Market Trends

OVERLAP Opportunity

Serving patients who need both PAP equipment and oxygen is a strong way to expand business. Are you doing enough to diagnose and treat this population?

The term “overlap syndrome” was coined in 1985 to describe patients who have both chronic obstructive pulmonary disease and obstructive sleep apnea. Since then, it has been recognized that the co-existence of COPD and OSA is associated with increased morbidity.

Estimates of the incidence of overlap syndrome depend on how one looks at it. The clinical literature suggests that about 10 percent of OSA patients have some degree of COPD, and between 20 percent to 40 percent of COPD patients have some degree of sleep-disordered breathing, according to Ann Tisthammer, BS, RRT, vice president of clinical education and training at ResMed, San Diego.

Either way, respiratory therapists report that they encounter overlap patients in their work for HME businesses, and that the population benefits from using two technologies, positive airway pressure devices and oxygen equipment. Ricky Hubbard, CRT, respiratory manager at Zurcare LLC in Ridgeland, Miss., says this group of patients is unique. “They tend to be more compliant with their treatment because their condition is more involved than a typical CPAP patient,” he says. “They realize there could be more consequences if they are not compliant, and the consequences may be more severe than if they were just an OSA patient.” Zurcare has a program to monitor compliance with regular data downloads and some wireless technology.

However, Hubbard says that only about 5 percent of Zurcare’s patients have overlap syndrome. He says they typically start out receiving sleep therapy, and then oxygen is added when desaturation is discovered via an overnight oximetry study. Few patients come onboard with orders for PAP and oxygen equipment at the same time, he says.

For Zurcare and HME providers everywhere, a low census of overlap patients may mean that some cases haven’t yet been diagnosed. And that represents an opportunity for providers to help more patients and expand their businesses. What could be better than a group of patients motivated to use two therapies eligible for reimbursement?

Strategies to Identify Overlap Syndrome Business

Tisthammer says there are practical strategies so HME providers can better identify these folks. “Say you have 200 patients on oxygen service,” she says. “Are you looking out for those patients who are complaining of not sleeping well and morning headaches? They may have sleep-disordered breathing. Or say you have lots of CPAPs out there, but maybe some patients are still having problems with symptoms. Through overnight oximetry studies, you may find they are desaturating.”

Building stronger patient intake processes could speed up the path to diagnosis and treatment, Tisthammer says. “Create a program to screen oxygen patients by asking questions at the initial setup. Have them do a quick Berlin Questionnaire. Make it part of the educational process to inquire about their sleep, and you might uncover some patients who have sleep disorder signs and symptoms.”

This approach also works for CPAP patients, Tisthammer says. “How many CPAP patients do you ask, ‘Do you have a history of lung impairments, are you a cigarette smoker or what kind of work did you do in the past?’ It is important to know that a CPAP patient is a 30-year smoker, has episodes of bronchitis and is on respiratory inhalers p.r.n.”

Tisthammer says: “We need to get clinicians asking broader questions about the patient vs. just looking at the one particular thing they have to do, which may be an oxygen setup or a CPAP setup. Look a little broader, if you want to grow your business and provide the best therapy.” Cultivating the overlap market may take more of therapists’ time, which she knows may be a struggle for some.

Still, technology can be therapists’ ally in this effort. To measure saturation levels, oximetry modules are now available to attach to most PAP devices, and manufacturers are working toward building oximetry capabilities right in. And home sleep screening devices can be used on oxygen patients to see if a formal sleep study is warranted. “The challenge for therapists is that [trying to detect issues] might require them to do an overnight oximetry study or a sleep screen, but they don’t get reimbursed for that stuff,” Tisthammer says. “If they want to grow the business, they may have to do that for free.”

Petersen Medical in St. George, Utah, reports that about 10 percent to 15 percent of its patients have overlap syndrome. Jason Smith, CRT, RCP, regional manager, says many typically start out with the company as oxygen users who then get diagnosed with OSA. “These patients are a little easier to manage,” he says. “Since they are already on oxygen, they are used to having a therapy, so adding another one is easier for them than a person who is not on oxygen and needs a CPAP for the first time. Even the little things matter. Oxygen patients are used to having something on their face all day, so putting on a CPAP mask is not as great a jump.”

