen C. Rasmus  Vicki Loving  Tosha Allen  Mike Malloy  Alyssa Barkalow  Brian Dirksen  Mikel O’Klock  Neil Flynn 6/18/2015Lemke, GHS Business Intelligence Center

6. Special Thanks  Maja Zingmark  Chris Lynn  Dr. Claudy  Gina Gore  Candice Elias,  Tami Gumpert  Braxton Lancial  Lynn Colberg  Dianna Paustian  Amanda Wesson  Every Physician and Every Nurse who has had a frank discussion about sleep apnea.  All of the Sleep Techs  All of the Respiratory Techs 6/18/2015Lemke, GHS Business Intelligence Center

7. National Perspective  ALL 41 Institutes in NIH claim diagnosis and treatment of sleep apnea is crucial to their mission.  Sleep disordered breathing is associated with health conditions across ALL organ systems.  Changing definitions and documentation are changing who is an inpatient, outpatient, or observation patients; and will be making it even more difficult to track patients across hospitalizations by using different coding systems.  Schneider Trucking with comprehensive diagnosis and treatment had 74% reduction in accidents and 91% reduction in hospitalizations (Lazar 2007). 6/18/2015Lemke, GHS Business Intelligence Center

8. Sleep Apnea Risk Groups 3. No Dx-Probable Sleep Apnea 4. No Dx-Unlikely to have Sleep Apnea 1. Dx-Adherent 2. Dx-Nonadherent 6/18/2015Lemke, GHS Business Intelligence Center

9. Methods 1)Inclusion: Genesis Medical Center first inpatient admission screened for sleep apnea status since November 4, 2012. [We do screen others on admission as well, but not for these analyses.] 2)Classification: Each inpatient is classified relative to their sleep apnea status at each admission (details soon). If already screened, status is carried forward until there is evidence of change. 3)Duration of Stay: Censored if patient expires, goes AMA, or is transferred to another acute care facility. 4)Duration of Follow-up: Censored if patient expires, goes AMA, is transferred to another acute care facility other than a GMC facility or until November 3, 2014. 6/18/2015Lemke, GHS Business Intelligence Center

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12. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective8034774093,8925,581 Nonelective2,2502,4303,27914,01521,974 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.76 (0.70, 0.83) Less Likely to Have Sleep Apnea SA Dx vs. Probable 2.19 (1.87, 2.57) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.82 (1.54, 2.15) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Nonelective 6.44 times the Opportunities than Elective

13. Sleep Apnea Status by Major Diagnostic Categories with at least 24 Cases and 3 Cases per Status 6/18/2015Lemke, GHS Business Intelligence Center

14. Sleep Apnea Status by Major Diagnostic Categories with at least 24 Cases and 3 Cases per Status 6/18/2015Lemke, GHS Business Intelligence Center

15. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Endocrine, Nutritional & Metabolic 179981276051,009 Else2,8742,8093,56117,30226,546 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.25 (1.05, 1.48) More Likely to Have Sleep Apnea SA Dx vs. Probable 1.37 (1.03, 1.83) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.79 (1.28, 2.51) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Endocrine, Nutritional & Metabolic: 225 Opportunities for Improvement

16. Sleep Apnea Status by Major Diagnostic Categories with at least 24 Cases and 3 Cases per Status 6/18/2015Lemke, GHS Business Intelligence Center Percent of Probables among those with Some Indication of Sleep Apnea

17. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Musculoskeletal System 534386 30424,348 Else251925213302148652519 All Encounters30532907368817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.81 (0.70, 0.84) Less Likely to Have Sleep Apnea SA Dx vs. Probable 1.56 (1.32, 1.85) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.38 (1.14, 1.67) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Musculoskeletal System: 772 Opportunities for Improvement

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20. Syndromes with Sleep Apnea Syndrome Z Sleep Apnea + Metabolic Syndrome After 3 months of CPAP-treatment the patients had a reduction in blood pressure, glycated hemoglobin, triglycerides, LDL, total cholesterol and BMI (Soneja et. al. 2012) Overlapping Syndrome Sleep Apnea + COPD 6/18/2015Lemke, GHS Business Intelligence Center

