SLEEP : An SLEEP : An UpdateUpdate

The Village Sleep LabThe Village Sleep LabAccredited by the Accredited by the

American Academy of Sleep American Academy of Sleep MedicineMedicine

Juan A. Albino, MD, FCCPJuan A. Albino, MD, FCCPBoard Certified in Sleep MedicineBoard Certified in Sleep Medicine

751-4955; February, 2009751-4955; February, 2009

Thank You !!!Thank You !!!

Phillip Ratliff, AWAKE GroupPhillip Ratliff, AWAKE GroupLois Brach, AWAKE GroupLois Brach, AWAKE GroupHeather Ellington, Office Manager Heather Ellington, Office Manager Melyssa Rivera, Sleep TechnologistMelyssa Rivera, Sleep Technologist Jim Grazis, Sleep TechnologistJim Grazis, Sleep TechnologistMiyoshi Scott, NurseMiyoshi Scott, NurseLisa Grasso, ReceptionistLisa Grasso, Receptionist

IntroduceIntroduce Sleep Sleep TechnologistsTechnologists

Melyssa RiveraMelyssa Rivera Jim GrazisJim Grazis Anna BarkerAnna Barker

Update on Sleep ApneaUpdate on Sleep Apnea

Relationship with cardiovascular Relationship with cardiovascular diseasedisease

Atypical presentation for sleep apneaAtypical presentation for sleep apneaPositive pressure devices: types, Positive pressure devices: types,

monitoringmonitoringHome studies for diagnosis: insurance Home studies for diagnosis: insurance

issuesissuesQuality issues: physicians, facilities, Quality issues: physicians, facilities,

technicians, vendorstechnicians, vendors

Heart Attacks & StrokesHeart Attacks & Strokes

Studies on patients admitted to the Studies on patients admitted to the hospital for heart attacks and strokeshospital for heart attacks and strokes

After discharge had sleep studiesAfter discharge had sleep studiesHeart attacks: at least Heart attacks: at least one thirdone third

had sleep apneahad sleep apneaStrokes: at least Strokes: at least halfhalf had sleep had sleep

apneaapnea

Sleep Apnea: Risk FactorSleep Apnea: Risk Factor

Sleep apnea risk factor like Sleep apnea risk factor like hypertension, high cholesterol, hypertension, high cholesterol, diabetes, smokingdiabetes, smoking

Metabolic SyndromeMetabolic Syndrome: obesity, : obesity, borderline: hypertension, diabetes, borderline: hypertension, diabetes, cholesterolcholesterol

Suggestion: add sleep apnea to the Suggestion: add sleep apnea to the Metabolic Syndrome listMetabolic Syndrome list

Presentation of Sleep ApneaPresentation of Sleep Apnea

Snoring and Sleepiness and ApneasSnoring and Sleepiness and ApneasObesity and High blood pressureObesity and High blood pressureUsually a combination of signs or Usually a combination of signs or

symptomssymptomsBut sleep apnea: chronic disease that But sleep apnea: chronic disease that

slowly worsens over timeslowly worsens over timeBeware: women and over 65 do not Beware: women and over 65 do not

have to be obese and often snore very have to be obese and often snore very littlelittle

Presentation of Sleep ApneaPresentation of Sleep Apnea

First symptom or sign can be a heart First symptom or sign can be a heart attack or strokeattack or stroke

Day: fatigue and exercise intolerance Day: fatigue and exercise intolerance Night: restlessness and insomnia Night: restlessness and insomnia Problem: spouse no longer sleeps in Problem: spouse no longer sleeps in

the same roomthe same roomProblem: other illness has the same Problem: other illness has the same

or similar symptoms or similar symptoms

Positive Pressure DevicesPositive Pressure Devices

CPAPCPAP: Continuous Positive Airway Pressure one : Continuous Positive Airway Pressure one pressure over face, cheapest device for OSASpressure over face, cheapest device for OSAS

AutoPAP or AutoPAP or AutoCpapAutoCpap: pressure varies : pressure varies depending on resistance, snoring, depending on resistance, snoring,

BIPAPBIPAP: Respironics, : Respironics, BilevelBilevel positive airway positive airway pressure, on inhalation higher pressure than on pressure, on inhalation higher pressure than on exhalation, more expensive exhalation, more expensive

Bilevel AutoBilevel Auto, varies pressures, varies pressures Adaptive Adaptive Servo VentilationServo Ventilation: : SVSV device used for device used for

some types of difficult central sleep apnea, varies some types of difficult central sleep apnea, varies pressure continuouslypressure continuously

