Effects of telemonitoringon treatment of sleepdisordered breathing
Oct 2015
This report is a deep dive into
sleep clinics in Finland andin the UK.

100%
Increase in capacity for new
patients.

-90%
In number of early drop-outs.

Photo: ResMedwww.pwc.se

Contents
Executive summary........................................................................3
Introduction...................................................................................4
Sleep-disordered breathing prevalence in Europe..........................6
Introduction to the patient pathway..............................................8
Use of telemonitoring in Finland..................................................10
The challenge: Increasing number of patients..............................12
The solution: Introduction of telemonitoring ..............................14
The results: Improved capacity to treat patients...........................16
Use of telemonitoring in the UK....................................................20
The challenge: Constrained resources..........................................22
The solution: Clinics experimenting with telemonitoring.............24
The results: Improving clinic efficiency........................................26
Case study...................................................................................30
Outlook and conclusions..............................................................32
Brief overview of selected European countries.............................34
Succeeding with barriers to telemonitoring.................................362

Effects of telemonitoring on treatment of sleep-disordered breathing

Executive summary

New solutions to treat
sleep apnea are required
Sleep-disordered breathing is a very
common but often overlooked medical
condition. It is estimated that 26%1 of
adults between 30-70 suffer from someform of sleep-disordered breathing.
Increased awareness and screening of
selected risk groups of the condition istriggering a rapid increase in the numberof patients. At the same time, resources
allocated to sleep clinics are limited,resulting in an impossible equation formany clinics across Europe.
Introducing telemonitoring
The first clinics in Finland introduced
telemonitoring in 2013, while several
sleep clinics in the UK are now in theprocess of introducing telemonitoring
to the patient pathway.
Finnish clinics needed to increase
patient throughput while keeping within
the limits of a fixed budget. The clinics
identified a means of replacing physicalvisits to the clinic with telemonitoring
and telephone interaction. Results fromthis indicate an up to 100% increase incapacity to treat new patients.

Clinics in the UK are still in the adoption
phase but are already seeing positive
benefits. Clinics report being able tointeract with twice the number ofpatients in the same time period whenusing telemonitoring technology. At thesame time they see huge benefits for thepatients that no longer need to take a
day off from work to travel to the clinic.
Early indications from UK clinics using
telemonitoring are lower drop-out rates.
Lessons from Finland and the UK
applied to other European countries
Outdated reimbursement models
requiring physical visits at clinics havebeen identified as one of the key barriers
to the adoption of telemonitoring, inboth Finland and the UK as well as
across several European markets.
A way forward is to find a way to encourage virtual patient interaction in placeof physical clinic visits. By using telemonitoring we note that sleep clinics cansave resources and time while improving
both quality and health outcomes andpatient satisfaction.

1. Peppard et al. Increased Prevalence of Sleep-Disordered
Breathing in Adults. Am J Epidemiol. 2013 (5.17)

A deep dive into sleep clinics in Finland and the UK3

Introduction

4Effects of telemonitoring on treatment of sleep-disordered breathing

A deep dive into sleep clinics in Finland and the UK

5

Sleep-disordered breathing
prevalence in Europe
The number of patients diagnosed with sleep-disorded breathing is
growing dramatically across Europe, putting a strain on sleep clinics
which face the challenge to treat additional patients while caring forthe patients already on treatment.
Sleep-disordered breathing encompasses
a range of conditions characterised byabnormal breathing during sleep. Prevalence of sleep-disordered breathing isestimated at c. 26%2 of the total adult
population, indicating a massive numberof c. 70 million potential patients suffering from sleep-disordered breathing in
the EU28 area. It should be noted thata significantly higher prevalence is seenamong obese and the male population in
the older age groups.
The prevalence of mild to severe SDB
was approximately 2-fold higher in older
men than in younger men (37% vs. 18%,
respectively); among overweight women, the prevalence was approximately
5-fold higher in older women than in

2. Peppard et al. Increased Prevalence of Sleep-Disordered
Breathing in Adults. Am J Epidemiol. 2013 (5.17)

6Effects of telemonitoring on treatment of sleep-disordered breathing

younger women (20% vs. 4%, respectively). However, it is worth mentioning that far from all patients currently
receive treatment.
The most common form of sleep-disordered breathing is obstructive sleep
apnea and is thus the focus of this paper.
What is OSA?
Obstructive sleep apnea (OSA) occurs
when the relaxation of the throat muscles obstructs airflow for more than 10
seconds at a time. The severity is usually
measured as the Apnea-Hypopnea Index(AHI). The AHI is the number of apneas
and/or hypopneas per hour of sleep (orstudy time).

The person experiences apneas, hypopneas and flow limitation. Apnea: a
cessation of airflow for ≥10 seconds.
Hypopnea: a decrease in airflow lasting≥10 seconds with a 30% oxygen reduction in airflow and with at least a 4%
oxygen desaturation from baseline.
Flow limitation: narrowing of the upper
airway and an indication of an impending upper airway closure.
OSA syndrome causes daytime sleepiness, slow reflexes and poor concentration. Diabetes, high blood pressure,heart disease, stroke and weight gain arecommon long term impacts of untreated
OSA.
Increased inflow of patients
There are several factors behind therecent increase of patient inflow at sleep
clinics.
• Firstly, the awareness of the medical
condition is increasing, both among
general practitioners and the wider
population.

