Get 8 hours of sleep to lose weight

I have previously posted on the relationship between sleep deprivation and weight gain.

Carnie Wison agrees with me:

"Ever since I had my daughter, my focus is not on me; it's on her," says Wilson, who is currently a size 16. "For the past two-and-a-half years, I haven't slept. I am convinced there has to be a link between sleep deprivation and a slower metabolism ... the past year, my workouts have been lazy. I've been snacking on the wrong foods and not drinking enough water."

eHealthTech

The billing for my outpatient sleep practice as well as for Somnus Sleep Clinic (sleep studies) is done by eHealthTech. eHealthTech is stationed in MS, but handles medical billing and physician practice management across the country. I highly recommend eHealthTech to sleep physicians and sleep labs.

Confessions of a sleeping-pill junkie

MSNBC reports on an Ambien junkie (via Kevin MD):
Right off I had trouble adjusting to my new schedule. The workdays went by slowly and the evenings all too quickly, and by the time I got into bed, it was often midnight or later. Knowing I could get only six hours of sleep at the most, I would start to panic. Worrying about not sleeping kept me from sleeping, and by the time my alarm clock sounded, I was lucky if I’d gotten four hours.
So by the time I turned to the sleep aid Ambien for relief, I was desperate — and primed to become an addict.
And I started abusing it almost immediately: I ignored the prolific warnings on the package, called multiple doctors to get it, mixed it with alcohol and took more than the prescribed amount. The makers of this drug never intended it to be used in any of those ways. And neither did I.

Type 4 Devices for Home Testing for OSA

I received the press release below via email. The two main type 4 devices that meet CMS criteria for home testing for OSA are the Itamar Watch-PAT100 and the Resmed ApneaLink (with the optional oximeter). Neither device is acceptable by the AASM for accredited sleep centers. The AASM has approved certain type 3 devices for accredited sleep centers.
Press Release

Hold until 18:00 (13 March, 2008)

"Watch-PAT100 included as an accepted ambulatory device for Medicare and Medicaid beneficiaries"

Itamar Medical Inc. is pleased to report that the Centers for Medicare and Medicaid Services (CMS) has released today its final National Coverage Decision (NCD) where it has decided to cover the Watch-PAT 100 for home diagnosis of obstructive sleep apnea. This decision will make the Watch-PAT available to Medicare beneficiaries nationwide.

"Today's decision will mean that Medicare beneficiaries in the United States will have access to one of the most accurate, convenient, and cost-effective home sleep testing diagnostic device for sleep apnea," said Itamar Medical Inc. CEO Israel Schreiber. "Medicare now joins the Department of Veterans Affairs, Kaiser Permanente, and other organizations and physicians nationwide in recognizing the usefulness and benefits of Watch-PAT in the diagnosis of sleep apnea."

"The Watch-PAT is already a widely used home sleep testing device, and this coverage decision means that all Medicare beneficiaries suspected of having obstructive sleep apnea will have access to a device that was designed to provide uniquely convenient and comfortable use with proven accurate and reliable performance," said Gary Sagiv, Itamar Medical Inc's Vice President.

Another Update on Home Testing for OSA

Several weeks ago I posted that regional Medicare carriers in many states decided not to cover home testing. Apparently those decisions are not in effect and the new national decision takes precedence:
That's because CMS has not yet released its final decision on whether to cover at-home based sleep tests. The decision, expected March 13, will likely favor the proposal. Until then, local coverage policy cannot be updated, said Dr. Hughes."Until the rules change, the rules are what they are," he said.
So basically, the new CMS decision overrides any pre-existing rules, but now that there has been a national decision, local coverage policy can be updated (at least that's my understanding, it's a confusing issue).

Aetna Follows CMS Policy on Home Testing

Please see my earlier posts today about CMS approving home testing for OSA.

Aetna's Policy is very similar to Medicare's:

Aetna considers the diagnosis and treatment of obstructive airway disease medically necessary according to the criteria outlined below.
Diagnosis
Aetna considers any of the following diagnostic techniques medically necessary for members with symptoms suggestive of OSA:
Full-channel nocturnal polysomnography (NPSG) (Type I device) performed in a healthcare facility;
Unattended home sleep monitoring using a Type II, III, or IV device.
Split-night study NPSG in which the final portion of the NPSG is used to titrate continuous positive airway pressure (CPAP);
Note: On occasion, an additional full-night CPAP titration NPSG may be necessary if the split-night study did not allow for the abolishment of the vast majority of obstructive respiratory events or prescribed CPAP treatment does not control clinical symptoms.
Limited-channel NPSG for members with a high pretest probability of OSA (as suggested by the simultaneous presence of snoring, excessive daytime sleepiness, obesity, and observed apneas or nocturnal choking or gasping);
Video-EEG-NPSG (NPSG with video monitoring of body positions and extended EEG channels) to assist with the diagnosis of paroxysmal arousals or other sleep disruptions that are thought to be seizure related when the initial clinical evaluation and results of a standard EEG are inconclusive.
Thank you to my colleague in Ohio for sending me the link to Aetna's policy.

The Key Line in the CMS decision

Please see my post earlier today for the full CMS decision on Home Testing.

I found this line interesting:

unattended home sleep monitoring device of Type IV, measuring at least three channels

I only have a basic understanding of the main Type 4 device on the market, the Resmed ApneaLink. My understanding is that it utilizes a nasal pressure transducer. I just googled it and came up with this site:

http://www.resmed.com/en-us/products/clinical_systems/apnealink/apnealink.html?menu=products

It looks like there is an optional oximeter available, that adds 2 channels (pulse and oximetry) to the nasal pressure transducer channel, giving the required 3 channels.

Are most doctors who are currently using the Resmed ApneaLink also using the optional oximeter??? If anyone has some info about this device, please leave a comment. Thanks.

CMS Approves Home Testing for Obstructive Sleep Apnea

Decision Summary
We received a request to reconsider the 2005 National Coverage Determination (NCD) for CPAP Therapy for OSA (CAG-00093R) to allow coverage of CPAP based upon a diagnosis of OSA by home sleep testing (HST). After considering public comments and additional information, we are making the following changes to the NCD for CPAP. The revised indications and limitations NCD are noted in Appendix B.
Coverage of CPAP is initially limited to a 12 week period for beneficiaries diagnosed with OSA as subsequently described. CPAP is subsequently covered for those beneficiaries diagnosed with OSA whose OSA improved as a result of CPAP during this 12 week period.We remind the reader that Durable Medical Equipment, Prothetics, Orthotics, and Supplies (DMEPOS) suppliers are required to provide beneficiaries with necessary information and instructions on how to use Medicare-covered items safely and effectively. 42 CFR 424.57(c)(12). Failure to meet this standard may result in revocation of the DMEPOS supplier’s billing privileges. 42 CFR 424.57(d).
CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:
polysomnography (PSG) performed in a sleep laboratory; or
unattended home sleep monitoring device of Type II; or
unattended home sleep monitoring device of Type III; or
unattended home sleep monitoring device of Type IV, measuring at least three channels
We remind the reader that, in general, pursuant to 42 CFR 410.32(a) diagnostic tests that are not ordered by the beneficiary’s treating physician are not considered reasonable and necessary. Pursuant to 42 CFR 410.32(b) diagnostic tests payable under the physician fee schedule that are furnished without the required level of supervision by a physician are not reasonable and necessary.
A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Distress Index (RDI) are met:
AHI or RDI greater than or equal to 15 events per hour, or
AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.
If the AHI or RDI is calculated based on less than two hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a two hour period.
We are deleting the distinct requirements that an individual have moderate to severe OSA and that surgery is a likely alternative.
I wish to thank my colleague in Ohio for sending this to me.

Behavioral Sleep Medicine- Who Should Practice It?

I would like to thank Dr. Perlis for his thougtful response to my Saturday March 1 post. Since not everyone reads the comments, I think that Dr. Perlis's reply deserves its own post and am reprinting it below:

===========> Michael Perlis Reply RE: Michael Rack, MD Post #1169The Threat FROM Psychologists===========>
It is interesting that Dr. Rack phrased the subject to his email this way. I think many people who specialize in Behavioral Sleep Medicine would see this differently, i.e., be concerned about recent initiatives by the AASM as a THREAT TO the continued participation of Psychologists in Sleep Medicine.
MR: Has anyone read the editorial in this month's issue of JCSM by Michael Perlis, Phd? In this editorial about behavioral sleep medicine/CBT-insomnia, Dr. Perlis advocates for the requirement that all accredited sleep disorders centers be required to "have a provider on staff (full time or part time) who is BSM "boarded" or board eligible. ===========>

This was indeed one of many recommendations. There are two issues here. First, it is a fact that most accredited Sleep Disorders Centers (SDCs) do not have people who specialize in the assessment and tx of insomnia. Second, it is a fact that the people who are "boarded" in BSM specialize in the assessment and tx of insomnia and are the only Sleep Medicine clinicians with any certification to conduct CBT-I. So it follows that fully accredited SDCs
Given that the need to provide treatment for all sleep DXs Incl. insomnia
Given the desire to provide the highest standard of care possible
should have BSM "boarded" or board eligible on staff.

