Tuesday, September 25, 2007

Read about Insomnia at MySleepCentral.com

I am now a blogger for MySleepCentral.com. Read my latest post about Insomnia, here.

Friday, September 21, 2007

Update on home testing for osa

The American Academy of Sleep Medicine reports:
The Medicare Evidence Development and Coverage Advisory Committee (MedCAC) met September 12, 2007, to evaluate national coverage determination (NCD) 240.4 continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA).

Alex Chediak, MD, president, and Mary Susan Esther, MD, president-elect, represented the American Academy of Sleep Medicine (AASM). As communicated to AASM members via the Weekly Update, Dr. Chediak presented official testimony, completely based on available published evidence and data, on behalf of the AASM.

Download his testimony by visiting www.aasmnet.org/resources/pdf/testimony.pdf.
According to its Web site, the Centers for Medicare & Medicaid Services (CMS) has until December 14, 2007, to issue a preliminary decision memo, which will be followed by a 60-day public comment period. CMS expects to publish the final NCD by March 14, 2008.

The AASM will continue to communicate more information on NCD 240.4 to members as it becomes available.

I am currently at a CME conference sponsored by the AASM. I hope to post more when I get back to Mississippi on Sunday.

Thursday, September 20, 2007

Home Testing for Obstructive Sleep Apnea

As reported in Sleep Review, last week Medicare (actually the Medicare Evidence Development and Coverage Advisory Committee) met to decide the future of sleep medicine:
On September 12, industry leaders with varying positions about adopting home testing for the diagnosis of OSA gathered to present their opinions to a Medicare Evidence Development & Coverage Advisory Committee (MedCAC) panel. Based on the content of the meeting, the panel will make a recommendation to CMS about the future of home testing.
Earlier this year, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) submitted a formal request to CMS to revisit its national coverage determination (NCD) to not reimburse patients for positive airway pressure therapy if their sleep apnea was diagnosed with any form of testing other than in-laboratory polysomnography (PSG).
The AAO-HNS letter triggered the home testing debate...

rest of sleep review quote deleted at their request.

The MedCAC panel recommendation is expected to be out December 14, 2007, when the proposed decision memo is due.

Currently a polysomnogram (sleep study) performed in a sleep lab is required by CMS (medicare) to cover the purchase of a CPAP machine, the most common treatment for obstructive sleep apnea. Usually another sleep study, a CPAP titration (in which the CPAP settings are adjusted), is performed before CPAP is prescribed.
If CMS approves home testing for the diagnosis of sleep apnea, it will be disastorous for sleep labs that are currently in operation. Most private insurance companies follow CMS guidelines, and there will be a drastic drop in the number of sleep studies performed. Many sleep labs will close. It takes a lot of money to keep a sleep lab going, the typical yearly overhead (technician costs, equipment, rent) for a sleep lab is approximately $100,000 per bed, and much of this expensed is fixed.
Home testing, in my opinion, will be bad for patients. Sleep apnea will be less accurately diagnosed. CPAP will be titrated inadequately, and patients will get poorer results with CPAP.

I don't think that CMS is going to make the change, though. The final decision is expected March 14, 2008

Saturday, September 15, 2007

Wednesday, September 12, 2007

I am not Responsible for your CPAP Machine

CPAP (Continuous Positive Airway Pressure) is the most common treatment for obstructive sleep apnea. Most sleep physicians do not directly provide their patients with CPAP machines, but instead give a prescription for each patient to take to a durable medical equipment (DME)company. I typically give patients a list of several companies to choose from, while telling them that they are legally free to pick any DME company they desire.
Once a patient selects a DME company, he is essentially stuck with that company for 5 years. Due to reimbursement issues, it is difficult to switch companies (though there are a few exceptions- insurance reimbursement for CPAP is a complicated matter). Choosing the right DME company is critical- the DME company is responsible for adjusting the settings (as ordered by a physician prescription), supplying/fitting CPAP masks, periodically replacing filters and other supplies, and servicing the CPAP machines.
So pick a good DME company- go with your doctor's suggestion.
Do not lose your CPAP machine. There is nothing I can do about it. Medicare and most other insurance companies won't cover a new CPAP machine for 5 years, unless your machine becomes unrepairable. If you lose your machine, you are out of luck.
If you plan on moving soon, pick a national DME company, such as Lincare or Apria. If your DME company does not have an office in the state you are moving to, it may be difficult to get your CPAP machine serviced.
I am not responsible for your CPAP machine. If it malfunctions, I will try to help out and will call your DME company, if necessary. However, I am often limited in what I can do. If you are one of my patients, please go to one of the companies that I recommend. I only recommend companies that provide good service.

