Sourced from Classic Sleep Care Blog
In the early 1990s I launched a large research project to measure the impact of imagery rehearsal therapy on chronic nightmare patients, while simultaneously training to increase my clinical experience in sleep disorders medicine and completing my board certification with the AASM. It is around this time we first suspected sleep apnea was more common among insomnia patients. The more I encountered OSA/UARS patients in clinic, the more I realized the “classic” presentation of OSA did not fit the majority of patients. Instead, patients often presented with many other sleep symptoms or different types of sleep disturbance complaints, and the picture often appeared as if the individual suffered from a current psychiatric condition that perhaps was the real or primary cause of the sleep disturbance. In other words, OSA/UARS was not the obvious chief complaint in patient’s mind.
For the next two decades, we published nearly thirty research papers in opposition to the idea that the psychiatric condition is the sole cause of sleep problems. We broached the topic in the reverse order by attempting to explain how sleep disorders should be more clearly understood and treated as primary conditions, co-occurring with mental health disorders. We declared that “sleep problems as a secondary feature of psychiatric conditions” reflected a flawed and outdated model. In a new perspective, we preached the expectation that treating an independent sleep disorder would not only improve sleep but might also improve mental health. The work listed above was one of the first research articles to demonstrate that treating nightmares (a sleep disorder functioning as an independent condition) led to decreases in both sleep complaints and mental health symptoms such as anxiety, depression and posttraumatic stress.
In the 1990s and 2000s Dr. Kenneth Lichstein was among the limited number of researchers exploring this relationship. In 1999 Dr. Lichstein published one of the first articles on occult sleep apnea in elderly patients, followed by a seminal commentary in 2006 on insomnia comorbidity with the provocative title: “Secondary insomnia: a myth dismissed”. Although this paper discussed all facets of comorbidity, not just the co-occurrence of insomnia and sleep apnea, the term “comorbid insomnia” came to mean insomnia manifesting in the context of another illness while retaining an independent character requiring specific insomnia treatments. Some of the common co-occurring conditions noted were: PTSD, anxiety, depression, cancer, pain syndromes, menopausal states, chronic fatigue, fibromyalgia, post-concussive syndrome, heart conditions, neurologic conditions and so on. The list may prove to be nearly limitless when we consider how vulnerable our sleep is to any sort of medical or psychological disturbance.
We applaud the use of the comorbid insomnia terminology, because it pushes more physicians and therapists to recognize the clinical relevance of aggressively treating insomnia; whereas, in the past, many healthcare providers focused solely on treating the co-occurring condition (e.g. pain, anxiety, menopausal symptoms) with the expectation the insomnia would dissipate. Or, they offered only simplistic therapeutic approaches such as prescription or over-the-counter sleep aids, instead of referring patients for comprehensive care at sleep medical centers. Sadly, the treatment of the primary condition first and/or the use of sleep aids is still one of the most widely used practice models in medical clinics around the world. Nonetheless, among health professionals now learning about comorbid insomnia, many are gaining sufficient education to recommend evidence-based, sleep-oriented treatment approaches to a growing number of patients.
With this background, we still believe some refinement is needed in terminology, which is why we view the term complex insomnia as a better fit for many of these patients instead of comorbid insomnia. We also believe the term COMISA should be considered as well. To begin this exploration of terms, we think a most relevant analysis would determine what is the most common co-occurring condition linked to insomnia. For example, arguments could easily be made for mental health as the single most frequent comorbid condition with chronic insomnia. Reading the DSM-5 nosology handbook that lists all psychiatric disorders strongly supports this point of view, because nearly all mental health conditions include sleep disorders as criteria for the diagnosis of the psychiatric condition itself.
A potentially large flaw in the argument in favor of mental health comorbidity, however, is the presumption that psychiatric factors must be the only cause of the insomnia. And, yet this last statement is confusing, because there can be no doubt that anxiety, depression or PTSD cause or aggravate insomnia through well-documented psychophysiological factors. You can imagine that someone with any type of mental health issue must at times show some difficulties coping with life stressors; therefore it would be no surprise for poor sleep to arise as well.
Given the crucial juncture in the timetable of a psychiatric patient’s insomnia, it does not seem likely some other factor, physical or mental, could be more common as the co-occurring condition. In other words, whichever came first, insomnia or the mental health condition (or perhaps both emerge at the same time), it stands to reason the two conditions are joined at the hip….
….unless, we were to discover these patients actually have a special vulnerability to a sleep-disordered breathing condition that only emerges covertly during the inception of the patient’s sleep problems. In this hypothetical and speculative model, we are proposing sleep breathing problems are already present in a large proportion of mental health patients. Or in a corollary to this speculation, unbeknownst to these patients, they already possess a nasal or oral airway anatomy susceptible to the development of sleep breathing problems.
Let’s analyze both examples.
- In the first example, the mental health patient has a known sleep-breathing symptom, such as snoring, that causes mild sleep fragmentation. Add in the factor of sleep fragmentation associated with virtually any mental health condition, and at first glance this double whammy of sleep fragmentation appears to be from two seemingly unrelated sources. However, in studies dating back to 1994, Canadian researchers Sériès F, Roy N, and Marc I. were able to demonstrate that sleep fragmentation itself worsens sleep breathing. That is, sleep breathing-induced sleep fragmentation worsens breathing, and any other sort of sleep fragmentation appears to worsen sleep breathing as well. This presumably occurs through changes in the central nervous system (CNS) that affect the natural respiratory drive of the individual. Simply stated, while awake, you breathe according to one part of the CNS, and while asleep you switch to another CNS area. Obviously, these two respiratory drive systems overlap to an extent, but it seems sleep fragmentation causes a problem in how these two systems interact. Specifically, arousals and awakenings during the night (sleep frag) trigger too much alternation between the two breathing drives (waking and sleeping). This theory, while not very well researched, remains the most commonly described hypothesis among sleep experts who theorize on how someone with insomnia might develop a sleep breathing disorder.
- And, to quickly summarize the second scenario, potential insomniacs suffering anatomic irregularities (e.g. deviated septum, enlarged tonsils, crowded airway, large tongue, etc.) are naturally vulnerable to the future development of a sleep breathing condition. If accurate, then this individual’s sleep breathing might worsen under stress-induced sleep fragmentation.
To encapsulate the above, if breathing system vulnerability underlies insomnia problems by the interrelationship of sleep interruptions (fragmentation) and breathing events (apneas, hypopneas, flow limitations), then a new rationale would view the physical or physiological dimension to insomnia as more prominent than the psychological factor. This idea is highly relevant to clinical care when we consider current research interestson how well CBT-I works among chronic insomnia patients with known OSA/UARS. The premise of such research alleges that despite the physical sleep fragmentation of OSA/UARS, patients who learn cognitive-behavioral instructions to cope with insomnia will report fewer episodes of unwanted sleeplessness regardless of the persistence of their sleep breathing events. However, the reverse of this paradigm must also be researched once we understand the full breadth and depth of these interactions. That is, if someone with chronic insomnia is treated with PAP therapy, how much would insomnia improve despite the lack of CBT-I to change their coping skills? In both instances, questions arise as to whether residual sleep breathing events still need to be treated in patients receiving only CBT-I and whether residual insomnia behaviors still need to be treated in patients receiving only PAP therapy.
Back to the terms, I trust you see the direction taken in this post indicates a larger role for sleep breathing than the actual mental health condition, and the parsimony of the hypothesis would be upheld if chronic insomnia in pain, cancer, or cardiac patients as three examples also manifested the same nexus between sleep fragmentation and sleep breathing events. While these theories certainly warrant more research to verify or disprove the priority of sleep-disordered breathing, the selected term would convey insomnia and sleep-disordered breathing as the relevant disorders joined at the hip. If so, the COMISA term appears the most salient of the three discussed, because it is the only one to convey both disorders as in CoMorbid Insomnia Sleep Apnea.