MR: I am a DABSM and also certified in sleep medicine by the ABIM. I have also passed the AASM behavioral sleep medicine certification exam, and so I periodically receive emails from Dr. Perlis regarding the issue of who can provide behavioral sleep medicine services (I am also a member of the behavioral sleep medicine committee, but I will not reveal those confidential discussions). There is a growing movement among psychologists who are upset because they are not eligible for the new physician sleep boards to require accredited sleep centers to have BSM-certified individuals (primarily psychologists) on staff.===========>
While there is a contingent of PhD clinicians that are indeed upset about not being eligible for the ABMS exam, this is not the main issue for BSM clinicians. In fact, this issue is old news. The BSM exam was designed and established by the original AASM Presidential Committee for BSM (of which I was a member) precisely to fill the void left by the closure of the ABMS to PhD clinicians. Note: Unlike the new Sleep Medicine Exam… The BSM exam is (and should continue to be) open to PhDs and MDsThe current debate is whether to extend the credentialing process to MA level clinicians (NPs, PAs, etc.). The commentary written by Dr. Smith and I airs out the issues related to this movement and how this might be achieved in a manner that guarantees the highest standards of care be maintained. Finally, please note that one of the recommendations made in our JCSM Commentary is that both BSM and ABMS certified individuals should supervise MA level clinicians.
MR: I encourage all sleep physicians to write the AASM Board of Directors and support the position that physician board certification in sleep medicine qualifies the physician to practice all aspects of sleep medicine, including behavioral sleep medicine. ===========>
There is no question that the certification in sleep medicine does indeed proffer the right for all such certified individuals to practice BSM. The real questions are
1. Do most MDs certified in sleep medicine feel themselves qualified to practice and/or supervise CBT-I and other BSM interventions ?
2. Do most MDs want to practice in this arena ? I think the answer to both questions would be an emphatic “No!”. Perhaps the best analogy, as I understand this, is that MD degree and license is sufficient to for any MD to conduct any form of medicine. So any MD, for example, can conduct assessments and treatment for sleep disorders. The question here, again, is should they ? Are they really qualified? Will they provide the best possible treatment? Like Dr. Rack – I also encourage you to engage these issues and, whatever your opinion, share them with the BSM section leaders and the AASM BOD.
MR: In addition, consider attending the Insomnia Section meeting at Sleep 2008. The Insomnia Section has become a center for psychologists who support Dr. Perlis's position.===========> Please do attend. Although if your expecting this to be a Perlis Supporter Che-Guevara-type meeting… you’ll likely be very disappointed. Sincerely Michael Perlis

Restless Legs Syndrome and Cardiovascular Disease

Dr. Poceta at Sleep Expert recently posted about the link between Restless Legs and Heart Attacks. It seems that restless legs syndrome isn't just an abnormal sensory/motor experience, it also has adverse health consequences:
In a recent blog post,
I reviewed a new study that showed an increased risk of heart disease in patients with restless legs syndrome (RLS). This study and others suggest that RLS, like sleep apnea, is more than just an unpleasant sleep disorder; such that RLS actually raises the chances of having a serious medical condition.
RLS is more than a feeling—patients with RLS have poor sleep and also have periodic limb movements (PLM's) during sleep.
PLM's are the repetitive movements of the foot, leg, and thigh that happen mostly during sleep in patients with RLS.
A recent study sheds some light on how and why RLS could lead to heart attacks—by raising blood pressure during the PLM's.
The study is published in the medical journal Clinical Neurophysiology in mid 2007.
I encourage you to read the full post at Sleep Expert, a revolutionhealth blog.

The Growing Threat from Psychologists

I recently posted the following in the American Academy of Sleep Medicine discussion forums. There is a growing movement among sleep psychologists to limit the ability of sleep physicians to practice the full aspect of sleep medicing. Specifically, some sleep psychologists are trying to make it a condition of sleep center accreditation that the sleep center has a practioner certified in behavioral sleep medicine (which is an AASM certificate examination) on staff. The AASM behavioral sleep medicine certification is primarily for psychologists, though some MD's, including myself, have taken and passed the exam.

Has anyone read the editorial in this month's issue of JCSM (The Feb issue of the Journal of Clinical Sleep Medicine) by Michael Perlis, PhD?
In this editorial about behavioral sleep medicine/CBT-insomnia, Dr. Perlis advocates for the requirement that all accreditied sleep disorders centers be required to "have a provider on staff (full time or part time) who is BSM "boarded" or board elgible.
I am a DABSM and also certified in sleep medicine by the ABIM. I have also passed the AASM behavioral sleep medicine certification exam, and so I periodically receive emails from Dr. Perlis regarding the issue of who can provide behavioral sleep medicine services (I am also a member of the behavioral sleep medicine committee, but I will not reveal those confidential discussions).
There is a growing movement among psychologists who are upset because they are not elgible for the new physician sleep boards to require accredited sleep centers to have BSM-certified individuals (primarily psychologists) on staff.
I encourage all sleep physicians to write the AASM Board of Directors and support the position that physician board certification in sleep medicine qualifies the physician to practice all aspects of sleep medicine, including behavioral sleep medicine. In addition, consider attending the Insomnia Section meeting at Sleep 2008. The Insomnia Section has become a center for psychologists who support Dr. Perlis's position.

Sleep psychologists are trying to force sleep disorders centers to hire them on staff, using AASM accreditation as the enforcement mechanism. Most sleep physicians, including myself, would have no problem with referring CBT-I (cognitive behavioral therapy for insomnia) cases out to qualified psychologists. We board-certified sleep physicians should not, however, be force to hire psychologists, nor be limited in our ability to practice the full spectrum of sleep medicine, including, if we choose, behavioral sleep medicine.

Obtaining Coverage for CPAP and CPAP titrations

Medicare and some insurance companies have strict criteria about covering the purchase of a CPAP machine for a patient. Here is my response to a question on the AASM discussion forums about getting CPAP and CPAP titrations covered for patients who have OSA/Upper airway resistance, but don't meet their insurance company's criteria for CPAP:

My understanding is that the MEdicare criteria (4% desat, etc), are for the coverage of the cpap machine. The actually cpap titration is covered if the attending feels it is medically necessary. So if the AHI (using 4% desat criteria for hypopneas) is less than 5, one approach would be to do a cpap titration-covered by Medicare- and then try to get a DME company to sell the pt a used, discounted cpap machine.

This approach also works with other insurance companies- usually diagnostic testing/titration is covered by a different department within the insurance company than DME. Though it may seem illogical, even insurance companies that have strict criteria for cpap machines will usually approve cpap titrations (at least in the state of Mississippi).

Update on Home Testing for OSA

Sleep Well and Live reports that home testing for OSA will not be covered in many states:

Effective April 1, 2008: “For a study to be reported as a polysomnogram, sleep must be recorded and staged and must be attended. Sleep studies should be performed in a hospital, sleep laboratory or by an Independent Diagnostic Testing Facility that is supervised by a physician (MD/DO) trained in analyzing and interpreting the recordings and should be attended by a trained technologist. Sleep studies performed in the home are not covered.”

The LCD affects the following primary geographic jurisdictions: American Samoa, California, Connecticut, Delaware, Guam, Hawaii, Kentucky, Illinois, Indiana, Maine, Marina Islands, Massachusetts, Michigan, Nevada New Hampshire, New Jersey, New York (with the exception of Queens County), Ohio, Vermont, Virginia, West Virginia, and Wisconsin.

The decline of physician-practice sleep labs

There are 3 basic business structures of sleep labs:
1. hospital-owned
2. independent diagnostic and testing facility (IDTF's)
3. extension of a physician practice

At the AASM Sleep Management course I went to in February, it was reported that business structure 3 comprised less than 5% of sleep labs. The differences between the 3 business structures can be complex, and I plan to talk about this more in future posts. To briefly illustrate the complexity, I will just mention at this time that physicians are often part-owners of IDTF's and hospital associated sleep labs. Physicians sometimes fully own an IDTF.