NIV Devices: NIV Devices: Noninvasive ventilationNoninvasive ventilation

Medicare: CPAP MonitoringMedicare: CPAP Monitoring

Medicare mandating monitoring of PAP Medicare mandating monitoring of PAP devices for sleep apnea begin: Jan 2009devices for sleep apnea begin: Jan 2009

From day From day 31 to 9031 to 90 of using CPAP there of using CPAP there must be objective evidence of usagemust be objective evidence of usage

Use Use over 4 hoursover 4 hours, over , over 70% of 70% of nightsnights

This is minimum usage necessary to This is minimum usage necessary to see positive results, but the greater the see positive results, but the greater the compliance the greater the benefitcompliance the greater the benefit

Home Studies for Sleep Home Studies for Sleep ApneaApnea

Patient sent home with monitoring Patient sent home with monitoring equipment to diagnose sleep apneaequipment to diagnose sleep apnea

Patient must be capable of Patient must be capable of understanding the equipmentunderstanding the equipment

Two visits to sleep facility: put on and Two visits to sleep facility: put on and take offtake off

Who interprets the studies, judges Who interprets the studies, judges their quality, Medicare wants sleep their quality, Medicare wants sleep specialistsspecialists

Home Sleep StudiesHome Sleep Studies

Not intended for patients with: for patients with: heart disease, lung disease, heart disease, lung disease, neurological disease, little home neurological disease, little home supportsupport

Not intended for patients that may for patients that may have: central apnea, periodic leg have: central apnea, periodic leg movements, behavior disordersmovements, behavior disorders

Artifacts or recording problems Artifacts or recording problems negate many studiesnegate many studies

Home Sleep StudiesHome Sleep Studies

Intended forIntended for: young or middle aged : young or middle aged obese males that snore loudly, with obese males that snore loudly, with witnessed apneas, sleepy during day, witnessed apneas, sleepy during day, and otherwise healthyand otherwise healthy

Intention of Medicare is to save Intention of Medicare is to save money while not sacrificing quality money while not sacrificing quality carecare

But main intention of many But main intention of many companies is to sell equipmentcompanies is to sell equipment

Home Sleep StudiesHome Sleep Studies

Problem: once diagnose sleep apnea Problem: once diagnose sleep apnea at home, how to treatat home, how to treat

Either: bring to lab to titrate or do Either: bring to lab to titrate or do CPAP study, or give Auto-CPAPCPAP study, or give Auto-CPAP

But: if bring to lab for sleep study But: if bring to lab for sleep study then no benefit over split night studythen no benefit over split night study

If use Auto-CPAP then must guess at If use Auto-CPAP then must guess at the mask and machine expensivethe mask and machine expensive

Medicare Advantage Plans: Medicare Advantage Plans: HMOs & OthersHMOs & Others

Health Maintenance Organizations: very Health Maintenance Organizations: very spotty record but push home studiesspotty record but push home studies

Medicare Part D in effect run like an HMOMedicare Part D in effect run like an HMOTrying to come into VillagesTrying to come into VillagesNever been shown to improve health careNever been shown to improve health careNever been shown to save money Never been shown to save money Do make money for the administrators Do make money for the administrators

and owners who quickly move onand owners who quickly move on

Medicare Advantage Plans: Medicare Advantage Plans: HMOs & OthersHMOs & Others

Patients often do not know what they are Patients often do not know what they are getting intogetting into

Told that this is Medicare but “better”: Told that this is Medicare but “better”: dental and eye care added, besides medsdental and eye care added, besides meds

Ways of making money: cut back services Ways of making money: cut back services to patients, cut back on brand name to patients, cut back on brand name drugs, cut back on doctor & hospital drugs, cut back on doctor & hospital reimbursementsreimbursements

Real Goal: short term profits among profit Real Goal: short term profits among profit making plans, some plans non-profitmaking plans, some plans non-profit

Medicare Advantage PlansMedicare Advantage Plans

Aggressively moving into the areaAggressively moving into the area Much positive advertising and endorsements Much positive advertising and endorsements Run by commercial insurance companies or Run by commercial insurance companies or

business peoplebusiness people False claim: save money, deliver better and False claim: save money, deliver better and

more medical care (except: dental, eye)more medical care (except: dental, eye) However these plans receive However these plans receive 12% more

funds than regular Medicare, or over $10 funds than regular Medicare, or over $10 billion/yearbillion/year

