Planting Bariatric Roots

How Obesity Is Shaping the Future of Respiratory

Growth. For plants, generators of the air we breathe, the process begins small. A seed unfurls roots. The roots penetrate deeper into the earth, stabilizing the plant and drawing in nutrients for cell reproduction. The plant grows larger. The deeper the roots go, the greater the chance for the plant’s survival.

The respiratory business has flourished in a similar manner. Asthma and sleep apnea share the same soil and respond to the same elements necessary for growth: prompt customer service, favorable reimbursement and ongoing education.

Though treatment varies, these conditions have more in common than we like to think. Obesity might just be a unifying thread. Consider the statistics: Many sources cite that around 65 percent of the adult population is within some definition of obese, from overweight to morbidly obese. Translation: Two-thirds of respiratory patients are likely obese.

With the ever-rising statistics pointing toward an all-out obesity epidemic, the bariatric population needs the help of respiratory therapists and equipment providers now more than ever.

Obesity greatly impacts the body’s ability to take in oxygen sufficiently. Symptoms such as wheezing or interrupted sleep can appear as the respiratory system responds to excess weight. As the oxygen supply is depleted, many other body systems can begin to fail, including the heart and brain. Getting respiratory conditions under control —- improving breath — is essential for survival.

In a world of reimbursement drought, respiratory providers have struggled to maintain the essential elements for survival. Just as spring promises renewal, the bariatric marketplace also infuses the industry with new opportunities for digging deeper roots. Providers looking for ways to expand their respiratory divisions can integrate bariatric patients into many product areas, including CPAPs, bi-level devices and nebulizers.

Research about the way obesity impacts respiratory function reveals that HME providers who are already covering the bariatric market must also develop a respiratory division to fully meet their clients’ needs. Likewise, respiratory providers, if they haven’t already, will likely see a huge shift of obese patients infiltrating the sleep and asthma segments of their businesses.

Planting roots in bariatrics beneath each of these conditions could in fact strengthen the respiratory industry, generating more revenue and further stabilizing the health of the U.S. population.

A Sleeping Seed: Trends in Obesity Offer Potential for Growth in Sleep Apnea Segment
The greatest potential for growing the respiratory business in conjunction with bariatrics lies with obstructive sleep apnea — an area long associated with obesity. After all, OSA basics tell us that the typical obstructive sleep apnea patient is “obese” with a “thick neck.”

Physiologically, obesity greatly impacts the mechanical function of the respiratory system. “Obese patients carry most of their weight in the chest and the abdominal area,” says Ann Tisthammer, BS, RRT, vice president of Clinical Education at ResMed, Poway, Calif. “The impact of this excess weight on breathing is significant. Excess fatty tissue around the upper airway, especially in the throat and the neck, predisposes a person for obstructive sleep apnea and increases the potential for upper airway collapse.”

Obesity actually impacts the respiratory system in different ways, says Dave Henry, DeVilbiss clinical education specialist for Sunrise Medical, Longmont, Colo. He calls the respiratory conditions associated with obesity “restrictive,” meaning that added weight actually limits breathing by restricting the movement of the thoracic cage.

“This inability to take a deep breath can even cause easy breathing to be labored and physiologically decrease oxygen saturation levels in the blood that ultimately increase the carbon dioxide levels,” says Henry. “All body systems can be impacted when this occurs.”

Essentially, the fatty tissue surrounding the respiratory system reduces the space necessary for the system to function. “The respiratory system is physically crunched,” says Sharon Baer, MBA, RRT, marketing manager for Clinical Marketing and Medical Education, Sleep and Home Respiratory Group, Respironics, Murrysville, Pa.

Sleep exacerbates the problem by further limiting the airway and, in the case of morbid obesity, increasing the chances that the airway will close off completely.

“When you sleep, there are certain periods of the night called REM sleep, where all of your muscles grow paralyzed except for your diaphragm,” says Baer. Bariatric patients require those muscles to move the lungs and the diaphragm. As a result, “they have significant desaturation when they hit REM, which may cause the person to stop (breathing),” says Baer.

But just harvesting the garden-variety OSA patient will not yield increased growth in the sleep business. Take a look at the following areas where a deeper connection with bariatrics might just help you reel in smart referrals and diversify your business strategy.

Trend #1: Bariatric Surgery Is on the Rise
As bariatric surgery becomes more accessible, a growing number of seniors are turning to surgery as a solution for obesity-related illnesses. For example, 20 percent of the Cleveland Clinic’s bariatric procedures are performed on seniors, according to a study released in February 2006.

Part of the reason for this shift is because payor sources are increasing their coverage of bariatric surgery. In the past, insurance companies did not readily pay for bariatric surgery, but that door has been opened a little more, says Tisthammer.

Another startling trend is the prevalence of childhood obesity, which is causing more adolescents to undergo bariatric surgery as well.

“You’re going to see people in their 20s all the way up probably to their 60s plus (getting bariatric surgery),” says Tisthammer.

Statistics show that 77 to 98 percent of bariatric surgery patients have sleep-disordered breathing, says Tisthammer. Because of complications with anesthesia, it is imperative that patients get their SDB treated before undergoing surgery.

As more bariatric surgeries are performed, weight loss will trigger an increased need for CPAPs and masks that can adapt to the changing needs of the user.

After bariatric surgery, patients typically lose between 60 to 100 pounds a year, explains Tisthammer. “Commonly their CPAP pressure requirements will decrease as they lose weight; it doesn’t necessarily resolve their sleep apnea, but they may have lower pressure requirements,” she explains.