• Secondly, screening of risk groups,
such as patients with diabetes andcardiovascular diseases has increased
in some countries and specific hospitals typically driven by individual
doctors.
• Thirdly, the screening of selected professional groups, such as taxi or truck
drivers, is increasing as the prevalenceof OSA has been seen to increase therisk of motor vehicle accidents by up
to 300%3.
• Lastly, obesity levels are increasing
which has a direct impact on the prevalence of OSA.
Resource constraints
An aging population is putting increased
pressure on the European health caresystem. Sleep clinics are often forced
to treat more and more patients withconstant, or even decreasing, resources.
New methods are needed to increase
efficiency at sleep clinics while maintaining, or improving, treatment quality andoutcomes.

Clinics in Finland and the UK are looking at telemonitoring as a solution
Sleep clinics in Finland and the UK wereidentified as front runners in telemonitored solutions to treat OSA. The primary focus of this report is to investigate
how they have successfully been able toincrease the number of patients treated
while also improving the quality of treatment delivered.
PwC visited and analysed seven clinics inFinland and the UK in order to understand treatment pathway and utilisationof resources. Our findings from thesevisits are presented in this report.
We also visited more than 30 clinics inother European countries. We use findings from these studies to contrast andcomment the findings in Finland
and the UK.

3. EU – “New Standards and Guidelines for Drivers with
Obstructive Sleep Apnoea syndrome. Brussels, 2013”

A deep dive into sleep clinics in Finland and the UK

7

Introduction to thepatient pathway
OSA treatment follows the same basic steps in all studied countries.
However, the detailed patient pathway differs greatly between
clinics – even in the same country.
The treatment of OSA is normally
initiated when the patient seeks care,either for symptoms directly related to
OSA or symptoms related to diabetes,
cardiovascular diseases etc. When OSA issuspected, a sleep study is performed todetermine whether the patient is in fact
suffering from the medical condition andto determine a suitable treatment method. The methods of conducting the sleep
studies varies between different clinics.
When a patient is diagnosed with OSA
a treatment method is prescribed.
This report exclusively studies positive
airway pressure therapy as this is themost commonly prescribed treatment.
A non-obtrusive mask connected to asmall machine that delivers a constantor automatically varying positive airway
pressure (CPAP/APAP) to the sleeper is
used.

8

Effects of telemonitoring on treatment of sleep-disordered breathing

This flow holds open the collapsible
upper airway. Other treatment methods
include oral appliance therapy, surgery
and weight loss.
When a patient has been prescribed a
CPAP/APAP device he or she visits theclinic for a treatment initiation appointment. Most clinics then schedule
several follow up appointments during
the first year to ensure that the patientis responding well to the treatment. The
first weeks of treatment are identified by
the clinics as the critical time when thepattern of adherence is established forthe majority of patients. Clinics acrossEurope inform PwC that only 60-70%
of patients stay on the treatment after
the first 6 months, but reliable statistics
are not available as many clinics do not
systematically follow up their patients.

Basic treatment steps

Clinic variations

Patient seeks care

- Primary care
- Specialists

Sleep study- At home or sleep lab- Oximeter/ Polygraphy (PG)/
Polysomnography (PSG)

Diagnosis- By doctor or nurse- Thresholds and treatment
method differs by country

CPAP/ APAP
treatment initiation- At clinic or home
- Individually or in groups- One or several visits

Therapy review- From no follow up to multiple
follow up with PSG tests atclinicContinuous
treatment- From no follow up to annual
follow up with PSG tests atclinicA deep dive into sleep clinics in Finland and the UK

9

Use oftelemonitoringin Finland

10

Effects of telemonitoring on treatment of sleep-disordered breathing

A deep dive into sleep clinics in Finland and the UK

11

The challenge: Increasing
number of patients
Finnish clinics were faced with what they called “the impossible
equation”, an increasing patient inflow without a corresponding
budget increase.

Three sleep clinics of varying size andstage of telemonitoring adoption were
included in the study in Finland. The
number of patient set-ups per clinic
ranged from three hundred to almost
one thousand patient set-ups with up to
10,000 patients on continuous treatment. However, in spite of large differences in size and geographic uptake
area, all of the clinics faced very similar
challenges.
The impossible equation
Prior to telemonitoring the Finnish
clinics were all facing three very toughchallenges.

12Effects of telemonitoring on treatment of sleep-disordered breathing

•

•

•

The demand for clinic resources was
growing very rapidly, driven by bothan increased inflow of new patientsand by a growing number of patientsalready on treatment.
Clinic budgets were kept constantdespite the clinics treating more andmore patients. One clinic had evenhad their budget decreased in thelast year.
Furthermore, the waiting time forpatient set-ups in Finland should notexceed three months. Any violationof this leads to fines for the hospital

The clinics were forced to look for new
solutions if they were to continue toprovide high quality and timely care to
their patients.

“It would be impossible for me to run the clinic without
telemonitoring, we would be over-run with work.”

Increasing patient throughput
Waiting times for patient set-ups weregrowing rapidly as the Finnish clinics
lacked the resources to treat all of thepatients. At all of the three studied clinics nurse time was identified as the main
bottle neck while the doctors, typically,
had spare capacity and would be able toincrease patient throughput. In the worst
case, patients at one clinic were waiting
up to 10 months to receive treatment.
Extra nurses and evening clinics wereused as a short term solution but at avery high cost. The primary motivation
for using telemonitoring in the Finnish
clinics was therefore to reduce waitingtimes for patients.