On the surface, COMISA seems reasonable, but my concern with the term is it would be used too broadly for all patients who suffer both conditions. Why would such an approach prove problematic? COMISA might be too vague if it only functions as an umbrella term without actually conveying specific clinical relevance to a particular case. For example, although identifying a medical or psychological condition accurately with clear-cut terminology is an essential aspect of healthcare, the presentation of the disorder also plays a key part in how medical professionals recognize or treat the problem. In contrast to what is conveyed by COMISA (i.e. both conditions are present), comorbid or complex insomnia often present in varying ways based on patient perspectives, and these presentations factor a great deal in how medical professionals understand and treat a condition. In my opinion, a more incisive terminology is needed when we are dealing with insomnia patients who literally have no idea that a breathing disturbance is part of their disorder. Instead, the typical insomnia patient is more apt to report on insomnia symptoms with psychological words as in “stressed out, racing thoughts, overwhelmed,” while almost no attention would be given to breathing, let alone connecting breathing symptoms to the insomnia.
For the above reasons, when most chronic insomnia patients use the term insomnia directly or use substitute terms (e.g. horrible sleep) to describe their condition and thus appear overly focused on insomnia, I believe a better term would attend to the patient’s perspective. Thus, I favor using the word “insomnia” in the selected terminology, because most chronic insomniacs are not in a position to readily accept their condition as something caused or aggravated by a sleep breathing disorder. Instead, their mindset is more apt to believe they will require pills or psychological therapies. In the next post, I will return to our original term – “complex insomnia” – to argue why it is still the preferred way to communicate in describing these types of patients.
September 15th Symposium on Comorbid Insomnia and Sleep Apnea
Sourced from Classic Sleep Care Blog
Earlier this year, I joined with other experts in the field who are researching comorbid insomnia and sleep apnea—something we describe as “complex insomnia”—to deliver a symposium in Bologna, Italy at the annual European Sleep Research Society (ESRS) conference. The talks were attended by a few hundred participants and were well-received, although candidly I want to emphasize this topic remains too far out on the cutting edge and many sleep researchers and other sleep professionals still show difficulty digesting the clinical relevance and importance of this extremely common co-morbidity. I base this view anecdotally on the audience Q & A generated after each talk, which I believe showed little curiosity and even less in the way of corroborative experiences. Nonetheless, the symposium will hopefully prove to be a good start in raising our colleagues’ awareness and planting new seeds of discovery.
Each talk and related Q & A lasted about 30 minutes. Dr. Christian Guilleminault at Stanford (my former mentor during a sleep fellowship in 1993) kicked things off with a talk entitled “The early recognition of co-morbid obstructive sleep apnea and insomnia.” Dr. Guilleminault’s presentation was inspiring and emotional in light of his recognition of the likely connections between sleep breathing and insomnia in the early 1970s (40+ years ago). During part of this period he was training as a medical resident in Bologna, so we can only imagine how emotional the experience was for him to give this talk. Back then, he noted a connection between central sleep apnea and insomnia, and he collaborated on three different papers on the topic, which were all published in the early to mid- 1970s in prestigious scientific journals.
Oddly, this research topic all but vanished from the scientific literature until the late 1990s and early 2000s when a few papers noted the finding of occult sleep apnea in a few different samples of patients. Dr. Leon Lack, who chaired the conference as well as serving as the 4th and final speaker, noted this large gap in the literature, while introducing the next talk on our own work in the field dating back to 1999, “Positive airway pressure to treat co-morbid insomnia and sleep-disordered breathing: a rationale for advanced auto-adjusting dual pressure technology.”
I pointed out that our original spark of knowledge on comorbidity derived from our work with chronic nightmare patients with PTSD. Their intense and complex sleep disorders turned out to be due to additional factors beyond their self-reported complaints of insomnia and nightmares. In 2001, we published the “Complex Insomnia” paper inBiological Psychiatry, demonstrating a 90% rate of OSA/UARS in crime victims with PTSD. The second half of my talk delved into our experiences using advanced PAP technology, notably ABPAP and ASV, in the treatment of complex insomnia patients and how we were not only achieving higher use rates with these devices, but also these modes of PAP were strongly associated with marked improvements in insomnia severity. I closed with a few slides describing preliminary results in our current randomized controlled trial comparing CPAP vs ASV in complex insomnia patients.
Dr. Erla Bjornsdottir from Iceland delivered the third talk: “Insomnia phenotypes response to obstructive sleep apnea treatment in co-morbid insomnia/OSA.” Dr. Bjornsdottir raised very interesting questions about the impact of OSA treatment on different types of insomnia, generally classified as the sleep onset category (SOI) sleep maintenance (SMI), and early morning awakenings (EMA). In her research group, they found clear evidence for improvement in SMI with CPAP treatment but far less impact on the early or late varieties of insomnia. She then went on to described a very clinically relevant research project about to get underway at her center in which they will assess the impact of online psychological insomnia treatment (cognitive-behavioral therapy for insomnia, CBT-I). Their innovative study will examine a series of patients who will have all been diagnosed with OSA, but due to wait times for patients to return for retitrations and PAP setups, they will be use the intervening time to evaluate how such patients respond to CBT-I. All these patients will have been diagnosed with OSA, but during this waiting period only some will receive insomnia treatment. In other words, the research is an excellent test on whether or not CBT-I will decrease insomnia symptoms in patients with OSA before they are exposed to a CPAP treatment that might also decrease insomnia severity. This type of research is known as a dismantling study in the sense that if someone received CPAP and CBT-I, we would expect a very potent result. Instead, by focusing on just CBT-I, we might learne how much improvement can be achieved for insomnia symptoms before the OSA itself is treated.
Dr. Leon Lack from Australia delivered the fourth talk: “Treatment of insomnia before CPAP for co-morbid insomnia/obstructive sleep apnea,” and as you can see by the title, their work overlaps with Dr. Bjornsdottir’s up and coming study. Dr. Lack has previously presented on this important topic at an annual SLEEP conference in the USA, if memory serves more than 10 years ago. He described how the comorbid presence of OSA in one group of insomniacs compared to a group of insomniacs without OSA yielded no differences between the groups when treated with CBT-I. Recently, Dr. Lack and his graduate student colleague, Alexander Sweetman have published two thorough review articles on comorbid insomnia and OSA, the first, “Diagnosis and Treatment of Insomnia Comorbid with Obstructive Sleep Apnea” discusses how often insomnia in sleep apnea patients is undiagnosed, undertreated or untreated and how CBT-I in addition to improving insomnia may demonstrate value by increasing PAP adherence. The second article, “Developing a successful treatment for co-morbid insomnia and sleep apnoea” emphasizes the confusion currently in the literature on the best approach to treat patients with this condition, which they dubbed COMISA (i.e. comorbid insomnia and sleep apnea). Dr. Lack concluded his talk by describing further work to examine the timing of CBT-I in these patients.
Prior to the talk, several of us met for dinner to discuss our perspectives on comorbid insomnia and sleep apnea. Another young researcher in this area, Dr. Megan Crawford joined us and contributed to our conversation. Just in the past few years, she has co-authored papers with Dr. Jason Ong, another insomnia/sleep apnea researcher. Their three works include: 1) “Insomnia and Obstructive Sleep Apnea” ; 2) “Management of Obstructive Sleep Apnea and Comorbid Insomnia: A Mixed-Methods Evaluation”; and 3) “Evaluating the treatment of obstructive sleep apnea comorbid with insomnia disorder using an incomplete factorial design.”
