Empowering the sleep
apnea patient
How online patient engagement tools
improve adherence to treatment

www.pwc.se

Contents

Summary and highlights........................................................................3
Introduction...........................................................................................6
Previous studies on patient engagement and sleep apnea......................10
Description of studied patients.............................................................12
Germany..............................................................................................16
The UK.................................................................................................20
Introducing myAir to patients ..............................................................24
Analysis and Conclusions......................................................................26
Methodology........................................................................................29
Appendix..............................................................................................34

2

Empowering the sleep apnea patientSummary and highlights

Sleep apnea is a condition that affects more than 3 in 10 men and nearly 1
in 5 women¹. It occurs when an individual stops breathing for a period ofat least 10 seconds while asleep, and when this appears 5 times or more perhour. The condition is associated with comorbidities including heart failure,
diabetes, and hypertension. The gold standard treatment for sleep apnea iscontinuous positive airway pressure (CPAP) therapy, which keeps the airway open to prevent apnea events from occurring. Research has shown thatconsistent use of CPAP therapy is associated with improved health outcomes.
Increased awareness and screening of
selected risk groups is triggering a rapid
increase in the number of sleep apnea
patients across Europe. At the same time,
resources allocated to sleep clinics arelimited, causing a difficult situation formany clinics.
Telemonitoring has had considerable
impact on many clinics and home careproviders in managing sleep apnea patients. Mostly in how they work and treat
patients and often resulting in the clinics
and home care providers becoming moretime-efficient, typically with 30-50%
time savings2. They manage to treat
more patients, as telemonitoring enables
clinics and home care providers to treat
patients differently according to their
specific needs. Examples are low-touchand “virtual” consultations with somepatients, and frequent interventions withother patients.

Another use of telemonitoring is the possibility to track and share CPAP usage information with the patients themselves.
There is evidence that giving patients
access to information about their own
treatment leads to better adherence3,
and also that automated, trigger based
email- or text messages have the same
positive effect as traditional humaninterventions4.

Most patients today have a PC or
smartphone with internet access. Thisis also true for older patients indicating
technology is becoming prevalent inall patient groups, not only among theyoung and technology savvy. Yet, very
few patients today use the technology
they have at home as a tool in treating
their sleep apnea, mainly because it has
not been possible before CPAP devices
were connected to telemonitoring. Thishas changed with the introduction of
myAir, which is an online web-page
where patients can track their CPAP
treatment. myAir also provides notifications to alert the user to a problem or topositively reinforce behavior.

And interventions matter. Studies haveshown that different types of interventions increased daily usage between 30
minutes and 1h30 minutes5. There is acommon belief in the industry that patientengagement is one of the key elements
to successful treatment – and reminders,education and behavioural support are
all intended to empower the patient andfacilitate successful treatment.

This paper aims to test a simple hypothesis formulated as:“Patients that use myAir show significantly and measurably better adherence and usage than other patients.”

1. Peppard et al. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol. 2013 (5.17)
2. Effects of Telemonitoring on treatment of sleep-disordered breathing, PwC 2015
3. Kuna et al, 2015
4. Munafo et al, 2016
5. Wozniak et al, Cochrane Publications, 2014

Empowering the sleep apnea patient3

Respondents’ attitudes towards mobile solutions – by age group
Has health-related apps
63%
50%
21%
Owns a wearable device
29%
22%
10%
Plans to purchase a wearable device in the coming year
37%
32%
14%
0

18–34

35–54

35

55+

70

This paper presents the results of a studyof over 23,000 patients in Germany, theUK and Ireland, approximately 1,800
of which have registered for myAir. The
study aims to understand if and how
myAir patients behave differently fromother patients with regards to their PAP
device usage. We want to understandif access to treatment data and being
supported by myAir’s trigger-based andautomatic “interventions” have an effecton patients’ device usage and treatment
adherence.

We have looked at new and establishedpatients in both countries. Patients who
registered for myAir show significant increased daily device usage and improved
adherence to therapy.

The result: myAir patients show significantly better daily
usage, as well as higher adherence, than other patients(P<0.0001).

4

Empowering the sleep apnea patient•

The increase in daily device usage is 46 minutes on average over the studied 3
months period for all patients. myAir patients use their therapy device 6h 1m
on average, while other patients use their therapy device only 5h15minutes
on average per night•First week average adherence for new patients is 76% for myAir patients vs
71% for other patients

Daily average device usage

Both countries, all patients, 6 February to 28 April 2016.

myAir

myAir patients use the device on average 46 minutes longer every nightcompared to other patients.

Hours

6

not myAir
5
4
3

6 feb

28 apr

N=23,000 non-myAir, 1,800 myAir. P-value <0.0001 for entire model; P-value <0.0001 for myAir
patients; P-value 0.024 for other patients.

myAir patients also have higher adherence rates than other patients. Again, true forboth countries and all clinics and home care providers.