In my brief career in sleep medicine, the decline of stucture #3 has been a disturbing trend. Sleep Review Magazine reports on how a new interpretation of an old Florida law has led to severe restriction on this type of lab:

In responding to a request from Jacksonville Heart Center (Jax Heart), the State of Florida Board of Medicine finds that physicians of physician-owned labs must directly supervise sleep studies.
In its request, Jax Heart, a group practice comprised of 17 cardiovascular physicians, proposed to establish an eight-bed sleep center as part of its medical practice. The request stated, in part, “.... For sleep studies performed after normal business hours, a Jax Heart physician would be on-call and immediately available by phone."
.....the main issue with the request submitted by Jax Heart was whether the sleep center’s services were being conducted under the “direct supervision” of Jax Heart.
The State of Florida Board of Medicine stated, “If the Sleep Center does provide services under the direct supervision of Jax Heart, the Petitioner’s proposed arrangement does not constitute a ‘referral’ that is precluded by Section 458.053(5), Florida Statutes.
“We found that the law dictated that patients needing a sleep study would be supervised differently depending upon whether the lab was owned by a physician group rather than an IDTF/Hospital,” said Masters.
Ultimately, the Board found that Jax Heart would not be providing services under the “direct supervision” (meaning supervision by a physician who is present in the office suite and immediately available to provide assistance and direction throughout the time services are being performed), and that Jax Heart’s proposed referral of patients to its sleep center is precluded by Section 458.053(5), Florida Statutes.
“It is also important to note that the declaratory statement did not say that physicians are not able to own their own lab—rather that they must provide direct supervision for patient care in a sleep center,” Masters said. “Secondly, the Board reinforced that physician-owned sleep labs must only treat their patients in the sleep center. This provision would not change even if the Direct Supervision requirement was changed to be an exception.”
Read the entire decision here.
Basically, the state of Florida is requiring sleep labs that are an extension of a physician practice to have a physician present whenever sleep studies are run. This is a poorly written article; as I pointed out above, a physician can own all or part of an IDTF. There is a definite distinction between a physician-owned sleep lab and a sleep lab that is an extension of a physician practice.

My Last Comment about Home Testing for OSA

This is my last comment about home testing for OSA, until CMS makes its final decision in March. I have previously extensively discussed the AASM's task force report on home testing, and its role in bringing about home testing for obstructive sleep apnea (click on the Home Testing or Portable Home Testing label below for more details).

Nic Butkov, the RPSGT guru, discusses another development that paved the way to home testing in this month's issue of SLEEP REVIEW:
It has been suggested by some that the new scoring manual is paving the way for portable, limited channel sleep studies and automated scoring. The manual does, in fact, present the respiratory scoring parameters apart from the rest of the polysomnogram, without discussing the relevance of viewing respiratory patterns within the context of the patient's sleep/wake physiology. The only reference to other PSG channels is made by the brief mention of arousal, as a possible scoring criterion for the alternative hypopnea definition and as a criterion for the optional scoring of RERAs. The lack of discussion regarding other PSG parameters creates the impression that respiratory events can be evaluated based solely on respiratory tracings and oximetry, without viewing the polysomnogram as a whole. This is unfortunate because without correlating respiratory patterns with the patient's physiological state, and evaluating their effects upon that state, the interpretation of respiratory events becomes largely a matter of guesswork.
So in addition to the Task Force report, the new American Academy of Sleep Medicine Scoring Manual also played a role in bringing about CMS approval of home testing for qualifying a patient for cpap therapy. Although the AASM claims it is going to work with regional Mediare carriers to limit home testing to board certified sleep specialists (wouldn't it be funny if some carriers excluded diplomates of the American Board of Sleep Medicine but instead required passing the new American Board of Internal Medicine test?), it is my opinion that most Medicare carriers will not limit the specialties that can perform home testing. The AASM has made its bed and now has to lie in it.

Respiratory Therapists Try to Take over Polysomnography in California

I previously posted on the attempt of respiratory therapists to take control over polysomnography in California.
The process is moving forward. As reported by Sleep Review Magazine,
Introduced by State Sen Jeff Denham (R-Merced), the “Polysomnographic Technologist Act” Senate Bill 1125 aims to prevent criminal abuse and ensure proper medical diagnosis, as well as ensure a standard of training and accountability for the profession.
"Hundreds and possibly thousands of unlicensed technicians are working with patients in vulnerable circumstances where most have not had a criminal background check and competency testing is optional. Failure to perform competently and protect the consumer holds little or no consequence for unlicensed personnel," said Stephanie Nunez, executive officer for the Respiratory Care Board of California.
The actual text of the bill is here. Some key parts of the bill:
"Board" means the Respiratory Care Board of California.

b) The failure of an employer to provide documents as required bythis section is punishable by an administrative fine not to exceedfifteen thousand dollars ($15,000) per violation. This penalty shallbe in addition to, and not in lieu of, any other civil or criminalremedies. 3818. The board shall issue, deny, suspend, place probationaryterms upon, and revoke licenses to practice polysomnography andpolysomnography-related respiratory care services.
The board shall determine the hours of credit tobe granted for the passage of particular examinations. 3819.5. The board may require successful completion of one ormore professional courses offered by the board, the AmericanAssociation for Respiratory Care, the California Society forRespiratory Care, or the National Board for Respiratory Care in anyor all of the following circumstances: (a) As part of continuing education. (b) Prior to initial licensure.
As I interpret it, this California bill would give respiratory therapists, through their board, the power to license sleep lab technicians and fine labs that hire technicians not licensed by their board. This law is a slap in the face to the majority of sleep technicians who are not respiratory therapists.

The Failure of the AASM Leadership

The Feb 15 issue of the Journal of Clinical Sleep Medicine has an editorial on "Why CMS Approved Home Sleep Testing for CPAP Coverage", by Dr. Chediak, President of the American Academy of Sleep Medicine. The editorial is a glaring whitewash of AASM's role in this debacle. A sample statement from this editorial is: "While there was variance in the degree of conviction, in general, the AASM, ACCP, and ATS testified against the indiscriminate use of HST" (HST= home sleep testing).
Dr. Chediak makes no mention of the AASM Task Force Report on Portable Monitors in the Diagnosis of Obstructive Sleep Apnea. This report, which came out in the middle of the CMS decision making process, basically came out in favor of home testing (when performed by sleep physicians in AASM-accredited sleep centers). After the task force report came out, the perception among CMS officials and the public was that the AASM had approved of home testing. After this task report came out, how could CMS not approve of home testing?
----------------------------------------
Valid arguements can be made in favor of HST. However for the AASM to initially come out against HST and then months later publish a task force report that was widely viewed as being an endorsement of HST is an incredible lack of leadership on the part of the AASM's Board of Directors.
I think that every member of the AASM Board of Directors who voted to approve the Task Force Report should resign.

The life of a sleep doctor

I have answered 20 questions about the life of a sleep physician for the Student Doctor Network.
Here is a sample question and answer:
What is the best way to prepare for this specialty?
Sleep medicine is a one year fellowship after a psychiatry, neurology, ENT, family practice, pediatrics, or internal medicine residency. The best way to prepare is to do one or two sleep medicine elective months during residency. Sleep medicine is becoming a more competitive fellowship, and it is hard for someone who has only completed an internal medicine residency to get- general internists are competing with pulmonary specialists for slots. If a resident is trying to go straight from internal medicine residency to sleep fellowship (rather than doing a pulmonary fellowship first), some sleep research during residency would be helpful.
Read more here.

Treatment of Posttraumatic Sleep Disturbances

Sleep disturbance is common after head injury. Here is part of an article I wrote on posttraumatic sleep disturbance:

Patients with narcolepsy secondary to a head injury or posttraumatic hypersomnia often require stimulant medication such as methylphenidate or amphetamines in doses similar to those for idiopathic narcolepsy-cataplexy syndrome. Modafinil may be the medication of first intention; it has fewer side-effects overall than the other stimulants. The dosage is usually 300 to 400 mg, administered in 2 divided doses in the morning and at lunch time. Modafinil, however, activates hypothalamic regions and does not act directly through dopaminergic or noradrenergic pathways; and patients with severe head trauma who complain of intellectual slowness may benefit more from amphetamine-like medications. These medications will have a general “activating” effect that is not solely devoted to sleepiness. Of course, any coexistent sleep pathology or neurologic disease requires independent management. The potential beneficial effects of naps have not been studied; they should probably be restricted to less than 30 minutes to avoid significant sleep inertia effects. They should be taken when the patient feels sleepiest but not within 4 or 5 hours of habitual nocturnal sleep time.
Cases of sleep apnea resulting from a head injury are treated in the usual manner with continuous or bilevel positive airway pressure therapy. Sometimes the spontaneous/timed mode of bilevel positive airway pressure therapy is necessary for central sleep apnea and mixed obstructive/central sleep apnea. Adaptive-servo ventilation has recently become available to treat central and mixed sleep apnea, but experience in non-heart failure patients is limited. Treatment of sleep apnea should be conducted by a sleep disorders specialist. Posttraumatic organic insomnia has generally proven difficult to treat. Patients respond rather poorly to the benzodiazepine hypnotics employed to help initiate and maintain sleep. Cognitive behavioral therapy, including stimulus control, sleep restriction, cognitive restructuring, sleep hygiene education, and fatigue management, can improve nocturnal sleep quality as well as reduce daytime fatigue (Ouellet and Morin 2007

You can read more at Medlink Neurology

Cell Phones and Sleep

A new study suggests that mobile phones interfere with sleep:
By Geoffrey Lean, Environment Editor
Published: 20 January 2008
Radiation from mobile phones delays and reduces sleep, and causes headaches and confusion, according to a new study.
The research, sponsored by the mobile phone companies themselves, shows that using the handsets before bed causes people to take longer to reach the deeper stages of sleep and to spend less time in them, interfering with the body's ability to repair damage suffered during the day.
The scientists studied 35 men and 36 women aged between 18 and 45. Some were exposed to radiation that exactly mimicked what is received when using mobile phones; others were placed in precisely the same conditions, but given only "sham" exposure, receiving no radiation at all.
The people who had received the radiation took longer to enter the first of the deeper stages of sleep, and spent less time in the deepest one. The scientists concluded: "The study indicates that during laboratory exposure to 884 MHz wireless signals components of sleep believed to be important for recovery from daily wear and tear are adversely affected."
The embarrassed Mobile Manufacturers Forum played down the results, insisting – at apparent variance with this published conclusion – that its "results were inconclusive" and that "the researchers did not claim that exposure caused sleep disturbance".
But Professor Bengt Arnetz, who led the study, says: "We did find an effect from mobile phones from exposure scenarios that were realistic. This suggests that they have measurable effects on the brain."