One of the most revealing aspects of the discussion was the nearly universal belief of a widely underestimated prevalence of complex insomnia (as we call it) or COMISA (as penned by the Australian group) or simply comorbid insomnia (as described commonly by sleep researchers and clinicians). Although rates varied to a low of 40% and a high of 90%, all these proportions are very high and probably not widely accepted by the typical sleep doctor or even someone who specializes in insomnia research. Nonetheless, while rigorous protocols to detect accurate prevalence rates remain to be completed, it will be revealing when it is determined whether or not all of us in the trenches are over-estimating the frequencies because we are too close to these types of patients or whether we will prove more accurate because we are paying closer attention to the phenomenon.
Sourced From Classic Sleep Care Blog
In the past nine articles I have detailed nine gaps in knowledge that are affecting the field of sleep medicine today. The field is in quasi-crisis mode with concerns about the apparent decline in the number of sleep medical centers and the dwindling number of sleep physicians in the USA. Attending to the knowledge gaps I have highlighted will help sleep medicine leaders build an assertive stance, motivate young doctors to specialize in sleep medicine, and encourage communities to embrace the invaluable role of their local sleep medical centers. Below is a summary of these points and actions.
We need an undisputed definition of normal sleep.
The lack of a definitive statement and measurement for normal sleep is arguably the worst omission in the field. The effort to define a minimum quantity of sleep without addressing the underlying issue of sleep quality is not only a distraction, but also will be used inappropriately by various non-sleep medical professionals to push their own agendas. Unintended consequences will emerge in at least two ways:
- individuals sleeping less than 7 hours per night will be coaxed into using sleeping pills to sleep more hours, and
- regulatory agencies will create more policies that steer patients away from necessary sleep evaluations, because they will be led to believe they just need more hours of sleep.
It is both astonishing and regrettable that the field of sleep medicine and its research community has not worked diligently to establish the meaning of normal sleep.
We need to scientifically distinguish sleep-disordered breathing from normal breathing.
As an industry and field of science we have had major difficulties discerning the differences between sleep-disordered breathing—the single most common health condition treated by sleep medicine physicians at sleep medical centers—and normal breathing. The controversies regarding how to measure and score sleep breathing events continue to plague the field in several ways. Lack of an absolute definition of normal breathing leads to:
- confusion among both patients and doctors;
- missed diagnoses in potentially hundreds of thousands of cases; and
- inappropriate instructions to patients leading them to believe their sleep breathing condition is mild or non-existent.
These issues would be nullified if the field vigorously attacked the anti-patient policies and regulations of the insurance industry and government regulators whose efforts consistently attempt to set inappropriate criteria for defining sleep-breathing disorders. Moreover, the internal strife within the field itself must come to end and will only do so when a benchmark of normal breathing is established. Once properly defined, all other breathing patterns, no matter how subtle or how difficult to score, will be deemed abnormal. And, as is currently appreciated amongst a smaller cadre of practicing sleep specialists, when these patients treat their so-called subtle sleep breathing events, impressive health benefits are frequently gained in the vast majority of cases.
We need to acknowledge the existence of Upper Airway Resistance Syndrome (UARS).
It is time to resolve the ambiguity surrounding the UARS concept. I believe the American Academy of Sleep Medicine (AASM) made a mistake in trying to incorporate UARS into the nosology-defined umbrella of obstructive sleep apnea, thus forcing us to tell our UARS patients point blank “you have sleep apnea according to insurance criteria and AASM policies,” but by the way “you don’t have any apneas!” These nonsensical declarations must cease, and RERAs must be correctly accounted for and scored accurately on both diagnostic and titration studies. The current practice parameters lead the vast majority of sleep medical centers to be in recurrent conflicts with each other, because some practices understand and accurately use the UARS diagnosis while others completely ignore the condition. Reversing the AASM position is an essential step in consolidating the field of sleep medicine around unified definitions of what it means to suffer from sleep-disordered breathing.
We need to put more effective pressure on insurance carriers and government institutions.
Time and again, the policies and regulations set by insurance carriers and government institutions—beyond the hassles of excessive administrative burdens—ignore the actual science of sleep medicine. This chronic issue will no doubt continue as a perpetual problem, but there are plenty of current opportunities to engage with non-scientific entities on a routine basis, a strategy that should be guided by our industry body, AASM in collaboration with expertise of hundreds of sleep medicine physicians who must on a daily basis wade through the non-scientific insurance or government formulas to manage their patients.
The rejection of the UARS diagnosis and scientifically-determined rules for scoring flow limitation events is a prime example of insurer and government interference, which ultimately leads to a failure to understand and recognize the correct respiratory disturbance index. Such anti-patient practices interfere with and harm patients. The same goes for arbitrary sleep breathing metrics with idiosyncratic scoring rules designed purely to limit access to PAP devices, most notably in geriatric populations, where many patients with mixed UARS and mild OSA patterns are epidemic. The AASM and its advocates should be battling with these entities on a regular basis, including widespread public relations efforts to shine light on insurance carriers and government regulators that are harming our patients. In addition, as feasible, lawsuits or at minimum widespread collection of patient complaints against insurers and government policy-makers should be a standard component of the AASM’s community outreach as one means of playing hardball against agents who have demonstrated willful ignorance towards our sleep patients and their sleep physicians.
We need to resolve confusion around coding for clinical encounters and special procedures.
The failure of the industry to advance the use of innovative (and already established) billing codes has created something of a logistical clinical nightmare in which codes for patient encounters with sleep technologists are often misapplied. For example, CPT 94660 and CPT 95807 both fall under the aegis of Procedures and thus are acceptable with general supervision from the sleep physician. Using these codes encourages not only expedient management of patient, sleep tech, and physician time, but also provides small yet sufficient reimbursements to cover administrative and labor costs while improving patient compliance with PAP therapy. Just imagine: higher quality care at a lower price! The AASM, and the industry as a whole, need to support the correct use of these codes and to collaborate more actively with sleep centers in the trenches, many of whom consistently and correctly apply these procedures and related billing practices to the advantage of their patients. Regrettably, the AASM has fumbled on this particular issue in a number of ways, most notably at annual and other sponsored conferences when its representatives unwittingly appear to disseminate inaccurate guidelines on how to use these codes.
We need to improve insurance coverage for diverse approaches in applying PAP therapy.
Insurance-driven prior authorizations are predicated on the belief the majority of sleep apnea patients present with classic snoring or other breathing symptoms and daytime sleepiness. For these straightforward cases, sufficient care can be provided through home sleep testing and a doctor-prescribed auto-adjusting CPAP device.
In our clinical experience, the insurance perspective is insufficient because the typical,most common OSA/UARS patient suffers multiple co-morbid conditions that either directly interfere with sleep or create barriers to individual efforts to use PAP therapy. Moreover, auto-adjusting PAP devices (set to auto mode) do not meet AASM criteria for a valid and effective titration of pressure settings. Allowing insurance companies to dictate this model of care enables the steady degradation of sleep medicine.
A corollary to this set of problems is the failure of the industry as a whole and the field of sleep medicine in particular to recognize the tremendous value of in-lab retitration studies for complicated patients whose pressure settings and related PAP challenges (e.g. mask fit, mask leak, mouth breathing, nasal congestion, aerophagia) are in need of routine attention, often due to the problematic effects of co-occurring conditions such as obesity, heart disease, hypertension, and mental health disorders. The AASM currently has no practical policy to encourage the use of retitrations in a timely fashion because it does not appear to recognize that pressure settings in patients often change over time and does not appear to embrace the clear relationship between pressure setting accuracy and outcomes.
Worse, the AASM has not coordinated maximum pushback to the home testing phenomenon in our clinical practices, leaving us all to continually play catch-up and usually with a defensive attitude. While the AASM’s reputation largely remains good, it would be a stronger institution if it directly and more forcefully confronted insurance carriers and government regulators on these issues.