Weekly average adherence (minimum 4 hours of daily use)
Both countries, new patients, calibrated to day 1, first 8 weeks

myAir patients have higher adherence than other patients, also overtime

% of patients
myAir		Not myAir		
Difference

Week 176%
71%
5 pptsWeek 2
81%
70%
11 ppts

Week 3
79%
68%
11 ppts

Week 478%
67%
11 ppts

Week 579%
67%
12 ppts

Week 678%
66%
12 ppts

Week 779%
67%
12 ppts

Week 881%
68%
13 ppts

Differences are seen in the first week of treatment and remain over time. In addition to
helping patients achieve better usage, we have some early indications that the “empowered” patients are less prone to call the clinic for help. Or as one clinic puts it:“In the last few months since we started promoting myAir,
we’ve seen a significant decrease in the number of incoming
phone calls”

Empowering the sleep apnea patient5

Introduction

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 characterisedby abnormal breathing during sleep.
Prevalence of sleep-disordered breathingis estimated at c. 26%1 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 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 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 inyounger women (20% vs. 4%, respectively). However, it is worth mentioning that far from all patients currently
receive treatment.

1. Peppard et al. Increased Prevalence of Sleep-Disordered
Breathing in Adults. Am J Epidemiol. 2013 (5.17)
6

Empowering the sleep apnea patient

Treatment of sleep apnea
Treatment of sleep apnea is normally initiated when the patient seeks care, either
for symptoms directly related to sleep
apnea or symptoms related to diabetes,
heart diseases etc. When sleep apnea issuspected, a sleep study is performed todetermine whether the patient is in fact
suffering from the medical condition
and what treatment method is suitable.
The methods of conducting sleep studies
differs between countries and clinics.
When a patient is diagnosed with sleep
apnea a treatment method is prescribed.
This paper exclusively studies positive
airway pressure therapy as it is themost commonly prescribed treatment.
A device and a mask that deliver constant (CPAP) or automatically varying
pressure (APAP) to patients during their
sleep are used in positive airway pressure therapy. 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 start appointment.
Most clinics then schedule several follow
up appointments during the first year toensure that the patient is responding to
the treatment. The first weeks of treatment are identified as the crucial time
during which patients either drop out oftherapy or stay adherent to the treatment. Clinics and home care providers
across Europe estimate that 60-70%
of patients stay on the treatment after
the first 6 months, but reliable statistics
are not available as many clinics andhome care providers do not systematicallyfollow up their patients and because treatment pathways differ between countries.

Clinic variations

Basic treatment steps
Patient seeks care••

Primary care
Specialists

Sleep study••

At home or sleep lab
Oximeter/PG/PSG

Diagnosis••

By doctor or nurse
The thresholds and treatment methods differs by country•••

At clinic or home
Individually or in groups
One or several visits•

Varies from no follow up to multiple
follow up visits with PSG tests at clinic•

Varies from no follow up to multiple
follow up visits with PSG tests at clinic

CPAP/APAP
Treatment start

Follow up on
treatment startContinuous
treatment

Empowering the sleep apnea patient7

Treatment and adherence
Adherence – whether a patient uses
the prescribed treatment sufficiently toachieve the best possible results – is amajor concern for sleep treatment professionals. Much thought and effort goes
into finding ways to support patientswith education, technical support, regular and/or ad-hoc interventions, etc.
Many clinics and home care providers
work to increase the motivation of theirpatients to follow their therapy. Someencourage their patients to keep a diaryto track progress of how much better
they feel, others have group sessions
with patients to foster an environmentof positive social support. Many clinics
and home care providers spend considerable time explaining how CPAP
treatment works, and on showing anddescribing how to use and adjust masks
and machines - so much, that they areconcerned with overload:“A patient will not be able toremember more than a thirdof what we tell them”

8

Empowering the sleep apnea patient

Recent years’ introduction of telemonitoring has given clinics and home careproviders a tool to identify and proactively intervene to help patients starting
CPAP treatment. An interesting exampleof how telemonitoring helps is a clinic in
the UK that says:“We do group treatment
starts, which saves us a lot oftime. Obviously, this format
does not work for all patients, and they may not beable to fully understand theusage instructions. Thanks
to telemonitoring, we typically see, already during thefirst couple of days, which
patients are struggling withtreatment, and we call themto help them, individually.”
Anecdotal evidence suggests thatintervening early to solve problems hashelped many patients stay adherent tousing CPAP treatment. Telemonitoringalso means improvements for patients,
with typically fewer trips to the clinic
or home care provider, and a positive
understanding of being “monitored”
by their nurse, physician or home careprovider. All in all, telemonitoring has
resulted in more efficient work for clinics
and home care providers, with improved
and more patient centric care models.

Up to now, telemonitoring has mainly helped professional users in clinics
or home care providers to streamline
processes and operate more efficiently. A
natural next step is to involve the patientin his or her own treatment to a higher
degree than today.
myAir is a personalised therapy management tool for patients that encourages
them to start and continue on therapy
and resolve basic questions to increase
their comfort. myAir claims to maximise adherence and drive operational
efficiencies.

myAir is a tool built specifically to enable
the patient to track and improve treatment and device usage, through engaging the patient in his own treatment, orby identifying problems and providing
solutions.
This paper presents the results of a studyof over 23,000 patients in Germany, theUK and Ireland, approximately 1,800
of which have registered for myAir. The
study aims to understand if and how
myAir patients behave differently fromall other patients.

