I wrote a guest editorial in a national sleep trade publication Sleep Review for their July/August issue...

The title of the article is Pursuing an Elusive Dream.

Here is the link to the article - http://www.sleepreviewmag.com/issues/articles/2007-07_07.asp

I welcome your comments.


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Executive Director
American Sleep Apnea Association
6856 Eastern Avenue, NW Ste. 203
Washington, DC 20012
202-293-3650

Your editorial is certainly something to mull over.

One would think that defining the roles should be simple.  I used to think they were simple, but now I'm not so sure.  While working at my new job at a sleep study center and in my capacity as an ASAA volunteer and an AWAKE support group coordinator, I've been thinking alot lately about that term "role" as it relates to sleep apnea health care.

The PCP role isn't the one that troubles me the most.  It's the "Sleep Specialist" role that has begun to confuse me.  But also, I think that the PCPs might be confused by that sleep specialist role also.  When and if does a PCP need to direct a patient to a sleep specialist in order to make the determination that a sleep study is necessary?  And who should that specialist be?  And is a specialist always necessary?  When is a specialist necessary?

True, a PCP may not always be in a position to make the determination if a patient needs a sleep study.  So they refer them to a sleep specialist.  In my region, typically the PCPs refer patients to an ENT, or the only Pulmonary group in town where patients usually don't see the pulmonary physician but a nurse practitioner who specializes in sleep medicine.  But then a sleep study is given a final review by a Medical Director.  Where I work, the Medical Director is physician specilizing in sleep medicine who can, if need be, consult with sleep study patients after their study.  And of course all sleep study reports are submitted to the referring physician or sleep specialist, or to the PCP directly if the PCP ordered the sleep study.  Of course you know all this.  My point in reiterating it is because it seems the "sleep specialist" factor is confusing, especially to patients.

But I agree that the PCP is almost always the first line of defense (or diagnosis) for a patient.  And I applaud your statement:

Quote:

The PCP should know how to initiate the sleep apnea diagnostic process, have a basic understanding of sleep disorders, have the tools available, and have the ability to screen for such disorders.

Ideally, the PCP must have enough understanding of the condition to either order a sleep study or refer a patient to a specialist who can order a sleep study.  The responsibility of patient health care rests primarily in the hands of the PCPs, for without them, most patients may never see a sleep specialist.  

Then the question is how should PCPs be made knowedgable enough to identify possible sleep apnea and initiate the process?

I think that should be done at the very beginning, the initial patient visit.  I know this is an interest of yours.  Those long questionares of do you or have you had this, this, and this, is usually where it starts.  That sheet should include related sleep apnea questions, or at least attach a separate sleep apnea questionare... for every patient.  And I would like to see it mandatory that those questionares ask if the patient has had any family member who had or was diagnosed with sleep apnea.  The patients may scratch their heads on that one, but at the very least it will make them ask about what it means.  

PCPs are not the only ones who should be given assistance on how to recognize and identify symptoms of sleep apnea.  Specialists in fields other than those most knowledgable in sleep medicine also need to be informed ... such as Mental Health professionals, and medical professionals with other  specialties.  And yes, keeping the PCP in the loop is so very important as well.

I see sleep study centers with special roles as well.  If the ordering physician is a specialist, then there is little a sleep study center can teach the specialists, for the specialist can read and understand the data.  But where I live a good number of PCPs are now ordering sleep studies for their patients directly.  These PCPs are knowledgable enough to recognize the condition and seek diagnostic testing, but they don't always completely understand the results.  And they rely on the sleep study report and the professionalism of the sleep study center medical director who writes the interpretations.  

And ahhhhh.... followup.  I agree that followup is imperative to successful patient care of their chronic condition.  Followup is usually defined by the ordering physician.  But how knowledgable are physicians with the DME end of things?  Followup ideally should be tri-fold -- the PCP, the sleep specialist, and the DME provider.  But it's not a perfect world.   But I'm hopeful!


Sorry for the ramble.