Enter auto-PAP. Baer says that auto-PAP devices are recommended for bariatric surgery patients simply because of this change. “Their pressures initially after the surgery are very high and six months later may be 3 or 4 centimeters lower because they’ve lost weight,” she says.

Certainly, auto-PAPs make sense from a provider standpoint as well. A machine that automatically adjusts to the client’s changing pressure needs will reduce the costs associated with re-titrating the patient and readjusting the machines, not the mention the device will immediately improve the health of the patient.

“If you put an individual like that on fixed CPAP, the home care dealers will have to spend a lot of time, money and resources to continually monitor and adjust treatment pressure,” says Tisthammer. “It may also be necessary to send the individual back to a sleep lab to determine what pressures they require.”

Another potential pothole for respiratory providers treating bariatric surgery patients is addressing changing mask fit requirements. Fortunately, the need for flexible masks has not gone unnoticed by respiratory manufacturers.

Many manufacturers offer interfaces prepackaged with a variety of sizes that respond to the changing needs of the bariatric client as he or she loses weight.

“One of the things that Respironics really has focused on I would say over the last year and a half is making sure that when devices — interfaces specifically — are put out that the variety of sizes are included in the package vs. just one,” says Baer. “From a cost perspective, the patient doesn’t have to go and buy another interface that’s just a size smaller. They have that part in the kit already.”

In addition, ResMed offers masks that adjust in shape size and with the movement of the facial area. Essentially, an interface with built-in flexibility offers the most cost-effective and hassle-free choice for obese clients.

Another theory for bariatric treatment is giving the device a little more power. Sunrise’s line, for example, offers CPAPs with an increased upper pressure limit of 25 cm H20 to treat severe obstructions typical of morbidly obese patients.

Trend #2: Co-morbidities Offer New Opportunities
In recent years, the connection between sleep apnea and obesity has been further cemented by studies linking cardiovascular disease, such as stroke and hypertension — co-morbidities of obesity — to sleep-disordered breathing. As researchers continue to piece together the complexities of sleep apnea, other co-morbidities are sprouting.

Case in point: The recent uncovering of the connection between sleep apnea and Type 2 diabetes, also a known risk factor for overweight and obese individuals, has opened up a new avenue for growth in the sleep business. Initial research has shown a significant prevalence of sleep apnea in Type 2 diabetes.

“From a clinical perspective, the more that a patient is obese, the more likely they are to have other consequences of that obesity,” says Baer. That includes Type 2 diabetes.

“Like with any new market, what they’re yet to show unequivocally is the exact mechanism,” says Tisthammer.

As a result, the question remains of what came first, sleep apnea or diabetes. Right now, it’s easier to make the association with the fact that Type 2 diabetes, obesity and hypertension all led to sleep apnea.

“Studies have shown that CPAP does impact blood glucose levels,” says Tisthammer.

In fact, a German study published in 2004 showed that CPAP treatment improved insulin sensitivity, while another study published by the American Medical Association in 2005 indicated that CPAP reduced after-meal blood sugar levels dramatically throughout the day.

Also, several studies have linked sleep apnea with the production of hormones that regulate appetite and satiety, including leptin and ghrelin.

What does this connection mean for respiratory providers? If you’re not already targeting co-morbidities of sleep apnea to grow your business, you should be. Partnering with cardiovascular surgeons and physicians to screen patients for sleep apnea is vital, and targeting diabetes educators can have an equally important impact on business growth.

Though providers may be wary of new markets, Tisthammer says many diabetics are not necessarily going to an endocrinologist. In fact, the primary targets for referrals are primary care physicians and diabetes educators. Marketing sleep to a diabetes educator is not a hard sell, says Tisthammer. Diabetes educators, by definition, love to educate their clients. Providers do not need to explain diabetes to these sources but rather the basics of sleep.

“You’re teaching these individuals to simply assess and screen these diabetic patients for sleep apnea,” says Tisthammer.

Tisthammer recommends that providers assure diabetes educators that they will not be responsible for tackling mask issues and fielding phone calls about the equipment. Providers must also follow up on the back end to make sure that clients aren’t lost when they go to a sleep lab.

“Same with primary care docs,” says Tisthammer. “You’re not going in and teaching them everything there is to know about diabetes. You’re simply trying to set the stage for the correlation between some of the diabetes literature and research that’s been done and emphasizing the need of just a simple screening device or a questionnaire to try to get these patients identified. There’s a 50 percent-plus (chance) that a Type 2 diabetic patient will have sleep apnea.”

One way ResMed is reaching out to providers is through the development of a clinical education program called the ABCs of Zzzs. The program, available through ResMed sales representatives, helps HME providers understand the goals of diabetes educators or clinicians treating Type 2 diabetics. The letter “A” represents Hemoglobin A1C, which indicates blood sugar levels. “B” represents the patient’s blood pressure and “C” is a reminder that cholesterol needs to be kept at a certain level. “Zzzs” represents sleep.

“It goes back to that triumvirate of health: nutrition, exercise and healthy sleep,” says Tisthammer. “So, if we take care of the basics, the disease has to be addressed as well. We know if we can normalize the sleep-disordered breathing, that has an impact on all other aspects of health.”

Tisthammer says one of the things she gets asked frequently in the field from providers is how to grow their sleep business in the face of oxygen reimbursement cuts. “Expanding your business to address co-morbidities, particularly those with an abundance of data to back them up, is an excellent way to grow your business, differentiate yourself from your competitors and deliver quality patient care,” she says.

This article originally appeared in the Respiratory Management May/June 2007 issue of HME Business.

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