We need to emphasize the importance of outcomes over compliance.
A further challenge to advocacy for retitration studies stems from insurance carriers’ routine conflation of compliance and outcomes. Stating that someone achieving PAP compliance must be doing just fine is like saying a patient who is using their anti-diabetic medications regularly must be doing just fine, so we do not need to check any lab work.
Insurers have so much influence over sleep physicians and their practices, that many sleep staff (including specialists) are now wholly focused on compliance and fail to recognize the mediocre responses in compliant patients who only look good “by the hours.”
In developing our REPAP protocol (repeat, rescue, re-titrations) at Maimonides Sleep Arts & Sciences, we remain concerned by the large number of compliant patients who manifest residual sleep complaints such as insomnia, sleepiness, fatigue, and nonrestorative sleep. We hope to publish a paper soon on the REPAP protocol, an approach that clearly goes against the trend towards home sleep testing. Regardless, it is a physician’s responsibility to accurately measure the response to PAP beyond the simple tabulation of hours and dig into the overall sleep quality changes and related daytime improvements or lack thereof. As an industry and field of science we need to focus on the important role of outcomes over compliance numbers, and vigorously defend the purpose of retitrations in patients with poor outcomes to improve patient care.
We need to develop a niche focus on each of the comorbidities in sleep apnea patients.
The field of sleep medicine is finally realizing how much it has to offer many other fields of medicine. However, the leading experts in sleep medicine have not yet recognized the value in pushing the development of these niche markets.
While the field of cardiology now has its own specialty sleep practice organization, many other medical and psychological fields need to be penetrated by sleep medical experts and institutions. There are enormous opportunities in many different areas – such as Urology, Otolaryngology (ENT) and oral surgeons, Nephrology and hypertension clinics, Obstetrics, Neurology and Neurosurgery, Ophthalmologists and optometrists – with none as large and dramatic as sleep medicine’s impact on the field of mental health. These issues go beyond opportunities; all sleep medical specialists and researchers have an unequivocal responsibility to push hard to demand a seat at the table in the fields of psychology and psychiatry, because of the undeniable capacity for our specialty to positively influence the care of their patients.
In sum, consider just these three examples of important questions about comorbid sleep disorders that should be on the minds of all of us in the field of sleep medicine:
- Do we really want to see nocturia patients continue to be exposed to unnecessary surgical procedures?
- Do we want pre-exclampsia patients to spend prolonged times in the hospital?
- Do we want the untreated sleep disorders of millions of mental health patients to go undiagnosed and untreated?
Again, as sleep experts, it is our duty to push this agenda to the limits, and doing so will not only enhance the care of many undiagnosed and suffering patients, but it will also serve to expand and stabilize the field of sleep medicine.
We need to change the reliance on AHI and RDI metrics.
Last but certainly not least, the field of sleep medicine needs to challenge the use of thearbitrary metrics known as the apnea-hypopnea index (AHI) and the respiratory disturbance index (RDI). In a nutshell, these two metrics are largely qualitative ways of establishing a diagnosis of OSA or UARS. Yet, they often do not reveal the true severity of a sleep-breathing problem in a manner that accurately informs the patient of the full breadth and depth of his or her disorder.
This issue was created when the field of sleep medicine was influenced down the pathway of insurance-based reimbursements. This initially made sense in order to gain coverage for our patients, but in the long-run by sticking with the insurance model, prices on all sleep medicine services and sleep durable medical equipment remain inflated beyond what the consumer should be paying.
As a result, incessant games of tug of war play out between insurers, government regulators and physician representatives, not to mention the squeeze on DME companies. The emerging objective at this point is a concerted effort to drive down all these costs, which is now having the secondary and highly problematic effect of forcing some sleep centers out of business and discouraging young doctors from considering the field of sleep medicine. For these reasons, the field desperately needs to work on a non-insurance or cash-basis model of care, which could lead to sleep medical centers managing a considerably larger volume of sleep disorder patients to balance the inevitable lower costs of care. And, it would permit the field of sleep medicine to establish its own scientifically determined metrics for sleep breathing disorders unconstrained by non-scientific entities. Think LASIK and the incredible growth and advances in technology in this field, and you’ll get the picture. The end result would salvage many sleep centers and yield new stability for the field. The AASM’s expansive efforts to forge a telemedicine program for our field is an outstanding first step, but much more is needed.
To conclude, it cannot go without saying how necessary it is for leaders in the field of sleep medicine, including AASM officials and leaders from other reputable sleep institutions, to seriously reevaluate how to move the field forward. The AASM is currently engaged in such endeavors, but to my knowledge very few of the concepts and themes described in this document are addressed by their efforts. Instead, they are attempting primarily to find more government-sponsored funding to assist in promoting the training of sleep medicine doctors as well as to establish a new model of care delivery (“hub and spoke”), which in my opinion places too much emphasis on academic sleep medical institutions. At the most recent annual meeting of sleep physicians and researchers in Denver, much discussion ensued on these points. It seemed, in my opinion, that the large audience at this 3-hour discussion was unable to form a clear-cut consensus. Many audience participants raised questions and objections to the proposals that were not responded to in clarifying fashion by the panel leading the discussion.
To be sure, AASM leadership offered several other ventures and proposals on how to solve the crisis in sleep medicine, and no doubt they will continue to work earnestly and diligently to develop and implement new plans and strategies. A major difference between my perspective and that of the AASM is that every single item addressed in these posts directly or indirectly solves a knowledge gap that currently compromises quality of care or returns control to the field of sleep medicine so specialists can provide a higher level of care. Given the long-standing complaints lodged at the field of sleep medicine for poor adherence rates among PAP users as well as the notable inconsistencies between different types of sleep physicians and sleep centers, I am increasingly persuaded a new focus on the quality of patient care in sleep medicine may serve both our short and long term interests better than some of the administrative approaches suggested. Along these lines, one final and pivotal example must be presented.
We need to rethink the default approach to treatment of sleep-disordered breathing.
The application of CPAP therapy as the default approach to the treatment of sleep-disordered breathing must be recognized for the harm it does to many patients unwilling or unable to use this somewhat outdated fixed pressure system. In no uncertain terms, a substantial number of patients are traumatized by their initial encounters with CPAP devices, even with auto-adjusting systems, because of their inability to tolerate breathing out against the fixed pressure delivered inward during expiration. The traumatic exposure experienced by these patients leads to a classic posttraumatic set of avoidance behaviors, where the individual drops out of care for months or years, because of their awful first encounter with a CPAP device. Technically, this problem borders on medical mispractice, because a sizeable proportion of these patients present risk factors of anxiety, nightmares, insomnia, and claustrophobia, as well as an array of psychiatric conditions and yet still are initiated on CPAP. Sleep medicine physicians, sleep technologists, and DMEs are all aware of the patients who cannot tolerate fixed CPAP, and fortunately many of these professionals are moving in the direction of expiratory pressure relief systems or preferably dual pressure devices (bilevel). Nonetheless, the number of patients who suffer traumatic exposure to CPAP is unknown but not a rare occurrence. And, sadly, this particular problem is one of the main factors continually soiling the reputation of the field of sleep medicine. This singular experience of acute, traumatizing CPAP failure leads to obvious disrespect for the field and its doctors and is regularly spread through word of mouth by numerous dissatisfied sleep apnea patients.