My Official Comment on Home Testing

Although several posts ago I stated that I was not going to comment on home testing for osa at the official CMS comment site, I changed my mind. Here is what I posted a few minutes ago:

Comment: I am against home testing for osa, but if home testing is to be implemented, allow me to make the following suggestions:
1. DME companies should not be allowed to provide home testing, due to the conflict of interest in providing a qualifying test for a product the DME company provides.
2. Any licensed physician should be able to provide home testing for osa. I am not aware of any precedent limiting a diagnostic test to a particular specialty, and I do not believe that limiting a safe test such as portable monitoring for osa to sleep specialists is justified.
3. Related to point #2, home testing should NOT be limited to sleep labs. One of the main rationales of home testing for osa is to expand diagnosis of osa to areas/populations currently not being served by sleep labs, and limiting home testing to sleep labs would defeat this purpose.

I am against home testing for osa. With the rapidly expanding number of sleep labs, I think that most of the US is now within convenient location of a sleep lab, and I don''t see the need for a test that is inferior to in-lab polysomnography. However, now that the American Academy of Sleep Medicine has signed off on home testing, I don''t see any point in arguing further against it, and hope that you will consider my suggestions for implementing home testing.

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Resmed Consultant Behind Home Testing Movement

Sleep Well and Live has an interesting post today about the movement for home osa testing and its originator:
At the 2004 Annual Meeting of the American Academy of Otolaryngology - Head and Neck Surgery Foundation in New York, Terence Davidson, an Otolaryngologist (ENT) and Dean of Continuing Education at the University of California, San Diego, was invited to give a “mini seminar” entitled “Thinking of Opening a Sleep Lab?” Dr. Davidson could also be called the “father” of the current attempt to get Medicare to approve unattended home testing for sleep apnea. It was his Jan. 29, 2004 letter to the Centers for Medicare and Medicaid Services (CMS) that argued that the current policy is inhibiting the diagnosis of obstructive sleep apnea (OSA) because the nation’s 692 sleep labs are simply too full.

During Dr. Davidson’s presentation in New York, he had some interesting opinions and comments and also seemed to have some conflicts of interest and an astounding degree of arrogance towards the Sleep Medicine and Pulmonary Medicine professions.
Although he has claimed to have no conflicts of interest, Dr. Davidson is on the Medical Advisory Board of Directors of ResMed, Inc. as a paid consultant. ResMed and their auto titration CPAP units stand to benefit substantially from gaining Medicare’s approval of in-home, unattended testing.
As to Dr. Davidson’s assertion that the current policy for our Medicare population is inhibiting the diagnosis of OSA because the nation’s sleep labs are simply too full, recent data from the American Academy of Sleep Medicine states that the availability of sleep laboratories across the United States based on a 2001 study of 2001 data estimates that 427 PSG were performed per year per 100,000 population. (5) Since 2001, the number of sleep laboratories accredited by the AASM has more than doubled to 1,169, with 129 applications having been received in just the first three months of 2007, alone.
In a 2004 AASM survey, there was an average wait of about three weeks for a sleep study or sleep consultation. An independent survey in 2004 by Shariq estimated there were more than 2,500 accredited and non-accredited sleep laboratories in the US with an average wait time for a PSG between two and three weeks.
I encourage you to read the full post.

osa home testing hits the mainstream media

This is the first news article I've seen about home testing for osa outside of an industry publication:
Last month, the American Academy of Sleep Medicine, which represents sleep centers, changed its position to say home tests can help certain high-risk patients - but should be administered by sleep specialists.Medicare's proposal wouldn't limit which doctors offer home tests. The American Academy of Otolaryngology, head-and-neck surgeons, requested the change.
There are some inaccuracies in the article, like this statement:
In fact, Medicare concluded a sleep-lab test isn't perfect, either - and thus proposed that all patients get a 12-week trial of CPAP treatment. Only if their doctors certify they're being helped would treatment continue.

Why I am not commenting (officially) on Home Testing

On the AASM discussion forum (open to members only), some have been advocating that sleep physicians comment on the CMS (Medicare) website either 1) in oppostion to home testing for osa or 2) to request that home testing be limited to certain devices or to AASM accredited sleep labs. I posted this on the AASM discussion forum a few minutes ago:

I am not going to comment on the CMS website comment section because:
1. Home testing is inevitable. How can a sleep physician argue against home testing when industry publications, such as Sleep Review Magazine, have "AASM Approves Home Sleep Testing to Detect Sleep Apnea" as one of their headlines.
2. Some have argued that sleep physicians should try to limit home testing to type 3 devices, as opposed to type 4. This would make very little economic difference to sleep centers. Frankly, if home testing is going to be a reality, I would like the freedom to pick the device that I, as a sleep professional, felt was most appropriate for the situation. For example, home oximetry could be useful for triaging patients to psg vs split-night study. Here is a study from the JCSM that supports the use of the ApneaLink, a single channel recording device: http://www.aasmnet.org/jcsm/Articles/030409.pdf
3. Some have argued that home testing should be limited to AASM-accredited labs. As an accreditation site visitor for nearly a year, it is my understanding that AASM accreditation was always meant to be voluntary, and that the AASM's position was that it did not promote accreditation status as being necessary for insurance reimbursement. The AASM is not a government agency! I don't think that the AASM should have the power to determine which sleep labs are elgible for government (Medicare) reimbursement. Michael Rack, MD

sleep and diabetes

The evidence continues to grow linking poor sleep to diabetes:
WASHINGTON (Dec. 31) - When Shakespeare called sleep the "chief nourisher of life's feast," he may have been well ahead of his time, medically at least. Researchers at the University of Chicago Medical Center report that disrupting sleep damages the body's ability to regulate blood sugar levels, potentially raising the risk of developing type 2 diabetes.More than 18 million Americans have diabetes and the most common form is type 2, in which the body either becomes resistant to insulin or doesn't produce enough of it to regulate sugar in the bloodstream.In a small experiment, researchers led by Dr. Esra Tasali, an assistant professor of medicine, found that disrupting the deepest sleep periods of volunteers rapidly resulted in reduction in their ability to regulate blood-sugar levels.The findings are reported in Monday's online edition of Proceedings of the National Academy of Sciences.The researchers studied the sleep patterns of nine volunteers, five men and four women, all of normal weight, in good health and aged 20 to 31.Normal sleep is divided into several stages, with the so-called slow-wave sleep considered the deepest.Whenever the volunteers went into slow-wave sleep the researchers made noise — enough to disturb the sleep though not to fully awaken them.After just three days the ability of the volunteers to regulate blood sugar was reduced by 25 percent, the researchers reported.Earlier studies have indicated that lack of sleep can reduce the ability to regulate sugar, and this report adds evidence that poor sleep quality is also a diabetes risk."This decrease in slow-wave sleep resembles the changes in sleep patterns caused by 40 years of aging," Tasali said in a statement. Young adults spend 80 to 100 minutes per night in slow-wave sleep, while people over age 60 generally have less than 20 minutes. "In this experiment," she said, "we gave people in their 20s the sleep of those in their 60s.""Since reduced amounts of deep sleep are typical of aging and of common obesity-related sleep disorders, such as obstructive sleep apnea, these results suggest that strategies to improve sleep quality, as well as quantity, may help to prevent or delay the onset of type 2 diabetes in populations at risk," said co-author Dr. Eve Van Cauter, a professor of medicine.