The clinics recognised that up to 70%
of patients responded well to the treatment and had no reason to come to theclinic for a follow-up visit during the firstmonth. However, the problem was thatwithout telemonitoring there was no
way of knowing which patient did notneed to come to the clinic.
By introducing telemonitoring during
the first 2-3 weeks of treatment the
Finnish clinics were able to identify patients responding well to the treatment
and thereby significantly reduce theneed for follow up visits. Telemonitoring
resulted in an increased capacity to treat
new patients by up to 25%.

70%
of patients responded wellto the treatment and had noreason to come to the clinic
for a follow-up visit during
the first month.

A deep dive into sleep clinics in Finland and the UK

13

The solution: Introductionof telemonitoring
By introducing telemonitoring to the treatment pathway gradually,
Finnish clinics were able to enjoy increased efficiency with very limited
investment in time and money.

Gradual implementationof telemonitoring
Telemonitoring was gradually introduced at the studied clinics in Finland.
A gradual introduction helped theclinics avoid large organizational andfinancial change. During the first phasea few nurses volunteered to try telemonitoring during patient set-ups (2-3weeks) on a limited number of patients.
At first, approximately half of all new
patients were treated on the telemonitoring pathway. Patients selected forthe traditional path included:• Senior patients (above working age).
• Patients with an oxygen saturation
below 90%.
• Other patients that the nurse
deemed to need a physical check-up.

Once the clinics had an established workflow and patient pathway, they gradually
started increasing the share of patientson telemonitoring. The clinic with themost experience of telemonitoring put
70% of all patients on the telemonitored
pathway. And interestingly, they tend touse telemonitoring increasingly for themost complex patients, as they need themost care.
Currently, the clinics only use telemonitoring for the first 2-3 weeks of treatment. The clinics have started to look at
the benefits from increasing the periodof time using telemonitoring, but at thetime of this study this has not been implemented by any clinic in Finland.

4. “The doctor is in – your smartphone”
PwC Sweden, 201514

Effects of telemonitoring on treatment of sleep-disordered breathing”We rapidly realised that our most complex patients needed more care than others;
they were the ones that would really benefit from telemonitoring.”

Majority of patients are
positive towards telemonitoring
Testimonials by clinic personnel indicatethat patients are very positive towards
telemonitoring in their treatment. This
was also confirmed in a recent study5
by PwC in Sweden. The study foundthat 74% of respondents were open to
virtual monitoring if they were subject
to a cardiovascular disease – and these

respondents were answering a purely hypothetical question. Among patients thatare already on telemonitoring, acceptance is even higher: 92% were satisfied
or very satisfied in a French survey of
OSA patients6.
Creating a coherent patient pathway
Prior to telemonitoring the patient
pathway at the Finnish clinics differedsignificantly, causing both in-equality
in treatment quality and higher cost
per treated patient. When introducing
telemonitoring, the clinics were able toaccess best practices from other clinics which resulted in a more coherent
patient pathway. On the following pages
we will investigate the new patient pathway in greater detail.

Gradual introduction of telemonitoring

Stage 3: Increase timeon telemonitoring*

Stage 1: Selected patientsfor patient set-ups• Less than 50% of patients.
• Patient results are reviewed
after 2 weeks.
• Easy to implement.

5. “The doctor is in – your smartphone”
PwC Sweden, 2015

Stage 2: Increase share ofpatients• More than 80% of patients.
• Easy to increase portion ofpatients when a patient pathway is already established at
the clinic.

• Increase time on telemonitoring.
• Patient results are reviewed atdetermined points in time.
• Reduced need for follow up visits
during the first year.
* To date, not seen implemented
at studied clinics

6. OpinionWay survey of 1012 French OSA patients
being telemonitored. February 2014

A deep dive into sleep clinics in Finland and the UK

15

The results: Improved
capacity to treat patients
How Finnish sleep clinics increased the number of treatedpatients by 10-25% while being able to improve complianceand treatment quality.

50%
less time needed totreat patients by using
telemonitoring.

16

Telemonitoring during the first 2-3
weeks of treatment was identified as thebest way to introduce telemonitoring
into the patient pathway in Finland. It
is during this time that both the risk ofpatients dropping out and the potential
to save nurse time is the greatest.
75 minutes saved forevery new patient treated
At treatment initiation all patients
visit the clinic to receive a CPAP/APAP
device. The patient is instructed on how
to operate the device and the device isregistered in an online database. Whenthe patient goes home the clinic staff
is able to see if and for how long thepatient is using the device – from thevery first night. The device also reports
how well the patient is responding to thetreatment.

Effects of telemonitoring on treatment of sleep-disordered breathing

During the first 2-3 weeks of treatment
all patients are reviewed by the clinic,
allowing the staff to intervene if a patient is for some reason using the device
or not responding to treatment. At theend of the period, data from the device
is coupled with qualitative informationfrom the patient through a phone call.
With this procedure all three clinics wereable to replace one or two physical clinic
visits with telemonitoring and a phonecall. This resulted in the clinics savingon average 75 minutes for every new
patient treated. In addition the clinics
could follow up on patients during thefirst critical week rather then months
later.

Traditional treatment process
1 weekDiagnoseand test
machine3 months

Treatment
initiation

Follow up
visit

Physician

1 year

1 yearFollow up
visit

Annualfollow up

30

Nurse

120

150 minutes

Process with telemonitoring

50%
less time

Telemonitoring
1 weekDiagnoseand test
machine2 weeks

Treatment
initiation

1 yearFollow upcall

1 yearFollow up
visit

Annualfollow up

Stage 2: We saw that the positive effects
on the clinic increased as more and morepatients were put on telemonitoring. The
clinic that over time increased the shareof telemonitored patients to 70% of
patients saw a 25% increase in capacity
to treat new patients compared to thesituation prior to introducing telemonitoring.