21. Severity of Illness Prior (P) and With (W) the Two Midnight Rule 6/18/2015Lemke, GHS Business Intelligence Center

22. Severity of Illness MILDMODERATEMAJOREXTREMETotal PRIOR Adherent 206 (14.1%) 480 (32.8%) 540 (36.9%) 237 (16.2%) 1463 WITH Adherent 202 (12.8%) 555 (35.3%) 566 (36.9%) 249 (15.8%) 1572 PRIOR Nonadherent & Probable 450 (16.1%) 939 (33.6%) 939 (33.6%) 468 (16.7%) 2796 WITH Nonadherent & Probable 507 (13.6%) 1139 (30.5%) 1368 (36.6%) 722 (19.3%) 3736 Severity of Illness Comparative Analysis under Sleep Apnea Status with Two Midnight Rule 0.81 CI (0.68, 1.18) 0.87 CI (0.86, 1.26) 1.04 CI (0.80, 1.32) P-VALUE 0.9055 1.14 CI (1.02, 1.46) 1.31 CI (1.10, 1.43) 1.18 CI (1.01, 1.41) P-VALUE 0.00006

23. Risk of Mortality Prior (P) and With (W) the Two Midnight Rule 6/18/2015Lemke, GHS Business Intelligence Center

24. Risk of Mortality MILDMODERATEMAJOREXTREMETotal PRIOR Adherent 581 (39.7%) 366 (25.0%) 329 (22.5%) 187 (12.8%) 1463 WITH Adherent 630 (40.1%) 375 (23.9%) 362 (23.0%) 205 (13.0%) 1572 PRIOR Nonadherent & Probable 1041 (37.2%) 715 (25.6%) 660 (23.6%) 380 (13.6%) 2796 WITH Nonadherent & Probable 1246 (33.6%) 936 (25.1%) 909 (24.3%) 643 (17.3%) 3734 Risk of Mortality Comparative Analysis under Sleep Apnea Status with Two Midnight Rule 1.27 CI (1.03, 1.35) 1.29 CI (1.05, 1.37) 1.42 CI (1.10, 1.59) P-VALUE 0.00001 0.97 CI (0.83, 1.22) 1.04 CI (0.89, 1.21) 1.02 CI (0.75, 1.29) P-VALUE 0.8572

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27. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Alcohol/Drug Use 93881288416 Else3,0442,8693,60717,61927,139 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.82 (0.62, 1.08) Less Likely to Have Sleep Apnea SA Dx vs. Probable 0.35 (0.21, 0.57) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.22 (0.07, 0.57) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Alcohol/Drug Use: 119 Opportunities for Improvement

28. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Respiratory System 4994715362,2323,738 Else2,5542,4363,15215,67523,817 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.30 (1.18, 1.42) More Likely to Have Sleep Apnea SA Dx vs. Probable 1.14 (0.98, 1.33) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 3.03 (2.59, 3.55) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Respiratory System: 1,007 Opportunities for Improvement

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34. The Changing Inpatient Profile Impact of the Two Midnight Rule on Sleep Apnea Status of Inpatients Sleep Apnea Status Admissions prior to Oct. 1, 2013 Admissions since Oct. 1, 2013 Percent Change SA Dx-Adherent1,540 (11.6%)1,753 (11.3%)-2.4% SA Dx-Nonadherent1,117 (8.4%)1,960 (12.6%)+50.4% No Dx-Probable1,764 (13.3%)2,069 (13.4%)+0.5% No Dx-Unlikely8,854 (66.7%)9,706 (62.7%)-6.0% All13,275 (100%)15,488 (100%) Test of Homogeneity P-value < 0.0005. 6/18/2015Lemke, GHS Business Intelligence Center

