Diagnosis and treatment of sleep disordered breathing in hospitalized cardiac patients: a reduction in 30-day hospital readmission rates

Abstract

Background: Sleep disordered breathing (SDB) is associated with significant cardiovascular sequelae and positive airway pressure (PAP) has been shown to improve heart failure and prevent the recurrence of atrial fibrillation in cardiac patients with sleep apnea. Patients who are hospitalized with cardiac conditions frequently have witnessed symptoms of SDB but often do not have a diagnosis of sleep apnea. We implemented a clinical paradigm to perform unattended sleep studies and initiate treatment with PAP in hospitalized cardiac patients with symptoms consistent with SDB. We hypothesized that PAP adherence in cardiac patients with SDB would reduce readmission rates 30 days after discharge.

Methods: 106 consecutive cardiac patients hospitalized for heart failure, arrhythmias, and myocardial infarction and who reported symptoms of SDB were evaluated. Patients underwent a type III portable sleep study and those patients diagnosed with sleep apnea were started on PAP. Demographic data, SDB type, PAP adherence, and data regarding 30-day hospital readmission/ED visits were collected.

Results: Of 106 patients, 104 had conclusive diagnostic studies using portable monitoring systems. Seventy-eight percent of patients (81/104) had SDB (AHI ≥ 5 events/h). Eighty percent (65/81) had predominantly obstructive sleep apnea, and 20% (16/81) had predominantly central sleep apnea. None of 19 patients (0%) with adequate PAP adherence, 6 of 20 (30%) with partial PAP use, and 5 of 17 (29%) of patients who did not use PAP were readmitted to the hospital or visited the emergency department (ED) for a cardiac issue within 30 days from discharge (p = 0.025).

Conclusions: Performing diagnostic unattended sleep studies and initiating PAP treatment in hospitalized cardiac patients was feasible and provided important clinical information. Our data indicate that hospital readmission and ED visits 30 days after discharge were significantly lower in patients with cardiac disease and SDB who adhered to PAP treatment than those who were not adherent.

Commentary: A commentary on this article appears in this issue on page 1067.

Keywords: 30-day readmission rate; hospitalized patient testing; portable sleep studies; sleep disordered breathing.

Figures

Figure 1. Disposition of the 106 consecutive cardiac patients who underwent an in-hospital sleep study between January 2012 and March 2013.

There were 31 patients who were discharged without PAP due to patient refusal of treatment, further in-lab testing, heart failure optimization required for treatment prescription, or death before discharge. Insufficient compliance data were secondary to 1 death and 1 patient requiring a tracheostomy within 30 days from discharge. Full PAP use was defined as use of PAP ≥ 4 h per night on 70% of nights during a consecutive 30-day period in the first 90 days of PAP treatment. SDB, sleep disordered breathing; OSA, obstructive sleep apnea; CSA, central sleep apnea; PAP, positive airway pressure.

Figure 2. Kaplan-Meier analysis and curves for readmission demonstrating the difference in readmission rates between the 3 PAP usage groups.

Full users were defined as patients with use of PAP ≥ 4 h per night on 70% of nights during a consecutive 30-day period in the first 90 days of PAP treatment. Readmission was defined as hospitalization or visit to the emergency department from 48 h to 30 days after discharge. PAP, positive airway pressure.