70

75 minutes

Note: Patient pathway based on example from one clinic

Increasing the share ofpatients on telemonitoring
Stage 1: We saw that clinics chose c. 50%
of patients for the telemonitoring pathway while the other half were treated on
the traditional treatment pathway. Thisway, clinics using telemonitoring wereable to treat a 10-16% greater numberof new patients with unchanged nurse
resources.7

5

Increase in capacity to treat new patients

25%

16%

10%

Clinic 1

Clinic 2

Stage 1: c. 50% of patientson telemonitoring

Clinic 3
Stage 2: c. 70% of patientson telemonitoring

7. The variation between clinics is from how effective they
were before telemonitoring.

A deep dive into sleep clinics in Finland and the UK

17

Further efficiency gains at Finnish clinics
Group patient set-ups and increased
time on telemonitoring were both
identified as further opportunities toincrease efficiency at clinics in Finland.
Group patient set-ups
Group patient set-ups were shown to
work very well in combination withtelemonitoring in Finland. Two of theclinics introduced group patient set-ups
at the same time as they introduced
telemonitoring while the third clinic
tried out group patient set-ups afterusing telemonitoring for about one year.
Group sizes varied from 5-6 patients at
two of the clinics to up to 12 patients at
one clinic.
One of the biggest concerns with grouppatient set-ups was that some patientswould fail to understand how to use thedevice and drop out of treatment as thesymptoms continue. With telemonitoring it is possible for clinic staff to spotthese patients and intervene, ensuringthat they stay on the treatment. A recent
study in Germany8 confirms the decrease
in drop-out for telemonitored patients.
Increasing time on telemonitoring
Extending the time on telemonitoringis seen as the next step by clinics inFinland. Similar to the current process,clinics could replace one to two follow up
visits during the first year with a phonecall. However, clinics have expresseda specific concern that needs to be addressed first:

18

Effects of telemonitoring on treatment of sleep-disordered breathing• To succeed with increased use of telemonitoring, the clinics must develop
a way to handle the large amount ofpatient data that would become available by extending the time patientsare on telemonitoring. In effect, theyneed to find a way to use patient information as a means to interact withthose who need help, while spending
less time on those patients that are
doing well.

Drop-out rates decreased from 10% to 6%
for patients on telemonitoring.
10
-40%
8
6
4
2
0
APAP/CPAP
No telemonitoring
With telemonitoring
Source: Telemonitoring solutions for a homecare
provider in obstructive sleep apnea (OSA), PwC
Case study, 2015

Efficiency gains remain the strongest
driver for adopting telemonitoring in
Finland. However, clinics note several
other positive effects on the treatment.
Improved treatment
quality and outcome
The driving force for the Finnish clinics
has been improving treatment process
efficiency to be able to treat all of thepatients in need. However, all clinics recognise a long list of qualitative improvements attributable to the introduction oftelemonitoring.
Improved overall health economics
When patients are being efficiently treated then the overall long term benefits toboth the patient – and the payor – arehigher. Also, the cost of NOT treating apatient is potentially very large. Several
studies indicate for example 23-50%
higher healthcare costs for patients prior
to starting treatment.8
Spotting patients with problems early
The first 10 days of treatment are considered to be critical for the overall successof the treatment of OSA9. The majority ofpatient drop outs occur during this time.
By using telemonitoring Finnish clinics
were able to spot patients not responding
to the treatment early on. By intervening
and correcting the problem the clinics
can ensure that more patients continue
on the treatment. One clinic estimates a
90% reduction in early drop-out rates forpatients on telemonitoring.

Reducing patient travel time
Sparsely populated areas are common
in Finland and some patients require an
entire day’s travel back and forth to thenearest sleep clinic. Furthermore, somepatients require ambulance transport toand from the clinic. By eliminating clinic
visits, the clinic and hospital can also
save significant ambulance resources.

Experience with external modems in the initial phase
When the clinics in Finland firststarted using telemonitoring there
were no devices on the market that
had built-in telemonitoring capabilities. A modem had to be attachedto the device during patient set-ups.
The modem was then returned by
the patient through mail two weeks
later. This set-up created some logistical issues having a limiting impact
on the positive efficiency gains fromtelemonitoring.

One of the clinics is now in thetransition phase to start using
devices with integrated telemonitoring capabilities. Instead of attachingan external module they can now
manage all telemonitoring activities from the clinic without patient
effort. This has helped the clinic tofurther improve efficiency benefits
from telemonitoring.

“We are still in the testing phase, but so far, out of 80
patients treated on telemonitoring only two have dropped
out during the first months.”

8. “What Are Obstructive Sleep Apnea Patients Being
Treated for Prior to This Diagnosis?*” Smith et al, Chest, 2002
9. Lichuan, Ye, Pack Allan I, Maislin Greg, Dinges David,
Hurley Sharon, McCloskey Susan, et al. 2012. “Predictors ofcontinuous positive airway pressure use during the first weekof treatment.” Journal of sleep research 21 (4)A deep dive into sleep clinics in Finland and the UK

19

Use oftelemonitoringin the UK

20

Effects of telemonitoring on treatment of sleep-disordered breathing

A deep dive into sleep clinics in Finland and the UK

21

The challenge:
Constrained resources
UK clinics are under pressure to keep waiting times for patient set-ups
below 18 weeks. Until now measures to meet this target have been
mainly temporary. Telemonitoring is now being introduced asa means to permanently improve clinic capabilities.
Telemonitoring has only recently been
adopted by sleep clinics in the UK andcomparable results from long-term use is
therefore not available on a broad basis.
Four clinics in various stages of telemonitoring adoption were chosen for the indepth study in the UK. Clinic experiencefrom telemonitoring ranges fromno practical experience to c. 6 months
experience. The selected clinics werealso of various sizes and locations withc. 200 to 1,200 patients per year.