A belief that much of treatment successdepends on the patient himself is common among sleep apnea practitioners,
and much effort is going into supporting
patients. Many professionals say motivation makes all the difference, “youcan lead a horse to water but you cannot
make it drink”, or “it is very much dependent on the patient if he really wants toimprove his health condition”.

This paper aims to test a simple hypothesis formulated as:“Patients that use myAir show significantly and measurably better adherence and usage than other patients.”

Empowering the sleep apnea patient9

Previous studies on patientengagement and sleep apnea
In addition to interviewing clinics and home care providers, we have readand referenced a number of other studies on patient engagement and adjacent subjects. This chapter summarises these other studies, and some of thesesources will also be used as commentary throughout the report.
Study on how interventions canimprove usage
Can interventions improve CPAP usage?
Educational, supportive and behaviouralinterventions to improve usage of continuous positive airway pressure machines
in adults with obstructive sleep apnoea,
Wozniak DR, Lasserson TJ, Smith I, Cochrane Publication, 2014
This systematic review investigated threedifferent kinds of interventions, andhow they influence machine usage. The
authors conclude that:“In combining the results from alltrials, we found that all three typesof interventions increased CPAP
usage to varying degrees. Ongoingsupportive interventions were more
successful than usual care in increasing CPAP usage by about 50 minutes
per night. Educational interventions
resulted in a modest improvement of
about 35 minutes per night. Behavioural therapy increased machine usage by just under one and ahalf hours per night.“

Interventions – education,
supportive or behavioral – allaffect CPAP usage positively.

Foto: ResMed

10

Empowering the sleep apnea patientStudy on telehealth
Can interventions be automated, andbased on pre-set triggers, and built on
daily telemonitoring of patients’ device
usage?
A telehealth program for CPAP adherence
reduces labor and yields similar adherence
and efficacy when compared to standard ofcare, Dominic Munafo, William Hevener,
Maureen Crocker, Leslee Willes, Sarah
Sridasome, Ma’an Muhsin, 2016
This is a study looking into whether
telehealth/telemonitoring can help
reduce the workload on the clinics, and if
patients’ adherence to treatment differs
depending on the method of care theyreceive: standard of care (SOC) where
patients received scheduled calls, or
telehealth (TH) where patients received
web-based automated text messages oremails triggered by preset conditions.
The study followed 122 patients in total.

Study on web-based access forpatients to their own data to
improve usage
Can providing access to patients’ own
usage data have an effect on daily usage?

patient group with web-based access weredivided into two sub-groups, one of which
received a small financial incentive foreach day they logged into the website.
Kuna et al. says

Web-Based Access to Positive Airway
Pressure Usage with or without an Initial
Financial Incentive Improves Treatment
Use in Patients with Obstructive Sleep
Apnea, Kuna ST, Shuttleworth D, Chi
L, Schutte-Rodin S, Friedman E, Guo
H, Dhand S, Yang L, Zhu J, Bellamy SL,
Volpp KG, Asch DA, SLEEP 2015

“Average daily use in the first week
was 4.7 +/- 3.3 hours in the usual
care group compared to 5.9 +/-2.5 h
and 6.3 +/- 2.5 h in the Web accessgroups with and without the financial incentive, respectively”.

This study tested if providing patientswith daily web-based access to their CPAP
usage improves adherence and functional outcomes. The study followed 138
patients over a three month period. The“Positive airway pressure adherenceis significantly improved by giving
patients Web access to information
about their use of the treatment”

And they conclude:

Average first week daily usage in the three groups studied by Kuna et al 2015
Kuna et al. study:
Usage first week

Average usage

Std deviation

Munafo et al found no statistically significant differences in daily CPAP usage
or Medicare adherence - but all trends
favoured the TH group. Munafo et alconclude that:

Web-accessWeb-access + financial incentive
Usual care

6h18m
5h54m
4h42m

+/- 2h30m+/- 2h30m+/- 3h18m“Use of a web-based telehealth program for CPAP adherence coachingsignificantly reduced the coachinglabor requirement compared with
SOC, while maintaining similar
adherence and effectiveness.”

Can myAir have a positive effect onadherence to CPAP therapy?

Study on digital self-monitoring“PAP adherence was significantly
improved for patients that used the
myAir application”
A propensity-adjusted comparative analysis
of PAP adherence associated with use of
myAir, Maureen Crocker, Sue Lynch, Leslee
Willes, Colleen Kelly, Adam Benjafield
CHEST Journal, 2016
This retrospective, observational study
included 128,037 US patients. myAirusers and non myAir users were matchedon propensity scores to minimize risk ofpotential bias. Patients in both groups
were effectively treated with PAP therapy over the 90 days the study included.
There was a significant improvementin the percent of patients that reached
US Medicare adherence within 90 days
(87.3% for myAir patients vs. 70.4% for
AirView-only patients, with a p value lessthan 0.0001), showing a 16.9% improvement in adherence. Additionally mean
daily PAP usage was also significantly
higher in myAir patients comparedto AirView-only (5h54min hours vs.
4h54min, respectively).