Linda (aka "confused in the wacky world of sleep medicine") ....    

Sorry for my rambling.


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Ed,
Thank you for the article. I found it to be a very knowledgeable and well written opinion on the subject. I am going to read it a couple of times, as it covers several important areas.

Linda,

Linda wrote:

PCPs are not the only ones who should be given assistance on how to recognize and identify symptoms of sleep apnea.  Specialists in fields other than those most knowledgable in sleep medicine also need to be informed ... such as Mental Health professionals, and medical professionals with other  specialties.  And yes, keeping the PCP in the loop is so very important as well.

I believe that this year, 2007, is the first year that the American Board of Medical Specialties begins offering Subspecialty Certificates in sleep medicine. This is being done through their member boards in the areas of Family Medicine, Internal Medicine, Otolaryngology, Pediatrics, Psychiatry, Neurology, and Neurology with Special Qualifications in Child Neurology.
Reference Link: http://www.abms.org/Who_We_Help/Physicians/specialties.aspx

I think, hope, that this will lead to significant improvement in patients receiving proper diagnosis in the future.

Regards,
Guest MJ (Mary)

I found your article interesting. There are 2 things that strike me right off that I would like to ask about.

First, it appears that you are suggesting the use of the Pillar procedure and/or dental devices as first-line treatments to be considered for mild to moderate sleep apnea. Since my apnea falls into this category and since I have neither considered nor had either of these treatments recommended to me, this leads me wondering aboout whether I should consider one or another of these treatments. Do you have any references you could provide about these and could you say a bit more about your reasons for advocating these procedures as first-line treatment for apnea?

Second, I am taken by your apparent advocacy of at-home testing for apnea and titration for xPAP treatment. I think there is much to be said for the cost-efficiency and practical efficiency of such an approach. And it does seem to be an approach that is gaining in popularity. On the other hand, it does seem to me that if you have other sleep-related disorders that a full sleep study has definite advantages and reliance upon at home studies might contribute to the overlooking of other sleep problems. Again I would find any comments you might provide here interesting and worth further consideration.

Thank you for sharing youor thoughts on these important issues and thank you for your efforts on behalf of those affected by sleep apnea.

Best wishes,
Bill

Bill,

The reason you were not made aware of the other possible treatments for your sleep apnea is precisely why the title of my piece is an elusive dream.

The American Academy of Sleep Medicine, the medical authority on questions of treatment for sleep disorders recently (2006) issued practice parameters for their members to say that oral appliances can be considered a first line treatment for mild to moderate sleep apnea. The problem... oral appliances are the province of dentists qualified in sleep medicine and not something your sleep doctor can provide in-house. The Academy has not issued any guidelines on the Pillar Procedure and will likely not... my reason for referencing it is that apnea sufferers who a mild to moderate condition have options for treatment and in a prefect world should have all the alternatives presented to them to determine which they are more likely to be adherent to.

Technology for unattended sleep studies, as I understand it, has been more than adequate for diagnosing sleep apnea for a long time. It is true that it will never replace full in-lab polysomnography. In my perfect world, the sleep doctor will, using his/her best judgement use the technology that is best suited to the needs of the patient in order to get the patient treated as quickly and efficiently as possible. N.B. I say the sleep doctor and not any old GP who took a weekend course on doing sleep medicine for fun and profit. It seems that everyone misses this important caveat.

In the time I have spent learning about sleep medicine, I am convinced, that treating sleep apnea is not just a question of slapping a CPAP machine on someone's face and kicking them out the door... for exactly the reasons you state... there could be more to their sleep disorder than a blockage of the upper airway. If someone is having problems sleeping, a state we spend a 1/3 of our lives in, you need to consult a physician who specializes in it to help figure out what is happening to create the problem. In my perfect world, the sleep doctor uses all the tools available including referring the patient to another health professional for treatment if appropriate.

I hope this helps.


_________________
Executive Director
American Sleep Apnea Association
6856 Eastern Avenue, NW Ste. 203
Washington, DC 20012
202-293-3650