We would like to thank Dr. Kieran Walsh for her acknowledgement, perspective, and questions.1 The intent of medical publications is not to make definitive claims or establish fact, but rather to introduce scientific observations and answer clinical questions. The results of any publication, even if found to be reasonable and informative, should be critically appraised, analyzed, and questioned regarding aspects that may have overlooked some important concept. Dr. Walsh did exactly this and we appreciate viewing our work from a different perspective. We hope that this response further advances the understanding of both our manuscript, the concept it explored, and, ultimately, allows readers to better appreciate if and how this can be applied to their own clinical practices.
In our recently published manuscript, “The Impact of Group Education on Continuous Positive Airway Pressure Adherence,” we explored CPAP use in over 2000 consecutive patients initiating therapy at our institution.2 Approximately half of these individuals began therapy after undergoing an individual clinic appointment where they discussed the need to treat OSA and therapeutic options with their sleep provider, followed by formal mask selection and fitting and CPAP education by a specially trained sleep therapist. The other half participated in a group clinic. These individuals received similar education regarding OSA and CPAP, as well as formal mask selection and fitting. However, the education was more formalized and delivered in a group setting. We observed that initiating CPAP in a group setting did not adversely impact subsequent adherence. In fact, future CPAP use was improved in those participating in a group clinic.
We hypothesize that this improvement was largely the result of external validation. Despite a greater awareness and understanding of sleep disordered breathing, many people still have a negative image of sleep apneic patients. This negative image is propagated by the lay press, television, and movies that frequently portray CPAP as an archaic, uncomfortable device used exclusively by only one demographic of patients. In a group setting, patients gain an appreciation that sleep disordered breathing occurs in many people, regardless of age, gender, or body habitus. Granted, any education that provides patients with a better understanding of the detrimental effects OSA has on both health and quality of life, as well as the benefits of CPAP, can clearly contribute to better adherence. However, patients in both the individual and group arms received similar education. As such, education alone could not explain the differences in observed CPAP use.
Although both arms received similar education, they were not identical. Those participating in the group clinic had a longer educational experience. As Dr. Walsh points out, the time that patients spent in an individual sessions was 45 minutes, while the group session lasted over two hours. Part of this difference was the result of longer times required to provide mask selection and fitting to a group of individuals. Additionally, all participants were individually seen by a sleep provider during this session. These factors will inherently prolong the time needed to complete the process compared to those undergoing CPAP initiation as an individual. Nonetheless, the actual education delivered was somewhat longer for those in the group setting. The teaching regarding OSA and CPAP were delivered in a formal and standardized lecture. The counseling regarding better sleep habits typically given by the sleep providers during an individual clinic appointment was presented as a group discussion led by a nurse educator. So, it is possible, and probably likely, that the longer experience further contributed to the improvement in outcomes.
It should be noted that we were not attempting to compare the impact of a 45 minute experience with 120-150 minutes, but rather the benefits of a group versus individual initiation of CPAP therapy. A group setting allowed us to begin therapy in 15 patients in the same amount of time it would have taken for significantly fewer people undergoing an individual appointment. Even with overlapping the portion of the clinic appointment devoted to the providers and CPAP specialists to optimize clinic efficiency, more patients can be processed per unit of time, with a reduced amount of “time per patient” using a group educational model.
Dr. Walsh also discusses our brief and somewhat superficial analysis of costs and resource allocation and the differences in these related to our two different strategies. We agree. This was, in part, the result of modifications to our manuscript following peer review. And rightly so. It is difficult to assess the cost of many aspects of our group clinic. Providing a lecture to a group of patients, facilitating a discussion with a nurse educator, and interactions with a CPAP specialist do not follow traditional billing codes commonly used in clinical practice. And, in our setting, there is no direct cost of medical care for our patients. Given this, we were not able to perform a true cost analysis and focused more on clinic efficiencies and the difference in objective measures of CPAP use. However, salaries, facilities, and consumable resources would be the same whether a group clinic or a clinic filled with individual appointments was conducted. As stated, more patients can be seen per unit of time using a group clinic compared with an individual clinic. Therefore, it would logically follow that the cost per patient would be lower. However, we agree that the only way to definitively determine the cost difference between these two strategies would be to conduct a prospective assessment that accounted for all related expenses.
The views expressed in this manuscript are solely those of the authors and do not reflect those of the Department of the Army or Department of Defense. Dr. Lettieri serves on the speaker's bureau for Cephalon (now Teva Pharmaceuticals). Dr. Walter has indicated no financial conflicts of interest.
Lettieri CJ; Walter RJ. Group education on CPAP–a response. J Clin Sleep Med 2013;9(9):975-976.
Walsh K, author. Group education on continuous positive airway pressure adherence: could it be more efficient as well as more effective? J Clin Sleep Med. 2013;9:973. [PubMed]
Lettieri CJ, Walter RJ, authors. Impact of group education on continuous positive airway pressure adherence. J Clin Sleep Med. 2013;9:537–41. [PubMed]