CPAP funding, management and use | FOI document library

FOI 24/25-1215 DOCUMENT 2 Research paper OFFICIAL For Internal Use Only

CPAP funding, management and use

The content of this document is OFFICIAL. Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

Research question: Are there publicly funded or subsidised CPAP services available in Australia? What is the prevalence of CPAP use? Where are the machines sourced and what is an average cost? Are CPAP machines effective as a treatment for anxiety or depression? Date: 14/02/2022 Requestor: Shannon s47F- personal priv Request endorsed by (EL1): n/a Cleared by: Stephanie s47F- personal privacy

Contents CPAP funding, management and use ……………………………………………………………………………. 1
Contents ……………………………………………………………………………………………………….. 1
Summary ………………………………………………………………………………………………………. 2
CPAP use in Australia ……………………………………………………………………………………… 2 3.1 Cost and retailers of CPAP machines in Australia …………………………………………….. 3
Public funding of CPAP machines …………………………………………………………………….. 3 4.1 National ……………………………………………………………………………………………………… 3 4.2 Victoria ……………………………………………………………………………………………………….. 4

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only 4.3 New South Wales ………………………………………………………………………………………… 5 4.4 South Australia ……………………………………………………………………………………………. 6 4.5 Western Australia ………………………………………………………………………………………… 6 4.6 Tasmania ……………………………………………………………………………………………………. 7 4.7 Northern Territory ………………………………………………………………………………………… 7 4.8 Australian Capital Territory ……………………………………………………………………………. 7 5. Effect of CPAP on anxiety and depression …………………………………………………………. 7 6. Correspondence …………………………………………………………………………………………….. 8 6.1 State-wide equipment service ………………………………………………………………………… 8 6.2 Eastern Health …………………………………………………………………………………………….. 9 7. Cost of CPAP machines in Australia ………………………………………………………………… 11 8. References ………………………………………………………………………………………………….. 12 9. Version control ……………………………………………………………………………………………… 14

Summary CPAP is a commonly used device that is the first line treatment for moderate to severe obstructive sleep apnoea (OSA). There is no data for use of CPAP machines across Australia though moderate to severe OSA is quite common with adult prevalence ranging from 7% to 16%. Online retailers based in Australia often offer trial and rental of CPAP devices. The most common brands of CPAP are generally above $1000 though new machines can be found for as little as $695. There is strong evidence that CPAP use can treat symptoms of depression in people who meet criteria for clinical depression. Evidence suggests CPAP use does not have the same effect on symptoms of anxiety.
CPAP use in Australia A CPAP machine is: A type of positive airway pressure ventilator that applies continuous mild air pressure. It keeps the airways continuously open in people who are able to breathe spontaneously on their own, but need help keeping their airway unobstructed (AIHW, 2021, p.27).

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only CPAP therapy is used to treat OSA and is the usual first line treatment for moderate to severe OSA (Askland et al, 2020, p.12; Pinto & Sharma, 2021). It can also be used to treat respiratory distress syndrome in pre-term babies (Pinto & Sharma, 2021). I am unable to accurately determine prevalence of CPAP use in Australia. According to a 2021 Australian Institute of Health and Welfare (AIHW) report, there is no prevalence data for use of CPAP in Australia (AIHW, 2021, p.23). A 2017 systematic review estimated OSA prevalence across the general population. Prevalence of moderate to severe OSA in the adult population ranged from 6% to 17% with frequency increasing with age (Senaratna et al, 2017). This may give some indication of the percentage of adults who could benefit from CPAP therapy. Another tool for approximating CPAP use across Australia is found in tracking Medicare Benefits Schedule item 12204. This is used when a clinician needs “to assess positive airway pressure. This study is performed overnight in a sleep study centre following diagnosis of a sleep disorder and the recommendation of CPAP therapy” (AIHW, p.27). According to the AIHW report, 16,631 patients received item 12204 in 2019.