Nasal Orexin for Sleepiness

Wired.com reports on an experimental orexin nasal spray that combats sleepiness. Orexin deficiency is the main cause of narcolepsy with cataplexy. This sounds like a promising treatment for narcolepsy and idiopathic hypersomnia. I do not think this would be an appropriate treatment for voluntary sleep deprivation (except perhaps in the military):
Darpa-funded scientists might have found a drug that will eliminate sleepiness.
A nasal spray containing a naturally occurring brain hormone called orexin A reversed the effects of sleep deprivation in monkeys, allowing them to perform like well-rested monkeys on cognitive tests. The discovery's first application will probably be in treatment of the severe sleep disorder narcolepsy.
"It reduces sleepiness without causing edginess."
Orexin A is a promising candidate to become a "sleep replacement" drug. For decades, stimulants have been used to combat sleepiness, but they can be addictive and often have side effects, including raising blood pressure or causing mood swings.
The monkeys were deprived of sleep for 30 to 36 hours and then given either orexin A or a saline placebo before taking standard cognitive tests. The monkeys given orexin A in a nasal spray scored about the same as alert monkeys, while the saline-control group was severely impaired.
The study, published in the Dec. 26 edition of The Journal of Neuroscience, found orexin A not only restored monkeys' cognitive abilities but made their brains look "awake" in PET scans.
Siegel said that orexin A is unique in that it only had an impact on sleepy monkeys, not alert ones, and that it is "specific in reversing the effects of sleepiness" without other impacts on the brain.
Such a product could be widely desired by the more than 70 percent of Americans who the National Sleep Foundation estimates get less than the generally recommended eight hours of sleep per night
The research follows the discovery by Siegel that the absence of orexin A appears to cause narcolepsy. That finding pointed to a major role for the peptide's absence in causing sleepiness. It stood to reason that if the deficit of orexin A makes people sleepy, adding it back into the brain would reduce the effects, said Siegel.
"What we've been doing so far is increasing arousal without dealing with the underlying problem," he said. "If the underlying deficit is a loss of orexin, and it clearly is, then the best treatment would be orexin."
Dr. Michael Twery, director of the National Center on Sleep Disorders Research, said that while research into drugs for sleepiness is "very interesting," he cautioned that the long-term consequences of not sleeping were not well-known.
Both Twery and Siegel noted that it is unclear whether or not treating the brain chemistry behind sleepiness would alleviate the other problems associated with sleep deprivation.
"New research indicates that not getting enough sleep is associated with increased risk of cardiovascular disease and metabolic disorders," said Twery.
Still, Siegel said that Americans already recognize that sleepiness is a problem and have long treated it with a variety of stimulants.
"We have to realize that we are already living in a society where we are already self-medicating with caffeine," he said.
He also said that modafinil, which is marketed as Provigil by Cephalon and Alertec in Canada, has become widely used by healthy individuals for managing sleepiness.
"We have these other precedents, and it's not clear that you can't use orexin A temporarily to reduce sleep," said Siegel. "On the other hand, you'd have to be a fool to advocate taking this and reducing sleep as much as possible."
Sleep advocates probably won't have to worry about orexin A reaching drugstore shelves for many years. Any commercial treatment using the substance would need approval from the Food and Drug Administration, which can take more than a decade.

Home Testing Comments

Interested in commenting on home testing for OSA? Here is the link:

http://www.cms.hhs.gov/mcd/viewpubliccomments.asp?nca_id=204&rangebegin=12_14_2007&rangeend=01_13_2008

Or you can just read the comments others have made to CMS.

AASM Holiday Sleep Tips

AASM Issues Holiday Sleep Tips (via Sleep Review)
Rest of Sleep Review quote deleted, due to their request
Chediak offers these suggestions for better sleep during the holiday season:
• Take time to relax, and ensure time to wind down before bed.• Keep a regular sleep schedule. Maintain a regular bedtime and wake-up time. Other regular rituals, such as a warm bath, a light snack or a few minutes of reading, also may help.• Plan ahead for holiday activities. Set aside time earlier in the day to wrap gifts, decorate the house, plan your holiday menu, and do similar tasks. To stay on track, write these “appointments” in a daily planner.• Drowsy drivers should pull off to a rest area and take a short nap, preferably 15 to 20 minutes in length.• Do not eat heavy meals right before bedtime. This might cause heartburn or discomfort, which can disturb sleep.• Love eggnog? Avoid too much alcoholic eggnog or coffee at evening holiday parties. Alcohol and caffeine can inhibit normal sleep patterns.

IDTF's can no longer perform sleep studies in hotels

Sleep Review reports that:
Hotels/Motels Not Appropriate for Sleep Studies, CMS Says
New regulatory standards for independent diagnostic testing facilities released by CMS last month are scheduled to take effect January 1, 2008.
Among the standards is one that rules out the use of hotels and motels for performing sleep studies.
For more info, see here.
I believe that this ruling only applies to IDTF's. As an AASM accreditation site visitor, I have inspected a university-owned sleep lab that was based in a hotel. It was a nice operation. I don't agree with this CMS decision, though it will affect only a few sleep labs.

More on home testing for sleep apnea

Sleep Review Magazine reports on home testing for osa:
Last week, home testing took a step closer to becoming a covered benefit under CMS....
deleted upon request of Sleep Review Magazine.
reimbursement criteriaRead the entire announcement by clicking here.

Portable Monitoring Webinar

From the American Academy of Sleep Medicine website:

Get an in-depth overview of the new guidelines for portable monitoring and answers to frequently asked questions by registering for Portable Monitoring Discussion Forum.
AASM Portable Monitoring Task Force chair Nancy Collop, MD, will lead this 60-minute Webinar on December 18, 2007, at 12 p.m. CST. Please note that registrants must submit questions in advance to rrosenberg@aasmnet.org. The deadline to submit questions has been extended to 5 p.m. CST, December 14, 2007.
Log on to www.aasmnet.org/SleepEdSeries.aspx to register for Portable Monitoring Discussion Forum.
The new guideline will be published in the December issue of the Journal of Clinical Sleep Medicine; visit www.aasmnet.org/PortableMonitoring.aspx for comprehensive information.

Preliminary Approval for Home Testing for OSA

Home testing for OSA preliminarly approved: http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?from2=viewdraftdecisionmemo.asp&id=204&

Not only were type 2 (unattended polysomnogram) and type 3 devices (four channel) approved, but unexpectedly type 4 (1 or 2 channel) devices were also approved.

I am glad that I sold off my shares of Sleep Holdings Inc last week. I wish I would have bought Respironics instead of Resmed on Friday- Respironics makes the superior pulse oximeter (type 4 device)- the 920 M series.

Organized Medicine Endorses Home Testing

I've previously blogged in depth about the American Academy of Sleep Medicine endorsing home testing for the diagnosis of obstructive sleep apnea. Now the American Board of Internal Medicine has also (implicitly) endorsed it:

The ability to interpret results of polysomnography multiple sleep latency testing, maintenance of wakefulness testing, actigraphy, and portable monitoring related to sleep disorders.The ability to interpret results of polysomnography multiple sleep latency testing, maintenance of wakefulness testing, actigraphy, and portable monitoring related to sleep disorders.
From the ABIM website, training and procedural requirements for sleep medicine certification

The preliminary decision from the Center for Medicare Services regarding home testing for osa is expected today.

Sleep Lab Busted by Medicare

Sleep Review magazine reports that HMS Diagnostics Inc was recently busted by CMS (Medicare) for having uncertified technicians run sleep studies on Medicare patients:
Sleep Lab Medicare Claims Under Investigation
According to the release, the US Attorney's Office seems to be suggesting that any CPT 98510 or CPT 98511 study not actually performed by a credentialed technician cannot be billed. The fact that the credentialed technician is on site and supervising apparently is not a factor, HMS Diagnostics stated in the release.
Rest of quote from Sleep Review article deleted, due to their request
“If what CMS is saying is true, then the amount of money that would be owed to Medicare by the industry is phenomenal,” says Goodman. “The liability potential on an industry such as ours with Medicare could be a very big number.”
This is a disturbing development. The requirement for tech certification is virtually unknown in the sleep community. On the AASM message boards, we were recently discussing a new CMS regulation that All studies are to be done by a certified polysomnographer by January 1, 2008 in Arkansas, Louisiana, Eastern Missouri, New Mexico, and Oklahoma and by October 1, 2008 in Rhode Island; and the consensus was that uncertified technicians were ok for the time being in most other states. Most sleep labs have a combination of certified and uncertified techs, and I agree with the article that if CMS is going to enforce this newly discovered regulation, the amount of money owed would be phenomenal.

