The Sleep Center at National Jewish Medical and Research Center in Denver maintains its excellence through education, research, and offering comprehensive care

Lori Spindler, director of operations of the Sleep Center at National Jewish Medical and Research Center in Denver, remembers that laboratories dedicated to studying sleep disorders used to be relegated to quiet corners of hospitals and patients would be referred for studies only on an occasional basis; however, growing awareness on a global scale about the impact of sleep has brought programs that address sleep issues to the forefront in terms of the space they occupy, the resources they require, and the respect they are given in the medical field.

“Today, we have a dedicated person who serves as a resource in assisting the community physicians and their staff to access sleep services and educational information relating to sleep, and 4 years ago that would not have been the case,” says Spindler of the center, which was founded as a small in-hospital facility in the 1970s and now boasts a staff of 37, 14 beds that are operational 7 nights a week, and some 4,000 diagnostic studies performed annually.

In fact, the Sleep Center at National Jewish is the largest in the Rocky Mountain region, and growing; a second location was added in Littleton, Colo, 3 years ago, and Spindler says the hospital is considering adding another satellite location in North Denver. The center’s diagnostic and acquisition system also was upgraded last year to include Respironics’ ALICE host systems and top-of-the-line continuous positive airway pressure (CPAP)/bilevel PAP equipment to perform polysomnography (PSG) and to set up patients for treatment.

From left, Robert Ballard, MD, medical director; Lori A. Spindler, director of operations; and Maria Chernoff, account manager.

Scope of Services
Where the facility really differs from other sleep centers in the immediate region, says Robert Ballard, MD, medical director of the center, however, is in the scope of services it offers to the public. “We not only do sleep studies, we offer comprehensive care that deals with all aspects of sleep problems,” Ballard says. “So in addition to offering baseline PSGs, split-night studies, Multiple Sleep Latency Tests (MSLT), Federal Aviation Administration-required Maintenance of Wakefulness tests for pilots, and pressure titrations, we hold a multitude of half-day clinics that cater to a wide spectrum of patients with narcolepsy, restless legs syndrome, insomnia, nocturnal seizures, and rapid eye movement (REM)-stage disorders.”

Patients who come to the clinics fill out a six-page questionnaire, then meet with one of the center’s board-certified specialists, who decides if a study is necessary and can offer treatment options, such as setting up CPAP therapy. While the sleep center is certainly dealing with a growing awareness of the importance of sleep, Spindler says the biggest challenge is still trying to get patients to understand the impact that a sleep study can have on their lives. “This is an elective procedure, so they must opt for it,” she says. “Then we have to help them prepare for it in advance. Unlike x-ray procedures, which may take an hour, a sleep study requires planning on the patient’s part, and may involve special arrangements at work and with their family so they can come and spend the night for the study.”

She says that insomnia remains the biggest complaint among patients coming to the clinics, while the majority of those coming in for diagnostic studies have apnea or periodic limb movement disorder. Ballard agrees with the assertion, noting the shift from the patient makeup in previous years. “If I went back 5 years, patients predominantly had obstructive sleep apnea (OSA), which was also easily controlled,” Ballard says. “Now there is a real shift in our patient base, in part because the primary care physician has become more comfortable taking care of OSA. Therefore, I see more difficult patients, such as those who have had surgical intervention and not responded to it, or those with severe refractory asthma in association with sleep-disordered breathing (SDB).

“How we treat these issues, of course, heavily depends on the specific nature of the patient,” Ballard continues. “It is fairly typical to see a patient with overlapping syndromes between SDB and another disorder. We try to provide them with the garden-variety treatment for apnea as well as respiratory support for the underlying problems, for instance bilevel PAP for chronic hypercapnia.

“Insomnia, in particular, is increasing in prevalence in Western society and many physicians are uncomfortable with treating it,” Ballard continues. “Use of sedative hypnotics is not good on a long-term basis, so many of those patients are already referred to us, and I anticipate that will increase as time goes on.”

When evaluating those with chronic insomnia, Ballard first rules out other medical and psychiatric problems, as well as other sleep disorders—for which he might administer a PSG. “For treatment, we typically emphasize behavioral changes such as sleep restriction or avoidance,” Ballard says. “We also counsel them on relaxation techniques. Sometimes what is most successful is to refer them to a systematic cognitive behavioral therapy program, therefore we maintain ties with mental health care providers also available within the National Jewish network.”

Ken Rothwell, RPSGT, monitors a CPAP patient.

Since the center is affiliated with the University of Colorado Health and Sciences Center, that allows them to steer patients to other physicians or services that might help with the issues impacting their sleep. “This alliance gives us access to a wider range of options for patients in terms of assisting them with sleep issues,” Spindler says.

Unlike many other sleep laboratories, the Sleep Center at National Jewish has a full-time sleep counselor, Kathi Breen, CRT, who is a respiratory therapist with a background in sleep medicine. She not only addresses sleep issues from a mechanical standpoint as it pertains to PAP therapy, but is a resource for educating patients about OSA and their CPAP/bilevel PAP equipment.

Patient Referrals
And while the center caters to a clientele of nearly every age, it does refer out patients under 5 years of age to the nearby Children’s Hospital. “Children have a very different sleep architecture than adults,” Spindler says. “The staff at Children’s Hospital is expert in our region and we look to them to assist these patients.”