Take-aways from these studies
Key take-aways from the four studies
are as follows:• Interventions help improve CPAP adherence anywhere from 35 minutes
to over 1h30 minutes;•

Trigger-based and automated text
or email messages based on telehealth leads to at least the same
CPAP usage as traditional scheduled
follow-up calls but with much lesseffort from the clinicians;•

Providing patients with web-based
access to their own usage data improves daily usage more than 1h in
the first week;•

American myAir users show statistically better usage and treatment thanother patients – myAir seems to be an
efficient way to drive adherence.

This paper will address some of thelimitations and concerns identified in theother studies; namely, we will study alarge sample (over 23.000 patients); we
will have a control group (patients withand without myAir), and we will coverboth established and new patients.

The study was presented on October 26,
2016, at the CHEST Annual Meeting in
Los Angeles.
Empowering the sleep apnea patient11Description of studied
patients

Basic information on
population and usage
On average, the studied patientsuse the device just over 5 hours pernight, with typically some 10 minutes more usage on the best night(Sunday) than on the worst night(Saturday).

Average daily device usage

Both countries, all patients, 6 February to 28 April 2016

5

4

Hours

3

On average, the studiedgroup of patients use thedevice between 5h 10min and5h 25min per night2

March 26: Easter weekend - more travels tofamilies, attendance of church ceremonies atnight.
Additionally pre-EURO2016 training gamebetween England and Germany in the evening

1

0

6 Feb

N=23,000 patients

12

Empowering the sleep apnea patient

There is a clear weekly
pattern where patients use
the device most on Sundaynight, and then less andless during the week

28 AprAverage daily device usage by country

Both countries, all patients, 6 February to 28 April 2016

Hours

Country
Germany

5

UK

4
3

6 feb

28 apr

N=21,000 patients in Germany, 2,500 patients in the UK. Country factor significance: P<0.0001

The graph above shows the difference
in device usage between UK/Ireland andGermany: the difference is 15 minutes
on average over the entire studied
period. Possibly, the difference can be
explained by stricter adherence measurements in Germany. One German homecare provider representative is of theopinion that:“Many of our patients have employers that demand proof of adher-

ence. Others have to reach at leasta threshold to receive continued
support from their insurance companies.”
The graph below shows the difference
between new and established patients.
The difference is smaller than the one
observed when comparing the countries.
On average it is only 8 minutes over theentire period.

Average daily device usage by patient type

Both countries, new and established patients, 6 February to 28 April 2016
Established

Hours

5

New

4
3

6 feb

28 apr

N=15,000 established patients, 2,000 new patients. New/established factor significance:
P<0.0001

Empowering the sleep apnea patient13

When looking at the difference between
myAir users and other patients, we candraw an interesting conclusion: a large
and significant difference is observed.
The daily use difference is 46 minutes

over the entire period. The difference
between the groups is significant at
P<0.0001.

Average daily device usage by myAir patients / non myAir patients
Both countries, all patients, 6 February to 28 April 2016

myAir

6
Hours

myAir patients use the device 46
minutes more every night

not myAir
5
4
3

6 feb

28 apr

N=23,000 non-myAir, 1,800 myAir. myAir / not myAir factor significance: P<0.0001

Since we know there are regulatory differences between UK and Germany that
may affect behaviour, and because there
is a significant difference in the average

14

Empowering the sleep apnea patient

device usage between the countries, wewill look closer into patients’ behaviourin Germany and the UK separately.

Empowering the sleep apnea patient15

Germany

patients use the device alsmost 6 hours
per night, while the non-myAir grouponly uses the device just under 5 hours
per night. The difference is 57 minutes(5h53m and 4h56m respectively).

The graph below show the average daily
usage for German patients, split into thetwo patient groups of myAir users, andnon-users. There is a significant difference in usage between the groups. myAir

Average daily usage first month by myAir / non myAir patients
Germany, new patients, data calibrated from day 1

Hours

6

myAir
not myAir

5
4
3
0

2

4

6

8

10

12

14

16

Days

18

20

22

24

26

28

30

N=4,627, whereof 251 myAir. myAir / not myAir factor significance: P<0.0001

A still more detailed look, through a
Box-whisker diagram, of the first 7 days
shows that the myAir group has a moreconsistent behaviour – with less variancewithin the group, and a better lowest
level of device usage.

16

Empowering the sleep apnea patient32

Daily use days 1-7, box-plot by myAir / non-myAir
Germany, new patients, data calibrated from day 1
The upper and lower box limits mark the
25th and the 75th percentiles; meaning
50% of all the patients’ daily usage iswithin the box; with the “worst” 25% of
patients below the box, and the “best”
25% of patients above the box.

myAir

10

Median5
Hours

The median is the middle pointof all the data for that day

Not myAir

0

1

2

3

4

5

6

7

Day

1

2

3

4

5

6

7

Day

N=4,627 non-myAir, 251 myAir

The left hand side shows patients notusing myAir; the right hand side shows
patient using myAir. This picture confirms what we already suspected: themyAir group does “better” than the other
patients, already from the first daysof treatment. It is also noticeable thatthe lower whisker is above zero (40-60
minutes) for myAir patients already fromday 2.