More on Portable Home Testing and Auto-CPAP

In response to a reader who emailed regarding my predictions of cpap vs. auto-cpap useage:

I don't think that APAP will entirely replace CPAP, but its marketshare will increase somewhat. This will be good for Respironics/RESmed, and bad for the durable medical equipment companies (DME's are reimbursed the same for cpap/auto-cpap machines and therefore there is a higher profit margin on the regular cpap machines for the DME companies). APAP will be prescribed in certain rural areas of the country by some primary care docs. After diagnosing a patient with portable home testing, they will tend to prescribe an auto-cpap machine rather than refer their patients to a sleep lab for a cpap titration. This will have little economic effect on the primary care doc, they will do this to maintain control of the process and maintain their independence from sleep labs. Some primary care docs, especially family practitioners in rural areas, take pride in being able to handle most problems themselves rather than referring to specialists.

Don't Blame the Turkey

Feel sleepy after a big Thanksgiving meal? Contrary to popular thinking, it's not the turkey's fault.
While there is an amino acid in turkey that induces sleepiness, experts say it's much more likely the reason you're tired after having Thanksgiving dinner is a combination of simple factors: you ate and drank too much and didn't sleep enough.
So don't blame the turkey.
"The poor turkeys have enough problems on Thanksgiving," said Dr. Carol Ash of Somerset Medical Center's Sleep for Life Center in Hillsborough, New Jersey.
The reason turkey gets blamed for making people sleepy is because it contains tryptophan, an amino acid that produces the brain chemical serotonin, which promotes calm and sleepiness. But as part of a big dinner, the tryptophan has a hard time reaching the brain.
Even if it did, "you'd have to ingest quite a number of turkeys" for it to have an effect, she said.
If the tiredness has anything to do with dinner, Ash said, it would be because of carbohydrates, which studies show are more likely to make people sleepy. And even that would only be a small factor, she said.
There's the travel, working longer days to get things done and lack of sleep, along with the carbs and alcohol, she said.
Overeating also contributes to feeling tired at Thanksgiving, said Joan Salge Blake, a registered dietitian and nutrition professor at Boston University.
"You're just eating a whole heck of a lot of foods and are stuffed," said Salge Blake.
On top of that, she added, you're "often just sitting around afterward, watching football."
From Cnn.com
Bottom line: if you are sleepy after thanksgiving dinner, it is probably due to a combination of over-eating, alcohol, sleep deprivation, and excessive carbohydrates. It's not due to the tryptophan in turkeys.

Duloxetine may improve sleep in patients with diabetic neuropathy

Clinical Psychiatry News reports on a poster presentation suggesting that duloxetine improves sleep in in patients with diabetic neuropathy:
WASHINGTON – Not only does duloxetine appear to reduce the severity of pain, especially during the night, but it may also help patients with diabetic peripheral neuropathy get a better night's sleep, according to a poster presentation at the annual meeting of the American Pain Society.
After 12 weeks of treatment, patients on 60 mg of duloxetine once or twice daily had improvements in average daily pain severity, night pain severity, and pain-related sleep interference, wrote Dr. David A. Fishbain, professor of psychiatry and behavioral sciences at the University of Miami, and his colleagues at Eli Lilly, maker of duloxetine (Cymbalta).
Although causality cannot be demonstrated between duloxetine and better sleep, the findings suggest that improvements in pain will be associated with less interference in sleep, the authors wrote.
The researchers pooled data from three double-blind, placebo-controlled trials of duloxetine in patients with diabetic peripheral neuropathic pain (DPNP). In the first study, 457 patients were randomized to receive 20 mg of duloxetine once daily, 60 mg of duloxetine once or twice daily, or placebo. In studies two and three, 334 and 348 patients, respectively, were randomized to receive 60 mg of duloxetine once daily, 60 mg of duloxetine twice daily, or placebo. Although the primary efficacy measure for the studies was the reduction in the weekly mean of the 24-hour average pain score, secondary end points included average daily night pain severity (measured on an 11-point Likert scale) and the Brief Pain Inventory sleep interference item.
Patients were included in the trials if they were 18 years or older with pain because of bilateral peripheral neuropathy caused by type 1 or type 2 diabetes mellitus. Pain had to have begun in the feet with relatively symmetric onset. Diagnosis was confirmed by a score of at least three on the Michigan Neuropathy Screening Instrument. Daily pain had to be present for at least 6 months. Patients also had to have at least a 4 on the 24-hour average pain severity (11-point Likert) scale and stable glycemic control. Notably, patients with a current or recent (within the last year) diagnosis of major depressive disorder as defined by the DSM-IV were excluded from the studies.
The researchers identified a subset of nonsomnolent patients by excluding those who reported treatment-emergent somnolence or who were on concomitant sedating medications. Treatment-emergent somnolence included reports of daytime sleepiness, drowsiness, being drowsy upon awakening, excessive daytime sleepiness, a feeling of residual sleepiness, groggy, groggy and sluggish, groggy on awakening, hard to awaken, less alert on rising, sleepiness, sleepy, and somnolence.
In all three studies, 339 patients received placebo. Of these, 307 met the criteria for the nonsomnolent subset. A total of 685 patients received 60 mg or 120 mg per day of duloxetine in all three studies. Of these, 607 met the criteria for the nonsomnolent subset. Patients in the nonsomnolent/nonsedating subgroup who were on duloxetine showed improvements in daily average pain and night pain severity, compared with those on placebo. The improvements started as early as 1 week and were maintained for 12 weeks. At 12 weeks, subset patients on 60 mg of duloxetine once and twice daily had improvements in daily average pain severity of 47% and 50%, compared with 29% for those on placebo.
Also at 12 weeks, subset patients on 60 mg of duloxetine once and twice daily had improvements in night pain severity of 47% and 51%, respectively, compared with 34% for those on placebo.
Most of the SSRI's and dual reuptake antidepressants can cause insomnia when used to treat major depressive disorder. This study suggests that by improving pain, duloxetine (which increases synaptic levels of serotonin and norepinephrine by inhibiting their reuptake) improves sleep in non-depressed patients with diabetic neuropathy. One limitation to this study is that patients who developed somnolence were excluded from analysis.

Respiratory Therapists Try to Take Over Polysomnography

Sleep Review Magazine reports on the attempt of California respiratory therapists to take control of polysomnography:
Respiratory Care Board of California Increases Efforts to Regulate Sleep Industry
In August, the Respiratory Care Board of California (RCB) voted unanimously to pass a motion allowing for the issuance of citations and fines for the unlicensed practice of respiratory care associated with polysomnography. Not only are investigations stemming from this motion under way, but also the RCB has now drafted new licensure legislation.
According to the Respiratory Care Board of California's Fall 2007 newsletter (launches PDF), "Citations may be issued to both unlicensed personnel and employers of unlicensed personnel illegally practicing respiratory care, with fine amounts up to $15,000. The issuance of these citations and fines is separate from, and in addition to, citations issued to employers by the Department of Health Care Services for failure to use properly licensed personnel."
This move heated up debate among many sleep professionals who feel requiring licensure of RPSGTs is doing little more than widening a divide between the sleep and the respiratory care professions.
Signed into law in 1983, the Respiratory Care Practice Act tasks the RCB with overseeing the licensure and regulation of respiratory professionals.
"In 2002 we added a code, Section 3767, which authorized us to cite and fine for the unlicensed practice of respiratory therapy," said Stephanie Nunez, executive officer for the Respiratory Care Board of California (Sacramento). Section 3767 became effective January 1, 2003. "We've been working on this since 2001 and have reached out to the community through surveys and roundtable meetings. Unfortunately, because these individuals are not licensed or regulated, we were very limited in how we were able to contact them." Nunez added that in 2004, there weren't many techs who were credentialed, a fact that has changed in recent years.
While, to date, there have not been any citations or fines issued to either sleep techs or their employers, there has been an ongoing effort from the RCB to inform the community about the new requirement.
"We sent a [online] survey out to more than 400 people, as well as a notice, in 2004," Nunez added. A hard copy of the survey was also distributed to about 150 people. "We received only 29 responses." This type of minimal involvement is a point of frustration for Nunez.
Polysomnographic Technologist Act
In addition to gathering information from the industry on, among other things, how licensing should be instituted, the RCB has put forth its suggested solution, the Polysomnographic Technologist Act. The proposed legislation—which is available on the organization's site (launches PDF)—is sitting idle, waiting for backing by a public official who could push it into law.
According to an AASMAdvocacy e-mail to AAST members, the proposal would require a sleep technologist to fulfill one of the following criteria to obtain licensure: - Possession of a current license to practice respiratory care in California.- Completion of an accredited respiratory care program as prescribed by the board and has an associated degree.- Completion of an accredited electroneurodiagnostics program as prescribed by the board and has an associated degree.- Completion of a polysomnography educational program prescribed by the board and has an associated degree.- Completion of 18 months or 3,000 hours of full-time paid work experience as an applicant sleep technologist, including 1,000 hours in polysomnography-related respiratory care services as prescribed by the board and satisfactorily performed as verified by a physician or surgeon.
The e-mail also stated, "AAST and AASM are formulating a number of strategies to counter this measure, one of which includes introducing our own bill, but no decision has been made at this time. Though we have not made a decision, we will still be working with our attorneys on our own bill so we are prepared for the upcoming legislative session."
The tone of the e-mail conveys concern—a feeling that Nunez has also recognized among techs. "The feedback we are getting is that [those in the sleep field] are adamantly against any type of regulation, but the fact is that respiratory care has to be performed by a licensed person," Nunez said. "So, we are seeking a resolution to this, and we've tried to stress that we want the techs to get involved, we want them to help us fix this problem."
Those techs are also feeling frustration. In many cases, they view the RCB as "playing favorites" and as trying to eliminate or ignore sleep professionals with additional legislation. Such accusations are unfounded, according to Nunez.
"We recognize that respiratory therapists need additional training in this area and that RPSGTs are probably the best qualified," she said. "Our recommendation is to establish a license category within our board, and it isn't excluding anyone: it recognizes the BRPT exam, it recognizes experience, and it recognizes all the people who are in the practice right now. It is not a turf war. It is a consumer protection effort."
Driving the goal of licensing is the ability to screen and monitor those in the profession. Among other requirements, licensure would mandate that techs pass a criminal background check. Not all hospitals—and very few independent facilities—perform such checks, according to Nunez, and even those who do are not privy to the privileged information the government can access.
"Licensure also addresses employees who are incompetent or who did something unethical. In those cases, the employer, most times, will terminate the tech and that person goes on to work somewhere else, with no record of it," said Nunez. "Granted, someone can do an employment check, but not everyone does—and employers are also leery of giving out that type of information, for fear of being sued."
Accusations of sexual assault by a respiratory therapist this summer focused the spotlight on the importance of regulating the profession, said Nunez.
"I think what's happening right now is the good [techs] are taking offense, because they feel they're being accused and criticized for not being good enough—and that is absolutely not true," she said. "It is the other people that we are worried about. It is about creating a level playing ground and ensuring that everyone has competency testing, such as the BRPT [Board of Registered Polysomnographic Technologists] exam or the NBRC [National Board for Respiratory Care] exam, if that comes about. We are not putting one above the other—we would recognize both."
Essentially, what the Respiratory Care Board of California (RCB) is doing is stating that the performance of sleep studies (polysomnography, cpap/bipap titrations) is respiratory care, and that any sleep center technician who is not a licensed respiratory therapist will be fined, along with their employer (the sleep center).
Rumor has it that in Mississippi respiratory therapists are planning a similar power play, and will try to get state legislation passed in 2008 to require a respiratory therapist to be present whenever cpap/bipap is titrated.
I personally strongly disagree with the RCB in its assertion that polysomnography is respiratory care. Polysomnogaphy was originally developed by psychiatrists, not pulmonologists. The RPSGT credential is the standardard in polysomnography, not the RRT credential.

