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Sourced from Classic Sleep Care- Sleep Center Models of Care – advantageous or outdated?

In the field of sleep medicine, there are various models of care delivery that generally divide up into traditional medical versus non-traditional. The traditional model is based on a principle of initiating care with a doctor-patient encounter in which the individual seeking care enters the clinical environment to meet with a medical professional such as a physician, nurse practitioner, physician’s assistant or registered nurse. There are several premises that underlie this model, some of which are advantageous and others of which are outdated.

The main beliefs about the traditional model of care include:

  • -Patients must start with a discussion and education session with a medical professional as an essential launching point.
  • -This initial type encounter greatly increases the chances the patient would follow through on taking action, because of the rapport established with the provider or from a change in motivation post-education or both.
  • -Patient’s presenting knowledge or understanding about sleep issues is so limited, no other way forward seems feasible.
  • -Conventional wisdom has forged a general consensus around these ideas and encourages most medical systems, sleep medicine or otherwise, to follow the same plan.

Obviously, in the Age of the Internet, virtually all the beliefs listed above could be accommodated through different or non-traditional systems. However, the doctor-patient interaction (or other medical professional) would remain a crucial ingredient of any system (at least until the robots take over the planet), albeit the timing of such encounters may vary. As a prime example of a transformative step to accommodate rapid acquisition about the patient’s health information, a system can be employed on-line to gather data by patients completing various surveys with click and point technology, but more on this point later.

The most frequently employed non-traditional model of sleep care harkens back to the laboratory-centered approach where in earliest days of sleep medicine many patients were referred to the lab for testing after having been evaluated by their primary physicians who was typically not a sleep-oriented physician. Of course, this approach appears more stream-lined and worked in many situations, particularly rural environments during the very beginning eras in sleep medicine in the 1970s and 1980s. However, for a variety of reasons, this approach was frowned upon largely because of the perception and reality that a sleep doctor never interacted with the patient, which might have led to a lower quality of care. Over the next few decades, several institutions banded together to attempt to eradicate this model of care, which was largely successful.

However in many locations, particularly more rural settings, a part-time medical director relationship served to permit these laboratory-based models to remain in place. It should be noted many of these lab-oriented centers were also in the business of selling DME equipment (i.e. PAP devices and supplies); and, therefore because of their intimate contact with patients in the lab and afterwards in managing PAP, some centers demonstrated very high rates of PAP compliance, arguably much higher than centers focused on the traditional medical model. In the context of these turf wars, a unique company like Classic Sleepcare emerged and recognized the highly relevant window of opportunity for selling only sleep-related DME (again, PAP and supplies), thus providing a superior service from which many traditional sleep medical centers now benefit.

Regardless of which side of the debate you find yourself on, it is very clear both models of care have pros and cons, and to be sure no model is perfect in light of the miserable rates of non-compliance still rife within the innumerable sleep apnea cohorts seeking treatment all across the globe. The question that arises is whether there is knowledge to be gained from both these models to inform an innovative pathway, one that extracts the best from both enterprises.

To some extent, we have formed a mixed model derived from the standard traditional and the lab-based centers, and our center has been practicing this approach for more than a decade and a half. Our results are very good to excellent to outstanding for different types of patients, but certainly we have not attained anything close to perfection. Nonetheless, our model is unconventional (while still following all insurance rules and AASM policies), and I would like to describe key features, so others may investigate whether similar approaches are worth testing out at their own centers.

First and foremost, we do not believe a patient sitting down with a doctor or another degree-holding sleep medicine professional is a necessary starting point for the vast majority of sleep apnea patients. In fact, we have been persuaded for 25 years that this standard model has several pitfalls that may lead to just as much harm as benefit.  The harms we are referring to are not that sleep doctors or mid-level professionals cannot do a decent to outstanding job in educating and communicating with their patients on the essentials of diagnosis and treatment of sleep apnea. Rather, the problem is this sort of attempt to connect with patients is based on several faulty premises on the nature and style of the how and why patients seek care for sleep apnea.

As discussed previously, patients who are treatment-seeking and straightforward (a surprisingly rare occurrence at most sleep centers) would absolutely do fine in this traditional model, although nowadays this model is often a waste of their time and resources, because 90% or greater could easily and happily start in the sleep lab with a split night study before ever meeting with a physician. Or, they could reasonably start with the HST/APAP model and see the doctor or even the sleep technologist at first follow-up. And, the same could be said for the HST/OAT model as well. Check out this link from HST America, a company offering home sleep testing services and sleep apnea education.

