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.

Perfect Storm - Delivering the right therapy

As mentioned earlier... up until the mid-eighties the treatment of sleep apnea was exclusively the province of ENT surgeons. UUUP surgery and variants was a novel replacement for a trach. The commercialization of Dr. Sullivan's discovery of Continuous Positive Airway Pressure in the mid-eighties changed the landscape considerably. While ENT surgeons are still more likely to prescribe CPAP than other medical specialties - there are pulmonologists, neurologists, psychiatrists and even general practices physicians who are prescribing CPAP (on the basis of PSG). Once the prescription was written for this new therapy and it would be reimbursed by insurance - who would provide it? The Durable Medical Equipment industry of course. They have experience with delivering oxygen therapy to patients and this was the same thing, right? Wrong! CPAP is about as different from oxygen therapy as anything could be.

Oxygen therapy is straightforward, once the correct flow is determined. A driver would stop by and replace the tank every 30 days or so for as long as the patient was alive (which was never for very long, back in the day anyway). The practice of just dropping off the CPAP device and mask is something DMEs have done and in some cases still do - with disappointing results.

No real consideration (i.e. patient input) was given to the distribution model for CPAP once it became commercially available.

There you have it - the elements of the perfect storm: a condition that is more prevalent than previously thought, a system for testing that is better suited for research than for diagnosing an epidemic, and a distribution channel that fails to recognize that treating the condition requires something more than someone delivering a box to the door.

Next up... surviving the storm and moving ahead.

The Perfect Storm - Arriving at a Diagnosis

Two stories... there was a time, a while back, when a noted physician invited a group of residents into a patient's room to show them someone with sleep apnea. A condition he said that they might only see a couple of times in their professional career. Another noted sleep medicine physician when talking about diagnosing people with sleep apnea says that janitor who works in building is capable of "diagnosing" patients while they sit in the waiting room.

Sleep disordered breathing in the form of obstructive sleep apnea is not rare, far from it. The increasing age of the population and the increasing body mass index is making all too prevalent. Sadly, it becoming more common in children as well..

What are the tools required to determine whether obstructive sleep apnea is present and sufficiently severe to warrant a therapeutic intervention. How much information is enough information to say yes, this person has sleep apnea and needs treatment. 

There are some who believe the only definitive way to determine whether sleep apnea serious enough to requirement treatment is using a sophisticated research tool - monitored in-lab polysomnography (PSG). PSG collects a lot of information - it should, it is a valuable research tool - but could it be TMI when considering that sleep apnea is not as the earlier noted physician indicated a rare condition... a medical curiosity.

The janitor in the sleep lab determining who has the condition may likely be too much in the other direction - not enough to assess what are likely the less severe cases (mild to moderate including Upper Airway Resistance Syndrome).

Technology exists, actually it has existed all along that provides enough information to conclude there is a condition to be treated. In fact, the technology is getting more and more sophisticated - able to record more channels of information for the physician to use to arrive at a diagnosis.

The use of out of center or home sleep testing, as is becoming the requirement of health insurance companies through their proxies, will certainly increase the number of diagnosed patients. But, if once diagnosed the patient doesn't have someone trained to guide them to the appropriate treatment and help them manage the condition - we have accomplished nothing, perhaps made the situation worse.

If the first element of the Perfect Storm was a condition that was poorly understood in terms of its prevalence in the general population, the second element is how we arrive at a diagnosis for a condition once thought to be rare, but that is so common the janitor in the sleep lab could recognize it (at least the more severe cases).

                                                     (to be continued....)

Sleep Apnea and Health Care redux

I have commented elsewhere in this journal about the value of being in Washington. This past week was another example of the opportunities that present themselves when you are located in the Nation's Capital.

At the beginning of the week I attended a forum entitled “Health care reform, what's next?” This event had been postponed two weeks previously owing to the shootings in Tucson and before the vote in the House of Representatives to repeal the Affordable Care Act.

I go to these events, like most, hoping to gain some nugget of insight that might otherwise not make it through the media's filter. Another reason, again why most go, is the networking opportunity the gatherings provide. Hey, this is Washington.

The nugget for me came from Republican pollster Bill McInturff. who indicated that the majority party in the House of Representatives had nothing to “replace” what they had recently “repealed.” Without an alternative, HR 2 would go nowhere.

Unfortunately, I had to leave early and so had to miss the comments of Neera Tanden. Her perspective on how health care reform has evolved, given that she has been working on it since the beginning, would have been interesting.

I shared a table at the event with someone in federal affairs from AHIP, America’s Health Insuance Plans, the health-insurance lobby, and used the opportunity to remind my companion how important it is that health insurers provide coverage for the diagnosis and treatment of sleep apnea.

I left early to attend a briefing by the Nancy Brown, CEO of the American Heart Association, on a new economic study by her organization on the future cost of heart disease. My interest in attending the briefing was to introduce myself to her, which I did after the meeting. But I also used the briefing to raise a question about the role of healthy sleep in preventing heart disease. She wasn't quite ready for that question, though she did admit that quality sleep was important to her.

When I did get a chance to speak with her, she acknowledged that sleep is important and that there is some evidence of a causal relationship between OSA and heart disease, but she stressed the need for better medical evidence of the relationship. I was reminded of the summary section from an article that appeared in a 2008 issue of Circulation, the AHA journal, that highlighted numerous hurdles facing heart specialists in developing best practice principles to limit the adverse cardiovascular impact of sleep apnea.

We exchanged business cards. We have subsequently exchanged e-mails. We'll see what happens.

At the end of the week I was back at the National Press Club, this time for a briefing by the president of the American College of Physicians, Fred K. Ralston, M.D. ACP is the medical professional society that represents 130,000 general practice physicians in the United States. Ralston presented the State of the Nation's Health Care 2011. The ACP supports the Affordable Care Act, but sees room for improvement.

The ASAA has not taken a position on the law. Our concern has to make sure that diagnosis and treatment of sleep apnea is covered. We have asked visitors to our web site to write to HHS Secretary Sebelius requesting that coverage be included as the rules and regulations for the law’s administration are drawn up.

The points made by the ACP and its interest in pursuing “High Value, Cost Conscious Care” makes a lot of sense. Our own experience is that early diagnosis and treatment of sleep apnea can significantly reduce the cost of health care down the line.

We will explore further working with the ACP to educate primary care physicians, nurse practitioners, and physician assistants about sleep apnea and the benefits of treatment.