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36. ROMMILDMODERATEMAJOREXTREME PRIORAdherent 581 (39.7%) 366 (25.0%) 329 (22.5%) 187 (12.8%) WITHAdherent 630 (40.1%) 375 (23.9%) 362 (23.0%) 205 (13.0%) PRIORNonadherent 394 (36.0%) 269 (24.8%) 259 (23.9%) 162 (14.9%) WITHNonadherent 574 (32.2%) 458 (25.7%) 431 (24.2%) 321 (18.0%) PRIORProbable 647 (37.8%) 446 (26.1%) 401 (23.4%) 218 (12.7%) WITHProbable 672 (34.5%) 478 (24.5%) 478 (24.5%) 324 (16.6%) PRIORUnlikely 3563 (41.2%) 2140 (24.8%) 1834 (21.2%) 1108 (12.8%) WITHUnlikely 3575 (39.4%) 2314 (25.5%) 1915 (21.1%) 1280 (14.1%) 0.97 CI (0.8, 1.2) 1.04 CI (0.8, 1.2) 1.02 CI (0.7, 1.3) P-VALUE 0.8572 1.28 CI (1.02, 1.48) 1.20 CI (1.07, 1.41) 1.32 CI (0.99, 1.61) P-VALUE 0.0123 1.28 CI (1.03, 1.38) 1.31 CI (0.98, 1.46) 1.47 CI (0.98, 1.74) P-VALUE 0.0007 1.11 CI (1.01, 1.16) 1.05 CI (1.03, 1.14) 1.08 CI (1.01, 1.25) P-VALUE 0.0008 Risk of MortalityMILDMODERATEMAJOREXTREME PRIORAdherent 581 (39.7%) 366 (25.0%) 329 (22.5%) 187 (12.8%) WITHAdherent 630 (40.1%) 375 (23.9%) 362 (23.0%) 205 (13.0%) PRIORNonadherent 394 (36.0%) 269 (24.8%) 259 (23.9%) 162 (14.9%) WITHNonadherent 574 (32.2%) 458 (25.7%) 431 (24.2%) 321 (18.0%) PRIORProbable 647 (37.8%) 446 (26.1%) 401 (23.4%) 218 (12.7%) WITHProbable 672 (34.5%) 478 (24.5%) 478 (24.5%) 324 (16.6%) PRIORUnlikely 3563 (41.2%) 2140 (24.8%) 1834 (21.2%) 1108 (12.8%) WITHUnlikely 3575 (39.4%) 2314 (25.5%) 1915 (21.1%) 1280 (14.1%) 0.97 CI (0.83, 1.22) 1.04 CI (0.89, 1.21) 1.02 CI (0.75, 1.29) P-VALUE 0.8572 1.28 CI (1.02, 1.48) 1.20 CI (1.07, 1.41) 1.32 CI (0.99, 1.61) P-VALUE 0.0123 1.28 CI (1.03, 1.38) 1.31 CI (0.98, 1.46) 1.47 CI (0.98, 1.74) P-VALUE 0.0007 1.11 CI (1.01, 1.16) 1.05 CI (1.03, 1.14) 1.08 CI (1.01, 1.25) P-VALUE 0.0008 Lemke, Genesis Health System – Business Intelligence Center