More commonly, most sleep apnea patients report numerous complexities or co-morbidities to their cases, not the least of which are several mental and physical symptoms or disorders for which they are also attempting to treat or in many cases not attempting to treat. Infrequently would a patient enter a sleep center environment anticipating that many or most of their other ills would improve by fixing their sleep problems. All these points, then, immediately suggest education would be a high priority before the patient sets foot in the lab. However, this premise turns out, we believe, to be faulty, because it assumes sleep apnea patients would retain this knowledge. Take an example where you are persuaded you developed the perfect system that educates sleep apnea patients extremely well at whatever level of educational background, and your system guaranteed the patient would retain 90% or greater of the information. If so, I would support the traditional model of care. But, I’m not convinced this outcome is occurring at the majority of sleep centers. And, though undoubtedly there are some centers better than others, we routinely meet with second opinion patients where they report never having been instructed at any point in their care on the following factors:

  • -Three types of breathing events including apneas, hypopneas and RERAs.
  • -Clinical relevance of RERAs and why they must be aggressively treated in most patients.
  • -How sleep apnea causes nocturia and how it can be reversed with PAP therapy.
  • -The huge array of mask styles and the value of each one (nasal pillows, nasal masks, and full face masks) as an all options on the table approach.
  • -Intricate distinctions between mouth leak, mouth breathing, and jaw dropping (without mouth breathing) and the role of chinstraps or mouth taping in problem-solving.
  • -Interference from chronic rhinitis, especially nonallergic rhinitis, and the treatment steps to overcome these problems.
  • -Why and how fixed pressurized airflow is a major obstacle to regular use of CPAP and how advanced technology is readily available to solve the problem.
  • -Relationships between sleep apnea and chronic insomnia and how treatment of the former frequently decreases or cures the latter.
  • -Relationships between sleep apnea and chronic nightmares and how treatment of the former frequently decreases or cures the latter.
  • -Relationships between sleep apnea and parasomnias and how treatment of the former frequently decreases or cures the latter.
  • -Special impact of RLS and PLMD leg movement symptoms and disorders on overall sleep fragmentation and their adverse influences on PAP users.

Irrespective of when a sleep patient might have been counseled on these items, be it before testing or after starting PAP, we repeatedly encounter cases where most or none of this information has been dispensed to the patient, a void in the field of sleep medicine for which we can offer no explanation. Then again, I trust the above list (which I daresay remains incomplete) would overwhelm most sleep patients at their intake unless they bring a special kind of perspective to the encounter. This last point brings us to the heart of the problem with sleep apnea patients in general.

Sleep apnea patients experience the problem of sleep apnea while they are sleeping. Thus, on the most basic cognitive level it could be argued they don’t experience sleep apnea at all. Which means any instruction or knowledge you provide to a sleep apnea patient will be viewed as either an abstraction or speculation or both. No matter how much you might attempt to drill this information into the patient’s mind, it just cannot be fully understood or comprehended in ways that carry forward in high retention fashion. Instead, whatever information is given generally fades away and in some cases might scare the patient enough to steer them away from proceeding with testing. Not as an aside, keep in mind that the sleep fragmentation these patients suffer from undoubtedly affects their memory, concentration and attention, which further compromises the capacity to retain even the most important clinical information about their potential sleep apnea diagnosis.

Compared to the traditional approach, our mixed-model is based on an experiential paradigm. We believe sleep apnea patients need to experience things first-hand in the sleep lab to more rapidly digest the likely diagnosis of OSA or UARS; and, such experiences are retained more fully and more accurately. Consider that when anyone undergoes a test, he or she is vigilant to the experience, because it is an extremely personal one. Someone else, a medical professional, is paying very close attention to something about the way your mind or body or both are operating. The patient believes that some important and hopefully useful information will be forthcoming from the test, and when the individual receives this information there is no abstraction or speculation. In the case of sleep testing, patients place their trust in the sleep technologist who provides them with all manner of information, knowledge, and assurance about the experience they are undergoing, often with repeated interactions requiring sleep tech assistance throughout the night. The patient is being cared for by a professional who is helping them through a somewhat stressful and sometimes difficult experience. By the end of the night, a degree of rapport has been established far greater than can be established when a doctor and patient talk abstractly about sleep apnea. Finally, in the morning, we have developed standardized verbiage on how our sleep techs use the computer to review with the patient the key parts of the PSG findings.

