Hypnotic Prescribing Trends

A new survey finds that latency to sleep onset (rather than sleep maintenance) is what Primary care doctor's consider the most important attribute in selecting a hypnotic:
Decision Resources, a research and advisory firm focusing on pharmaceutical and health care issues, finds that a drug's effect on latency to sleep onset is the attribute that most influences the prescribing decisions of surveyed primary care physicians (PCPs) in the treatment of insomnia.
I prescribe Ambien, which is good for helping a person fall asleep, much more than Ambien CR, which is better for sleep maintenance. Ambien is also now generic and much cheaper than Ambien CR.

Pills don't cure Obstructive Sleep Apnea

The life sciences company BTG is developing a pill that will supposedly treat obstuctive sleep apnea:

BGC20-0166 is a novel combination of two marketed serotonin modulating drugs being developed for the treatment of OSA.

Various sertonergic and serotenergic/noradrenergic antidepressants, including Prozac and protriptyline, have been used to treat OSA. These medications have a mild effect on osa. They slightly improve osa by increasing upper airway tone and also possibly by decreasing REM sleep. The effects are mild and antidepressants are not considered to be an effective treatment for OSA.

I don't recommend buying stock in BTG.

Starting a Sleep Lab, part three

There are 3 basic types of sleep labs: hospital associated, extension of a physician practice, and independent diagnostic and testing facility (IDTF).
Assuming that a physician is not starting a sleep lab in association with a hospital, the basic choice comes down to IDTF or extension of a physician practice.
In my case, I started Somnus Sleep Clinic with some non-physician owners, so IDTF was the only option.
For a physician or physician group, either form could be appropriate. The key difference is how patients are referred to the sleep lab.

For an IDTF, the Feds mandate that most of the referrals for sleep studies come from outside physicians. Practically, what this means is that the outside physicians refer the patients directly for the sleep study. The sleep physician then sees the patient (if the patient is going to be seen by the sleep physician) after the sleep study (within 3 months will meet AASM guidelines). You need to put some type of statement on the psg order form (which should be signed by the outside referring physician) that a cpap titration will be performed if clinically appropriate- then both studies will count as ordered by the outside physician.

For a sleep lab that is an extension of a physician practice, most of the sleep study referrals (85% is a figure I've heard several times before) need to come from inside the practice. Practically, what this means is that the sleep studies need to come from either the practice's own patients and/or patients referred to the practice for a sleep evaluation (and seen by the practice prior to the sleep study). The order for the sleep study needs to come from a physician in the practice.

There are some other differences between IDTF's and physician practice sleep labs, more to come later.

Postpolio syndrome

ADVANCE magazine has an interesting article about Postpolio syndrome, focusing on respiratory disturbances:

Disordered breathing is among the most misdiagnosed and misunderstood symptoms polio survivors face later in life. Too often their breathlessness and inefficient coughs are misdiagnosed as asthma or chronic obstructive pulmonary disease. For many aging polio survivors, it largely has been up to them to initiate their care and educate their doctors on the medical literature.

One-third to one-half of polio survivors experience new or increased weakening and pain in the muscles later in life. This typically occurs 10 to 40 years after recovering from original polio. This weakening can affect the diaphragm and breathing muscles, causing such disorders as obstructive sleep apnea, central sleep apnea, pneumonia, pulmonary restriction, shallow breathing, pneumonia, and diffuse muscle twitching during sleep.

He warns that split-night sleep studies are not appropriate for polio survivors I agree with this; home testing is not appropriate either.

Polio survivors should be given portable volume-pressure ventilators to use with nasal interfaces for ventilatory assistance rather than CPAP or bilevel positive airway pressure, Dr. Bach said. Polio survivors do not benefit from the expiratory positive pressure, he said, and it detracts from the positive inspiratory pressure in assisting the inspiratory muscles.
I disagree, many do have some element of obstructive sleep apnea and benefit from BiPAP. Typically these patients do require a wide differential between the EPAP and IPAP.

A few patients still use the iron lung, a form of negative pressure ventilation. Negative pressure ventilation can predispose to or worsen obstructive sleep apnea, but is very effective in some patients with postpolio syndrome.

"Moderate" does not mean "Mild"

I was in clinic most of the day. I told 2 of the patients that their sleep studies showed "moderate sleep apnea". Both of them looked relieved and said almost exactly the same thing, "so it's not that serious?" This necessitated additional time to explain that moderate obstructive sleep apnea is indeed a significant condition that usually affects daytime functioning as well as cardiovascular health.

I'm not sure why this confusion occurred. Maybe "moderate" means something different to lay people than physicians.

I guess I should change my classification, when speaking with patients, to "mild obstructive sleep apnea", "obstructive sleep apnea," and "severe obstructive sleep apnea" to promote clarity.

The Latest on Home Testing

I want to thank everyone who's been leaving comments about home testing. Currently the situation is unclear. It seems like a new LCD is written every week. If you have questions about what is covered in your state/Medicare region, I would encourage you to contact your local Medicare carrier or your state sleep society.

If anyone out there has successfully qualified a patient for cpap using home testing and/or has successfully billed for home testing, please leave a comment and share your experience.

A reader asked the following question:

I have some questions reguarding who will or who will be required to give a sleep study at home? Can a sleep technican hook up a patient at their home, by himself? Are can only a sleep technologist hook the patient up, in there home? This just seems like a slippery slope for sleep medicine. To me at the minimal a sleep technican, but what about Nurses or Respritory Therapist? Thank you for responding.

I don't think there are any standards for the hook up. The patient can hook himself up, or he could be hooked up by a technician, nurse, or secretary. I agree with your concerns.

I will be getting a type 3 home testing device in about 2 weeks. I'll let the readers of this blog know how things work out.

Military Sleep Interventions

This month's issue of Focus Journal has an interesting article about interventions that various branches of the military use to promote alertness (PDF file).
I wish caffeinated gum was available for civilians.

Home Testing not covered in many states

The AASM just linked to a new Local Coverage Determination for the following states:
Illinois, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska and Wisconsin.

Here is the link

http://www.aasmnet.org/Resources/PDF/WPSIC.pdf


Based on a quick read of the LCD, it appears that home testing will not be covered in the above states.