22

Effects of telemonitoring on treatment of sleep-disordered breathing

UK clinics are under pressure to keep
waiting times below 18 weeks. Also,
they have only 6 weeks to diagnose thepatient. All studied clinics are currently
meeting these requirements; however, inmany cases they have been forced to findshort-term trade-offs to cope with thesituation.
• Weekend and/or evening clinics• Temporary extra staff.
• Reduced and/or delayed follow-up
checks.

The clinics have started to recognisethat the current situation is not sustainable in the long run. Even though
the referral rate of new patients would
remain constant, the number of patientson treatment would continue to growand demand increased clinic resources.
Furthermore, the temporary solutions
put a strain on clinic staff, making iteven more difficult to attract and retain
qualified staff.

Improved efficiency
and treatment quality
Clinics trying out telemonitoring in the
UK are already seeing clear benefits.
Efficiency and patient benefits are
summarised as follows:• Time saved through virtual patientinteractions.
• Pro-actively managing early issues withtherapy adherence, e.g. mask leak.
• Improved compliance.
• Travel time and expenses for patients.
In the following pages we will elaborateon the benefits and will in detail describe
how the clinics introduced telemonitoring.

A deep dive into sleep clinics in Finland and the UK

23

The solution: Clinics
experimenting withtelemonitoring
All studied UK clinics which had begun to try out telemonitoring had
developed a clinic specific approach and patient pathway. This differsfrom Finland where a coherent pathway was established at the clinics
with telemonitoring.

The clinic approach to introducing
telemonitoring to the treatment process
differs greatly between clinics in the UK.
We identified two distinct approaches:• Varying experimental approaches• Service-wide approach
Several clinics had chosen an experimental approach whereby they selected a small portion of patients to try
telemonitoring. In contrast, one clinic
had introduced telemonitoring into themainstream treatment pathway, putting
all patients on telemonitoring.

24

Effects of telemonitoring on treatment of sleep-disordered breathing

UK clinics also differed compared with
Finnish clinics in terms of telemonitoring
duration. While the Finnish clinics
introduced telemonitoring by using it
only for the first 2-3 weeks, and are now
reviewing telemonitoring as a viable
longer-term solution, the UK clinics
are planning to keep patients on telemonitoring for the first 3-24 months oftreatment.

Experimental approach
Two of the studied clinics adopted anexperimental approach to introducing
telemonitoring to selected patients only.
Patients were selected mainly based on
the following criteria:• Medical condition requiring more
follow-up.
• Long travel distance for patient.
For these clinics, the use of telemonitoring is mainly motivated by improving
treatment quality for a selected few patients. Efficiency gains remained limited
as the share of patients on telemonitoring remained very low, as little as eightpatients so far in one of the clinics.

An experimental approach has a limited
impact on clinic operation and overall
service delivery. The existing patient
pathway is kept unchanged for other
patients and only a small portion of thestaff need training in new methods. It
is then, possible for the clinics to scale
up the portion of patients on telemonitoring in a controlled manner. From ourinterviews is seems very likely that theshare of patients on telemonitoring will
increase, as the clinics express satisfaction with the trials so far.

Service-wide approach
One of the clinics chose to do a service
wide introduction of telemonitoring.
The clinic changed the patient pathway
for all patients to include telemonitoring.
Compared with the experimental approach, benefits of this approach include
eliminating the need for two parallelpatient pathways. The service-wide
approach also enables the clinic to reap
efficiency benefits from day one. The
clinic was able to reduce a 30 minutephysical follow up visit to a 10-15 minutevirtual follow up (through phone or even
Skype).

A deep dive into sleep clinics in Finland and the UK

25

The results: Improving
clinic efficiency
Several benefits of telemonitoring were identified at the sleep clinics
in the UK, with increased clinic efficiency comprising a strong benefit.
Other benefits include improved treatment quality, as well as patient
convenience and comfort.

40%
of our time slots forfollow-up are wasted due torescheduling and “DNAs”.

Despite only being in a trial phase, theclinics had identified several clear benefits from using telemonitoring to treat
OSA syndrome. Four main benefits areillustrated and discussed below.
More efficient follow-up
One of the main challenges for the UK
sleep clinics was to keep up with theneed to execute follow-up on patients,
both at the beginning of treatment andin annual follow-ups. Follow-up appointments were constantly being delayed,jeopardising the quality of treatment.
Clinics found that telemonitoring improved the efficiency of follow-up visits
in two ways:• Reduced required nurse time bycalling patients instead of physicalvisits at the clinic.
• Reduce the share of “do not attends”(DNAs).

26

Effects of telemonitoring on treatment of sleep-disordered breathing

Improved efficiency – time spend on
physical vs virtual visit

30
minutes15
minutes

Physicalvisit

Virtualvisit withtelemonitoringand phone/Skype.