By the end of the experience, patients not only have established the sense of successfully completing an important health test, but also when they can be shown the test “results” immediately (technically, the standardized impressions) the proverbial light bulb switches on in their heads and a huge “aha” or “wow” ensues. Such encounters lead someone to “feel” the importance of the experience and thus emotional connectivity is generated that will almost invariably either cause them to remember the information very well or said another way, prevent them from forgetting they stop breathing at night.

These differences between a traditional versus an experiential model are not minor distinctions. To paraphrase a Sufi adage, “speech may very well be the annihilation of experience, because speech clearly is not the experience.” Talking about things is not even close to experiencing things. And, while it is true many of the knowledge points listed above must eventually be addressed for the majority of OSA or UARS patients, the dispensing of this information works best on a readiness timeline. Once the patient has gained experience and thus a more direct perception of the sleep problem, this initial context or foundation now permits a more rapid introduction of more knowledge into the patient’s mind.

As the best example, how would a patient relate to learning about PAP masks and tubes as well as pressurized air immediately after viewing the computer impressions of the sleep apnea? The answer should be obvious compared to sitting in an office and hearing about an abstract discussion regarding, “…and once we diagnose you with sleep apnea, then we can fit you with this mask and pump air into your throat to keep it open.” By way of analogy, do you remember going into the classroom to listen to an instructor explain the mechanics of how bicycles operate before you set foot on the pedals? Worse, do you recall someone talking to you about how to pedal the bike, how to stay balanced and how not to fall before you got on the bike? Or, did you just get on the bike with someone helping you a bit? The latter approach of course is experiential and is the universally tried and true one.

What happens next in our mixed-model approach? To backup for a moment, recall we mentioned the possibility of the on-line intake system. Our on-line system called WebIntake, which is designed to eliminate paper, pencil, and clipboard in the medical center’s reception area, not only collects valuable and pertinent health history to be incorporated into the patient’s first sleep study or first clinical encounter, but also provides us with so much information that 98% of the time we can guide patients to start taking certain instructional or therapeutic steps from the outset as well as guide them in how we think they should start in our system, for example, doctor’s clinic appointment, sleep tech appointment, night in the lab appointment, daytime PAP-NAP, or with an administrator for complex billing or insurance issues. We have used the on-line intake system for more than 15 years, and some years ago I presented our model in a Meet the Professor session at the annual SLEEP conference. One highlight from the session was the enthusiastic response we received for this online system as an innovative way to gather intake data. My understanding is that many other medical clinics, including sleep clinics, are beginning to adopt such systems.

The second step for many patients is to experience PAP therapy in the sleep lab with the sleep study known as the titration procedure in which pressures are titrated to open the airway and decrease breathing events. Here, the patient enters into a more experiential situation whether they undergo the full titration or the PAP-NAP. The titration experience is the single most important encounter for a great many OSA/UARS patients, easily the vast majority, because it can so easily make or break the patient’s motivation to move forward. A positive experience with PAP guided by the trusting hands of a compassionate sleep tech greatly influences patients capacity to endure the inevitable hassles that always arise in the first few days, weeks, or months after initiating PAP at home.

In contrast, a bad experience in the lab, leading to a poor response to PAP, in the hands of an under performing sleep tech will often prove sufficient to provoke outright PAP rejection. In such cases, the patient will not even consider a prescription for use of PAP at home, and either ignores the OSA/UARS diagnosis, begins exploration for another evidence-based approach such as OAT or possibly surgery, or simply searches the Internet for conservative tools such as nasal dilator strips, special pillows, supine-position prevention devices and numerous nasal hygiene regimens. Some are persuaded by their physicians, unsurprisingly, to enter a weight loss program, which sounds reasonable, but it is based on the faulty premise that weight loss eliminates OSA or UARS. Weight loss decreases the severity of these conditions but rarely cures it. Most importantly, it is much more difficult to lose weight than it is to learn how to use a PAP device—assuming you can get the right PAP device for you.