A large oversight by many in our field is to imagine that failure to initiate CPAP in such circumstances can be written off with phrases like “poor adapter” or “CPAP intolerant” without recognizing the long-term harm done to patients who have been pushed into these unpleasant experiences. It is imperative to realize this problem is not simply a matter of low adherence rates. Instead, these specific consequences are often interpreted to suggest the field of sleep medicine is knowingly indifferent to its patients because it does not raise objections that would attest to a serious concern about this adverse effect. If anyone doubts the relevance of the traumatizing influence of initial CPAP encounters, you only need to look at the way every other treatment option (e.g. OAT, Provent, ENT surgery, bariatric surgery) advertises their wares. Each talks about the hassles, hardships and horrors of CPAP, and they could not promote their alternative in this style if it were not true at some level. Indeed, even within the community of CPAP vendors you will find language like, “Don’t Let CPAP Destroy Your Sleep” when referencing a nasal pillow style. I strongly believe the frequency of these traumatizing experiences is much higher than most sleep professionals are willing to admit or are able to recognize. Identifying, naming and addressing this negative outcome would go a long way towards improving quality of care in sleep patients and upgrading the reputation of sleep medicine.
All in all, it remains uncertain whether the field of sleep medicine will survive as a full-fledged specialty area of medicine or whether it will be eventually co-opted by various disease-centered markets (e.g. cardiac care, mental health institutions, and pulmonary medicine). We need to unite and look at new pathways going forward to yield more prudent decision-making for the long-term health of clinical sleep medicine. It is my sincere hope the information conveyed in this extensive series will promote more innovative thinking and actions to improve the quality of sleep medical clinical care.
Sourced from Classic Sleep Care Blog
Diabetes is a systemic illness that can wreak havoc on virtually every organ system in the body. When blood sugar levels are abnormally elevated, for example when after eating a meal the sugar rises rapidly to abnormal levels and remains high for longer than in a non-diabetic, this excess glucose attaches itself to blood hemoglobin, the special protein in red blood cells that transports oxygen through the bloodstream. The glucose attachment to hemoglobin is called glycation and can occur in any human, but it occurs more so in diabetics due to the excess glucose in the system. To read a brief and interesting story about the discovery of this biomolecule, now known as Hemoglobin A1C (HbA1c), you can go to this piece in PubMed about Dr. Samuel Rahbar, the man making the discovery in 1968.
The remarkable thing about HbA1c is how closely it correlates with the disease of diabetes. In other words, the higher your A1C levels, the worse the diabetes. The more tightly controlled the A1C, hopefully near levels close to what is measured in normal, nondiabetics individuals, the more likely diabetes will have less impact. Some research predicts diabetic-related kidney or eye diseases are more common in those with A1C levels > 8.0; whereas the more recent recommendations for A1C control indicate levels < 7.0 are protective against damage inflicted by diabetes. Many doctors recommend their patients keep A1C levels in the 6.0 to 6.9 range, but some patients actually achieve levels < 6.0. However, in this latter case, these low HbA1c levels may create new risks in cardiac patients, because this extremely tight control of glucose may herald more hypoglycemic episodes, especially while sleeping, which in turn can trigger serious problems with heart function, including sudden death.
As you might imagine, the HbA1c biomarker has proven exceptionally useful in monitoring and treating diabetic patients. And, the HbA1c biomolecule is one of the most powerful measuring tools in all of medicine. Other markers with which you might be familiar are cardiac enzymes when a person suffers a heart attack, creatinine and blood urea nitrogen levels in kidney failure, and liver enzymes in patients with acute or chronic alcoholism.
Regrettably, in sleep medicine, there is no biomarker that correlates with the major sleep diseases such as OSA/UARS, insomnia, restless legs syndrome (RLS) and periodic limb movement disorder (PLMD), or even with the main waking complaints of sleepiness or tiredness. The absence of such biomarkers in this developmental phase of sleep medicine clearly hampers our efforts to treat patients, because we are relying exclusively on patients’ self-reports on their improvements in symptoms or lack thereof. While we have access to objective markers of sleep diseases, for example, how many breathing events or leg jerks while sleeping or how much sleep loss in a night of insomnia, these numbers often do not correlate with the severity of the diseases or the intensity and duration of the daytime symptoms. Even notable outcomes such as hypertension or nocturia (bathroom trips during the night), both of which are common in OSA/UARS patients cannot be specifically correlated with the severity of the sleep breathing disorder.
A biomarker for sleep diseases and symptoms due to impaired sleep will represent an enormous scientific breakthrough that will dramatically improve our ability to understand and treat sleep disorders. Some noteworthy articles on this topic include ones that discuss how biomarkers will lead to greater precision in sleep medicine, ones that describe how biomarkers will lead to easier diagnosis of OSA/UARS without relying on PSG, and ones that may demonstrate new treatment approaches to lessen the impact of sleep-breathing disorders on human health.
Root Causes for and Clinical Attention to RLS/PLMD
Although there are troubling signs different types of physicians and medical staff are not paying attention to the epidemic of OSA/UARS in numerous patient cohorts, there are equally bothersome indicators within the sleep medicine community of physicians who are not paying attention to RLS/PLMD. The reason for this oversight seems uncertain, but the main issue tends to be an entrenched conventional wisdom that diminishes the relevance and impact of these leg movement disorders.
This conventional wisdom dates back several decades where minimizing the consequences of RLS/PLMD was routinely discussed at the annual sleep conferences. At various points in the 1990s, expert researchers in the field declared that leg jerks had no impact whatsoever on sleep quality or daytime symptoms. Even to this day, there are many sleep physicians and researchers who presume leg jerks are unlikely to be a factor in the management of sleep disorders’ patients.
Some of this perspective is accurate in so far as increasing evidence reveals leg jerks are often a sign of arousal activity caused by the primary condition of sleep-disordered breathing. Nonetheless, there remains a substantial number of patients where leg jerks turn out to be truly independent, meaning the limb movements independently disrupt sleep. The problem arising is the long time it often takes, many months or longer, and the considerable effort to sort out these diagnoses. For example, if the patient’s airflow curve is not normalized, how can the sleep staff figure out whether or not the leg jerks are independent? This factor alone may create long delays in attempting to determine leg movement status. And, many patients are reluctant to try medications for RLS/PLMD until it is clearly proven to them this co-occurring disorder needs its own treatment. Obviously, patients with noticeable RLS are more interested in drug therapy sooner in the course of clinical care, but even some of these cases, remarkably, turn out to be caused by untreated sleep-disordered breathing.
The bottom line is the field of sleep medicine needs research that more accurately defines these movement problems and the actual causes of RLS/PLMD. Knowing such info would go a long way towards expediting care for this disorder in relevant patients. This gap is substantial and severely impacts those patients who suffer from these leg movement disorders and who often experience considerable delays in diagnosis and treatment.
Understanding the Role of Sleeping Pills and Their Sub-optimal Results
As the pharmaceutical industry continues its never ending quest to find the perfect sleeping pill, a number of trends in both the fields of sleep medicine and psychiatry are moving in opposite directions. Although not a groundswell by any means, it is very clear more and more physicians in sleep and mental health practices are recognizing the limited roles and value of sleeping pills. And, this vanguard of physicians are now educating their patients on why they should forego this approach to insomnia.
In mental health circles, the same phenomenon is occurring regarding the over-use of psychotropic medications, among which are frequently prescribed sedating antidepressants, anxiolytics, or antipsychotics. While a conventional wisdom favoring sleep aids still holds sway in many practices, for the first time in my career as a physician dating back to 1979 I am routinely hearing from mental health providers of all types, including psychiatrists and psychologists who express the opinion that enough is enough when it comes to sleep and psychotropic drug prescriptions. To these professionals, the complexity of mental health disorders and sleep disorders just cannot be cured with meds in the majority of cases. Rather, they want to see patients exposed to more sophisticated forms of psychotherapy that go well beyond the conventional and largely discredited “talk therapy” model.
