By Alyx Arnett
For decades, the process of starting obstructive sleep apnea (OSA) patients on CPAP therapy has remained largely unchanged: Patients meet one-on-one in person with a clinician who demonstrates how to set up and use the device, including instructions on how to tighten the mask and incorporate accessories such as heated humidification.
But this familiar approach is time- and labor-intensive, says William Kaigler, founder and CEO of sovaSage, a maker of artificial intelligence-based software and services for OSA, an inefficiency that has driven interest in virtual CPAP setups.
The COVID-19 pandemic accelerated the adoption of telemedicine and demonstrated that remote CPAP setup can be just as effective as the in-person model.1 Meanwhile, a growing shortage of respiratory therapists further highlighted the limitations of the traditional, manual setup process.2
In response, sleep businesses are exploring virtual CPAP setup and management tools, and vendors are launching new solutions. These innovations present “an opportunity to streamline operations and adapt to a changing healthcare landscape,” says Charles Hartson, vice president of product management, consumer solutions at ResMed.
Virtual approaches also reduce barriers to care, says William Hevener, RPSGT, clinical initiatives manager at national virtual sleep care provider BetterNight. The traditional CPAP onboarding process is often lengthy and inconvenient for patients, involving multiple in-person visits, long wait times, and numerous referrals. “The reality in sleep is that we hold a burning hula hoop in the sky and tell patients who don’t fully realize they have a disease to jump through it,” Hevener says.
Also because today’s machines are more intuitive and modern masks are smaller, more comfortable, and less prone to leaks, Hevener says virtual CPAP setups are more viable than ever before.
Can Remote CPAP Setup Work?
With long-term adherence already a challenge for CPAP therapy, the shift from face-to-face setup to virtual methods has raised concerns about making adherence even more difficult.3 BetterNight’s Hevener had his doubts. “As a clinician, I questioned how and if this would work,” he says.
The concept of virtual setup contradicted everything he had been taught—and taught others. As a former sleep lab manager, Hevener ran key performance indicators, which were about ensuring respiratory therapists spent “every possible minute patient-facing.”
So before rolling out BetterNight’s virtual CPAP setup program nationwide, Hevener conducted a study to assess whether removing the physical involvement of a respiratory therapist in CPAP-naive patients would impact the Centers for Medicare and Medicaid Services (CMS) 90-day compliance rates.1
To his surprise, it didn’t. The results showed similar success rates: 75% compliance at 90 days in the observed but physically unaided setup group (n=393) versus 77% in the conventional setup group (n=5,287). There were also no differences in adherence rates at 10 and 30 days or in mask re-fits required during those periods.
BetterNight has since rolled out its virtual setup program. Its average Medicare compliance rate is 76%.
Digital Sleep Clinics Offer Remote CPAP Setup
Digital sleep clinics, including BetterNight and Dreem Health, are among the solutions supporting virtual CPAP setup. BetterNight’s program sends patients a portal link to schedule a virtual setup session with a clinician after receiving their CPAP by mail. According to Hevener, most patients can schedule an appointment within two days.
Approximately 70% of patients schedule a virtual setup call, during which clinicians ensure the device is properly configured and address any issues, such as mask fit or comfort. (The 30% of patients who don’t schedule an appointment either set up their CPAP on their own, or, in rare cases, BetterNight will send a clinician to a patient’s home.)
Interestingly, about 80% of patients seen during the initial video call have already set up and used their device for at least one successful night. Sometimes clinicians “forget that we’re dealing with capable human beings,” Hevener says.
Dreem Health, recently acquired by Sunrise, launched its virtual CPAP setup program this year. Central to this approach is ResMed’s mask-fitting tool, which uses facial scanning technology. Once patients receive their CPAP device and mask by mail, Dreem Health schedules a series of virtual appointments, beginning with a mask-fitting call with a sleep tech. “They’ll ask, ‘Are there any areas not sealing well?’ or ‘Do you hear any air escaping?’” says William Lu, MD, medical director at Dreem Health.
Next, a setup call walks patients through the device’s features and proper usage. Dreem Health then schedules follow-up calls—one a week after setup and another after a month—to troubleshoot. “We really want to make sure that we hold their hands, and so we actually have a system in place where they see our sleep tech four times before the compliance [90-day] call,” says Lu.
Medicare compliance rates are operating at close to 80%, according to Lu.
A New Solution for DMEs to Offer Remote Setup
While telehealth companies are finding success with remote CPAP setups, many durable medical equipment (DME) providers face challenges in streamlining the process.
According to sovaSage’s Kaigler, “every one of those DMEs that tell you they’re only doing 20% telemedicine would tell you that if they had a better way to do that, they would do more,” Kaigler says. “What you’ve got here is a classic scenario where the market is asking for something, and the supply chain—which in this case is the DME channel—is not yet positioned to provide it in a good, efficient, effective way.”
To address this gap, sovaSage developed Ready Set Go Virtual Setups, a platform that integrates into the DME workflow, handling patient scheduling, delivering educational content, and coordinating equipment shipping.
Ready Set Go seeks to overcome a challenge posed by the CMS 90-day compliance period, which begins when equipment is shipped. If patients miss their setup appointments—a situation often caused by miscommunication, forgetfulness, or unexpected conflicts, according to Kaigler—they lose valuable time. “And so they have a bad experience, and now they have less time to achieve their goal,” Kaigler says, referring to CMS’ definition of compliance as having at least one month with an average use of four hours or more on 70% of nights.
