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.

October 03, 2014

The End of Sleep Medicine (part 1)

"Rumors of my demise are greatly exaggerated" - Mark Twain
I believe the field of Sleep Medicine about to enter a golden age. There is a convergence of several occurrences that leads me to that.
First, people spend a lot time talking about their sleep, mostly how they don't get enough of it. The technology (i.e. smartphones) has now advanced to point it can provide the tools for people to not only measure, relatively accurately, how much sleep they are getting but help improve the quality of their sleep.
Witness the success of the Kickstarter campaign that raised $1,000,000 in four days for the "Sense" device (http://www.theverge.com/2014/7/23/5927613/sense-sleep-tracker-is-a-glowing-sphere-that-watches-over-you-while-you-sleep) A device that takes all those sleep apps for the smartphone one-step better. Even the Positive Airway Pressure device manufacturer ResMed is getting involved with their introduction of the S+ device to monitor and improve sleep (https://www.keepyoursleep.com/#home) independent of treating sleep-disordered breathing.
Further evidence that many people are actively using sleep monitoring technology comes from Jawbone. Two recent news releases from them provides, what I believe to be the first publication using "big data" on sleep. The Jawbone Blog published the results of an analysis of sleeping patterns ten of thousands of Jawbone wearers - worldwide. (https://jawbone.com/blog/jawbone-up-data-by-city/) They were able to discern which city's the most sleep, the least sleep and other characteristics. The second blog post from 
Jawbone was published after the earthquake in Napa California. (https://jawbone.com/blog/napa-earthquake-effect-on-sleep/) The graph shows the disruption in sleep depending on how close they were to Napa.
The second occurrence that leads me to believe that we are entering the golden age of sleep medicine is the amount published research in the field. A recent search of the National Library of Medicine (www.pubmed.gov) on the terms "sleep disorders" and research resulted more than 9600 entries, with the earliest being 1963. The pace of published research is accelerating with a doubling of the number of published items in just the last 10 years.
People everywhere are interested in sleep, improving it as much as possible through appropriate monitoring technology. The amount of research related to sleep is increasing at an exponential rate. 

Far from the demise, those involved in Sleep Medicine have much to do in terms of helping the public better understand the data from their smartphones and to build on the research currently underway to comprehend the mysterious, little understood third of our lives.

The future is rich with possibilities.

Finally, improving sleep by diagnosing and effectively treating what may well the most common chronic sleep disorder, sleep apnea, has reached out beyond a limited number of specialists, primarily pulmonologists to other medical professionals (primary care physicians, cardiologists and dentists). The number of diagnostic modalities has increased as have the number of treatment options. 
It is this change, that I will discuss in part two of the end of sleep medicine.