Empowering the sleep apnea patient17

A clinician in Germany confirms that:

Adherence“A typical pattern is thatthe patient’s behaviour inthe first days and weeks arestrongly indicative of futureadherence”

Average daily use is one aspect of thetreatment. Adherence – also called
compliance or minimum daily use – isanother.
We define adherence as minimum 4
hours of daily use. We measure adherence on a day-by-day basis, or as an average over a time period. Consequently
a patient is or isn’t adherent each single
night. The therapy is efficient if the patient has obtained a stable level of usage
above the adherence threshold.

Weekly average adherence (minimum 4hours of daily use)
Germany, new patients, Calibrated to day 1; first 8 weeks

Adherence% of patients

Week
1

Week
2

Week
3

Week
4

Week
5

Week
6

Week
7

Week
8

myAir

81%

87%

82%

81%

83%

84%

85%

87%

Not myAir

73%

72%

70%

68%

68%

67%

69%

70%

Difference

8 ppts15 ppts

12 ppts

13 ppts

15 ppts

17 ppts

16 ppts

17 ppts

Again, the myAir group is better with
81% of patients being adherent in thefirst week, rising to 87% over 8 weeks.
This is compared to all other patients

18

Empowering the sleep apnea patient

starting with 73%, and ending after 8
weeks at 70%.

Daily adherence (minimum 4 hours of daily use)

Germany, new patients, Calibrated to day 1; first 8 weeks, missing data excluded

Day

100%
80%
Not myAir

60%

Share of patients

40%

myAir

20%
0%
100%
80%
60%
40%
20%
0%

2

4

6

8

10

12

14

16

18

20

Missing data
Zero minutes
Less than 4 hours, but more than zero
More than 4 hours of use

22

24

26

28

30

32

34

36

38

40

42

44

46 48

50

52

54

56

58

60

Day since therapy start

The myAir group is better with 75%
of patients in adherence in the firstday, rising to 80% in the first week oftreatment

Empowering the sleep apnea patient

19

The UKUsage
The group of new patients in the UK,
split into myAir users and all others,
shows there is a significant difference
between the two groups, with the

myAir patients at 5h30m on average,
and the other patients using the device
4h43m on average. A difference of 47
minutes per night.

Average daily usage first month by myAir / non myAir patients
UK, new patients, data calibrated from day 1

myAir

Hours

5

not myAir

4
3

0

2

4

6

8 10 12 14 16 18 20 22 24 26 28 30 32 34
Days

N= 569 in total, whereof 119 with myAir. myAir / non-my air P<0.0001

20

Empowering the sleep apnea patientA Box-whisker diagram of the first 7 days
shows that the myAir group has a moreconsistent behaviour – with less variancewithin the group.
The left hand side shows patients not using myAir; the right hand side shows patient using myAir. This picture confirms

what we already suspected: the myAir
group does “better” than other patients,
already from the first days of treatment.
Significant is also that the median value
increases between day 1 and day 7 forthe myAir group; but it decreases day by
day for the other group.

Not myAir

The upper and lower box limits mark the
25th and the 75th percentiles; meaning
50% of all the patients’ daily usage iswithin the box; with the “worst” 25% of
patients below the box, and the “best”
25% of patients above the box.

10

Median5
Hours

The median is the middle pointof all the data for that day

myAir

0

1

2

3

4

5

6

7

1

2

3

Day

4

5

6

7

Day

Adherence
Difference in weekly average adherence (minimum 4hours of daily use)
myAir/non myAir
UK, new patients, Calibrated to day 1; first 8 weeks, missing data excluded

Adherence% of patients

Week
1

Week
2

Week
3

Week
4

Week
5

Week
6

Week
7

Week
8

Difference

12 ppts

17 ppts

19 ppts

18 ppts

16 ppts

11 ppts

18 ppts

19 ppts

Because of the reimbursement models
in Germany with insurance companies demanding 4 hours PAP usage forcontinued financing of treatment, allclinics and home care providers use thesame instuctions and demand the same
behaviour from all their patients. Thisshows in consistent levels of adherence
for German home care providers.

– resulting in strong variations between
different clinics. However, the difference
between myAir and non myAir patietns
is stable and similar across all studied
clinics.
Similarly to Germany, the myAir patientgroup shows 11-19 ppts better adherence
than other patients.

In the UK, it is different with no common “standard” for adherence targets
Empowering the sleep apnea patient

21

Case
study:

Patient engagement in Manchester
About the hospital and Sleep Clinic
The sleep clinics in the University Hospital of South Manchester (UHSM) under theleadership of David Jones have transformed their entire operations in the last coupleof years. Currently, the sleep department manages over 6,000 patients, and every
year 1,000 new patients are started on treatment.
The largest clinic – in Wythenshawe Hospital – is quite advanced in the use oftelemonitoring for sleep apnea treatment. For instance, the clinic monitors all new
patients for the first week and intervenes with supporting phonecalls if the patients
have not successfully used the CPAP device. Also, the clinic strives to minimise
unnecessary travel and has many consultations via Skype and phone, enabled by thetelemonitored data available to the consultants.
myAir patients
Naturally, UHSM was one of the first clinics to start encouraging their patients to use
myAir, which they did in autumn 2015.