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38. ROMMILDMODERATEMAJOREXTREME PRIORAdherent 581 (39.7%) 366 (25.0%) 329 (22.5%) 187 (12.8%) WITHAdherent 630 (40.1%) 375 (23.9%) 362 (23.0%) 205 (13.0%) PRIORNonadherent 394 (36.0%) 269 (24.8%) 259 (23.9%) 162 (14.9%) WITHNonadherent 574 (32.2%) 458 (25.7%) 431 (24.2%) 321 (18.0%) PRIORProbable 647 (37.8%) 446 (26.1%) 401 (23.4%) 218 (12.7%) WITHProbable 672 (34.5%) 478 (24.5%) 478 (24.5%) 324 (16.6%) PRIORUnlikely 3563 (41.2%) 2140 (24.8%) 1834 (21.2%) 1108 (12.8%) WITHUnlikely 3575 (39.4%) 2314 (25.5%) 1915 (21.1%) 1280 (14.1%) 0.97 CI (0.8, 1.2) 1.04 CI (0.8, 1.2) 1.02 CI (0.7, 1.3) P-VALUE 0.8572 1.28 CI (1.02, 1.48) 1.20 CI (1.07, 1.41) 1.32 CI (0.99, 1.61) P-VALUE 0.0123 1.28 CI (1.03, 1.38) 1.31 CI (0.98, 1.46) 1.47 CI (0.98, 1.74) P-VALUE 0.0007 1.11 CI (1.01, 1.16) 1.05 CI (1.03, 1.14) 1.08 CI (1.01, 1.25) P-VALUE 0.0008 Severity of Illness MODERATEMAJOREXTREME PRIORAdherent 206 (14.1%) 480 (32.8%) 540 (36.9%) 237 (16.2%) WITHAdherent 202 (12.8%) 555 (35.3%) 566 (36.0%) 249 (15.8%) PRIORNonadherent 154 (14.2%) 364 (33.6%) 363 (33.5%) 203 (18.7%) WITHNonadherent 204 (11.4%) 531 (29.7%) 682 (38.2%) 367 (20.6%) PRIORProbable 296 (17.3%) 575 (33.6%) 576 (33.6%) 265 (15.5%) WITHProbable 303 (15.5%) 608 (31.1%) 686 (35.1%) 355 (18.2%) PRIORUnlikely 1687 (19.5%) 3042 (35.2%) 2737 (31.7%) 1179 (13.6%) WITHUnlikely 1543 (17.0%) 3269 (36.0%) 2916 (32.1%) 1396 (14.9%) 0.81 CI (0.68, 1.18) 0.87 CI (0.86, 1.26) 1.04 CI (0.80, 1.32) P-VALUE 0.9055 1.38 CI (1.05, 1.72) 1.46 CI (0.94, 1.59) 1.12 CI (1.10, 1.44) P-VALUE 0.0019 1.16 CI (1.11, 1.43) 1.25 CI (1.01, 1.41) 1.25 CI (1.04, 1.52) P-VALUE 0.0061 1.23 CI (0.93, 1.32) 1.07 CI (1.01, 1.17) 1.12 CI (0.98, 1.28) P-VALUE 0.0001 Lemke, Genesis Health System – Business Intelligence Center

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40. Analysis Options  Recommended Partitioning or Contrasts  Previously Diagnosed vs. Not  Probable vs. Unlikely  Adherent vs. Nonadherent  Evidence of Sleep Apnea vs. Unlikely  Diagnosed vs. Probable  Adherent vs. Nonadherent  At Risk: Nonadherent or Probable vs. Adherent or Unlikely  Nonadherent vs. Probable  Adherent vs. Unlikely 6/18/2015Lemke, GHS Business Intelligence Center

41. Sleep Apnea Status by Site Sleep Apnea Risk Group DavenportSilvisAledoDeWittTotal: Dx – Adherent 2,659 (12.0%) 366 (7.2%) 15 (10.3%) 13 (6.7%) 3,053 (11.3%) Dx – Nonadherent 2,405 (10.9%) 448 (8.8%) 20 (13.8%) 34 (17.6%) 2,907 (10.6%) No Dx – Probable 3,068 (13.9%) 574 (11.2%) 19 (13.1%) 27 (14.0%) 3,688 (13.4%) No Dx – Unlikely 13,979 (63.2%) 3,718 (75.3%) 91 (62.8%) 119 (61.7%) 17,907 (65.0%) Total 22,111 (100%) 5,106 (100%) 145 (100%) 193 (100%) 27,555 (100%) - More than expected - Less than expected 6/18/2015 Lemke, GHS Business Intelligence Center