“With telemonitoring, we can interact with two patients in the same amount of time.”
When introducing telemonitoring, clinics were able to replace physical visitswith remote reading of patient data.
One clinic noted that they could double
the number of slots for follow-ups with
the new method.
Furthermore, the capacity at UK clinics
was strained as up to 40% of planned
follow-up time slots were wasted due
to patients not attending or rescheduling at the last minute. Initial trials oftelemonitoring showed that the portionof wasted timeslots was minimised
when the clinic staff reached out to thepatient.
A study in Derby found that the useof telemonitoring could reduce thenumber of physical visits by a patientfrom an average of 4.5 for the traditional pathway, to only 2.3 for monitored
patients. And, the DNAs frequency
dropped to zero.10

1

More efficient
follow-up

Patient
convenience4

Benefits withtelemonitoring

Improved
treatment
quality2

Improved
compliance3

10. “An evaluation of the benefits of a telemedicine
service for CPAP follow up” Fillingham R C, ClinicalMeasurement Department, Royal Derby Hospital 2014

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27

Improved treatment quality
Identifying and helping patients withissues is seen as an important measureof treatment quality. If a patient is not
responding well to the treatment, there
is a high risk that he or she will dropout. One clinic had started to systematically use telemonitoring to identify
and reach out to patients with issues,
thereby significantly increasing thequality of treatment.
Furthermore, the same clinic has notedthat the number of patients calling tobook an additional follow-up visit has
decreased. By reacting to non-compliant patients and doing virtual patientinteractions, the clinic was able tofree up time slots that were previously
required for extra follow-up visits.
A German study provides additional
underpinning evidence to the trends
seen in the UK clinics – namely: asignificantly increased compliance fortelemonitored patients compared to
traditional patients.11

11. “Telemonitoring solutions for a homecare provider inobstructive sleep apnea (OSA), PwC Case study, 201528

Effects of telemonitoring on treatment of sleep-disordered breathing

Target patients:
compliance improvement
Professional drivers were identified asa large patient group with a need for
certified compliance. Despite frequentclinic visits to ensure compliance forthis target group, clinics cannot havefully updated information as to how thepatient is responding to the treatment.
Telemonitoring provides reliable andcontinuous data on compliance for thisgroup of patients.
Patient convenience
Patient convenience is recognised as
one of the major benefits from telemonitoring in the UK. A physical visit istroublesome for patients in two distinct
ways:• Direct travel expenses (fuel andparking).
• Have to take time off from work totravel to and from the clinic.
Some patients also require ambulancetransport to the clinic. Cost of ambulance transport is often not part of theclinic budget but significant savings canbe made at a hospital level.

Without telemonitoring or intervention

With telemonitoring and intervention

110

110

100

100
Compliance in %Compliance in %Overview of patient compliance without and with telemonitoring and intervention

90

80

70

60

90

80

70

60
0

6

12

Months in therapy

24

0

6

12

24

Months in therapy

PAT gender
FemaleMale

Source: Telemonitoring solutions for a homecare provider in obstructive sleep apnea (OSA), PwC Case study, 2015

Patient interaction matters
Frequent and high quality patient interactions are seen as very important by
clinic staff treating OSA patients. However, the interviewed physicians do not
see physical visits as a guarantee to achieve this. Virtual interactions utilisingmodern technology, such as telemonitoring, can be used to reach the same, oreven better, results.

A deep dive into sleep clinics in Finland and the UK

29

Case
study

Wrightington,
Wigan and LeighNHS Foundation
Trust Hospital
In 2014 the sleep clinic at Wrightington, Wigan and Leigh NHSFoundation Trust Hospital was running at maximum capacity
treating over 500 new patients per year. The clinic hoped to improve
efficiency by introducing ResMed Air Solutions, a telemonitoring
solution by the company ResMed.

One hospital within the NHS network,
Wrightington, Wigan and Leigh NHSFoundation Trust Hospital, provides
healthcare services to a population ofover 300,000 patients in North-WestEngland. The Sleep and Respiratory clinic within the hospital is staffed by four
clinicians and one consultant working
across sleep and respiratory wards. The
clinic was established in 2009 and now
supports over 2,000 patients setting up
over 500 new patients per year.
Identifying the problem
Prior to October 2014, the clinic wasexperiencing major capacity issues
and faced the prospect of exceeding its
commitment to treat diagnosed patients
within 18 weeks of referral. At the sametime, the therapy review period – thefollow-up visits – was being stretched.
One of the clinics senior clinicians, Claire
Goulden, recognised that the traditional
pathway would not be viable long term
without some changes. Goulden says,“there was no scope for extra staff tocope with rapidly increasing demandwhilst being able to cost-effectively
maintain the traditional level of patientcare”.
Goulden then learnt about AirView™,part of ResMed Air Solutions, and wasinterested in the opportunity to increase
efficiency in their care pathway. Aftercompletion of NHS IT & Information
Governance approvals, the activationof ResMed Air Solutions commenced.

With telemonitoring the sleep clinic was able to increase thenumber of patient set-ups, patient satisfaction while boosting thequality of care.

Maximising capacity
Goulden says “by using AirView, the careteam was soon able to quickly identify
those patients who were non-compliant
or experiencing problems”. Using AirView enabled the care team to increase
new patient set-up slots by 25% andfollow-up slots by 14%, whilst reducing
unnecessary out-patient appointments
and therefore appointments where thepatient does not attend.
Increasing efficiency
and patient satisfaction
Previously when patients reported
issues, the patient would be inconvenienced by having to return their device
to the clinic or for those patients unable
to travel, two clinical staff, (due to safety
precautions), would have to drive tothe patient’s home. Goulden says “withResMed Air Solutions in place, the careteam could remotely check the device

status using AirView’s ‘Remote Assist’feature and if required update therapy
settings without leaving the clinic”.
Boosting quality of care
The time savings realised by using
ResMed Air Solutions has allowed
Goulden and the team to spend moretime on more complex patients, such as
those with Central Sleep Apnoea (CSA)and Cheyne-Stokes Respiration (CSR)
that can also be identified via AirView.
Goulden says, “by implementing
ResMed Air Solutions we will be able toreplace the current six month follow up
visit, typically 30 minutes in duration,
for all patients with a targeted consultation for only the patients that require
it. This will lead to further significant
clinician time savings”.