3.1 Cost and retailers of CPAP machines in Australia Refer to 7. Cost of CPAP machines in Australia for a table of comparative costs. There are several Australia-based online CPAP retailers. The two most common brands of fixed pressure CPAP machine are ResMed and Fischer & Paykel. New machines in both common brands are generally over $1000. DeVibliss, BMC and SmartMed produce machines that generally retail for under $1000. Parts and consumables such as tubes, masks, filters etc may come with purchase of the machine and then require replacement. CPAP Australia offers trial or rental of the ResMed Airsense 10 Elite for $35 / week (CPAP Australia, CPAP trials and rentals). CPAP Victoria offers trials for $30/week for a minimum of 4 weeks (CPAP Victoria, Trials). CPAP Direct deducts the cost of the first month of machine hire from the purchase price (CPAP Direct, CPAP Machine Hire). 4. Public funding of CPAP machines

4.1 National If a patient has a Commonwealth concession card, they may also be eligible for the Essential Medical Equipment Program through Services Australia. This program provides $164 per year to assist with the electricity costs of essential medical equipment including CPAP machines (Services Australia, 2021).

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only 4.2 Victoria On 8th February I spoke to Jenny from State-Wide Equipment Service (SWEP). She said that SWEP does not fund CPAP machines at all. She transferred me to Empower Care Options, who assist NDIS participants and non-funded Victorians with equipment purchase and repair. Lydia from Empower Care Options confirmed SWEP does not fund CPAP machines. She said that Empower Care Options has a stock of 10 new ResMed Air Sense 10 Elite CPAP machines which they are selling to consumers at a reduced cost. The overall cost is $900 plus $20 delivery charge. This brand of CPAP machine retails for between $998 and $1374 (7. Cost of CPAP machines in Australia). Lydia also confirmed that they do not fund or subsidise the cost of repairs or maintenance to CPAP machines they have sold (refer to 5.1 State-wide equipment service). The Australian Sleep Association (ASA) conducted a brief inquiry into public funding of CPAP machines in 2019. The funding of CPAP machines in Victoria was found to be “fragmented and highly variable”. Individual public hospitals were able to offer CPAP machines to some patients depending on severity of sleep apnoea and financial difficulty. The criteria varied and were determined by individual hospitals (Australian Sleep Association, 2019). Jennifer s47F- personal priva a sleep scientist from Box Hill Sleep Clinic confirmed in a phone conversation on 8th February that all hospitals have their own criteria for providing CPAP machines to patients. In a follow up email Jennifer confirmed that to be eligible for a CPAP machine funded by the hospital, patients need: • a diagnosis of severe OSA • either aged or disability pension • to demonstrate compliance with treatment (at least 4hours/night over 4 weeks) • to have purchased their own mask (refer to correspondence in 5.2 Eastern Health).

In a phone conversation on 9th February, Dr Christopher s47F- personal privacy Director of the Sleep Laboratory at Austin Health, described their process for funding CPAP machines for patients. A patient may be eligible for a subsidised CPAP machine if they have had their sleep study performed at the Austin and they can demonstrate a financial need. The latter is usually demonstrated by possession of a health care card but this is up to the discretion of the clinician. If a patient is eligible, they can pay $50 for a 4-week trial of a CPAP machine. If trial is successful, they can pay an additional $295 to have the machine permanently. This cost includes mask and tubes but does not include repairs or maintenance. The Austin will only subsidise one device for the patient. I reached out to 3 other hospitals in Victoria but have not received any further responses. The Victorian government offers a concession on power costs for people who have a concession card and use a life support machine which takes at least 1880 kilowatt hours per

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only year. They state, “[m]ost continuous positive airways pressure (CPAP) machines do not meet the 1,880-kilowatt hour threshold” (Department of Families, Fairness and Housing, 2021).

