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Homogeneous vs. Heterogeneous Environments and Impact on Sleep Therapy Compliance Contributors Jacob McCabe, RN, Clinical Educator, National Sleep Therapy Eric Cohen, Co-Founder, researcher, National Sleep Therapy Executive Summary Currently, most sleep therapy equipment is delivered to a patient diagnosed with sleep apnea in the home (heterogeneous environment). This delivery model is susceptible to quality and consistency variations that can have a significant negative impact on clinical outcomes. Using this model typically results in CPAP adherence of less than 50%. In contrast, using the National Sleep Therapy model, CPAP dispensing and education is provided in the clinical setting (homogenous environment). This is shown to substantially raise CPAP compliance and patient engagement. National Sleep Therapy works with physicians and sleep centers to raise compliance using advanced clinical protocols showing compliance rates as high as 84% and patient satisfaction of 99.44%. Environment variations Homes are considered heterogeneous environments due to their variability and unpredictability from patient to patient. No two homes are identical and therefore heterogeneous. Children, pets, lack of space, television, and other distractions are a routine part of every traveling homecare worker’s day-to-day experience. The heterogeneous environment typically has uncontrolled lighting, sound and space. General environmental conditions are not conducive to the focus and attention required for learning, long-term patient engagement and positive outcomes. By contrast, the clinical environment in a sleep center or physician practice is better suited for proper education and engagement of the sleep therapy patient. This homogeneous environment (controlled and standardized for all patients) affords the ability to provide every sleep therapy patient with a consistent and “designed” experience that leverages best practices and established clinical protocol. Patient outcomes can be measured and environments can be adjusted to further improve outcomes in a controlled and measureable system. Patients show greater respect for the sleep therapy process when introduced in a clinical setting. Role of Environment on Therapy Sleep Therapy is a process rather than a single diagnostic and therapeutic event that can often require ongoing patient interaction, support, counsel, and equipment modification. It is demonstrated that patient engagement is critical to longterm therapeutic benefit. When patients are engaged in the therapeutic process, compliance is higher. Therefore, the initial patient education and engagement is critical to long-term success. Heterogeneous setting and the negative impact on compliance In the heterogeneous setting, there are a number of factors that decrease quality of the experience and long-term patient outcome: Scheduling problems Patients are more likely to delay appointments making subsequent appointments late, which results in a severely compromised patient experience. Clinician variability Aside from the fact that many “DME” companies deliver CPAP to patients using untrained employees, even when clinicians carry out this function, variability from clinician to clinician is considerable. For this reason, the ability to train and deliver a compassionate, engaging educational experience to the patient is compromised and cannot be guaranteed to meet any minimum standards for best practice. Framework and learning The home environment lacks a framework conducive for learning. Optimal education relies on the ability of the learner (i.e. the patient) to understand and internalize information in such a way that it is perceived relevant and meaningful. Helping patients achieve the necessary “openness” for learning is difficult due to the variability of the skill set of the person delivering equipment (driver? clinician? mailman?) and the environment at the time. Patients often report, “They dropped off my equipment and told me how to use it. I don’t remember anything about it. I need help.” Lack of focus In the home setting, variability in this environment ranges from friendly and inviting, to dangerous and nonconductive to any clinical education. Many clinicians report conditions so uncomfortable that they were only able to drop off equipment and would not enter the home. While these environments are not ideal for proper clinical education, they may also put healthcare workers at risk. Because heterogeneous environments are unpredictable and do not facilitate a consistent patient education experience, the industry, in using this model, demonstrates compliance rates of less than 50% unless substantial provider involvement occurs in the clinical setting. The authors acknowledge that there are some home settings and clinicians that in combination can lead to good patient outcomes. This scenario is the exception rather than the norm and should not be relied upon for high quality patient care. The goal of a consistent point of care education and set up process is to control those factors that can be controlled and thereby maximize the possibility of better compliance and resulting outcomes. Homogeneous environments (clinical setting) and high compliance In the homogeneous setting, there are a number of factors that increase the quality of the experience and long-term patient outcome: Patient Expectations Patients are more likely to keep appointments with the expectation that they will meet an expert in the sleep field that will support their clinical needs. They tend to have more respect for a clinician’s time in the clinical environment than in their home environment. Clinical Access Participating in a defined process in the clinical setting provides the opportunity for a patient to have immediate access to additional resources as necessary. For example, a physician can be involved with the patient as a set up is being conducted to confirm the diagnosis and support the entire process. Consistent Education Every patient receives a consistent, high quality education using a carefully designed clinical protocol in a controlled setting. This consistency enables providers to deliver high quality care more efficiently due to the educational foundation provided at the initiation of CPAP therapy. iPads and other techniques are employed to inform, empower, and engage patients. Trust and Collaboration With proper messaging during CPAP education, and due to the physical proximity of CPAP in the clinical setting, patients associate therapy with a clinical need. This association provides patients with a greater awareness as to the importance of CPAP therapy and overall health thus improving compliance. Patients enter a system of “closed-loop” collaboration between provider and National Sleep Therapy whereby information is shared consistently and quality of care is increased. Long-term engagement When the CPAP initiation process is controlled, patient engagement increases. Increased engagement results in an increase in “permission to support” and ultimately favors long-term adherence to CPAP therapy. Summary Traditional methods for delivering sleep therapy equipment in the home setting are sub-optimal and result in low industry compliance averages. The home (heterogeneous) environment lacks the structure and control required to follow a best practice protocol to raise patient engagement and compliance. By contrast, following National Sleep Therapy’s education protocol, administered in a controlled clinical setting (homogeneous), results in substantially higher CPAP compliance rates as high as 84% and patient satisfaction of 99.44%. In addition, self-reported patient data suggests a greater percentage of patients experiencing the overall health benefits of CPAP therapy including weight-loss, reduced dependency on medications, improved daily function, and an overall better outlook on life.