Also, many of these practitioners are taking the same stance as sleep physicians in rejecting the value of chronic use of sleep aids. While nearly everyone accepts the potential role for acute use of sleep aids to treat acute or transient bouts of insomnia, more providers now recognize a patient’s demand for regular use of sleep aids is not in his or her best interest. Instead, these professionals are increasingly aware of the importance for comprehensive sleep evaluations or the implementation of newer psychological therapies, either of which can lead to curative results.
Many of these patients suffer from complex mental disorders that frequently fail medication approaches because the underlying problems may be psychological conditions described as personality disorders or dimensions. Such patients need highly specialized psychotherapies such as dialectical behavioral therapy (DBT), acceptance and commitment therapy (ACT) or a variety of therapies to treat emotional dysregulation such as emotion-focused therapy (EFT) or somatic experiencing (SE). Often, these patients are medicated for years for their supposed anxiety and depression and their intractable insomnia. These examples are just some of the specific problems the fields of psychiatry and psychology are coming to grips with due to the failure of medication approaches in mental disorders and sleep disorders.
This gap is very large and likely to remain unaddressed due to the long-standing entrenched ideas about the role and value of psychotropic medicines to treat mental health patients and their sleep disorders.
Changing Our Reliance on the AHI and RDI Metrics
Many OSA/UARS patients are harmed by the inadequacies of these metrics. In the most glaring example of the problem, hundreds of thousands of patients undergo upper airway and nasal surgeries for sleep-related breathing conditions, and yet the follow-up evaluations post-surgery often reveal at best only qualitative corroboration of the surgical treatment effects; whereas the AHI/RDI quantitative information frequently proves most unreliable and misleading.
As discussed at the outset of this lengthy series on gaps in sleep medical knowledge, the current use of AHI/RDI metrics do not help us understand the nature of normal sleep, and they do not assist us in appreciating the severity of sleep breathing disorders. Even when the flow limitations are accurately scored and counted in the RDI, we still do not have a clear picture on the severity or intensity of sleep breathing disorders.
Just recently the American Thoracic Society published a study on the problem of interpreting mild OSA, and one of their first results after reviewing numerous articles on this topic was: ‘Studies were incongruent in their definitions of “mild” OSA.’ (1) In other words, to this day there remains no clarity on how to measure this allegedly low severity level of OSA and what exactly would be defined by a low AHI. The paper purports mild OSA is highly prevalent in adults, which means tens of millions of people suffer from this condition, yet the gap in sleep medical knowledge is huge in this area, because so little can be explained to a patient in this situation, at least according to the ATS review of the literature.
Thus, in attempting to help patients undergoing nose and throat surgeries or patients who are recommended for various sleep breathing treatments, the field of sleep medicine’s failure to pin down exact clinical meaning to our current breathing metrics greatly confuses our efforts to diagnose and treat these patients. And, this confusion adds to the mistrust patients may develop about the field of sleep medicine. Astonishingly, this gap appears to be growing not shrinking in size.
- ATS Ad Hoc Committee on Mild Obstructive Sleep Apnea. An Official American Thoracic Society Research Statement: Impact of Mild Obstructive Sleep Apnea in Adults. Am J Respir Crit Care Med. 2016 May 1;193(9):e37-54. doi: 10.1164/rccm.201602-0361ST
Sourced from Classic Sleep Care Blog
A very large gap in sleep medical knowledge, one that appears to be narrowing in the past few years, is the lack of recognition of the independent nature of most sleep disorders. We have been acutely aware of this conceptualization of sleep disorders, because we have been working with mental health patients since 1988 and have published multiple papers in the 1990s and 2000s describing this co-morbidity relationship and how it demands independent clinical attention, that is, specific sleep disorders’ treatments in addition to any therapeutic steps for the co-occurring psychiatric disorders. Others have published on this co-morbidity concept regarding co-occurring medical disorders, such as cancer, heart disease, diabetes and many others.
In mental health in particular, it is interesting that the American Psychiatric Association has outpaced the American Academy of Sleep Medicine. The APA is the main proponent and publisher of the Diagnostic and Statistical Manual aka the DSM, and their two most recent versions, DSM-IV-TR (2000) and DSM 5 (2013) have gone to great lengths to incorporate ideas on the need for thorough evaluation of sleep disorders in psychiatric patients, because of the high probability most sleep conditions will prove to be independent. And, to reiterate this crucial point in the reverse formulation, independent sleep disorders will not resolve following treatment of the psychological disorder; for example, treating anxiety, depression, or PTSD is no guarantee these patients’ sleep disorders will also improve or be cured. Thus, needing their own clinical attention means they need specific, evidence-based sleep medical treatments distinct from psychiatric treatments.
The same realization on the co-morbidity model has also been emerging in the field of cardiology, where it is now extremely common for cardiologists to serve as major referral systems to sleep center operations. Indeed, in the near future, we will probably witness the development of sleep medical centers, including both clinical and laboratory functions, integrated into the everyday operations of free-standing cardiac centers or heart hospitals. It is possible such programs are already being considered or implemented given the epidemic of sleep disorders in cardiac patients due both to the average age of these individuals and the impact of compromised heart function on sleep in general and sleep breathing in particular. Unfortunately, the same type of thinking has not yet taken hold for psychiatric hospitals where the benefits to patients would be a true game changer, given our understanding of the critical role of sleep in mental health.
I believe the AASM and many sleep experts and probably the vast majority of sleep professionals are relatively speaking all on the same page with this co-morbidity framework for sleep disorders, but the larger question may be how much longer will the field of sleep medicine embrace a defensive posture in its relationships with insurance carriers and government regulators, not to mention other major medical fields that directly intersect with sleep medicine practices? Our field should be aggressively marketing the essential concept of co-morbidity and while doing so should also be chastising those who block or reject this claim. In no uncertain terms, as one very good example, sleep professionals along with professionals in the fields of psychology and psychiatry need to be demanding that all mental health patients who complain of sleep problems receive independent clinical attention at first presentation of illness. Regardless of whether the clinical provider believes the primary psychiatric disorder instigated the co-occurring sleep symptoms, the new policy going forward must hold all physicians and therapists accountable to assess these sleep conditions subjectively or objectively and ideally both at the first opportunity to do so. Failure to complete this assessment or negligent attitudes toward the relevance of these early sleep assessments ultimately will attract the attention of medical malpractice attorneys, a phenomenon already lurking on the horizon.
While this approach would cut a wide swath across all types of mental health patients complaining of sleep issues, there is the urgent matter regarding the management of inpatient psychiatric conditions, where we suspect many of these patients have been mildly to moderately mismanaged when OSA/UARS, restless legs (RLS) and periodic limb movement (PLMD) go unrecognized and untreated. For these reasons, it may prove a life-saving strategy to push for psychiatric hospitals as well as residential substance abuse recovery programs to directly incorporate sleep laboratory testing into their facilities. Many of these patients have moderate to severe difficulties with sleep prior to their admissions for inpatient services, but the hospital environment quickly leads to deterioration in sleep in many cases. The only consistent response offered to these suffering individuals is more and more medication, either higher dosages or multiple drugs. Many of these patients might greatly benefit from PAP therapy devices or evidence-based medication for RLS or PLMD.
Using the same model of care in other fields of medicine, sleep professionals should be aggressively pushing to integrate sleep medicine practices into some of the more obvious occurrences of co-morbidity:
Urology: a great deal of prescribed medications and surgical interventions are selected as reasonable treatment options for nocturia (waking up at night to use the bathroom). Yet, OSA/UARS have clearly been shown to cause nocturia, and PAP therapy has clearly been shown to alleviate or eliminate nocturia.
