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Home Sleep Testing Monitor
Stanford University
Family doctors and sleep disorders:
Family practitioners waking up to sleep disorders
BY MIKE GOODKIND
Until every primary care physician in the United States recognizes and responds to the signs of life-depleting sleep disorders, Dr. William C. Dement believes his work will be unfinished.
Dement, director of Stanford's Sleep Disorders Clinic and Research Center, took that message to Washington last month. Testifying on March 26 before the House Subcommittee on Health and Environment, he said sleep disorders represent one of the nation's most serious health problems.
"The magnitude of suffering that results from sleep disorders is so large as to be almost incomprehensible," said Dement, who holds the Lowell and Josephine Berry Professorship in Psychiatry and Behavioral Sciences. He has estimated that sleep disorders cost the U.S. economy more than $100 billion a year, including lost productivity.
Yet many physicians do not take the time to recognize the signs of sleep disorders, including such maladies as obstructive sleep apnea, narcolepsy and insomnia, he said. Dement believes primary care doctors should look for, and can successfully treat, many sleep disorders.
He and Stanford colleagues have worked with primary care doctors in Walla Walla, Wash., and Moscow, Idaho, to establish pilot sleep programs there. The Stanford physicians have been working closely with physicians and other caregivers in the two target cities, providing education and consultation as needed to help local professionals gain the hands-on experience necessary to provide care independently.
These efforts are part of a National Primary Care Project funded by private corporations and a variety of nonprofit foundations. Dement is the principal investigator of the project, which is currently expanding to a third site at Alamo Clinic in Alamo, Calif.
"Our goals include educating and training a group of primary care physicians in the diagnosis and treatment of sleep disorders and also, based on what we are learning, to devise a national strategy to treat sleep disorders," he said. In addition, the pilot programs are providing an important base for much-needed research into sleep disorders, said Dement, who in the early 1990s chaired the congressionally appointed National Commission on Sleep Disorders Research.
These and other studies at the grassroots level are helping to uncover the prevalence of sleep disorders, said Dr. Clete Kushida, senior research scientist and Dement's associate on the Walla Walla and Moscow projects. A Stanford collaborative study of 975 patients in Moscow found that 32 percent suffered from insomnia, 19 percent from sleep apnea and 25 percent from restless legs syndrome, which prevents sufferers from lying quietly in bed. The detailed patient surveys, completed in early March, are being compiled for the Stanford researchers, who hope to publish their findings in about a year, said Kushida, who also serves as a staff physician at the Sleep Disorders Clinic.
"This was a typical group of patients in a rather typical American community. Relatively few of these patients probably need a referral to a specialty clinic. Many of these patients are being helped or cured with relatively simple measures, such as a simple breathing device, short-term medication or even educational counseling," said Kushida.
"Treating most sleep-disorder patients is not difficult as long as physicians recognize the symptoms," he added. "Our job as sleep specialists is also basic: to help our colleagues in family practice understand the warning signs of sleep deprivation, apnea and more sophisticated sleep problems."
Dement said he's gratified with the work in Walla Walla and Moscow because "an infrastructure of high-quality sleep medicine has taken root there." Dr. Richard Simon at Walla Walla Clinic is now the area's first board-certified sleep medicine specialist and is able to treat the most complex cases. In Moscow, Dr. John Grauke, medical director of the nearly two-year-old sleep center there, is keeping his colleagues informed about the need to screen for sleep disorders. In both towns, the local hospital and clinic have invested in equipment to evaluate conditions such as sleep apnea.
Throughout 1997, the Gritman Sleep Center in Moscow conducted 120 nighttime sleep studies using a polysomnograph, which tracks irregularities in breathing that trigger wakefulness. Walla Walla's Kathryn Severyns Dement Sleep Disorders Center (named after Dement's mother) has offered treatment to more than 2,000 patients in a community of 23,000. "I'd call this the healthy sleep capital of the world," Dement said.
The Walla Walla relationship began in 1992 after Dement, looking for a professional reason to spend more time in his hometown, walked into the clinic there and "fortuitously found a copy of my textbook on Dick Simon's office shelf."
Simon, who continues to practice internal medicine, said he recently reviewed the records of patients he had seen since 1983 and was surprised to find that a significant number of those whose initial diagnosis was fatigue or hypertension were later found to suffer from an underlying sleep disorder.
Of the 857 patients he has tracked since 1983, 8.5 percent have sleep apnea, he said. "I don't take snoring [a potential sign of sleep apnea] lightly," Simon said. "Physicians need to ask questions." Among those questions should be whether the patient suffers from telltale signs of apnea, such as constant fatigue or heavy snoring often interrupted by silence and then gasps.