Thus, of all the components of an experiential model of care, the sleep technologist is the single most important player in the PAP process and must be trained in ways to accommodate a wide variety of patient types. This statement is important to consider in the context of the traditional model of care. Many standard sleep medical centers severely restrict interactions between sleep technologists and patients. More importantly, many centers severely limit patient access to advanced PAP therapy modes, which often can turn a patient’s negative experience in the lab into a very positive one.

Of course, there is so much more to be said about the role of the sleep technologist, but we have delved into that arena in many previous posts, most recently in discussing their capacity to use advanced PAP modes by manually titrating them or in effect over-riding their auto-adjusting mode for portions of the night. Now, we will turn our attention to the additional infrastructure that supports our mixed-model or experiential paradigm.

Once I complete the review of a sleep study, I then finalize the Interpretation and Recommendation sections of medical report. In this process, I am reviewing all the pertinent historical aspects of the patient’s care to date. As the most relevant examples, we have Special Updates to detail any patient changes in six main categories: Insomnia; RLS/PLMD; Nightmares; Parasomnias; Narcolepsy/Hypersomnia; and Cardiac Health. And, there are distinct categories for two other areas of health: Medication Adjustments and Nasal/Oral Airway Health.  Every time a patient undergoes a sleep study, all these areas are updated as key factors playing crucial roles in whether or not a patient can respond well to PAP specifically; or in other instances, how these factors affect other sleep disorders or other aspects of general sleep health.

When all this information is finalized, the chart and report are turned over to the Results Coordinator (RC), where we employ some of our most experienced staff who typically work at the position for more than one year and some of whom have gone on to become sleep technologists. The very first steps taken by the RC are to email the patient the final report of the sleep study and set up a discussion time to review the details by phone and answer questions. These discussions go extraordinarily well for at least three reasons: (1) I complete my reading of studies 95% of the time the morning after, which means we are almost always contacting the patient in the morning or afternoon following the night of the sleep study (or Monday for weekend studies); (2) the patients have already engaged in discussion with the sleep tech regarding some of the standardized impressions as well as having viewed pertinent tracings on the computer to gain a foretaste of what to expect in the results discussion; and (3) the RC has completed these discussions with thousands of patients, and the RC and I are effectively in constant contact throughout the day to clarify any issues or questions that must be fielded by the doctor.

The beauty of this system and its inherent expediency is that the knowledge transfer that begins with a patient intake and culminates in the diagnostic phase of care delivery has been streamlined to the point that the overwhelming majority of patients embrace this information wholeheartedly and elect, as noted above, to proceed with the second sleep study to test PAP therapy. Admittedly, the system does not work well for everyone, particularly older patients who are more comfortable with the standard doctor-patient relationships. One way I have accommodated this need is to make phone contact with such patients a fairly routine affair. Even though I receive no reimbursement for these conversations, most of our patients appreciate receiving a doctor call, and conversations typically last between 5 and 15 minutes, after which most patients regain motivation or simply feel better educated or clearer about what lies ahead.

Taken together, what we have found up to this point in the patient’s pathway is that most are retaining the knowledge transfer. We also perceive we have sparked some degree of curiosity in our patients, which then leads them toward further exploration on their own. For any of our patients up to this point (i.e., completion of diagnostic testing), and always directly after a diagnostic test, on our website we provide ourPatient Process Brochure.

Finally, in wrapping up the discussion on this diagnostic phase, there will always be exceptions to the rule. We are mindful of specific patient types who may not be able to move forward with PAP, or who need RLS/PLMD treatment first, or who might need coaching on insomnia issues before even considering PAP. Over the years, the truly remarkable statistic for our center is that even among these types of cohorts, we still observe many patients who actually are better served by trying PAP initially and receiving a very pleasant surprise on how much better they immediately feel. As I am sure you can see where I am going with this point, let me briefly state that this experience is then the ultimate aspect in the experiential paradigm. The patient walks in the door ‘indoctrinated” to all sorts of ideas and speculations about sleep, but once a PAP experience generates the experience of higher quality slumber, the patient’s perspective is transformed instantaneously to recognize a pivotal if not primary component of his or her sleep disorder. This point reflects the ultimate in patient education, because the individual “knows” first-hand the experience of sleeping better.

In the next components, we’ll delve deeper into the infrastructure that has successfully linked our daytime and nighttime staffs to enhance the education and treatment successes of our patients.


Sourced from Classic Sleep Care- Sleep Center Models of Care – advantageous or outdated?