Justin Cowley, Petersen respiratory account manager, agrees that oxygen patients are often aware of sleep equipment. “Oxygen patients have been in the store and seen the masks on display,” he says. “They may have already thought about which one they would use. CPAP patients would not have considered that before going to the sleep lab.”

Speaking of sleep labs, Smith says that the ones in his market are top notch. “We have very savvy sleep labs in this area,” he says. “If you are not on top of managing your patients, they won’t do business with you.” That’s why all sleep equipment Petersen places with patients has wireless technology the company uses to monitor compliance easily by remote. “Each patient is monitored every night, and the sleep labs and our company both have access to the data,” Smith says. “We have a strong handle on what’s happening on a daily basis.” The company enjoyed a 75-percent compliance rate for the second quarter of 2010, according to Sherry Mildenberger, CRT, RCP, assistant manager.

Petersen Medical is getting creative when it comes to diagnosing apnea, working with primary care doctors to perform preliminary studies at no cost. “More than anything, we hear the statistic about 40 percent of potential apnea patients going undiagnosed,” Cowley says. “We want to serve the community and diagnose the problem effectively. The most reasonable thing to do is get oximetry tests out for as little cost as possible. And for those patients who show symptoms of co-morbidities or who don’t test positive with oximetry, we offer home sleep screeners.”

That’s just the approach Tisthammer recommends — taking initiative, partnering with other clinicians, and extending your impact for the betterment of patients’ lives and business. She concludes, “There are plenty of patients who need the combo therapy, and if you don’t have many of those, then are you really providing the best care?”

The Call For Better Treatment

Clinicians have been sounding the alarm about overlap syndrome for some time. All seem to agree that more research and better treatments are needed because patient outcomes are worse. Here are excerpts from the literature and their authors.

“The overlap syndrome is not an uncommon clinical entity. It can lead to overt cardiorespiratory failure. It is probably associated with a worse prognosis than either OSA or COPD alone. Better methods are required for the accurate delineation of the mechanisms of nocturnal desaturation in overlap syndrome patients. The role of noninvasive ventilation in patients with the overlap syndrome is yet to be determined.”
— David J. Barnes, MBBS, FRACP, and Leon Laks, PhD, FRACP, 1998

“Patients with overlap have a more important sleep-related oxygen desaturation than do patients with COPD with the same degree of bronchial obstruction. They have an increased risk of developing hypercapnic respiratory insufficiency and pulmonary hypertension when compared with patients with sleep apnea-hypopnea syndrome alone and with patients with ‘usual’ COPD. In patients with overlap, hypoxemia, hypercapnia and pulmonary hypertension can be observed in the presence of mild to moderate bronchial obstruction, which is different from ‘usual’ COPD. Therapy of the overlap syndrome consists of nasal continuous positive airway pressure or nocturnal noninvasive ventilation, with or without associated nocturnal oxygen. Patients who are markedly hypoxemic during daytime should be given conventional long-term oxygen therapy in addition to nocturnal ventilation.”
— Emmanuel Weitzenblum, MD, AriChaouat, MD, Romain Kessler, MD, and Matthieu Canuet, MD, 2007

“The overlap syndrome defines the relationship between obstructive sleep apnea and chronic obstructive pulmonary disease, and is a commonly noted but poorly studied disorder. Individuals who have the overlap syndrome have been recognized to have greater risk for pulmonary hypertension, right heart failure and hypercapnia than patients who have either disorder alone. In patients who have advancedstage COPD, concomitant OSA likely has significant adverse consequences. The interaction between these two diseases is unclear, however. Further clinical trials of the overlap syndrome are urgently needed.”
— David Hiestand, MD, PhD, and Barbara Phillips, MD, MSPH, 2008

This article originally appeared in the Respiratory & Sleep Management September 2010 issue of HME Business.

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