Breathing through the night does heart patients a world of good: For patients with heart failure and sleep disordered breathing, 30-day readmission rates dropped to zero when using continuous positive airway pressure (CPAP) adequately.
Lead author Shilpa R. Kauta, MD, from the sleep and circadian neurobiology center at the University of Pennsylvania in Philadelphia, and colleagues implemented a protocol for in-hospital sleep studies on cardiac patients with symptoms of sleep disordered breathing. Detection of sleep disordered breathing and apneas through unattended cardiorespiratory monitor recordings initiated CPAP therapy. For the study, they defined adequate CPAP use as four or more hours a night on a minimum of 21 days out of 30 post-discharge; partial use was anything less.
Of 106 patients reviewed for possible sleep disordered breathing, 81 had five or more apnea-hypopnea events an hour. These events included shallow breathing, gasping, snoring, choking and breathing pauses of 10 seconds or more. Sixty-five patients had obstructive sleep apnea, while 16 had central sleep apnea. Central apnea occurs when normally autonomous breathing signals become confused or stop. Nine of 16 patients had both central and obstructive sleep apnea.
Most patients in the study had heart failure, about 87.4 percent. Nearly half had atrial fibrillation or a combination of atrial fibrillation and heart failure.
Kauta et al discharged 50 apnea patients with CPAP devices, including five with central sleep apnea. Those who were diagnosed with some form of sleep disordered breathing but were not discharged with CPAP either refused treatment, needed further testing to determine best treatment, experienced incomplete heart failure management optimization or died before discharge. CPAP devices recorded usage.
Review of CPAP data revealed 45.2 percent of patients were full users and averaged better than minimum adequacy. These patients had no readmissions during the 30-day period.
Partial and nonusers of CPAP had similar readmission rates, around 30 percent and 29.4 percent respectively. Kauta et al noted this was a higher readmission rate than generally seen at the institution’s cardiac intermediate care unit, of around 12 percent to 18 percent.
While adherence to CPAP in the full-use group was excellent, outcomes may equally relate to adherence to other regimens, Kauta et al admitted, and no data was collected about these other factors that may have contributed to patient success.
Still, for Kauta et al, these findings support the cost of in-hospital sleep studies and CPAP use. They noted the average cost per heart failure hospitalization was between $13,000 and $18,000, with readmissions potentially costing hospitals more in Medicare penalties. They estimated the cost of sleep studies to be around $40,000 to $50,000, annually.
“Based on these numbers, decreasing 30-day hospital readmission rates by three to five patients per year would offset the cost of funding an inpatient sleep consult service,” Kauta et al wrote.
Sunil Sharma, MD, of the Jefferson Sleep Disorders Center at Thomas Jefferson University and Hospitals in Philadelphia, wrote in an editorial that these findings were promising. If confirmed through randomized controlled trials, Sharma noted, in-hospital sleep medicine could impact readmission rates and costs dramatically.
The findings were published Oct. 15 in the Journal of Clinical Sleep Medicine.