"One of the most gratifying results of my work," said Dement, "is that patients who never knew why they were so sick are finally getting sufficient sleep. Some patients who simply thought they were old, fatigued and sapped of energy are able to function successfully at work for the first time in years and are able to enjoy their lives."
A case in point is Moscow patient Gloria Barker, 42, who until a few months ago woke up an average of 111 times each night. Her snoring, caused by an obstructed airway, was so severe that her husband refused to sleep with her. Her apnea was diagnosed at the Gritman Sleep Center, and she was fitted with a continuous positive airway pressure (CPAP) machine, which delivers a small amount of air pressure through a mask over the nose to prevent blockage of the airway.
The results were almost instantaneous, Barker said. "This machine is wonderful. ...It's been wonderful for my family." SR
Causes of Obstructive Sleep Apnea
Obstructive sleep apnea is a common and serious disorder in which breathing repeatedly stops for 10 seconds or more during sleep. The disorder results in decreased oxygen in the blood and can briefly awaken sleepers throughout the night. Sleep apnea has many different possible causes.
In adults, the most common cause of obstructive sleep apnea is excess weight and obesity, which is associated with soft tissue of the mouth and throat. During sleep, when throat and tongue muscles are more relaxed, this soft tissue can cause the airway to become blocked. But many other factors also are associated with the condition in adults.
In children, causes of obstructive sleep apnea often include enlarged tonsils or adenoids and dental conditions such as a large overbite. Less common causes include a tumor or growth in the airway, and birth defects such as Down syndromeand Pierre-Robin syndrome that cause enlargement of structures such as the tongue and jaw. Although childhood obesity may cause obstructive sleep apnea, it's much less commonly associated with the condition than adult obesity.
Regardless of age, untreated obstructive sleep apnea can lead to serious complications, including cardiovascular disease, accidents, and premature death. So it's important that anyone with signs and symptoms of obstructive sleep apnea -- especially loud snoring and repeated nighttime awakenings followed by excessive daytime sleepiness -- receive appropriate medical evaluation.
A Visual Guide to Sleep Disorders
Other Risk Factors for Obstructive Sleep Apnea
In addition to obesity, other anatomical features associated with obstructive sleep apnea -- many of them hereditary -- include a narrow throat, thick neck, and round head. Contributing factors may include hypothyroidism, excessive and abnormal growth due to excessive production of growth hormone (acromegaly), and allergiesand other medical conditions such as a deviated septum that cause congestion in the upper airways.
In adults, smoking, excessive alcohol use, and/or the use of sedatives is often associated with obstructive sleep apnea.
Obstructive Sleep Apnea and Overweight
More than half of people with obstructive sleep apnea are either overweight or obese, which is defined as a body mass index (BMI) of 25-29.9 or 30.0 or above, respectively. In adults, excess weight is the strongest risk factor associated with obstructive sleep apnea.
Each unit increase in BMI is associated with a 14% increased risk of developing sleep apnea, and a 10% weight gain increases the odds of developing moderate or severe obstructive sleep apnea by six times. Compared to normal-weight adults, those who are obese have a sevenfold increased risk of developing obstructive sleep apnea. But the impact of BMI on obstructive sleep apnea becomes less significant after age 60.
BMI isn't the sole marker of obesity that's important. Men with a neck circumference above 17 inches (43 centimeters) and women with a neck circumference above 15 inches (38 centimeters) also have a significantly increased risk of developing obstructive sleep apnea.
In addition, extreme obesity (defined as a BMI above 40) is associated with obesity-hypoventilation syndrome (Pickwickian syndrome), which can occur alone or in combination with obstructive sleep apnea. In this syndrome, which affects up to 25% of the extremely obese, excess body fat not only interferes with chest movement but also compresses the lungs to cause shallow, inefficient breathing throughout the day and night.
Although modest weight loss improves obstructive sleep apnea, it can be difficult for fatigued and sleepy patients to lose weight. In extremely obese patients,bariatric surgery is associated with an 85% success rate in improving the symptoms of obstructive sleep apnea.
Demographics and Obstructive Sleep Apnea
In middle-aged adults, the prevalence of obstructive sleep apnea is estimated to be 4%-9%, although the condition is often undiagnosed and untreated. Among people over age 65, it's estimated that at least 10% have the condition. Aging affects the brain's ability to keep upper airway throat muscles stiff during sleep, increasing the likelihood that the airway will narrow or collapse.
Obstructive sleep apnea is up to four times as common in men as in women, but women are more likely to develop sleep apnea during pregnancy and after menopause. In older adults, the gender gap narrows after women reach menopause.