Otolaryngology (ENT) and oral surgeons: many patients undergoing upper airway surgery do not obtain post-surgical polysomnography to evaluate levels of success, and when these PSGs are conducted they often neglect to measure UARS, (i.e. the RERA components of OSA) with accurate technology. Thus, many of these patients suffer residual breathing events and persistent symptoms of nonrestorative sleep and daytime tiredness and sleepiness.
Nephrology and other hypertensive clinics: by now it should almost be obligatory for any patient diagnosed with so-called essential hypertension to undergo PSG and not just those patients with poorly controlled hypertension. The very presence of high blood pressure should be raising red flags throughout the medical community, because the prevalence of OSA/UARS in patients with high blood pressure will prove astronomical. Moreover, anti-hypertensive medications are not without side-effects; therefore, conceivably, a fair number of patients using PAP will decrease or cease use of their BP drugs.
Obstetrics: several studies have shown a connection to the problem of pre-eclampsia in pregnant women and how PAP therapy for OSA/UARS has beneficial effects on this condition, not the least of which is shortening periods of hospitalization. But, this potentially serious condition (pre-eclampsia) may be the tip of the iceberg because so many women without this specific diagnosis suffer horrible sleep problems during the third trimester, and it is incredibly common for such women to report new onset snoring, worsening of nocturia, debilitating fatigue and sleepiness. Clearly these symptoms are treatable, and it behooves the medical community to find rapid ways to treat pregnant women to enhance the quality of their lives in the final months of pregnancy.
Neurology and Neurosurgery: injuries to or diseases in the head or central nervous system frequently trigger the typically less common problem of central sleep apnea. Take the burgeoning epidemic of traumatic brain injury (TBI). TBI patients are often seen by a host of healthcare providers, including neurologists, neurosurgeons, neuropsychiatrists, psychiatrists, psychologists, behavioral health specialists, other mental health therapists, and occupational health therapists and now more than ever before, PTSD experts. In other words, the range of their symptoms is so vast and complex, it is quite likely some aspect of their evaluation with respect to sleep goes unnoticed, and the current theory is many of these patients are suffering from central sleep apnea.
Ophthalmologists and optometrists: increasing evidence is suggesting links between OSA and glaucoma, a condition routinely screened for when patients visit any type of eye doctor. Just think of the healthcare cost-savings when eye doctors start referring their patients for sleep evaluations.
Putting this altogether, the AASM and the entire sleep professional community must assert itself in very direct and authoritative ways to call out other fields of medicine for their negligence in refusing to conduct screening to evaluate sleep disorders in their patients. Unfortunately, all the areas described in this post are ripe for medical-legal encounters, which are likely to result in serious malpractice cases that could have otherwise been prevented by early screening prior to exposing patients to years of medications or invasive surgical procedures, not to mention prolonged hospitalizations and related morbidity, if not mortality when patients do not undergo comprehensive care connecting the dots between their medical or psychiatric illnesses and their undiagnosed and untreated sleep disorders, most commonly OSA/UARS.
We will finish this post by pointing out how the general concepts related to many of the gaps discussed in this series often play out in very specific ways in the mismanagement of many of these co-occurring conditions.
Urology: because so many medical professionals are wedded to the idea that nocturia must be an exclusive urologic condition, even after nocturia episodes are decreased from say three per night to once per night, the prevailing belief systems will insist the once per night episode can only be explained by a urologic pathophysiology. Yet, the more likely explanation will often turn out that the patient’s PAP therapy pressures were not fine-tuned. So, unless the gaps in knowledge on how to normalize an airflow curve are vigorously researched and promulgated such patients even when using PAP therapy will continue to receive inadequate sleep medical care.
Otolaryngology (ENT) and oral surgeons: we already stated that residual breathing events may not be accurately measured post-surgery, but an additional issue continually arises in the surgical approach to sleep apnea beyond this initial phase of under-treatment. Going down this pathway, most patients will want to believe the surgery must have done something positive and therefore must have improved the breathing problem at some level. Which means that for anywhere from 1 to 10 years later, when the patient continues to struggle with daytime symptoms, his or her focus will almost invariably be steered in all sorts of directions unrelated to OSA/UARS. Though no definitive resolution of symptoms occurs—for the obvious reasons that the OSA/UARS condition has not been cured—now, the problems are actually getting worse with aging.
Nephrology and other hypertensive clinics: the main issue with hypertension is the longer the sleep breathing condition goes undiagnosed and untreated, then the more the patient suffers the increased potential for worsening of cardiovascular disease. Now, the good news here is that recent evidence shows that even in OSA patients there is considerable protection from cardiovascular disease when the anti-hypertensives work well. Unfortunately, the bad news is untreated sleep apnea patients with hypertension are likely to need multiple medications at stronger drug dosages, which means greater risks for side-effects.
Obstetrics: Notwithstanding the nonsense spewed from the world of political correctness, many pregnant women suffer clear deteriorations in the quality of their lives in the final trimester. Undoubtedly, the clear loss of energy and drive in these women, affected by undiagnosed and untreated OSA/UARS will take a toll on family life, child-rearing and work performance. If someone were brave enough to publish the data on the loss of productivity at home or at work in these women, the economic losses would likely be quite high, which then might spur action to help them.
Neurology and Neurosurgery: brain injuries and diseases are risks for central apneas, but the problem here is that many sleep professionals have developed jaded views about CSA, either because they do not understand some of the mechanisms that cause the problem, or they believe that using advanced technology such as ASV is cost-prohibitive. Until these gaps in knowledge are overcome, many TBI and other neurological or neurosurgical patients will not receive the most advanced PAP devices to treat their ASV.
Ophthalmologists and optometrists: this area of medicine represents a newer field of research, so not much else can be stated beyond the decrease in quality of life when proper screening for sleep disorders is ignored.
In sum, there are many glaring knowledge gaps about specific co-morbid medical and psychiatric disorders that may lead directly to misdiagnosis, under-diagnosis or poor treatment of sleep disorders. And, these specific gaps in sleep knowledge will likely persist for some time and continue to plague these complex patients who are also suffering co-occurring health problems.
Read more from this series:
Sourced from Classic Sleep Care
The big push for compliance data (the hours a patient uses the PAP device) has mostly come from the insurance companies who sought to create a metric to determine which OSA/UARS patients should be eligible for coverage. Some years ago as sleep apnea research was blossoming, the question arose as to how many hours of sleep with a PAP machine would be needed to gain some degree of tangible benefit. Unfortunately, the question was answered by “begging the question,” that is, making the premise about the number of hours of sleep instead of recognizing the correct metric would be closer to something like the number of high quality hours of sleep.
Notable sleep experts in the field communicated with Medicare officials or other insurance carrier administrators who had been asking this question, because the latter were confused about their ability to determine what constituted a legitimate user of PAP therapy in contrast to the obvious non-user who might be letting his or her PAP device rest comfortably at night in the confines of a bedroom closet. Understandably, the insurance carriers would not be expected to reimburse the durable medical equipment (DMEs) companies if a patient never used the device. So, the question was reasonable in asking if there were a minimum number of hours to use it. And, the answer they received was on the order of 4 hours for at least 5 nights per week.
If you multiply 4 hours X 5 nights, the result is 20 hours per week; but, this amount was never acknowledged as an acceptable scientific metric, and there was not any formal attempt to prove its utility. Instead, the rule was first adopted by Medicare, and then several leading insurance carriers followed suit over the years. As discussed in prior posts, the inherent flaw in this metric is the obvious one where someone uses a device 3.50 hours per night for 7 nights per week, totaling 24.50 hours, but does not qualify for coverage under the Medicare guidelines. Unquestionably, many patients use a PAP device for less than 4 hours per night and gain substantial benefits, presumably the types of benefits (decreased sleepiness and insomnia) that would ultimately provide cost-savings to the insurance company in comparison to what they lose from costs related to untreated OSA/UARS. Yet, this logic has never been officially embraced by Medicare or any other insurance carrier, which means there are many patients who fit what we have called “sub-threshold adherence” in our recent paper in Respiratory Care, and these patients are clearly gaining benefits from their less than insurance-certifying number of hours of use.