“My team informs about myAir in the group set-up sessions
as part of the regular briefing instructions. There’s also a
myAir brochure in the box containing the CPAP device” explains David.

“I would expect muchhigher adherence froman engaged patient thanfrom other patients”
David Jones,
Sleep manager at UHSM

22

Empowering the sleep apnea patientAverage daily usage myAir / non myAir patients
Manchester, all patients

6

myAir

Hours

not myAir
54
3
11 feb1 may

N= myAir 80, not myAir 700, P<0.0001

In UHSM, as in all other studied clinics,
the myAir patients are doing significantly
better than the other patients: We see a
40-50 minutes better daily usage for thegroup of patients that have registered for
myAir.

Also regarding adherence, the myAir
patients do better.

Weekly average adherence (minimum 4 hours of daily use)
Manchester, new patients, Calibrated to day 1; first 8 weeks

Adherence

Week
1

Week
2

myAir

78%

Not myAir

63%

Difference

15 ppts% of patients

Week
3

Week
4

Week
5

Week
6

79%

76%

65%

66%

14 ppts

10 ppts

Week
7

79%

76%

65%

78%

78%

67%

67%

67%

63%

62%

12 ppts

9 ppts-2 ppts

15 ppts

16 ppts

Empowering the sleep apnea patient

Week
8

23

Introducing myAir to patients“After myAir was
released, we actuallysent an email to all
our existing patients,
informing them about
this new feature”

Clinics, as well as home care providers,seem enthusiastic about myAir; andinclude information in the set-up instructions. As explained by a clinic in the UK:“We explain about myAir as part ofour general instruction. We don’t
demonstrate it specifically, but wegive patients the brochure as part ofthe info pack”“We also stress the fact that on
myAir, the patients can see how they
are doing – very important for thosethat have a need to demonstrateadherence in order to keep their jobs,
like drivers or pilots. They can always know, they don’t need to guess
anymore”
One of the interviewed home care providers in Germany, however, went one
step further in promoting myAir to theirpatients:“After myAir was released, we actually sent an email to all our existing
patients, informing them about thisnew feature.

24

Empowering the sleep apnea patient

All interviewed clinics and home careproviders consistently introduce myAir
to all patients, not only to the young
people with smartphones. They say thatmost people, also the older, mostly haveand use smartphones, and if they don’t,
there is often someone in their closefamily that can help them.
All interviewees expect significantly
better behaviour from engaged patients,
and they believe in the potential of
myAir.
There are some examples of myAir
patients being treated in a more efficient
way by the clinics – here an example
from the UK:“For privacy and integrity reasons,
we don’t know if a patient has signed
up for myAir or not – it doesn’t showin our systems, However, when I do
talk to a patients calling for help andthey tell me they use myAir, I cansometimes point them to a video or
instruction on myAir to help them
faster than otherwise.”

The clinics and home care providers
we talk to say that myAir is very wellreceived when they present it to theirpatients. They also receive positive feedback from patients having used myAir,
and finding it motivating to “compete
against themselves”.

We also spoke to a clinic in Finland – aclinic that has used telemonitoring for along time, but only just recently started
using myAir. Although it is still too new
to have any statistically significant data,
they say patients seem quite interested in
the new tool:

Although not possible to confirm in thisstudy, several clinics and home care providers told us that they get the impression that patients use myAir intensively
in the first month. This result goes wellalong with patients needing more support at the beginning of the treatment
until they reach a stable level of adherence and get used to the therapy.

“So far, almost all patients haveexpressed strong interest in this. Forus, we hope it will enable more patients to manage themselves a little
bit on their own”

What do we expect from a “motivated”
patient compared to others?
As this paper investigates patient engagement in general, as well as myAir inparticular, we’ve talked to several clinics
and home care providers about theirgeneral view on patient engagement. All
clinics and home care providers tell us thesame thing: engagement makes all thedifference.

“I would expect an engaged patient
to sleep perhaps an hour, hour and ahalf more every night”

Empowering the sleep apnea patient25

Analysis and Conclusions

Intro

Results

We have conducted a study of approximately over 23,000 patients on CPAP or
APAP treatment for Obstructive Sleep
Apnea (OSA). The patients are treated bydifferent clinics and home care providers
in the UK, Ireland and in Germany, andthey are all monitored via telemonitoringby their nurse or physician.

The study can confirm the hypothesis tobe true: myAir patients show consistently
better device usage and adherence thanthe control group.

Around approximately 1,800 of thesepatients have also registered to use
myAir – a website enabling patients tofollow their own treatment, and get
automated feedback about their therapy.
The patient also gets a “score” indicating how well they follow the prescribed
treatment.
This paper has investigated if, and how,the myAir users differ from other patients, by testing the hypothesis “Patientsthat are engaged in their own treatment
show significantly and measureable
better adherence and usage than other
patients”.

26

Empowering the sleep apnea patientmyAir patients show better
daily usage than other patientsin this study

Usage
myAir patients show measurably better
daily usage than other patients. The
myAir patient group has higher average
use and lower variation than the control
group. This is true for all studied clinics
and home care providers in both countries, and for new as well as establishedpatients.