42. Caveats 1)We are only analyzing those that come to the hospital, and cannot compare them to those that are not hospitalized. 2)On admission we do not know whether or not a hospitalized patient will be an inpatient, except for specific procedures. Thus, the definition of inpatient is “IMPROPER” as Outpatient, Observation and Inpatient status is typically unknown on admission, when the clock starts. But, we begin screening on admission. 3)Some inpatients are screened by self report at one GMC site, transferred and then observed at another GMC site. 4)We have 11 months prior to the Two Midnight Rule and 13 months on the Two Midnight Rule. Most analyses have to control for the Two Midnight Rule period. 5)Since our screening includes observation during sleep, some earlier of the earlier inpatients had fewer opportunities for observation. 6/18/2015Lemke, GHS Business Intelligence Center

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45. Most Dramatic Differences in Sleep Apnea Status between Elective and Nonelective Hospitalizations within Major Diagnostic Category 1)ENDOCRINE, NUTRITIONAL AND METABOLIC 2)MUSCULOSKELETAL SYSTEM 3)CIRCULATORY SYSTEM 4)DIGESTIVE SYSTEM 5)KIDNEY AND URINARY TRACT 6)NERVOUS SYSTEM 7)EAR, NOSE, MOUTH, AND THROAT 8)SKIN, SUBCUTANEOUS TISSUE AND BREAST 6/18/2015Lemke, GHS Business Intelligence Center

46. Sleep Apnea Status by Major Diagnostic Categories with at least 24 Cases and 3 Cases per Status 6/18/2015Lemke, GHS Business Intelligence Center Top 7 in each row highlighted; sorted by Opportunities for Improvement.

47. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective111241162208 Nonelective6874116543801 All Endocrine, Nutritional & Metabolic 179981276051,009 Odds Ratios SA Dx or Probable vs. Unlikely 4.96 (3.18, 7.83) More Likely to Have Sleep Apnea SA Dx vs. Probable 10.03 (3.93, 25.64) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 5.03 (2.39, 10.98) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Endocrine, Nutritional & Metabolic: Nonelective 5.43 times the OFI’s than Elective

48. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective4282361771,9562,797 Nonelective1061502091,0861,551 All Musculoskeletal 534386 3,0424,348 Odds Ratios SA Dx or Probable vs. Unlikely 1.00 (0.84, 1.19) As Likely to Have Sleep Apnea SA Dx vs. Probable 3.06 (2.20, 4.26) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 2.57 (1.72, 3.83) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Musculoskeletal System: Elective 1.15 times the OFI’s than Nonelective

49. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Circulatory System 6737017953,4645,633 Else2,3802,2062,89314,4432,380 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.21 (1.12, 1.30) More Likely to Have Sleep Apnea SA Dx vs. Probable 1.09 (0.96, 1.24) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.89 (0.76, 1.04) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Circulatory System: 1,496 Opportunities for Improvement

50. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective1288598675986 Nonelective5456166972,7894,647 All Circulatory System 6737017953,4645,633 Odds Ratios SA Dx or Probable vs. Unlikely 1.44 (1.19, 1.76) More Likely to Have Sleep Apnea SA Dx vs. Probable 0.77 (0.54, 1.08) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.59 (0.39, 0.87) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Circulatory System: Nonelective 7.17 times the OFI’s than Elective

51. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Circulatory System 6737017953,4645,633 Musculoskeletal System 534386 3,0424,348 Total1207108711816,5069,981 Odds Ratios SA Dx or Probable vs. Unlikely 1.46 (1.30, 1.64) More Likely to Have Sleep Apnea SA Dx vs. Probable 0.73 (0.60, 0.88) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.69 (0.55, 0.87) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Circulatory System vs Musculoskeletal System

52. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Digestive System 3102864082,2603,264 Else2,7432,6213,28015,64724,291 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.80 (0.72, 0.89) Less Likely to Have Sleep Apnea SA Dx vs. Probable 0.89 (0.75, 1.06) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.04 (0.83, 1.29) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Digestive System: 694 Opportunities for Improvement

53. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective533235320440 Nonelective2572543731,9402,824 All Digestive System 3102864082,2603,264 Odds Ratios SA Dx or Probable vs. Unlikely 0.82 (0.60, 1.10) Less Likely to Have Sleep Apnea SA Dx vs. Probable 1.77 (1.01, 3.18) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.64 (0.87, 3.17) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Digestive System: Nonelective 9.36 times the OFI’s than Elective

54. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective 152721181244 Nonelective 1661943261,1661,852 All Nervous System 1812213471,3492,096 Odds Ratios SA Dx or Probable vs. Unlikely 0.59 (0.39, 0.88) Less Likely to Have Sleep Apnea SA Dx vs. Probable 1.81 (0.87, 3.96) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.65 (0.25, 1.61) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Nervous System: Nonelective 10.83 times the OFI’s than Elective

55. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Kidney & Urinary Tract 1081171728921289 Else2,9452,7903,51617,01526,266 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.82 (0.70, 0.96) Less Likely to Have Sleep Apnea SA Dx vs. Probable 0.80 (0.61, 1.05) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.87 (0.61, 1.25) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Kidney & Urinary Tract: 289 Opportunities for Improvement

56. References 1.Bradley T, Floras J. Sleep Apnea and Heart Failure: Part 1: Obstructive Sleep Apnea. Circulation 2003;107:1671-1678. 2.Flink B, Rivelli S, Cox E, White W, Falcone G, Vail T, Young C, Bolognesi M, Krystal A, Trzepacz P, Moon R, Kwatra M. Obstructive Sleep Apnea and Incidence of Postoperative Delirium after Elective Knee Replacement in the Nondemented Elderly. Anesthesiology 2012;116(4):788-796. 3.Goldstein L, Bushnell C, Adams R., Appel L, et al. Guidelines for the Primary Prevention of Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke, 2011. http//stroke.ahajournals.org 4.Gupta R, Parvizi, J, Hanssen A, Gay P. Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case- Control Study. Mayo Clin Proc. 2001;76:897-905. 5.Knecht KM, Alosco ML, Spitznagel MB, Cohen R, Raz N, Sweet L, Colbert LH, Josephson R, Hughes J, Rosneck J, Gunstad J. Sleep Apnea and Cognitive Function in Heart Failure. Cardiovascular Psychiatry and Neurology. June 2012. 6.Lee CH, Khoo SM, Chan MY, Wong HB, Low AF, Phua QH, Richards AM, Tan HC, Yeo TC. Severe Obstructive Sleep Apnea and Outcomes Following Myocardial Infarction. J Clin Sleep Med 2011;7(6):616-621. 7.Nieto FJ, Peppard PE, Young T, Finn L, Hla KM, Farré R. Sleep-disordered Breathing and Cancer Mortality. Am J Respir Crit Care Med. 2012;186(2):190-194. 6/18/2015Lemke, GHS Business Intelligence Center

57. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Nervous System 1812213471,3472,096 Else2,8722,6863,34116,56025,459 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.03 (0.91, 1.17) More Likely to Have Sleep Apnea SA Dx vs. Probable 0.70 (0.57, 0.85) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.77 (0.58, 1.00) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Nervous System: 568 Opportunities for Improvement

58. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Elective966115136 Nonelective991111667771,153 All Kidney & Urinary Tract 1081171728921,289 Odds Ratios SA Dx or Probable vs. Unlikely 0.38 (0.19, 0.70) Less Likely to Have Sleep Apnea SA Dx vs. Probable 1.98 (0.92, 16.57) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.68 (0.37, 8.81) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Kidney & Urinary Tract: Nonelective 23.08 times the OFI’s than Elective

59. References 7.Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome:A Retrospective Matched Cohort Study. Can J Anesth/J Can Anesth 2009;56:819- 828. 8.Lazar RA. An Emerging Standard of Care Requiring Commercial Driver Screening for Sleep Apnea: Practical Considerations and Risk management Strategies for the Trucking Industry. White Paper Published August 1, 2007. 9.Slaughter D, Thompson C, Wassmuth Z. What Causes Snoring and Obstructive Sleep Apnea? [Video]. Youtube. http://www.youtube.com/watch?v=inmop4Kv8PI. Published June 8, 2010. Accessed July 16, 2013. 10.Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52:686–717. 11.Soneja M, Singh V. Metabolic Abnormalities in Obstructive Sleep Apnea: A Double Whammy. Lung India. 2012;29(2):107-108. 6/18/2015Lemke, GHS Business Intelligence Center

60. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Infectious & Parasitic Disease 2162082911,1701,885 Else2,8372,6993,39716,73725,670 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.14 (1.01, 1.30) More Likely to Have Sleep Apnea SA Dx vs. Probable 0.89 (0.72, 1.10) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.99 (0.76, 1.28) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Infectious & Parasitic Disease: 499 Opportunities for Improvement

61. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Injury, Poisoning & Toxic Effects 4654101462663 Else3,0072,8533,58717,44526,892 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.80 (0.64, 1.00) Less Likely to Have Sleep Apnea SA Dx vs. Probable 0.61 (0.42, 0.88) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.81 (0.47, 1.38) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Injury, Poisoning & Toxic Effects: 155 Opportunities for Improvement

62. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Skin, Subcutaneous Tissue & B. 837480364601 Else2,9702,8333,60817,54326,954 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.21 (0.97, 1.51) More Likely to Have Sleep Apnea SA Dx vs. Probable 1.22 (0.85, 1.77) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.07 (0.70, 1.65) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Skin, Subcutaneous Tissue & B.: 154 Opportunities for Improvement

63. Comparison of Sleep Apnea Risk Groups by Sex Dx of Sleep Apnea (Group 1 + 2) No Dx of Sleep Apnea (Group 3 + 4) Total Male 3,388 (26.0%)9,631 (74.0%)13,019 (100%) Female 2,572 (17.7%)11,964 (82.3%)14,536 (100%) Total 5,960 (21.6%)21,595 (78.4%)27,555 (100%) Dx-Adherent (Group 1) Dx-Nonadherent (Group 2) Total Male 1,833 (54.4%)1,555 (45.6%)3,388 (100%) Female 1,220 (48.0%)1,352 (52.0%)2,572 (100%) Total 3,053 (51.7%)2,907 (48.3%)5,960 (100%) No Dx – Probable (Group 3) No Dx – Unlikely (Group 4) Total Male 1,916 (20.0%)7,715 (80.0%)9,631 (100%) Female 1,772 (14.7%)10,192 (85.3%)11,964 (100%) Total 3,688 (17.1%)17,907 (82.9%)21,595 (100%) 6/18/2015Lemke, GHS Business Intelligence Center

64. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Blood & Blood- Forming Organs 283769265399 Else3,0252,8703,61917,64227,156 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.94 (0.71, 1.23) Less Likely to Have Sleep Apnea SA Dx vs. Probable 0.58 (0.36, 0.92) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.72 (0.36, 1.41) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Blood & Blood-Forming Organs: 106 Opportunities for Improvement

65. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Female Reproductive System 155186197 Else3,0522,9023,68317,72127,358 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.10 (0.04, 0.23) Less Likely to Have Sleep Apnea SA Dx vs. Probable 0.74 (0.13, 4.78) Less Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 0.19 (0.00008, 2.79) Less Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Female Reproductive System: 10 Opportunities for Improvement

66. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Male Reproductive System 16109104139 Else3,0372,8973,67917,80327,416 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 0.62 (0.36, 1.03) Less Likely to Have Sleep Apnea SA Dx vs. Probable 1.79 (0.67, 5.81) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.53 (0.51, 5.00) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Male Reproductive System: 19 Opportunities for Improvement