To mitigate these challenges, Ready Set Go aligns equipment shipments with scheduled virtual appointments and enhances communication by sending reminders and educational content to the patient’s phone. “Those are all things that will improve the process. They won’t solve it completely—there will still be no-shows—but we think we’ll have much less of that occurring,” Kaigler says.
Ready Set Go Virtual Setups is set to launch fully at MedTrade in February.
Other companies also are developing tools to enhance remote CPAP setup. Among these efforts, ResMed has published a remote CPAP setup guidebook, spurred by the COVID-19 pandemic, that walks patients through the process and launched the Personal Therapy Assistant, a program for AirSense 11 users that offers interactive, voice-guided instructions to help patients set up their equipment and resolve common therapy challenges.
Personal Therapy Assistant also includes Test Drive, a therapy acclimation tool designed to help patients become more comfortable using their ResMed AirSense 11 or AirCurve 11 device.
For providers, ResMed offers tools like Remote Assist, which allows adjustments to pressure settings, therapy modes, and comfort settings without requiring in-person visits. Providers can also access patient data from myAir’s Care Check-In feature (with patient consent) to deliver more personalized interventions and track progress.
“ResMed is focused on designing products and solutions in alignment with both patient and provider needs while creating flexibility to enable providers to meet their patients where they are while providing tools for the patient to self-manage common therapy issues from the comfort of their home,” says ResMed’s Hartson.
The Case for In-Person CPAP Setups
While remote CPAP setups offer convenience for certain patients, Karin Johnson, MD, a sleep medicine physician at Baystate Health, cautions that they may fall short.
Johnson believes in-person setups are even more critical in the era of home sleep testing compared to when patients spent a night in a sleep lab testing masks and settings.
She recalls instances where patients who have received their CPAP by mail have come to her with unopened boxes six months later—and others have worn masks upside down because they were never taught how to use them. Others still, including prior CPAP users, have failed to use their equipment because they didn’t know how to put it together or were scared they were going to break it, she says.
“While remote setups may help for some patients who live too far away or are too busy to otherwise get set up, data shows that, in general, it is not the preferred option for most people,” she says.
She cites a 2022 study comparing different CPAP setup methods and their impact on adherence and discontinuation rates.4 The study evaluated three groups:
- In-person group setups (225 patients) achieved an adherence rate of 65.3 ± 2.1%.
- Virtual setups by choice (231 patients) had an adherence rate of 54.2 ± 2.4%.
- Mandatory virtual setups due to COVID-19 (210 patients) resulted in an adherence rate of 55.9 ± 2.5%.
Johnson penned an editorial in response to this study, centered on the idea that “we’re not there yet” for CPAP setup by mail. Johnson suggests that “more flexibility in time to become adherent, increased mask resupply coverage, and enhanced mask-fitting technologies should be further evaluated to see if this method can be optimized.”
In the study, remote CPAP setup patients were followed for three months, but the authors suggest that differences in adherence rates “may have changed if longer follow-up was completed.”
Follow-up Is More Important Than Setup
Hevener argues that it’s long-term follow-up—not initial setup—that will make or break a positive outcome. “Patients don’t fail at the doctor’s office when they’re learning how to use CPAP. They fail at home when they’re by themselves, and they don’t know how to use it,” he says.
He emphasizes that virtual programs should not be mistaken for drop-ship models, where patients are left to navigate therapy on their own after receiving their devices by mail.
BetterNight’s program boasts a one-year usage rate of 71%, which Hevener attributes to the company’s follow-up measures. One such measure uses artificial intelligence to monitor patient compliance. When non-compliance is detected, flagged patients receive notifications prompting them to re-engage with therapy, with the option to connect with a respiratory therapist.
By adopting virtual CPAP setups, Hevener notes, companies can free up respiratory therapists’ time to focus on long-term patient management. “No matter how well we do a setup, if you’re not using it at one year, what have we done?” he says.
Dreem Health’s Lu agrees that follow-up is critical to success. “This kind of video model doesn’t work if you meet them for 10 minutes and then say, ‘OK, see you in a year.’ It’s the timing. It’s the people. It’s the support you give, and it’s the total package that you have to really present to the patient to make it successful,” says Lu.
References:
- Hevener W, Barnes F, Munafo DA. Feasibility of observed but physically unaided continuous positive airway pressure set ups. Sleep. 2020;43(Suppl 1):A240.
- Groninger H. Why the world needs more RTs and how you can help. National Board for Respiratory Care. 2021 Aug 4. Accessed 2024 Nov 26. https://www.nbrc.org/why-the-world-needs-more-rts-and-how-you-can-help/
- Gabryelska A, Sochal M, Wasik B, et al. Factors affecting long-term compliance of CPAP treatment-a single centre experience. J Clin Med. 2021 Dec 27;11(1):139.
- Stanchina M, Lincoln J, Prenda S, et al. The impact of different CPAP delivery approaches on nightly adherence and discontinuation rate in patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):2023-27.
- Johnson KG, Johnson DC. CPAP setup by mail: we’re not there yet. J Clin Sleep Med. 2022;18(8):1897-8.