About 20% of the patient base is referred from physicians within National Jewish Medical Center, with the rest coming from external referrals by family practitioners, internists, ENTs, pulmonologists, cardiologists, OB/GYNs, endocrinologists, immunologists, asthma /allegists, neurologists, and psychiatrists nationwide. Edu-cational outreach helps the center garner those referrals, and reach members of the community who might be suffering from sleep disorders and not realize it.

“We are seeing more interest from people wanting to meet with us and get a better idea of what sleep entails,” Spindler says. “So I think there is an increased interest in sleep medicine today. And in my years here, I have noticed that there are more patients who are well educated about sleep disorders. That is probably in large part due to the media, and shows like Dateline and 20/20, which routinely carry segments about sleep disorders.”

Insurance Issues
Thankfully, for professionals in the sleep industry, insurance companies also believe that sleep studies are integral to health management. “The treatment options that insurance companies routinely cover without much issue are CPAP for OSA. Insurance providers see the treatment of OSA as a preventive measure for other more serious health risks such as strokes, heart attacks, hypertension, and motor vehicle accidents. Oral appliances as an alternative treatment are not currently covered by a lot of insurance providers,” Spindler says. “However, they usually okay a number of surgical alternatives.”

Since Denver is a heavily penetrated managed care environment, most of the patients who come to the sleep center are insured; indeed, the patient makeup includes 26% Medicare/Medicaid recipients, 20% fee-for-service, 54% managed care, and less than 1% workers’ compensation. “Since most health care is managed, the insurers prefer that we evaluate patients in the most cost-effective manner possible,” Ballard says. “So if someone is suspected of having OSA, we first screen them by taking telephone information. This allows us to better assess if they need a study or if a visit to the clinic will suffice.

“That differs from other labs located in Canada or parts of the United States that are not in a heavily managed care area where every patient is seen in a clinic prior to a diagnostic sleep study,” Ballard continues. “We would prefer to see every patient in the clinic first to make management simpler in the sense that you are implementing what you think is appropriate therapy, then following up to make sure the patient is complying. In our environment, we do not know if recommended therapy has been implemented or if patients are compliant with their therapy unless our sleep center is providing therapy for them.”

Education and research
The best way to tackle this issue continues to be education, and Spindler notes that National Jewish as an entity has a very definite commitment to providing education in conjunction with its commitment to providing the best clinical care to patients. As a result, the sleep center holds weekly sleep conferences that involve the staff as well as sleep specialists throughout the community. The conference addresses case studies, includes a journal club to discuss new research and recent articles, and invites guest speakers from throughout the field.

“Since we are all faculty members in the Department of Medicine at National Jewish, we provide education not only to our own sleep fellow trainees, but also to pulmonary fellows through the University of Colorado,” Ballard says. “There is a fair amount of education opportunities for community-based physicians as well, such as round-table discussions, continuing education, and dinner seminars.”

Kathi Breen, CRT, assists a patient with her mask.

The center also relies heavily on research to advance the field, therefore its physicians are involved with numerous clinical and research aspects of sleep. “Right now, we’re interested in investigating the role of circadian rhythms, particularly as they are related to melatonin production and the nighttime worsening of asthma,” says Ballard, who initially did his pulmonary research on that topic at National Jewish’s Sleep Center years ago. “Also, because we see a lot of patients here who are noncompliant with CPAP, we have a study to investigate the utilization of bilevel PAP to ‘rescue’ patients who have been unable to comply with CPAP therapy.

“We also have another project under way in which we are investigating the impact of sleep apnea with and without hypoxemia on cognitive function,” Ballard says. “We are located in a relatively high-altitude environment, so it is typical that many of our patients demonstrate hypoxemia. We want to see how this plays a role in contributing to long-term cognitive dysfunction, so we working with National Jewish Medical Center’s neuropsychology staffers to look at alterations in executive function in patients with or without apnea-associated hypoxemia before and after CPAP.”

Advantages of Home Sleep Testing
In terms of advancing the field, Ballard also sees a lot of promise in the realm of in-home sleep studies, which the center actually offered about 10 years ago. “We had a program initially where we did quite a few home sleep studies—maybe 10 to 15 per week—but at that time we realized that it was still necessary for patients to return for CPAP titration because most pa-tients coming to us had OSA,” he says. “If we applied the split-night study, we found that we could do that more economically and faster right away.

“And of course, lab PSGs must be applied in problem patients who require attentive monitoring and well-directed intervention. For instance, those with bilevel PAP in a setting of respiratory failure will always need to undergo a sleep study with an attendant,” Ballard continues. “However, the garden variety test to rule out OSA can be well served by in-home studies. I believe that, eventually, most sleep studies will be conducted in the home. In fact, I’m surprised that idea has not been embraced more quickly in this country. As technology develops and attitudes change, I think many of these studies can be done more easily in a home environment. Being part of a medical research facility, it is our goal to make sleep testing simpler and work better for our patients. The future of in-home sleep studies is looking more promising.”

For now, however, the sleep center continues on its mission to provide the best diagnostic studies and treatment plans possible for all of its patients—from those suffering from manageable OSA to more complex overlapping syndromes, such as severe chronic obstructive pulmonary disorder with chronic respiratory failure.

Liz Finch is a contributing writer for Sleep Review.