Claire Goulden – Wrightington, Wigan andLeigh NHS Foundation Trust Hospital

Increase in available time slots

40%

25%

14%

Follow
up slotsNewpatients
slots

CPAP trial
set up slots“By using AirView, the care team wassoon able to quickly identify thosepatients who were non-compliant orexperiencing problems.”

A deep dive into sleep clinics in Finland and the UK

31

Outlook andconclusions

32

Effects of telemonitoring on treatment of sleep-disordered breathing

Deep dive into clinics
Countries studied

A deep dive into sleep clinics in Finland and the UK

33

Brief overview of selected
European countries
Studies by PwC indicate that findings from Finnish and UK clinics
can be used to understand the state of OSA treatment across theEuropean continent.

PwC European sleep studies
PwC has conducted studies on the treatment of OSA in eight countries acrossEurope, including Finland and the UK.
The studies show that other European
sleep clinics face similar issues to theclinics in Finland and the UK.
• Resources for sleep clinics are limited.
• Reimbursement models are often
outdated, promoting inefficiencies
at the clinics.
• The demand for sleep clinic services
is growing as awareness of OSA isincreasing.

34

Effects of telemonitoring on treatment of sleep-disordered breathing

These issues have caused many clinics
in the studied countries to consider telemonitoring as part of a solution to thesituation. However, adoption takes time
and to-date telemonitoring is not widelyused in the studied countries. It is ourhope that this report will help clinics anddecision makers to see the benefits oftelemonitoring in the treatment of OSA.

A comparison of selected countries shows similar drivers and barriers to telemonitoring.
CountryState of sleep treatment

Drivers for telemonitoring

Barriers to adoptionUK• Lack of capacity to treat newand existing patients. Temporary measures employed.
• Hospitals are financially
penalised if they fail to meetthe 6 week time limit fromreferral to diagnosis, or the 18
weeks time limit from referral
to treatment.

• Maintain clinical standards
while increasing capacity withconstant resources.
• Improve patient convenience.

• Reimbursement model forsome clinics.
• Difficulties in changing patient
pathway to fit telemonitoring.

Finland• Growing waiting times.
• Hospitals are fined for overthree month waiting times.

• Reduce waiting times.
• Improve capacity for new andexisting patients within existing
budget.

• Clinics are awarded fixedbudgets regardless of thenumber of patients treated.

Sweden• Growing waiting times fortreatment.
• Over one year waiting time atsome clinics.

• Reduce waiting times.
• Improve capacity for new andexisting patients within existing
budget.

• Difficulties in changing patient
pathway to fit telemonitoring.
• Reimbursement for physicalvisits in some regions.

Norway• Growing waiting times
for treatment.

• Reduce waiting times.
• Increase number of treatedpatients.

• Reimbursement model.
• Physical visits receive muchhigher reimbursements thanvirtual follow-up visits.

Poland• Very low portion of population
on treatment – due to lack ofawareness and low priority.
• Limited follow-up done today
due to reimbursement model.

• Cost efficient method for follow-ups.
• Clinic concerned aboutcompliance.

• Reimbursement model.
• Clinics are only reimbursed
for diagnosis.

Belgium• Cost of treatment is
exploding.
• Partially due to outdated
reimbursement models.

• Government is looking
to cut costs.
• Telemonitoring is seen
as a way to go forward.

• Reimbursement requires
physical control visits.
• Patient data privacy
concerns.

Germany• Majority of treatments are
funded by insurancecompanies.
• Cost of treatment is a major
issue.

• Way to lower
cost per patient.
• Insurers demanding
proof of compliance.

• Focus on absolute cost.

Czech Republic• Very low share of population
on treatment.

• Patient convenience.

• Reimbursement model notsuitable for telemonitoring.

A deep dive into sleep clinics in Finland and the UK35

Succeeding withtelemonitoring

Despite evident benefits from telemonitoring, any widespread adoption
across Europe is still absent. Overcoming outdated reimbursement models and resistance to change is key going forward.
As has become evident in reviewing
sleep clinics in Finland and the UK,
telemonitoring can greatly improve clinic
efficiency while contributing to better
quality treatment and patient comfort.
But why is the adoption rate of telemonitoring remaining at a low level acrossEurope?
The reasons have been identified in thisstudy:• Stagnant clinic reimbursement
models.
• Resistance to change.

36

Effects of telemonitoring on treatment of sleep-disordered breathing

Successfully overcoming outdated
clinic reimbursement models
Clinic and hospital reimbursement models differ greatly, both between countries
and for clinics within the same country.
Some clinics have a variable compensation based on for example patient visits,
new patients treated and/or number ofpatients in treatment while other clinics
have a fixed budget, regardless of how
many patients are treated.
However, what is common for mostclinics is that the reimbursement models
were set-up before efficient telemonitoring solutions were introduced for OSA

Case 1: New reimbursement models
treatment. Variable reimbursement isoften based on what clinics do (e.g., seeing a patient at the clinic), rather thanhow patients are doing (e.g., patient is
responding well to the treatment), while
fixed reimbursement does not take treatment quality into account to any degree.
Some clinics even experience a negative
financial impact from introducing telemonitoring as only physical clinic visits
are reimbursed.
We propose that decision-makers at alllevels should take a patient perspective,
instead of a clinic perspective, whensetting reimbursement levels. Instead ofdemanding specific actions, sleep clinics
should be steered towards providing
efficient and high quality care for theirpatients. More patients could be treatedwith a high quality level and at a similar
or lower cost if this approach was betaken.