Postmenopausal women who receive hormone replacement therapy are significantly less likely than those who don't to develop obstructive sleep apnea, suggesting that progesterone and/or estrogen may be protective. But hormone replacement therapy is not considered to be an appropriate therapy for the condition since it can affect health in other ways.
Other factors associated with obstructive sleep apnea include:
Family history. About 25%-40% of people with obstructive sleep apnea have family members with the condition, which may reflect an inherited tendency toward anatomical abnormalities.
Ethnicity. Sleep apnea also is more common in African-Americans, Hispanics, and Pacific Islanders than in whites.
Complications Related to Obstructive Sleep Apnea
Increasing evidence suggests that obstructive sleep apnea is strongly associated with conditions such as high blood pressure (hypertension), stroke, heart attack,diabetes, gastroesophageal reflux disease, nocturnal angina, heart failure, hypothyroidism, and an abnormal heart rhythm. About half of sleep-apnea patients have hypertension, and untreated obstructive sleep apnea increases the risk of heart-related illness and death.
In addition, obstructive sleep apnea is associated with excessive daytime sleepiness which increases the risk for motor vehicle accidents and increased risk of depression.
Some complications may be related to the release of stress hormones, which may be triggered by frequent decreases in blood oxygen levels and reduced sleep quality. Stress hormones can increase heart rate and also can lead to the development or worsening of heart failure.
Medical treatment -- which includes control of risk factors, use of continuous positive airway pressure (CPAP) or oral appliances, and surgery -- may improve signs and symptoms of obstructive sleep apnea and its complications.
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PATIENT VOLUME GROWTH APPEARS STABLE
On average, respondents have seen patient volume grow 3.1% in the last 12 months and expect 7.2% growth in the next 12 months. We note that the most common responses were for 0% to 4% growth in both the last 12 months and the next 12 months. The reported and expected patient volume growth rates are different from the reported and expected bed growth rates (which were 0.9% and 7.9%, respectively).
Compared with our prior survey, last 12 month patient volume growth was stable at 3.1% while next 12 month patient volume growth declined slightly to 7.2% from 7.9%.
Additionally, Medicare's 2011 Physician Fee Schedule included a reduction to the professional component for sleep testing. Respondents indicated that this change would reduce their bed growth by an average of 0.8% (in line with -0.8% in our prior survey).
ORAL APPLIANCE USE EXPECTED TO RISE SLIGHTLY
In response to recent coverage updates, respondents expect to increase the number of their patients receiving oral appliances by an average of 1.7% (down from 4.4% in our prior survey).
APAP UTILIZATION SLOWS, BI-LEVEL FLOW GENERATOR USE STABILIZES
We asked the sleep centers how many of their patients use higher-end flow generators. According to the respondents, 12% of patients use auto-setting flow generators, a small decrease from 12.7% in our 1Q11 survey. And 11.9% of patients use bi-level flow generators, about in-line with 12% in our 1Q11 survey.
Sleep Centers Selling CPAP Equipment StabilizesOnly 17% of sleep centers report selling flow generators and masks. We think that some centers view equipment as an additional revenue source and a way to offset potential losses to home sleep testing. Over time, however, the portion of sleep centers selling CPAP equipment has remained relatively stable.
ABOUT THE SURVEY
Sleep Review and Mizuho Securities USA conducted a survey of sleep centers. We sent the survey to ~12,500 sleep professionals, and 622 responded to one or more of the survey questions for a response rate of 5%. None of the questions were mandatory, therefore response rates varied from question to question. Of the 622 respondents, 464 (75%) completed the entire survey. The responses were collected between January 9 and January 23, 2012.
We received responses from a range of sleep industry participants with registered polysomnographic technologists (34% of respondents) and sleep center directors/supervisors/managers (32% of respondents) representing the most common titles. Responses also covered every geographic region and all 50 US states with the Southeast (29% of respondents) and Midwest (29% of respondents) the most heavily represented regions.
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MASSACHUSETTS: A STATE OF CHANGE
Sleep centers in Massachusetts have been among the first to be impacted by insurers who have implemented policies that direct patients to home sleep tests as a preferred diagnostic method over in-lab polysomnography. With reports that sleep labs such as Massachusettsbased Sleep HealthCenters have seen 10% to 20% of its activity overall switched from in-laboratory to inhome sleep studies,1 we surveyed labs in the state to see how they fared in comparison to the rest of the country. While our sample was very low (10 respondents), those polled indicated a drop in average beds and patient volume growth.
