The End of Sleep Medicine (Part 4)

 "You've come a long way baby" Virginia Slims cigarette tagline ~ circa 1968

Nearly five years since I have put pen to paper (so to speak) regarding the "end" or goal of sleep medicine. During that time I have, mostly quietly watched, the (r)evolution of the field.  I thought to provide some reflections on a field of medicine that was my professional life for 10 years. I would like also to thank again those who were my teachers and colleagues in the pursuit of helping those with the chronic health condition - #obstructive sleep apnea (OSA) - #sleep disordered breathing.

I recently had the occasion to visit a #CVS near me and found much to my surprise (though not really) the following displays

My earliest memories of serving as the executive director of the American Sleep Apnea Association was attending as an exhibitor at the #American Thoracic Society's 2004 International Conference in Orlando Florida. It was there I first met many of the men and women who would be my mentors. It was there I also met many of the reps of the device manufacturers #Resmed, #Respironics (now part of #Phillips Healthcare), #DeVilbiss, and #Fisher &Paykel.

While I was setting up the booth I had two encounters that have stayed with me. First was a woman working with the company setting up the exhibit hall. She saw the sign and stopped to tell me how her husband has #OSA. She lay beside him in the bed with her hand on his chest to make sure he was still breathing. This was my first encounter with sleep apnea - the first of what would be many during my tenure.

The second conversation I had was with a vice president for sales with #ResMed the number 1 or 2 in sales of #Positive Airway Pressure devices or CPAP.  I remember the conversation as if it was yesterday and these two images from CVS moved it to the front of my mind.  #Ron Richards said to me in five years you will be able to get these devices over the counter. If they work for you keep it (and use it) and if not bring it back. Like his boss, #Peter Farrell was fond of saying the only way one of these can hurt you is if it falls on your foot.

It took longer than five years and there are likely still a couple of hoops to jump through when it comes with the device, but at least when it comes to the supplies they are available when needed.

A second meaningful experience was the first time I provided testimony before a committee of  #Medicare regarding the use of #home sleeping testing (HST) for the diagnosis of #obstructive sleep apnea. This led to the publication of an open letter in the #Journal of Clinical Sleep Medicine.  It would be some years before the sleep medicine community would accept that #HST would not decrease the number of people seeking treatment for OSA and there would always be cases where the use of #HST would not be indicated. 

One of the many companies vying for a portion of the #HST market was a company using a different modality of measuring the incidence of pausing in breathing. #Itamar does not use the limitation of airflow into the lungs, something the pulmonary sleep medicine physicians were less inclined to accept as an accurate measure of disease. Without getting into the relative merits of the two modalities. #Itamar's technology  Here is an explanation of how this modality works.

Perhaps more important an alternate diagnostic modality was this technique engaged a medical community that heretofore had been reluctant to engage - cardiologists.  It is well known that untreated OSA has significant consequences on the cardiovascular system.  As far back as 2008 in the journal Circulation, there was the recognition that untreated sleep-disordered breathing is a driver of heart disease.  Perhaps the Itamar WatchPat technology spoke to cardiologists in a way ResMed Apnealink did not.   The important point here is cardiologists seem to be more engaged than previously.

Another memory - a well-respected sleep medicine physician would frequently say diagnosing sleep apnea as was so easy the janitor at the hospital where she practiced could tell just from looking a people in the waiting room whether they were positive for OSA.

The third and final meaningful experience happened at a medical conference where the ASAA was an exhibitor.  Our booth happened to catty-corner to that of the Board of Registered Polysomnographic Technologist (BRPST) and as it happened members of the American College of Chest Physicians happened to be passing by. The College had recently considered developing a certificate program for an allied health position for sleep, something akin to the Diabetes educator.  It was something subsequently they did not pursue.  But it was something I believed would be vital especially as #HST became more the norm than the exception.  I had always felt that successful treatment meaning being completely adherence to whatever therapy or treatment worked for the OSA patient was more important than how the diagnosis was arrived at. I knew both the representatives of ACCP and BRPST, and so I brought them together suggesting that BRPST take on the certificate program for what then call the sleep educator. It took some time and some hard work, but eventually, the CCSH program was born.

Perhaps it is fitting this blog post, the last in a series is published today on the 40th anniversary of the publication in the journal  The Lancet of Colin Sullivan's seminal research study 

Thank you to all my teachers, colleagues, and most importantly the patients who made this experience one I will always cherish.

What does the Obama presidency mean to the sleep apnea patient?

I am not aware that President-elect Obama spoke directly to the question of sleep apnea during the campaign, but it is possible to infer from his major speech on the subject of health care and from his plan on health care reform some areas where the sleep apnea patient could benefit from the reforms he is planning.

Early in the plan he discusses the need to support disease management programs. He states "Over seventy-five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease, and high blood pressure."

These are all co-morbid conditions with untreated sleep apnea. One wonders if early intervention on sleep apnea would not decrease the economic burden with these life-threatening conditions.

He goes on to say "[M]any patients with chronic diseases benefit greatly from disease management programs, which help patients manage their condition and get the care they need."

Obstructive Sleep Apnea (OSA) is certainly a chronic disease. For many it starts at a young age and stays with them their entire life. A life shortened needlessly because of cardiovascular disease.

OSA is a condition that would benefit from being treated according a disease management model. A model where there is a continuum of care from awareness through diagnosis/treatment and long-term follow-up. I offered an "ideal" treatment pathway in an 2007 article I wrote for Sleep Review.

Further in the same section of the plan Obama states that he "... will support providers to put in place care management programs and encourage team care through implementation of medical home type models that will improve coordination and integration of care of those with chronic conditions."

The challenge here is to get sleep apnea recognized as a chronic condition in which disease management strategy would be appropriate.

Elsewhere in the plan, Obama discusses moving away from paying physicians based on the volume of services provided and towards payment based on the quality or effectiveness of care.

For the OSA patient could mean something beyond just a reduction of the number of apneas and hypopneas. Effectiveness of care may be measured in improvement in resting blood pressure and elimination of daytime sleepiness.

He also discusses the use of comparative effectiveness reviews and research as keys to eliminating waste and missed opportunities for improved treatment.

As new technologies are developed for the treatment of OSA, comparative effectiveness research will help physicians and patients better understand which treatment will provide greater efficacy.

OSA is a chronic condition that affects all segments of our society, but it disproportionately affect the minority populations in the United States. Another element of the Obama plan is to tackle disparities in health care. If sleep apnea can be effectively diagnosed and treated, it will certainly accrew additional benefits, such as reduced health care utilization and improved quality of life. Finally, the health care reform proposed by the Obama campaign includes coverage for pre-existing conditions. This is an important benefit for the treated apnea patient who no longer need worry about continuing their treatment should they need to change insurance carriers.

Health care reform is on the agenda for the upcoming Congress, so change is coming. There is an opportunity for the reform to include sleep apnea. Seize the moment to let President-elect Obama know that recognizing sleep apnea is a serious condition and needs to be included in reform considerations.

Contact your Member of Congress and let them know that sleep apnea is a serious condition and needs to be included in health care reform considerations.

Contact your Senators and them know that sleep apnea is a serious condition and needs to be included in health care reform considerations.

The ASAA published a position paper on sleep apnea as a public health concern, click here.

All the best,

Ed