4.3 New South Wales Enable NSW administers the Home Respiratory Program (HRP). To be eligible for support from Enable NSW, a person must: • be residing in NSW or Lord Howe Island • be enrolled with Medicare • require the assistive technology to support a health need • require the assistive technology to remain independent at home • not be eligible for compensation or damages • not be eligible to receive assistive technology through any other government-funded program.

In addition, to be eligible for HRP a person must have stopped smoking for at least 4 weeks. There are also other eligibility criteria specific to each respiratory device (EnableNSW, Home Respiratory Program). An adult must demonstrate one of the following criteria: • Oxygen desaturation index (ODI) ≥ 30/hr • Apnoea Hypopnea Index (AHI) ≥ 30/hr • Apnoea Hypopnea Index (AHI) ≥ 20/hr and a relevant comorbidity • Hypoventilation/ daytime hypercapnia with one of the following: transcutaneous carbon dioxide (TcCO2) rising ≥ 8 mmHg from baseline awake partial pressure of carbon dioxide (PaC02) ≥ 46 mmHg a rise in PaC02 of ≥ 8 mmHg (Enable NSW, 2021a). A person under 18 years old must demonstrate one of the following criteria: • Obstructive Apnoea Hypopnea Index (OAHI) ≥ 15/hr • OAHI ≥ 10/hr or OAHI ≥ 5/hr post adenoidectomy/tonsillectomy, and either: minimum oxygen desaturation ≤ 85% CO2 retention ≥ 8 mmHg TcCO2 > 50mm Hg for 25% of the sleep study documented evidence of significant cardiorespiratory co-morbidities (Enable NSW, 2021b).

Equipment through HRP is heavily subsidised. For adults on a pension or with a low income, or for children under 16 years old, there is a co-payment of $100. For adults with higher

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only incomes, they will be responsible for 20% of the total cost of the equipment. The customer is responsible for the purchase of their own CPAP masks. Enable NSW is responsible for repairs (Enable NSW, Home Respiratory Program).

4.4 South Australia The South Australian Department of Human Services administers the Equipment Program which provides some equipment to adults with chronic health conditions and palliative care patients (Department of Human Services, Equipment Program). Kaye from the DHS Equipment Program confirmed in a phone call on 10th February that they do not fund or subsidise CPAP machines. According to the ASA’s 2019 inquiry, South Australia does not have a state-wide system for funding CPAP machines. Further, as of 2019, the Southern and Central Adelaide Local Health Districts had limited budgets to provide CPAP machines for patients who have a concession card and meet certain OSA severity requirements (ASA, 2019).

4.5 Western Australia The Community Aids and Equipment program (CAEP) may fund equipment for people living in WA who have a pension or concession card and who are not eligible for NDIS or other commonwealth programs. The equipment is offered as a long-term loan and should be returned when no longer required. CAEP judges requests on an individual basis but may fund equipment that is: • essential for independent functioning and functional care at home • the most basic model/type that meets the clinical need • be for personal use only, that is not communal use • required for use in the person’s primary residence • more than $50 • required for safety and behavioural purposes where applicable.

The WA Sleep Disorders Research Institute is a CAEP specialist provider administering funding for all respiratory equipment including CPAP machines (Department of Communities, Community Aids and Equipment Program). ASA states the clinical criteria for CPAP funding in WA are: • AHI >15/hr • demonstrated satisfactory use (average at least 4 hours per night), at their own expense; and • benefit (either a reduction in Epworth Sleepiness Scale or clinician indicating clinical benefit was obtained) during a CPAP trial (ASA, 2019).

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only I have not been able to confirm that these criteria are still current.

4.6 Tasmania The state equipment provider TasEquip does not manage CPAP machine funding (Department of Health, Medical Aids and Equipment). I was unable to establish availability of other funding through local hospital districts.

4.7 Northern Territory CPAP machines are not on the Approved Equipment list for the Territory Equipment Program (NT Health, Territory Equipment Program). ASA refers to a Respiratory Appliances Loan Scheme but this program appears to no longer operate (ASA, 2019). I was unable to establish availability of other funding through local hospital districts.

