The Cost-Effectiveness of Telehealth versus In-Person PAP Set-Up for Patients with Sleep Apnea

Abstract

Introduction: Telehealth has been widely integrated into healthcare systems during the COVID-19 pandemic and is here to stay. At the Greater Los Angeles VA Healthcare System (GLA-VAHS), for patients newly diagnosed with sleep apnea pre-pandemic, the majority of initial positive airway pressure (PAP) set-ups and education was done in person. During the pandemic, this process was transitioned to telehealth using video/phone and PAP machines were mailed out to patients. The cost effectiveness of telehealth integration has not been well characterized. As part of a larger study examining the overall efficacy of telehealth versus in-person PAP set-up, we performed a cost analysis of these two modalities at the GLA-VAHS. Methods: We performed a cost analysis of telehealth versus in-person set-up of PAP for patients newly diagnosed with sleep apnea at GLAVAHS between March and October 2021 (n = 2,662 PAP set-ups). There was an average of 16 PAP set-ups per day with 11 set-ups (68.75%) via telehealth and 5 set-ups (31.25%) in person. We used a bottom-up analysis which includes only variable direct costs and factors out the high costs of healthcare infrastructure. Results: At GLA-VAHS, the cost of telehealth PAP set-up was $98.87 per patient and in-person PAP set-up was $49.85 per patient. For telehealth set-ups, there was an additional cost of mailing the PAP machine and more respiratory therapist (RT) time spent on educating patients compared to in-person set-ups (31.2% more RT time). After initial PAP set-up, a larger subset of patients required additional troubleshooting help from RTs about proper PAP use after telehealth compared to in-person set-ups (5% versus 1%). Conclusion: Telehealth PAP setups were nearly two times the cost of in-person PAP set-ups at GLA-VAHS due to the cost of mailing the PAP machine, more RT time spent on education, and a higher rate of troubleshooting. While the costs of telehealth implementation is one factor, one must also consider the benefits of telehealth including ability to capture more patients and higher patient satisfaction which may outweigh these costs. There are opportunities for institutions to alleviate bottlenecks with telehealth use such as supplemental educational materials about PAP use ahead of set-ups or scripting RT and patient dialogue when familiarizing patients with a PAP machine. In addition, as providers and patients become more familiar with interfacing with telehealth, efficiency with use of these systems is likely to improve and reduce costs in the long run.