One clinic in the UK was receiving only 30% of the compensation for remotely monitoring and calling the patient than theywould receive by physically dealing with the patient at the clinic.
With these conditions, it would have been financially unviable tointroduce telemonitoring and substitute a clinic visit with remotemonitoring and phone calls.
However, the clinic was determined to introduce telemonitoringin order to both improve treatment quality and clinic efficiency.
The clinic staff took the discussion to the regional NHS trust, andby showing the clear benefits from telemonitoring, the parties
were able to come to a conclusion. The compensation discount
was set at c. 65% of a physical visit. In effect, the clinic receives
65% of the revenue, and spends 50% of the time compared to aphysical visit, leading to an overall positive financial effect forthe clinic.
This made it possible for the clinic to adopt telemonitoring into
the treatment process. Three physical visits during the first yearof treatment could be replaced by remote monitoring and phone
calls, effectively decreasing the nurse time required for eachnew patient treated by up to 60%. At the same time, the Trust
was also able to significantly reduce the cost per patient.

A deep dive into sleep clinics in Finland and the UK37

Case 2: Successful change
Step by step, how a clinic in Finland
introduced telemonitoring
1.

Study and understand how telemonitoring is usedin other clinics in the country.

2.

Nominate one or two nurses as “champions” fortelemonitoring. They will also be responsible fortreating the first patients on telemonitoring.

3.

Develop a new pathway that can be usedsimultaneously with the existing patient pathway.

4.

Select patients or patient types to try thetelemonitoring pathway.

5.

Review the pathway, what worked well andwhat could be changed.

6.

Start to increase the portion of patients ontelemonitoring.

Using this step by step approach, the clinic was able
to try out telemonitoring while keeping the existing
pathway. Once they had first hand experience, theclinic was able to increase the portion of patients ontelemonitoring in a very controlled manner.

Overcoming resistance to change
Resistance to change is a common barrier as regards all types of technologicalinnovation. Many clinics that had not yet
started with telemonitoring expressed
concerns over telemonitoring with thetwo following worries often coming to
the fore:• “We fear telemonitoring will add to
our workload – where would we findthe time to use all that new information?”• “We’re unsure as to the data provided
by telemonitoring. Does it give me all
the data I need on my patients?”
However, clinics that have implemented telemonitoring are able to counter
these worries: The workload actually
decreases, as telemonitoring enables theclinic to have fewer physical visits while
increasing patient interactions. And the38

Effects of telemonitoring on treatment of sleep-disordered breathing

data provided by telemonitoring – often complemented by a phone call – isdeemed fully satisfactory by the interviewed clinics.
Clinics can overcome this resistance by
gradually introducing telemonitoring insmall steps, as clinics in both Finland andthe UK have done. This approach minimises the sudden changes that have to bemade in the patient pathway, while enabling the clinic to experience the benefits
first-hand. Furthermore, we suggest thatclinics that are interested in introducing
telemonitoring learn from other clinics
by studying established patient pathways
incorporating telemonitoring.

PwC and this research
The researchThis report is based on knowledge
gathered first hand at a number of sleep
clinics across eight countries in Europe.
The studies have been sponsored by
ResMed, a global leading provider ofsleep and respiratory care solutions.

PwC reports on eHealth• “The doctor is in – your smartphone”
2015

PwC
PwC helps organisations and individuals
create the value they are looking for. We
are a network of firms in 157 countries
with more than 195,000 people committed to delivering quality in assurance,
tax and advisory services. Tell us whatmatters to you and find out more byvisiting us at www.pwc.com. PwC refers
to the PwC network and/or one or moreof its member firms, each of which is aseparate legal entity. Please see www.
pwc.com/structure for further details.

• “Global health´s new entrants:
Meeting the world’s consumer”
2015• “Telemonitoring solutions for ahomecare provider in obstructive
sleep apnea (OSA)”, PwC Case study,
2015• “Emerging mHealth: Paths for rowth”
2014• “The global mHealth market opportunity and sustainable reimbursement
models” 2013
• “Touching lives through mobile
health” 2012
• “Moving towards good practice inthe reimbursement of CIED
telemonitoring” 2012

Find more reports from PwC at:
www.pwc.se/healthcare

A deep dive into sleep clinics in Finland and the UK

39

Contact us!
PwC Strategy
Christian Käfling+46 709 293926
christian.kafling@se.pwc.com
Niklas Carling+46 725 849217
niklas.carling@se.pwc.com

PwC Health Care Team
SwedenJon Arwidson+46 709 293102
jon.arwidson@se.pwc.com
Finland
Karita Reijonsaari+358 50 387 8119
karita.reijonsaari@fi.pwc.com
United Kingdom
Andrew McKechnie+44 20 721 26327
andrew.mckechnie@uk.pwc.com© 2015 PricewaterhouseCoopers i Sverige AB. Whole or partial duplication of the contents of this document is forbiddenin accordance with the Swedish Act on Copyright in Literary and Artistic Works (1960:729). This prohibition applies toevery form of duplication by printing, copying, etc.

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Effects of telemonitoring on treatment of sleep-disordered breathing