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.
Thursday, November 22, 2007
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.
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.
Wednesday, November 21, 2007
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.
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.
Sunday, November 18, 2007
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
From the New York Times Sunday Magazine
Saturday, November 17, 2007
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.
-------------------------------
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.
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.
-------------------------------
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.
-------------------------------------------------
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.
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.
-------------------------------------------------
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.
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.
Thursday, November 15, 2007
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
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
Tuesday, November 13, 2007
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.
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.
Sunday, November 11, 2007
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.
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.
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.
Saturday, November 10, 2007
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.
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.
Tuesday, November 06, 2007
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
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).
---------------------------------------
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
Sunday, November 04, 2007
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.
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