These numbers are well in line withKuna et al who studied the effect of providing web acccess to patients treatment
data:

These numbers are similar to thosefound by Crocker et al, with average
daily use of 5h54m for myAir patientsand 4h54m for other patients (patientsin the USA).

Established patients

New patients

Country

not myAir

myAir

not myAir

myAir

Germany
Average usage:

5h 18min6h 7min5h 2min

5h54minUK
Average usage:

4h 5min5h 22min

4h 41min

5h 40min

Kuna et al. study:
Usage first week

Average usage

Std deviation

Web-access

6h18m+/- 2h30m

Web-access + financial
incentive

5h54m+/- 2h30m

Usual care

4h42m+/- 3h18m

Germany
Usage first week

Average usage

Std deviation

myAir

5h55m

+/- 2h44m

Not myAir

5h2m+/- 3h7m

UK
Usage first week

Average usage

Std deviation

myAir

5h27m

+/- 3h5m

Not myAir

4h43m+/- 3h14m

In this study, as in other studies where patients areprovided access to their own usage data via patientengagement tools such as myAir; patient device usage
is well over 5 hours per night, regardless of whether
they are new or established patients, in the UK, US or
Germany.

Empowering the sleep apnea patient27

Adherence
myAir patients have higher adherence
than other patients. Again, true for bothcountries and all clinics and home careproviders. Below is a summary tablewith all new patients in all clinics during
the studied period.

myAir patients have higher adherence than other patients“myAir gives the patient a lotof information and insights
about his sleep condition andwhat the perfect situation
should be so they know what
to work on, this is reallyvaluable!”

28

Empowering the sleep apnea patient

Differences are seen in the very first daysof treatment, and remain over time.

Weekly average adherence (minimum 4hours of daily use)
Both countries, new patients, Calibrated to day 1, first 8 weeks

Adherence% of patients

Week
1

Week
2

Week
3

Week
4

Week
5

Week
6

Week
7

Week
8

myAir

76%

81%

79%

78%

79%

78%

79%

81%

Not myAir

71%

70%

68%

67%

67%

66%

67%

68%

Difference

5 ppts11 ppts

11 ppts

11 ppts

12 ppts

12 ppts

12 ppts

13 ppts

myAir promotion and experiences fromclinics and home care providers
The effort by the clinic or home care provider in introducing myAir to its clientshas a strong impact on take-up.
All clinics and home care providers
introducing myAir to their patients doso as part of the regular briefing instructions on how to set-up and use thedevice. One of the clinics also, regularly,
ask the patient about myAir set-up when
the patients calls in to the clinic for help.
Overall, all clinics and home care providers feel that myAir patients need lesstraditional support than other patients.

Anecdotally, there are some examples of
myAir patients being treated in a more
efficient way by the clinics:•

One clinic has started to use the
myAir website as an instruction
tool, when helping patients overthe phone. They guide the patient
onto the website, and point them tovideos or other resources to help thepatient in a more efficient way thantrying to explain for instance mask
adjustment over the phone

Methodology
Hypothesis
Our hypothesis is defined as follows:“Patients that use myAirshow significantly and measurably better adherence andusage than other patients”
Method – hard data
Access to data
In order to test whether patients that use
myAir show significantly and measurably
better adherence and usage than other
patients, PwC has conducted a comparative study using data for two groups ofpatients: those that have, and those thathave not, registered for myAir.

We have received the cooperation ofseveral clinics and home care providers
in the UK, Ireland and Germany, andthey have provided us with anonymous
daily usage data for all of their patientscurrently connected to ResMed AirView– i.e all patients in this study receive thebenefits of telemonitoring.
In addition, we have received a list ofserial numbers used to register a myAiraccount, and by combining these twosources we are able to create two separate
groups of patients: those that have, andthose that have not, registered for myAir.
Below is a summary graphic on the data
flows

Clinic / Home Care
Provideranonymous usage
data out of AirView

ResMedstudy
reportstudy
reportserial numbers which
are registered to myAir

PwC

Empowering the sleep apnea patient29

Use of data
The data provided to us regarding patients’ daily device use covers historical
data of usage. The different clinics andhome care providers have given us somewhat varying time periods to analyse.
However, for the period of 6 Feb 2016
until 28 April 2016, we have usage data
for all patients. This is the time period
we will use for the analyses.

What the data looks like
The picture below shows usage data fora random selection of patients, in theirfirst month since the therapy started.
All the patient data we have received isin this form. The data shows individual
daily usage for anonymous patients.
In the study, we group the patients together and look at averages rather thanat individuals.

Examples of first month daily usage

Germany, new patients, data calibrated from day 1
These examples show great variations in behaviour. We see a patient that started and gaveup, a patient that never started, a couple thatstruggle, and a few “good” patients.

Looks fairly good!

Varied, but mostnights look good

Never started

Started andgave upOnly occasionally reaches thethresholdAll the analyses will be performed comparing patient groups who have registered for myAir against patient groups
who have not registered for myAir.
“Adherence” is defined as at least 4 hoursof CPAP usage in a single night which is
the reference for most German insurancecompanies to keep paying for treatment.
The same definition is used for the UK.