Thursday, September 06, 2007


Obama's wife reports that he snores:
Referring to their daughters, Mrs. Obama says: “We have this ritual in the morning. They come in my bed, and Dad isn’t there — because he’s too snore-y and stinky, they don’t want to ever get into bed with him. But we cuddle up and we talk about everything from what is a period to the big topic of when we get a dog: what kind?”
According to the National Sleep Foundation, Snoring is noisy breathing during sleep. It is a common problem among all ages and both genders, and it affects approximately 90 million American adults — 37 million on a regular basis. Snoring may occur nightly or intermittently. Persons most at risk are males and those who are overweight, but snoring is a problem of both genders, although it is possible that women do not present with this complaint as frequently as men. Snoring usually becomes more serious as people age. It can cause disruptions to your own sleep and your bed-partner's sleep. It can lead to fragmented and un-refreshing sleep which translates into poor daytime function (tiredness and sleepiness).
About 25 % of people with snoring have obstructive sleep apnea. Some indications that your snoring may be a problem include:

Excessive daytime sleepiness
Morning headaches
Recent weight gain
Awakening in the morning not feeling rested
Awaking at night feeling confused
Change in your level of attention, concentration, or memory
Observed pauses in breathing during sleep

Sunday, September 02, 2007

CBT for Insomnia

Clinical Psychiatry News recently published a nice summary on the use of cognitive behavioral treatments for insomnia. The article focuses on secondary/comorbid insomnia, but the techniques discussed can also be utilized in primary insomnia:

Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.
Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.
The underlying assumptions—both of which he challenged—are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

Sometimes secondary insomnia does remit with treatment of the underlying condition, and optimal treatment of the underlying condition is important.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”
For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring—in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.
“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”
For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:
▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

Sleep hygiene alone is not very helpful, but can be useful when combined with other CBT techniques.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.
▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

I have found that sleep restriction is a powerful behavioral method for treating insomnia. The basic concepts are rather simple, but it does take time to explain to the patient and get them to comply- many are hesitant to use this technique.

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.
As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients—and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”
Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

Sleep deprivation and weight gain

Voluntary sleep deprivation has been shown to lead altered metabolic hormones and increased appetite. I have posted on this previously. Today, a newspaper article by Harry Jackson Jr. discusses this topic:

Sleep and insulin choreograph the dance between leptin, which tells the brain there's no need for food, and ghrelin, which tells the brain it's chow time.
Poor sleep, researchers learned, causes the dancers to start tripping over one another.
Here's what happened: The test subjects slept only four hours a night rather than eight. In only two nights, the hormones malfunctioned.
Leptin production decreased by 18 percent; ghrelin production increased by 28 percent.
On top of that, the test subjects - healthy, young, male college students - started eating like they were at a frat party. They reported craving more high-calorie, high-density, high-carbohydrate foods - including a 24 percent increase in appetite for candy, cookies, chips, nuts and starchy foods such as bread and pasta.
A week into the experiment, blood tests showed an inability to use insulin so intense that it mimicked diabetes. Also, lack of sleep increased the production of cortisol, a hormone associated with increased belly fat.
The researchers concluded that sleep starvation boosted appetite; increased appetite caused overeating; overeating caused weight gain. Weight gain causes obesity.

This short-term study suggests that voluntary sleep deprivation can contribute to obesity. Epidemiological studies have found a relationship between decreased sleep time (which can be caused by either insomnia or voluntary sleep deprivation) and weight gain.

It has been hypothesized (but not proven) that the sleep disruption produced by obstructive sleep apnea causes weight gain:
Once you're obese, you're more prone to sleep apnea, the collapse of the upper windpipe which interrupts breathing during sleep. That's the vicious circle: sleep apnea can help cause obesity, and obesity can cause sleep apnea.