The Sleep-Industrial Complex

A sleep boom, or as Forbes put it last year, “a sleep racket,” is under way. Business 2.0 estimates American “sleeponomics” to be worth $20 billion a year, which includes everything from the more than 1,000 accredited sleep clinics (some of them at spas) conducting overnight tests for disorders like apnea, to countless over-the-counter and herbal sleep aids, to how-to books and sleep-encouraging gadgets and talismans. Zia Sleep Sanctuary, a first of its kind luxury sleep store that I visited in Eden Prairie, Minn., carries “light-therapy” visors, the Zen Alarm Clock, the Mombasa Majesty mosquito net and a $600 pair of noise-canceling earplugs as well as 16 varieties of mattresses and 30 different pillows.
From the New York Times Sunday Magazine

More on Auto-CPAP

Currently there are a few major financial barriers to the use of Auto-CPAP:

Medicare and most insurance companies reimburse the DME companies for Auto-CPAP at the same rate as a regular CPAP machine. Auto-CPAP machines are more expensive (for the DME company) than regular CPAP machines. Unless a DME company is able to negiotiate a discount with the manufacturer, DME companies typically lose money on Auto-CPAP machines.

As far as using Auto-CPAP for an "at home titration study" (number 3 on my previous post)- that titration period (typically 3 nights) currently is unreimbursed and I am not aware of any plans for reimbursement for this.
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When portable testing is approved, I think that some primary care physicians will try to evaluate and treat osa without the involvement of sleep specialists by ordering portable testing and then treating the patient with an auto-CPAP machine (number 2 on my previous post). The auto-CPAP manufacturers have been known to negotiate discounts with large DME companies so this may be financially possible in certain areas. I think that we will see more auto-CPAP use by primary care doctors over the next several years, along with a temporary increase in profits by the Auto-CPAP manufacturers. However, results will be poorer than the current standard of having a patient undergo an in-lab titration before prescribing cpap. A lot of auto-cpap machines will end up sitting in closets and the auto-cpap trend will end by 2012.

Auto-CPAP in the new portable testing world

To paraphrase a reader question, what role will auto-CPAP play in the future?

Auto-CPAP is basically CPAP that is self-adjusting based on the patient's pressure needs (various manufacturers have different alogorithms to monitor airlow). There are 3 main ways to use auto-CPAP:

1. Some patients who undergoe an in-lab regular CPAP titration are found to have large pressure difference needs between different body positions or sleep stages. In these cases, the patient can be prescribed auto-CPAP within a preset pressure range. For example, if someone needs a pressure of 6 during stage 2 sleep and 10 during REM, he might be prescribed an auto-CPAP machine that was set to automatically adjust between 6 and 10.

2. A patient could just skip the in-lab titration and be sent home with an auto-cpap machine for permanent use. The pressure range might initially be set at 4-20 and then gradually narrowed based on the data generated by the auto-cpap machine.

3. Instead of an in-lab titration, a patient could be loaned an auto-cpap machine for a few days to use at home. Based on the data generated by the machine, the patient could be prescribed a regular fixed pressure cpap machine.

Most sleep specialists, including myself, do option 1 at times. Some sleep specialists will do options 2 and 3 occasionally, but this requires close patient follow up and in my opinion is not appropriate for widespread use, nor for use by non-specialists. If options 2 and 3 become more widespread it would reduce the number of titration studies done by sleep labs and have a negative financial impact on the sleep testing industry.
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Edit (11/21)

A reader asked about reimbursement for options 2 and 3:

I am not directly involved in the DME business, so I don't know exactly what the profit margin is on cpap and auto-cpap machines. For option #2, the physician would collect standard office visit fees and the DME company would sell the patient an auto-cpap machine. Currently, most insurance companies reimburse auto cpap machines (for permanent home use) at the same amount as a standard cpap machine. I have been told by DME companies that they lose money every time they do this.
For option #3, usually the patient (at least in my area) is not charged for borrowing the auto-cpap machine (from the DME company) for a few days for an at-home auto-cpap titration. The DME makes its money by then selling the patient a regular cpap machine. The physician charges standard office visit codes.

Is There a Sleep Study Backlog?

A reader asks: Is there actually a backlog of undiagnosed patients? If so, how significant is this backlog (2 weeks? 2 months?)? Do you believe the move to home testing will result in a quick resolution of this backlog?
In most urban areas, there is only a 1 to 2 week wait for sleep studies for patients with Medicare or commercial insurance. Not all sleep labs take Medicaid, so those patients may have to go to University sleep labs, which can sometimes have backlogs of 3 to 4 months. Waiting times in The Veterans Administration can be problematic; I have heard of patients waiting 6 to 12 months for sleep studies and I believe that portable testing may make sense in the VA system.

Not all rural areas have sleep labs, but more and more 2 bed sleep labs are popping in small community hospitals.

Overall I do not think that their is a significant backlog, except in the VA system and some university hospitals. There remains a large number of people with undiagnosed obstructive sleep apnea, but it's not due to a lack of sleep labs.

Quick Sleep Stock Pick

Respironic's products are superior to Resmed's, especially when it comes to the new servoventilation technology. Respironics is coming out with a new "PAP" machine which combines all the different PAP modalities (BiPAP, BiPAP ST, CPAP, SV) into one easily useable machine for sleep lab use- less work for the sleep lab technicians in switching from one treatment to the other. I remain bullish on Respironics and anticipate their stock reaching 55 within 6 months.