4.8 Australian Capital Territory People who hold a commonwealth concession and meet ACT residency requirements may be eligible for a permanent loan of a CPAP machine from the Domiciliary Oxygen and Respiratory Support Service (DORSS). Patients must meet the following clinical criteria: • be assessed and referred by an approved consultant • have completed studies at a recognised sleep study unit within the last twelve months and successfully trialled the recommended unit for a minimum of 1 month. • have a diagnosis of severe or moderately severe OSA confirmed by polysomnography as indicated below: severe OSA is diagnosed where Respiratory Disturbance Index (RDI) > 30 moderately severe OSA is diagnosed where RDI > 20 and minimum overnight Oxygen Saturation < 90% patients with an RDI > 10 accompanied by symptoms of excessive daytime sleepiness and documented cardiovascular diseases including hypertension, ischaemic heart disease or stroke.

There are no co-payments, though patients are responsible for purchasing replacement consumables (masks etc.). The CPAP machine remains the property of the ACT government. Repairs are conducted through ACT Government contract (Department of Health, ACT DORSS). 5. Effect of CPAP on anxiety and depression

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only Evidence of the effectiveness of CPAP use as a treatment for anxiety and depression in people with OSA is mixed though strongly suggests that it is effective on depressive symptoms. A 2014 systematic review and meta-analysis found use of CPAP improves depressive symptoms. However, there was significant heterogeneity between trials and comparative effect of CPAP versus other treatments of depression was unclear (Povitz et al, 2014). This contrasts with a recent American Academy of Sleep Medicine systematic review of treatments for obstructive sleep apnoea. The researchers performed a meta-analysis of 5 studies measuring effects of CPAP use on mood. The meta-analysis revealed no clinically significant improvement in mood as measured by the Hospital Anxiety and Depression Scale. The studies included in the meta-analysis did not recruit participants who already presented with depression or anxiety (Patil et al, 2019, p.311). This is noteworthy as other studies have found that the effect of CPAP on depressive symptoms was larger in populations that met the criteria for depression (Povitz et al, 2014, p.3-4; Zheng et al, 2019, p.94). A 2019 examination of 2687 subjects found a significant reduction in depressive symptoms but no clinically significant effect on anxiety symptoms (Zheng et al, 2019, pp.91-92). An associated systematic review and meta-analysis confirmed the effect on depression but not anxiety symptoms (p.94). Whether the subject was CPAP-adherent (defined as using the machine on average 4 or more hours each night) did not change the treatment effect (p.91). This is supported by a 2020 Cochrane review found that while certain interventions are shown to improve usage of CPAP machines, the current evidence does not demonstrate that increased usage improves functional or quality of life outcomes (Ackland et al, 2020). 6. Correspondence

6.1 State-wide equipment service From: Empower Care Options empowercareoptions@bhs.org.au Sent: Tuesday, 8 February 2022 3:31 PM To: [s47F- personal priv](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)acy Aaron <Aaron.s47F- personal privacy @ndis.gov.au> Subject: RE: [External Email] CPAP machine inquiry [SEC=OFFICIAL] I can confirm this is all correct. Thank you Kind Regards, Lydia s47F- personal priv|Administration Officer Empower Care Options|Ballarat Health Services/Part of Grampians Health P.O. Box 1993, Bakery Hill Vic 3354 P 1300 747 937 | E lydia.s47F- personal pri @bhs.org.au | E empowercareoptions@bhs.org.au V2.0 14-02-2022 CPAP Page 8 of 14 OFFICIAL Page 17 of 88

FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only Monday – Friday 8:30am – 5:00pm