It remains both an oddity and a gap that the AASM has not addressed this issue, but instead this institution simply appears to go along with the insurance carriers as if there is no recourse. Yet, sub-threshold adherence research has already been published prior to our work, and the AASM should be marshalling this information into a position paper that directly calls out the insurance companies for not paying attention to the scientific evidence demonstrating a lesser number of hours still provides benefit. Moreover, the AASM should be calling for research in this area to better guide insurance carriers as well as the field of sleep medicine, which in time would lead to greater precision in the way we measure how patients respond to PAP devices.
These problems, regrettably, worsen when a so-called standard with no scientific rationale becomes entrenched in a field of medicine and induces non-medical professionals (e.g. insurance administrators, government regulators and staff bureaucrats) to routinely misinterpret these rules. Nowhere is this flawed strategy more evident than in OSA/UARS treatment where policies conflate compliance with outcomes. And, this point also refers back to the mistaken belief that the number of hours of sleep is equivalent to the number of hours of high quality sleep, which we will return to soon enough.
By presuming a patient gains benefit by using the device 4 or even 5, 6, 7, or 8 hours per night is actually borderline irrational, given the fact there are innumerable patients doing just that yet still complain of being tired or sleepy during the day. In other words, despite their use of the device, they suffer from persistent nonrestorative sleep, and this poor quality of sleep is pronounced enough that no additional hours of sleep will decrease such patients’ complaints of tiredness or sleepiness during the day.
As you could imagine, if you were an administrator or bureaucrat with little knowledge of sleep medicine and knew only how to read a chart that lists the numbers of hours slept, it might easily escape your attention to consider other clinical aspects in the patient’s medical records you were reviewing. This scenario is repeatedly played out as discussed previously in dealing with prior authorizations, where the entire process is slanted toward the compliance numbers.
When talking with administrators we must explain a patient’s need for additional treatment steps and care, such as retitrations or attempts at a different type of PAP device, but during these discussions it is no rare occurrence that their immediate response is something like, “but the patient is already compliant with PAP?”
To which, we might reply, “So?” And, then I would pause to see if the individual on the other end of the phone line recognized the limited perspective he or she was bringing to the dialogue. Next, further explanation on the concept of outcomes must be presented. Sometimes, these concepts must be developed through a Socratic method, because individual administrators may be so indoctrinated to look only at compliance hours and so programmed to find ways to reject the requests of sleep specialists, they need to be challenged in provocative ways to get across the point. Even after these bureaucrats comprehend that the patient is suffering from persistent daytime fatigue and sleepiness or insomnia, they try to turn the conversation back to the number of hours of sleep as in, “well, the patient is already compliant, so maybe they just need to sleep more…what about a sleeping pill?” Soon, they bring up a pre-programmed list of alternative explanations, beyond any sleep-related issues like mask leak (which is a favorite because they think solving mask leak solves all sleep apnea patients’ problems and thus retitrations would never be indicated), such as depression, diabetes or some other co-occurring medical illness or another favorite, stress, as in maybe the patient is getting as good a response as possible for now and should continue on for several months and check back. These sample responses are highly representative of the ways in which many of these administrators think, and among the insurance companies’ own physician directors who are also trained to respond to our appeals, this style of thinking may only be slightly more advanced, especially when the physician director is board certified in another specialty unrelated to sleep.
I am of the opinion all these considerations could be posed as reasonable questions and concerns, but I also believe the context does not fit actual patient scenarios the majority of the time, because there are two main reasons any sleep apnea patient is not doing well despite attaining some arbitrary level of hours of sleep: 1) the patient needs more hours of sleep with the PAP device beyond the compliance levels; or, 2) the sleep obtained remains nonrestorative. Both issues require further investigation to attempt to detect previously unrecognized sleep factors or to re-examine known problems such as leg jerks, excessive brain arousal activity, residual breathing events (notably flow limitation), and specific sleep position effects that may worsen breathing or compromise the integrity of the mask seal. This short list of factors is more likely to prove pivotal in preventing a “compliant” patient from achieving good to optimal outcomes.
From this vantage point, it should be obvious there is sleep and then there is really good quality sleep. Astonishingly, there is no serious discussion of this issue either within insurance circles or to a surprisingly large extent within the field of sleep medicine itself. As more and more sleep facilities feel the pressure from insurance carriers and government regulators, the sleep staff often does not stop to think about these conundrums, or they have been intimidated to avoid investigating the rigorous physiological relationships between the various levels of sleep quality and a patient’s outcomes. I am certain some sleep patients reading this post are astonished by this pronouncement, and I would hope many patients have had much better encounters with their sleep staff than I am describing here. But, due to our extensive second opinion research we know anecdotally among a few thousand patients during the past decade that many of the conversations between sleep professionals and patients did not cover this ground in ways to have helped the doctor fight back against the arbitrary standards of the insurance industry. And, this lack of comprehension and curiosity about the highly relevant distinctions between sleep and really good quality sleep is rife within the field, because too many people who should know better are wasting precious resources obsessing about compliance instead of measuring the actual quality of the slumber in their patients and how the quality is affecting outcomes.
One the most remarkable aspects of this problem is the failure of the AASM to recognize the inherent value of retitration protocols. Through retitrations, it is abundantly clear that a dose-response relationship emerges between pressurized air settings and changes in the breathing events. Instead of capitalizing on this essential fact, there is almost no research targeting this process, because so many sleep experts are wedded to the belief CPAP therapy works for everyone, and CPAP pressure settings never need to be adjusted once a patient starts treatment following say a first titration in the lab. Making matters worse, with the advent of home sleep testing many sleep experts and a fair number of sleep professionals imagine they can make relevant pressure adjustments using data downloads, yet this approach is highly unreliable if the goal is to follow the AASM mandate to eliminate the flow limitation breathing events. Of course, my premise is faulty here, because so many clinical sleep professionals completely ignore the concept of flow limitation and only base results on changes in the apnea-hypopnea index (AHI).
This limited scientific perspective adopted by many sleep professionals will only worsen as older sleep docs retire and younger, new sleep physicians are over-exposed to the home testing model and thereby receive much less training or experience in the use of titration methodology, even for just a first titration. These newer recruits to the field will be tempted to believe their patients are doing well solely based on the numbers on the data download or the attainment of compliant hours, but when confronted with poor outcomes, how capably will they perform to provide top-notch clinical care?
Candidly, there are no easy or simple answers to this problem caused by conflating compliance metrics with patient outcomes. One would think the AASM would be a more patient-friendly institution, but judging by their lack of attention to these matters, it seems uncertain how such an organization will attempt to change the minds of insurance carriers and government regulators, albeit their recent efforts to outline new guidelines for the use of PSG vs HST in the diagnosis of OSA reflects a small step in the right direction. However, neither the draft guidelines nor the supplementary materialsmake note of the importance of RERAs (the discrete respiratory event measured in UARS) or explain how these more subtle breathing events factor into the use of the PSG vs HST technology. Thus, among those who believe this problem of conflating compliance with outcomes needs more attention, we instead perceive the AASM as neglecting a major contributor to sleep breathing disorders, which will over time further compromise sleep professionals’ abilities to communicate with insurance carriers on the necessity of looking beyond compliance numbers.
This gap is a large one and overlaps considerably with our lack of understanding regarding the definition of normal sleep breathing. Without such a clarifying definition, more patients will suffer as they will be labeled compliant and receive no further attention for their less than optimal outcomes.