Sleep Review Magazine reports on Portable Monitoring

AASM Gives Green Light to Portable Monitoring Systems
Formed by the AASM to examine limitations and unanswered questions related to the practice parameters published in 2003's "Practice Parameters for the Use of Portable Monitoring Devices in the Investigation of Suspected Obstructive Sleep Apnea in Adults" (launches PDF), the (AASM) Task Force spent the last year developing a set of sound recommendations based on a review of the available literature and expert consensus.
The result of their effort will be published in the December 15 issue of the Journal of Clinical Sleep Medicine.
Please note that the link above is to the old (2003) practice parameters, the new practice parameters are currently available only to AASM members

Reader Comments on Home Testing, "certified polysomnographer"

This is an interesting take on the issue. For me, "certified polysomnographer" does not by default include RRTs. THE ONLY ONE BY DEFAULT IT DOES INCLUDE IS RPSGTs.As a Sleep tech since the early eighties, the costs associated with PSG have grown from the staffing side of the equation. At first, I worked in a world class Neurology based sleep laboratory. I was paid a salary commensurate with other Neuro-based technicians. Only with my move to a pulmonary based sleep facility, did I enjoy a major "bump" in my salary, as the facility did not have a pay scale for this "sleep tech" classification. Taking this new job allowed me to be the only technical sleep person in the facility and as such, I fit a unique role, but got wedged into a generic technician job category. I quickly exceeded that description and moved up, and hired other techs to work under me. Some of them had Respiratory backgrounds, and thus, we equalized the sleep tech and respiratory therapists pay scale, since we had to pay some "techs" who were also RTs. This now raised our costs significantly. We are paid equal to the RTs in Respiratory, but that was just a market demand, the equation of duties is nowhere near equal. The RTs, working in "Respiratory" perform Respiratory treatments, and we perform Sleep testing and Sleep treatments, irrespective of one's background. The only RTs who can perform sleep medicine testing and therapies are the ones the AASM, ACCP, and ATS have considered appropriate; those that are properly educated and proficient in sleep medicine. Otherwise, they are performing outside of their scope of practice. So, in the end, my history does not offer a similar perspective on the issue of cost, as the equipment has lowered in cost, but the staffing has artificially increased. And, as these two major components of sleep testing continue to hurtle towards their eventual end points, the need to control quality sleep medicine in whatever aspect, arena or capacity a patient is tested in, should ALWAYS fall to properly trained and experienced individuals. As for a 3/1 pt/tech ratio, 3 techs (whatever their backgrounds) taking care of 9 patients with all of the hand holding and interaction that patients undergoing PSG for titrations, pediatrics, or seizures, etc, necessitate, it does at least include a modicum of expectation of response from the technical staff. The 3 patients being taken care of, offer no consolation for the 6 (66%) of the other patients possibly calling out for them.Proper ambulatory testing can be accomplished, if all portable testing go through sleep doctors; on the front end (proper sleep consultation) and the back end; (sleep doc interpretation.) This would force the "certified polysomnographers" to be the ones performing these portable testing duties, and how that will interplay with the expectations of different allied health field entrants into the pool of "certified polysomnographers," we will have to wait and see. Some of these entrants might get bored, thinking that portable sleep testing and therapies is below their training, and some might find it a very interesting and important aspect to the milieu of sleep testing, that if anything, this shows is not stagnate.
Thank you for your comments on this post. I agree that "certified polysomnographer" should = RPSGT. However, respiratory therapists are making power plays in some states. For example, in some states respiratory therapists are trying to enact statutes making it mandatory that a respiratory therapist be present during all CPAP/BiPAP titrations.
As for technician/patient ratio, I think that a 3:1 ration would be appropriate only under limited circumstances (adult patients, psg's - not titrations). I agree that the current standard of 2:1 leads to better quality studies. However, I feel that portable home testing is vastly inferior to both ratios.

Drowsy Driving

The National Sleep Foundation's first annual Drowsy Driving Prevention Week (DDPW) is November 5th through 11th.

Each year, crashes due to drowsy driving result in at least 1,550 deaths and 71,000 injuries.

One of the most common causes of sleepiness while driving is voluntary insufficient sleep. Although a majority of us have the physiological ability to obtain the 7.5 to 8.5 hours (up to 9.5 hours in teenagers) of sleep necessary each night to feel fully rested - work, school, and family pressures often make it difficult to find enough time to sleep. Alcohol, when combined with sleep deprivation, can be particularly deadly.

Other causes of sleepiness include disrupted sleep (from obstructive sleep apnea or other sleep disorders), medication effect, circadian rhythm disorders (more about these below) and medical conditions that directly cause sleepiness (e.g., narcolepsy). After insufficient sleep, obstructive sleep apnea is the most common cause of daytime sleepiness. Many medications, including anti-seizure medications and many psychiatric medications, can also cause drowsiness.

Circadian rhythm disorders are conditions in which the body's 24 hour clock is out of alignment with the environment, producing insomnia and/or sleepiness during unusual hours. Examples include delayed sleep phase syndrome and shift work sleep disorder. In delayed sleep phase syndrome, which is common among adolescents and young adults, the main sleep period is delayed. A typical sleep period with this disorder would be from 3 am to 11 am. Insomnia occurs if the person tries to sleep outside this time bracket. If the person needs to get up early for work or school, sleepiness will occur. Insomnia and sleepiness are also common in shift workers, especially if the shifts are rapidly rotating.

It is important to allow sufficient time in your schedule for sleep. If you feel sleepy despite obtaining 8 hours at sleep at night, consultation with a physician is recommended. Also, talk to your doctor if insomnia prevents you from obtaining the necessary amount of sleep to feel fully rested.

Do not drive if you are feeling drowsy. If you become drowsy while driving, pull over and take a break (and a nap, if possible). Caffeine can have a mild effect in improving alertness.

More on Home Testing for OSA

Anyone interested in learning more about the pro's and con's of home testing for obstructive sleep apnea is encouraged to review Public Comments for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R2) on the Medicare site.

I did not submit a comment at the time. As a sleep professional, I foolishly assumed that the American Academy of Sleep Medicine would adequately represent my interests in the matter.

Job Security in Sleep Medicine

A reader asks about the implications of portable home testing for OSA: Certainly some sleep labs will remain active. There are pediatrics and very sick patients that will need all night testing. I work as an RPSGT at a lab that is highly regarded and has a good reputation. What can I expect for the future? How will doctors discriminate between those patients that can use portable units at home and those that need in lab testing?

As a RPSGT, you have good job security, at least for the next 10 years. New AASM and Medicare standards (Medicare standards vary region by region) are making RPSGT's increasingly in demand.
For example in the following five states, all studies on Medicare patients must be performed by a "certified polysomnographer" by January 1 2008: Arkansas, New Mexico - Oklahoma - Missouri (Eastern) Louisiana. No one knows exactly what "certified polysomnographer" means but it almost definitely includes RPSGT's and probably also RRT's.

Due to Medicare/AASM standards, sleep studies are becoming increasingly expensive tests to perform. The AASM requirement of at least 1 tech per 2 patients, certification requirements for techs, restrictive policies on performing split-night studies, etc make sleep studies expensive. So what's their solution for high cost sleep studies? Portable home studies in which their will be no technician to replace electrodes that come loose and take care of other problems that invariably come up. Medicare and the AASM created the problem of expensive testing with all their requirements, and now their solution is a low cost, inferior test. If saving money is the goal, why not just relax the standards (maybe 1 tech for 3 patients) and lower the reimbursement a little bit. This would be a better solution, in my opinion, than widespread portable home testing.

Home testing for OSA is a complex subject, and I will be posting more about this in the coming weeks. Thanks for reading.

Stabbed in the Back

I previously posted regarding the controversy about portable home testing for obstructive sleep apnea. This Sept 20 post gives some background information about the issue. Briefly, CMS (Medicare) is considering allowing portable home testing for the diagnosis of OSA, prompted by a request by the ENT physicians. A little more info is provided in my 9/21/07 post. Initially, The American Academy of Sleep Medicine (AASM) opposed home testing for OSA.

Now, The bureacrats at the AASM have joined the ENT docs in stabbing the field of sleep medicine in the back. If you look at this link, you'll notice under recent announcements "AASM Approves Portable Monitoring in Adult Patients". Basically, an AASM task force report is coming out in December recommending portable testing for OSA.

It’s all over. With the AASM caving in and publishing a task force report recommending portable testing, it’s a done deal. CMS (Medicare) will approve home testing for OSA. Within 3 years, the financial foundation of sleep medicine will crumble. Much of the evaluation and tx of OSA (the bread and butter of sleep medicine) will now be done by Primary care docs, who will diagnose with portable testing and treat with auto-CPAP machines. This will lead to worse outcomes for patients and many sleep labs going out of business.

Buy Respironics (at under 49). Begin to liquidate your Sleep Holdings positions (or if you are a speculator like me, buy and sell the volatility). Disclaimer- my stock picking ability isn't perfect, I recently tried to get a bargain with Washington Mutual and ended up catching a falling knife.

I will post more about this issue later. I need to get ready for a trip to inspect a sleep lab for the AASM, as well as complete some committee work (for the AASM Behavioral Sleep Medicine Committee).
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Edit (11/8) Thank you to Kevin, MD for linking to this post. Also, I regret using the phrase "bureaucrats at the AASM". I should have used the phrase "academics at the AASM". The leadership of the AASM, like that of most of organized medicine, is out of touch with the needs of physicians out in the community.

Michael Rack, MD

Sleep Board Tip #4

Cardiac deaths and MI's tend to occur between 6 am and noon in the average person. In people with OSA, they occur between midnight and 6 am.