DROP IN BED GROWTH
In Massachusetts, respondents reported a decrease in bed growth of 5.5% during the last 12 months and reported an average of 13.8 beds versus 14.6 beds 12 months ago. We note that many respondents are indicating the total number of beds for multiple sleep centers, which pushes the average number of beds per respondent higher. Bed growth expansion is predicted to be flat with respondents expecting 0% growth. In the state, last 12 month bed growth and expected bed growth were below the national averages. Nationally, respondents saw 0.9% growth in the last 12 months and expected 7.9% growth in the next 12 months.
PATIENT VOLUMES DECLINE
On average, respondents saw patient volume decrease 5.3% over the last 12 months, although next 12 month growth is expected to be 6.3%. Nationally, respondents’ last 12 month patient volume growth was 3.1% and average next 12 month patient volume growth is predicted to be 7.2%.
HOME TESTING
Eleven percent of Massachusetts respondents said they offered home testing for Medicare patients, 33% offer the form of testing to privately insured patients, and 67% indicated they plan to offer home testing in the next 6 months.
Seventy-eight percent of respondents said the rise of home testing has impacted their facility’s expansion plans, compared to 33% nationally. In response to increased use of home testing, respondents said they will decrease beds per facility (24%), close facilities (12%), and increase involvement with home testing (35%). Nationally, respondents said they will decrease beds per facility (6%), close facilities (3%), and increase involvement with home testing (58%). Again, we emphasize that readers should keep in mind the small response rate when analyzing the Massachusetts results.
Sleep Center Expansion Appears to be slowing
Respondents reported bed growth of 0.9% during the last 12 months and reported an average of 8.5 beds per respondent versus 8.4 beds per respondent 12 months ago. Respondents also expect greater sleep center capacity expansion in the next 12 months (7.9% to 9.2 beds per respondent) than the growth seen in the last 12 months. Compared with our prior survey, both last 12 month and next 12 month bed growth declined to 0.9% from 3.6% and to 7.9% from 8.5%, respectively.
We offer a few caveats about these results. First, we note that sleep center growth covers only part of the entire sleep market, as sleep center growth drives new diagnoses and flow generator sales, while mask sales are mostly driven by replacement sales. Second, sleep center growth as defined in our survey represents only organic growth (beds per center) versus inorganic growth (new sleep centers). Third, as home testing becomes more prevalent, it is possible that sleep center growth may become less correlated with the overall growth in the sleep market. Finally, we note that many respondents are indicating the total number of beds for multiple sleep centers, which pushes the average number of beds per respondent higher (ie, we doubt that the average individual sleep center has 8+ beds).
Overall, we think that the survey indicates that sleep center growth has stabilized in the mid-single digits. For 2012, we expect the domestic sleep therapy equipment market to grow by 6% to 9% with 6% to 7% volume growth in new patients.
Physician Usage Study Quantifies Benefits Associated
with Using Home Testing
Midmark Corporation released a physician usage study demonstrating the viability, accuracy, and affordability of primary care physician-managed home sleep testing using the Midmark SleepView Monitor and Portal. The report shows that the complexity and costs for achieving a reliable diagnosis of obstructive sleep apnea (OSA) can be lowered as much as 70% by providing primary care physicians with the necessary technology and support.
For the 5-month study, Midmark worked closely with four physician practices to implement the home sleep testing device as part of their primary care services. Staff and physicians were given training on using the SleepView Monitor, patient instruction, and secure use of the SleepView Portal that enables a practice to manage test scheduling, remote test scoring, physician diagnostic interpretation, and data management. Training on the Epworth and STOP-BANG screening tests commonly used to identify patients at risk for OSA was also provided.
During the pilot program, a total of 60 home sleep tests utilizing SleepView were completed with patients identified as at-risk for OSA by their physicians. Of the patients tested, 80% were diagnosed as positive for OSA, with only 3.3% receiving inconclusive results requiring a retest in an overnight facility.
Even more significant was the fact that the results showed that diagnosing OSA through home sleep testing versus an overnight facility stay lowered the overall cost of care for the patients. Using Centers for Medicare and Medicaid Services national average reimbursement rates, the pilot program demonstrated a 70.4% reduction in diagnostic testing costs to the patient and insurer. This amounted to $29,334 savings for the 60 patients tested.
The pilot program also demonstrated that the physician's ability to order a sleep study at the patient home on the very night of the office visit was valuable. With the ability to achieve a diagnostic study immediately after identifying an at-risk individual, more patients agreed to be tested. As stated by participating physician, Dr Stewart Segal of Lake Zurich Family Treatment Center near Chicago, "The simple words, 'We can test you tonight at your own home,' as opposed to 'We can test you in 2 weeks at an overnight facility,' proved to be highly influential in getting the patients to agree to a test. When I said those words about having the test done immediately and at home, fewer patients objected."