67. Major Diagnostic Category AdherentNonadherentProbableUnlikelyCases Mental Diseases & Disorders 1310126499 Else3,0402,8973,67617,84327,456 All Encounters3,0532,9073,68817,90727,555 Odds Ratios SA Dx or Probable vs. Unlikely 1.02 (0.57, 1.76) More Likely to Have Sleep Apnea SA Dx vs. Probable 1.19 (0.51, 3.61) More Likely to Have a Diagnosis of Sleep Apnea Adherent vs. Nonadherent 1.24 (0.39, 4.21) More Likely to be Adherent 6/18/2015Lemke, GHS Business Intelligence Center Mental Diseases & Disorders: 22 Opportunities for Improvement

68. Genesis Health System Context  Genesis Health System has just received the first Iowa Recognition for Performance Excellence (IRPE; Baldrige Criteria) GOLD Award for a health system!  Genesis strategic planning has focused on Safety and Mortality for many years with exceptional results!  This challenges one who wants to extrapolate our results to other health systems. But, many significant sources of variation should be the similar.  Potentially, the impact of the diagnosis and treatment of sleep apnea on other healthcare systems could be much greater than you will see here. 6/18/2015Lemke, GHS Business Intelligence Center

69. 6/18/2015Lemke, GHS Business Intelligence Center

70. 6/18/2015Lemke, GHS Business Intelligence Center

71. Relative Risk for Medical Conditions 6/18/2015Lemke, GHS Business Intelligence Center

72. Sleep Apnea – Different Types  Obstructive Sleep Apnea (OSA): Apnea resulting from complete collapse of the pharynx during sleep  Central Sleep Apnea (CSA): Apnea resulting from complete withdrawal of central respiratory drive to the muscles of respiration during sleep  Mixed Apnea: Apnea resulting from an initial central component followed by an obstructive component 6/18/2015Lemke, GHS Business Intelligence Center

73. Hypoxia: The condition in which the body or region of the body is deprived of adequate oxygen supply. Hypopnea: A reduction in, but not complete cessation of, airflow to <50% of normal Apnea: Cessation of airflow for >10 s Apnea Hypopnea Index (AHI): The frequency of apneas and hypopneas per hour of sleep; a measure of the severity of sleep apnea AHI = (# of apneas + # of hypopneas)/hours of sleep Figure 1. Partial and complete airway obstruction resulting in hypopnea and apnea, respectively. Reprinted from Hahn PY, Somers VK. Sleep apnea and hypertension. In: Lip GYH, Hall JE, eds. Comprehensive Hypertension. St. Louis, MO: Mosby; 2007:201–207. Copyright Elsevier 2007. Used with permission. 6/18/2015Lemke, GHS Business Intelligence Center

74. Physician H&P Documentation ICD 9: Sleep Apnea ICD 9 CodeICD 9 Description 327.23Obstructive sleep apnea 327.21Primary central sleep apnea 327.2Organic sleep apnea 327.27Cntrl sleep apnea ot dis 327.29Organic sleep apnea NEC 327.20Organic sleep apnea NOS 780.51Insomnia with sleep apnea NOS 780.57Sleep apnea NOS 6/18/2015Lemke, GHS Business Intelligence Center

75. Objectives 1)To provide an overview of Sleep Apnea and the purpose of the Genesis Sleep Apnea Registry. 2)To understand how your diagnosis and treatment of sleep apnea impacts who becomes a hospitalized inpatient and why. 3)To recognize how your diagnosis and treatment of sleep apnea impacts your inpatients’ duration of stay and outcomes. 6/18/2015Lemke, GHS Business Intelligence Center

76. Selected Previous Research  Higher incidences of post operative complications - 44% vs. 28% (Liao et. al. 2009).  4.9 times as high cancer mortality in patients with severe sleep-disordered breathing (Nieto et. al. 2012).  OSA is the only identifiable risk factor for post surgical delirium (Flink et. al. 2012).  32% increase (from 37% to 49%) of Left Ventricular Ejection Fraction (LVEF) after one month of PAP use; results reversed after one week without PAP (Bradley et. al. 2003).  Schneider Trucking with comprehensive diagnosis and treatment had 74% reduction in accidents and 91% reduction in hospitalizations ( Lazar 2007). 6/18/2015Lemke, GHS Business Intelligence Center