August 10, 2017

The End of Sleep Medicine - Part 3

To quote Whitney Houston: "I believe the children are our future."

The problem of sleep-disordered breathing is epidemic, like diabetes, heart disease, and obesity. I would argue and have elsewhere in this blog that all three of those conditions can be attributed to, at least in part, the chronic intermittent hypoxia that occurs when the person sleeping is not getting air into their lungs.

For the most frightening development (if you can call it that) is the increasing occurrence of the conditions listed above in children.

The prevalence of sleep-disordered breathing is 3 to 5 percent among all children - this is scary!

One of the many challenges for the field of sleep medicine seeking to address this problem in a cost effective manner.  Of course, in lab polysomnography or even a sleep study done at home would provide more data reducing the possibility of false positives or false negatives, but the number of children at risk is too great and the cost in either case is prohibitive.

A study published in the ATS Blue Journal provides evidence that use of oximetry aided by computer analysis alone was sufficient to screen children to determine who needed an intervention.

This could be at a significant savings (90 to 95%) over what the cost might otherwise be. As described in the study this machine learning enabled test can provide an inexpensive test to anyone who has access to a smart phone.

An increased awareness about the importance of sleep particularly among children coupled with the ability to screen for sleep-disordered breathing cost effectively should, I would say must, incorporate this into to all pediatric practice.

The field (calling all Clinical Sleep Health Educators) has its work cut out for it to disseminate the availability of this technology to help insure there will be children in our future.

Again to quote Whitney Houston:  "It is the greatest love of all."

October 14, 2014

The End of Sleep Medicine (Part 2)

"You can have any color you want, as long as it is black." - Henry Ford

My earlier posts paint an uncertain picture about the future of sleep medicine as it relates to the diagnosis and treatment of obstructive sleep apnea. That said, I see that there are a number of inescapable realities. I have listed them below and included my thoughts about them. How the sleep medicine community chooses to deal with these realities and possibly others will likely dictate the future of sleep medicine.

Reality #1 - Obstructive sleep apnea (OSA), a chronic condition, is far more prevalent than originally imagined and is likely to become even more common due to the rising incidence of obesity and aging of the population. To call it an epidemic is no longer hyperbole.

The number of people suffering with sleep apnea varies depending on who you ask. But whatever number you believe, it is a very large getting larger.  And if you include children the figure are staggering. Something needs to be done to address the 80% who remain undiagnosed and the 50% who are nonadherence due to ineffective treatment.

Reality #2 - The consequences of untreated OSA are more than just reduced quality of life and excessive daytime sleepiness. The effects of OSA impact most, if not all, organ systems in the body.

Current medical research is showing connections between sleep apnea and other diseases, such as some forms of Cancer, Alzheimer's and ADHD in children.  These comorbid conditions arise in part from the chronic intermittent hypoxia that occurs during the apneic events. The connection with hypertension and other cardiovascular disease is solid and that alone warrants finding ways to prevent sleep apnea if possible or to treat it effectively to mitigate further injury.

Reality #3 - There is more  technology available to diagnose and treat OSA and will continue to increase in variety/sophistication in the coming years, including at some point a pharmaceutical intervention.

Diagnostic technology for “out of center testing” continues to improve and while it is unlikely to ever replace in-lab polysomnography insurance companies are now requiring a home test first to determine a diagnosis of OSA. Positive Airway Pressure therapy machines look less and less like medical devices and wireless communication contained in them is facilitating greater ease in monitoring adherence to therapy. Oral Appliance Therapy for mild to moderate OSA has evolved as well making it an acceptable first line treatment. Greater precision  for surgical options is improving the rate of success. Other therapies are in development as well to address the broad range of disease that present.

Reality #4 - The number of Board Certified Sleep Medicine Physicians is not increasing at rate to keep pace with the increasing number of people who need care.

The problem of a narrowing pipeline of physicians is also a problem in other specialities as well, including primary care. The need for appropriately trained allied health professionals, such as those Credential in Clinical Sleep Health to work with primary care and with sleep medicine specialists is great. These physician extenders are the key to getting the undiagnosed into treatment, and to insuring they are adherent. Dentists also have a role to play in screening patients for OSA and with appropriate training treating that portion that will respond to OAT.

Reality #5 - Deductibles and co-pays for health insurance coverage will be set at such a point now that many of the expenses associated with diagnosing and treating OSA will be out-of-pocket or using a health savings account.

There are a number of changes in how healthcare is delivered in the United States, among them is the financial participation required by the consumer. Affordability of diagnosis and treatment will play a role how, particularly those in safety sensitive positions like transportation, chose to proceed.

The future holds great possibilities for the field of sleep medicine, but success is contingent on a willingness to adjust to a changing landscape and to accept that there is plenty of work to go around. It is fair to say that the last sleep apnea patient is not walking through the door and that black is not the only color available.