From: [s47F- personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/) Aaron <Aaron.s47F- personal privacy @ndis.gov.au> Sent: Tuesday, 8 February 2022 2:09 PM To: Empower Care Options empowercareoptions@bhs.org.au Subject: [External Email] CPAP machine inquiry [SEC=OFFICIAL] Hi Lydia Thanks so much for your time this afternoon. As per our discussion, can you please confirm: • Victorian Aids and Equipment program / State-wide equipment program no longer funds or subsidises the purchase of CPAP machines • Empower Care has a stock of 10 reduced cost RESMED AIRsense 10 Elite CPAP machines available for purchase at $900 plus $20 delivery • you are not aware of any other equipment program in Victoria that funds or subsidises the purchase of CPAP machines • neither Empower Care, VA&EP or SWEP will fund or subsidise repairs to CPAP machines.

Thanks again and all the best Aaron s47F- personal privacy Research Officer National Disability Insurance Agency Email aaron.s47F- personal privacy @ndis.gov.au

6.2 Eastern Health From: s47F- personal privac Jennifer <Jennifer.s47F- personal priva@easternhealth.org.au> Sent: Wednesday, 9 February 2022 10:45 AM To: s47F- personal privacy Aaron <aaron.s47F- personal privacy @ndis.gov.au> Subject: Hospital Funded CPAP - Eastern Health

Hi Aaron, Further information after our conversation yesterday.

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only All patients need to be referred from a sleep physician in the public outpatients and have a least one overnight sleep study at Box Hill Hospital. Patient need: Diagnosis of severe OSA Either Aged or Disability Pension Demonstrate compliance – at least 4hours/night over 4 weeks Purchased their own mask

Hope that helps, Kind regards,

Jennifer s47F- personal priva Sleep Scientist Box Hill Hospital P: s47F- personal privacy | E: jennifer.s47F- personal priv @easternhealth.org.au Part time: Monday - Thursday

5 Arnold St, Box Hill

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Cost of CPAP machines in Australia

Machine CPAP CPAP Direct CPAP Victoria NSW CPAP The CPAP CPAP club Sleepzone Australia (link) (link) (link) clinic (link) (link) (link) (link) ResMed AirSense $1315.00 $1195.00 $1374.00 $1023.00 $998.00 $1250.00 10 Elite Fixed Pressure CPAP Machine

Fisher and Paykel $1395.00 $1195.00 $1395.00 $1330.00 $850 SLEEPSTYLE CPAP Machine

DeVilbiss $695.00 Sleepcube Standard Plus CPAP Machine with Humidifier BMC G3 C20 $895.00 $900.00 Fixed Pressure CPAP Machine

SmartMed $995.00 SmartMed iBreeze Fixed Machine

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References Askland, K., Wright, L., Wozniak, D. R., Emmanuel, T., Caston, J., & Smith, I. (2020). Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database of Systematic Reviews, 4, CD007736. doi10.1002/14651858.CD007736.pub3 Australian Sleep Association. (2019). Public funding of CPAP in Australia: submission 118 to the Inquiry into Sleep Health Awareness. Parliament of Australia. Retrieved February 8, from https://www.aph.gov.au/Parliamentary_Business/Committees/House/Health_Aged_Care_and_ Sport/SleepHealthAwareness/Submissions CPAP Australia. CPAP trials and rental. https://www.cpapaustralia.com.au/cpap- machines/shop-by-category/cpap-trials-rentals/ CPAP Direct. CPAP Machine Hire. https://cpap.com.au/pages/cpap-hire CPAP Victoria. Trials. https://cpapvictoria.com.au/pages/trial Department of Communities. (2021) Community Aids and Equipment Program (CAEP): Referrer’s Information Kit. Government of Western Australia. http://www.disability.wa.gov.au/Global/Publications/Services%20supports%20and%20eligibility /CAEP/CAEP%20referrer’s%20information%20kit.pdf Department of Families, Fairness and Housing. (2021). Life support concession. https://services.dffh.vic.gov.au/life-support-concession Department of Health. (2017). ACT Domiciliary Oxygen and Respiratory Support Service (DORSS). ACT Government. https://www.health.act.gov.au/sites/default/files/2018- 09/ACT%20Domiciliary%20Oxygen%20and%20Respiratory%20Support%20Scheme%20(DO RSS).docx Department of Health. (2021). Medical Aids and Equipment (TasEquip). Government of Tasmania. https://www.health.tas.gov.au/patients/support-services-your-visit-hospital/medical- aids-and-equipment-tasequip Department of Human Services. (2021) Equipment Program. https://equipmentprogram.sa.gov.au/ Enable NSW. Home Respiratory Program (HRP) – Providing equipment for long term respiratory support. NSW Government. https://www.enable.health.nsw.gov.au/about/publications/fact-sheets/home-respiratory- program Enable NSW. (2021a). Adult CPAP funding criteria. NSW Government. https://www.enable.health.nsw.gov.au/__data/assets/pdf_file/0004/262615/Adult-CPAP- Funding-Criteria.pdf

