Implementation of a Quality Improvement Program to Improve PAP Adherence, Care in a Pediatric Sleep Center

Treating children with continuous or bilevel positive airway pressure (PAP) poses several challenges related to behavioral, technical, and medical factors. Researchers analyzed the benefits of a quality improvement (QI) program aimed at improving PAP adherence and care involving sleep physicians, nurses, psychologists, and respiratory therapists. The details of the program and its implementation were published online as part of the ATS 2020 International Conference.

The program was implemented at the Children’s Hospital of Philadelphia. Patients with obstructive sleep apnea syndrome (OSAS) initiated on PAP from 2013 to present were included. Patients were managed per the center’s interdisciplinary practice, enrolled in a database, and regularly reviewed during QI meetings. Initiation cohorts were followed over time using electronic medical records. The main outcome measures were percentage returning for post-PAP polysomnography (PSG) within one year, time to post-PAP PSG, and PAP usage in initiation year and subsequent (maintenance) years. Data on hospital and emergency department admission during the 18-month periods preceding and following PAP initiation were collected.

The average number of patients initiated on PAP each year was 153 (range, 131-175 patients); as of October 30, 2018, the total was 1,055 patients. The average attrition rate—defined as patients inactivated or discharged/patients initiated—declined over the course of the study: 2013, 40%; 2014, 53%; 2015, 41%; 2016, 29%; 2017, 24%; and 2018, 15%. Attrition was attributed to resolution, transition to adult care, alternative treatment, transfer, or inability to follow up after three years. Over the course of the study, the mean four-month benchmark follow-up visit rate per cohort increased from 40% to 80%, and the time to first follow-up visit significantly decreased from more than 200 days to four days. Before PAP, the mean hospital readmission rate (2014-2017) was 9.4% versus 7.3% after PAP.

The study authors concluded that the QI program improved follow-up care and time to post-PAP PSG. The average PAP use exceeded four hours per night in active returning patients. They called for guidelines for interdisciplinary pediatric PAP care to confirm the usefulness of an interdisciplinary approach and recommended that analyses be conducted to assess interactions between PAP care and healthcare utilization adherence.