Quality Among Health PlansQuality Among Health Plans

National Committee for Quality National Committee for Quality Assurance (NCQA): Assurance (NCQA): www.ncqa.org: : monitors health care quality among monitors health care quality among health planshealth plans

NCQA accreditation of health plansNCQA accreditation of health plansTypes: commercial, Medicare, MedicaidTypes: commercial, Medicare, MedicaidNCQA with US News & World Report: NCQA with US News & World Report:

ranking of best health plans 2008-2009ranking of best health plans 2008-2009

NCQA: Accreditation and NCQA: Accreditation and RankingRanking

of Medicare Health Plans in of Medicare Health Plans in FloridaFloridaNumber 7: Capital Health PlanNumber 7: Capital Health Plan

Number 22: Health First Health PlansNumber 22: Health First Health PlansNumber 55: AvMed Health PlansNumber 55: AvMed Health PlansNumber 66: Health OptionsNumber 66: Health OptionsNumber 73: Universal Health CareNumber 73: Universal Health CareNumber 75: Number 75: Humana Medical PlanHumana Medical PlanNumber 77: Number 77: Freedom HealthFreedom HealthOut of 78 ranked, accredited plansOut of 78 ranked, accredited plans

Quality in Sleep Medicine:Quality in Sleep Medicine:Certification of PhysiciansCertification of Physicians

American Board of Sleep Medicine American Board of Sleep Medicine www.absm.org

American Board of Internal Medicine American Board of Internal Medicine www.abim.org

American Board of Family Medicine, American Board of Family Medicine, or Pediatrics, or Psychiatry & or Pediatrics, or Psychiatry & Neurology, or Otolaryngology Neurology, or Otolaryngology

Accreditation of Sleep Accreditation of Sleep CentersCenters

American Academy of Sleep Medicine: American Academy of Sleep Medicine: www.sleepcenters.org or email: or email: accreditation @aasmnet.orgaccreditation @aasmnet.org

Process is time consuming and Process is time consuming and expensiveexpensive

The Village Sleep Lab: only accredited The Village Sleep Lab: only accredited sleep center in the areasleep center in the area

Medicare also lists: The Joint Commission Medicare also lists: The Joint Commission as acceptable for payment purposesas acceptable for payment purposes

Vendors: Vendors:

DME: Durable Medical Equipment DME: Durable Medical Equipment supplierssuppliers

Medicare generally prohibits physicians Medicare generally prohibits physicians from providing CPAP equipmentfrom providing CPAP equipment

Physicians and health care facilities Physicians and health care facilities highly regulated, quality monitoredhighly regulated, quality monitored

Vendors have escaped close regulation: Vendors have escaped close regulation: buyer beware, quality not monitored, buyer beware, quality not monitored, room for improvement among manyroom for improvement among many

WebsitesWebsites The Village Sleep Lab: villagesleeplab.com The Village Sleep Lab: villagesleeplab.com National Sleep Foundation: sleepfoundation.orgNational Sleep Foundation: sleepfoundation.org American Sleep Apnea Association: American Sleep Apnea Association:

sleepapnea.orgsleepapnea.org American Academy of Sleep Medicine: American Academy of Sleep Medicine:

sleepeducation.comsleepeducation.com Restless Legs Syndrome Foundation: rls.orgRestless Legs Syndrome Foundation: rls.org National Center on Sleep Disorders: National Center on Sleep Disorders:

healthfinder.gov/orgs/HR2536.htmhealthfinder.gov/orgs/HR2536.htm Commercial: MyResmed.comCommercial: MyResmed.com Commercial: Respironics.comCommercial: Respironics.com Commercial: talkaboutsleep.comCommercial: talkaboutsleep.com Commercial: ABCpap.comCommercial: ABCpap.com

BooksBooks

The Promise of SleepThe Promise of Sleep by William Dement by William Dement Sleeping WellSleeping Well by Michael Thorpy by Michael Thorpy No More Sleepless NightsNo More Sleepless Nights by Peter Hauri by Peter Hauri A Woman’s Guide to Sleep DisordersA Woman’s Guide to Sleep Disorders by by

Meir H. Kryger Meir H. Kryger Restless LegsRestless Legs SyndromeSyndrome by Robert H. by Robert H.

YoakumYoakum Say Good Night to InsomniaSay Good Night to Insomnia by Gregg D. by Gregg D.

JacobsJacobs