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only Enable NSW. (2021b). Paediatric CPAP funding criteria. NSW Government. Paediatric CPAP Funding Criteria (nsw.gov.au) NT Health. (2021). Territory Equipment Program (TEP) and the Seating Equipment and Technical Service (SEAT). Northern Territory Government. https://health.nt.gov.au/__data/assets/word_doc/0007/1017835/TEP-Approved-Equipment- List.docx Patil, S. P., Ayappa, I. A., Caples, S. M., Kimoff, R. J., Patel, S. R., & Harrod, C. G. (2019). Treatment of adult obstructive sleep apnoea with positive airway pressure: An American academy of sleep medicine systematic review, meta-analysis, and GRADE assessment. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 15(02), 301–334. doi10.5664/jcsm.7638 Pinto, V., Sharma, S. (2021). Continuous positive airway pressure. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482178/ Povitz, M., Bolo, C. E., Heitman, S. J., Tsai, W. H., Wang, J., & James, M. T. (2014). Effect of treatment of obstructive sleep apnoea on depressive symptoms: systematic review and meta- analysis. PLoS Medicine, 11(11), e1001762. doi10.1371/journal.pmed.1001762 ResMed AirSenseTM 10 Elite CPAP Machine. ResMed Australia. https://shop.resmed.com.au/resmed-airsense-10-elite-cpap-machine/ Services Australia. (2021). Eligible equipment. Essential Medical Equipment Payment. https://www.servicesaustralia.gov.au/eligible-equipment-for-essential-medical-equipment- payment Senaratna, C. V., Perret, J. L., Lodge, C. J., Lowe, A. J., Campbell, B. E., Matheson, M. C., Hamilton, G. S., & Dharmage, S. C. (2017). Prevalence of obstructive sleep apnoea in the general population: A systematic review. Sleep Medicine Reviews, 34, 70–81. doi10.1016/j.smrv.2016.07.002 Zheng, D., Xu, Y., You, S., Hackett, M. L., Woodman, R. J., Li, Q., Woodward, M., Loffler, K. A., Rodgers, A., Drager, L. F., Lorenzi-Filho, G., Wang, X., Quan, W. W., Tripathi, M., Mediano, O., Ou, Q., Chen, R., Liu, Z., Zhang, X., … Anderson, C. S. (2019). Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis. EClinicalMedicine, 11, 89–96. doi10.1016/j.eclinm.2019.05.012

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FOI 24/25-1215 Research paper OFFICIAL For Internal Use Only 9. Version control

Version Amended Brief Description of Change Status Date by

1.0 AHR908 Research paper representing the first Cleared 09/02/2022 instalment of a body of research on CPAP machines. This paper focuses on: • publicly funded or subsidised CPAP services in Victoria • CPAP machines used as a treatment for anxiety or depression.

2.0 AHR908 Research paper expanded to include: Cleared 14/02/2022 • public funding available for CPAPs in Australia • prevalence of CPAP use • cost and retailers.

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