30

Empowering the sleep apnea patient

Missing data is excluded. If we instead
assume missing data means “zero usage
on that day”, all averages are lower, but
the statistical significance between the“myAir”- group and the other patientsremain (P<0,0001).

Difference in average device usage depending on treatment of
missing data
Both countries, new patients, 6 February to 28 April 2016

Country / patient group

Average daily use
missing data excluded

Average daily use
missing data = 0

myAir patients

5 h 47 m

4 h 57 m

Other patients

4 h 55 m

3 h 37 m

Difference

52 minutes

40 minutes

Creating sub groups for analysis
The data from the clinics and home careproviders also include the patient’s setup
date, which corresponds to the patientsfirst day on CPAP treatment. Using thisinfo, we have broken the data into two
additional sub-groups: Established patients and New patients.
•

New patients are all patients thatstarted treatment on or after 6
February, 2015 (this is the earliest
date for which we have data from allclinics).

•

Established patients are all patientsthat started treatment on or before
20 December, 2015.

•

When comparing the new and established patent groups, all patientswith a setup date between 20 December, 2015 and 6 February, 2016,
will be excluded, to ensure that theestablished group will have had time
to become just that.

We will also do analyses on the full patient group, regardless of whether they
are new or established.

Size of patient groups used in this analysis
Country /patient group

Established(set up before
20 Dec)New (set up on
or after 6 Feb)

All patients, i.e also
including patients
set-up between 21
Dec and 5 Feb

UK

1,537 (myAir 221)

569 (myAir 119)2,434 (myAir 392)

Germany

15,245 (myAir
1,080)

4,627 (myAir 251)

21,391 (myAir 1,425)

Analyses toperform• Adherence (%of patients thatare adherent on
any given day)• Average usage(average daily
use for any
given day)

• Adherence (% ofpatients that are
adherent on any
given day)• Average usage(average daily use
for any given day)• 1st week, 1stmonth behaviour(usage, adherence)• Adherence (% of patients that are adherent
on any given day)• Average usage (average
daily use for any given
day)

Empowering the sleep apnea patient31

Calibration of “day 1”
In order to analyse the new patients, wehave calibrated the data set so that setup
date=day1 in the analysis that looks
specifically at new patients. For all otheranalyses, we use actual dates, i.e. whencomparing daily usage between new andestablished patients, we use actual dates,
but when we look at first week adherencein new patients, we use calibrated data.

Limitations
There are two main limitations to thisstudy.
•Firstly, we do not know anything
about the patients except the country in which they are treated, theactivation date, and their daily device usage over a two month period.
We do not have access to their age,sex, AHI index or any other factors
which might possibly be alternative
explanations for the difference inbehaviour between myAir patientsand other patients.

•

Patients registering for myAir might
already be more engaged in their
CPAP therapy than others not registering.

•

The selection of patients includes
only patients who are monitored
through AirView, ResMed’s online tool for the telemonitoring ofpatients. This means we only study
patients using recent and modern
CPAP devices, and that are either
new patients, or that have recently been provided a new device.
Furthermore we do not compare thetelemonitored, engaged patients tothe classical care pathways without
telemonitoring

Method –Interviews and previous studies
In addition to receiving data, we have interviewed several clinics and home careproviders – the ones that have provided
data, but also others that were unwillingto share data or did not have a sufficientnumber of myAir patient records forstatistical analysis, but were interested
in discussing the implications of patient
empowerment.
We talked to the clinics and home careproviders on the importance of patientengagement in general, and how the clinics perceive and use myAir specifically.
The interviews were semi-structured;
all clinics and home care providers wereasked to discuss three areas specifically:
1.

If and how they promote myAir totheir patients

2.

What (if any) behavioural differences they have seen so far in myAir
patients

3.

What difference in adherence toprescribed treatment they would
normally expect from an “engaged”
patient compared to other patients.

The results from the interviews areinterspersed in the paper as quotes andcommentary on the data.
Previous studies
In addition to interviewing clinics andhome care providers, we have read andreferenced a number of other studies
on patient engagement and adjacentsubjects.

32

Empowering the sleep apnea patientEmpowering the sleep apnea patient33

Appendix
About this researchThis report is built on knowledge gathered first hand at a number of sleep clinics andhome care providers across eight countries in Europe. These studies have been sponsored by ResMed, a global leading provider of positive airway pressure devices.
About PwC
PwC helps organisations and individuals create the value they´re looking for. We´rea network of firms in 157 countries with more than 200,000 people who are committed to delivering quality in assurance, tax and advisory services. Tell us what matters to you and find out more by visiting us at www.pwc.com. PwC refers to the PwC
network and/or one or more of its member firms, each of which is a separate legal
entity. Please see www.pwc.com/structure for further details.
Recently published PwC reports on Health Care

34

Empowering the sleep apnea patient•“Effects of Telemonitoring on treatment of sleep-disordered breathing” 2015•

”The doctor is in – your smartphone” 2015•

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

”Global health´s new entrants: Meeting the world’s consumer” 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 in the reimbursement of CIED
telemonitoring” 2012

Empowering the sleep apnea patient

35

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christian.kafling@se.pwc.com

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Empowering the sleep apnea patient