In 1998, the American Sleep Disorders Association (now the American Academy of Sleep Medicine [AASM]) officially adopted the AMA Code of Ethics¹ as a guide for its own ethical practices.² The goal of establishing ethics (ie, standard principles of practice) in the sleep medicine profession is to govern how sleep workers interact with patients, coworkers, and the community. As a result, ethical practices protect the safety, dignity, and rights of patients; ensure the integrity and professionalism of sleep workers; and maintain the vision and mission of the sleep field. However, there are 10 practices that commonly occur in sleep centers that endanger patient care and/or undermine the integrity of the sleep profession and therefore are or border on unethical.

PRACTICE #1: SLOW TURNAROUND TIME FOR PSG INTERPRETATION

Many patients wait a month or longer to learn the results of their study. This backlog typically results from a shortage of scoring technologists or from insufficient time for technologists to score the data on a polysomnographic (PSG) record. In some centers, the backlog occurs because a sleep physician has insufficient time to review and interpret data—especially if the physician comes to a center only once a week or biweekly to review and interpret data scored by technologists.

A delay in scoring, reviewing, and interpreting data can create financial and treatment problems for a patient. A patient can be billed for a study for which they have no results; without results, the patient's insurance may not be willing to pay for the sleep study. A delay in getting results means delayed treatment for a sleep disorder. This can potentially be fatal if untreated symptoms (for example, excessive sleepiness) impair the patient while driving or doing any other activity that requires full alertness.

A chronic backlog problem is not an inevitable consequence of practicing sleep medicine. Some sleep centers are able to prevent huge backlogs by the use of autoscoring programs (ie, computer software that assists a technologist in scoring); by having technologists score on all shifts; and by outsourcing scoring. Through the use of these techniques, some labs are able to have results of a patient's study in 24 to 48 hours.

PRACTICE #2: INTERPRETERS FAILING TO REVIEW RAW PSG DATA

Some sleep physicians create a polysomnographic interpretation for a patient without reviewing the patient's raw PSG data. In other words, the sleep physician simply looks at values in a PSG analysis report and generates an interpretation from this.

This practice can result in a misdiagnosis if the information in the analysis report contains errors by the scoring technologist. For example, a technologist may miss subtle events (eg, the onset of rapid eye movement [REM] sleep before the appearance of REMs) and underscore certain stages, or a technologist may overscore certain stages (eg, wake in a patient with an extreme amount of alpha intrusion). By relying on inaccurate information in a PSG analysis report, a physician may give a patient improper treatment for a sleep problem. For this reason, it is important for sleep physicians to validate the information in an analysis report by reviewing the raw PSG data.

PRACTICE #3: PSG ANALYSIS BY AUTOMATED SCORING ALGORITHMS

Automated scoring (ie, autoscoring) programs assist technologists in scoring records more quickly. Autoscoring programs use a special mathematical algorithm to distinguish between sleep stages, respiratory events, and periodic limb movements. The programs are designed only to assist in scoring, but many sleep centers rely on them to reduce the need for (and therefore the expense of paying) scoring technologists.

A salesperson's pitch often leaves the impression that an autoscoring program is capable of scoring and analyzing data without human involvement. In actuality, the accuracy of autoscoring programs is less than that of manual scoring. For example in a 2007 study, scientists at the Merck Research Laboratories³ compared the stage scoring reliability of two autoscoring programs (Morpheus and Somnolyzer24x7) with manual scoring. They found that the autoscoring programs agreed with manual scoring 70% to 72% of the time. Other studies have had similar results.⁴

Although autoscoring programs can aid a technologist in scoring faster, their lower reliability increases the likelihood of improper diagnosis and treatment. To avoid this, scientists strongly recommend that an autoscored PSG be reviewed manually.⁵

PRACTICE #4: "TWEAKING" PSG ANALYSIS RESULTS TO MEET CPAP REIMBURSEMENT CRITERIA

The rules of reimbursement for services and medical equipment of some insurance payors can be very strict. If all criteria are not met, the insurance will not pay. This can be problematic for a patient who has mild obstructive sleep apnea (OSA), is symptomatic (eg, excessive daytime sleepiness), but has an apnea-hypopnea index (AHI) that is three to five respiratory events per hour less than the criteria established by an insurance company for reimbursement for a continuous positive airway pressure (CPAP) machine. A sleep center may feel forced to alter results of a test to ensure the patient gets the needed equipment.

If a patient has low-paying insurance such as Medicare, a sleep center may add fake respiratory events on the PSG record, although the patient is asymptomatic for mild OSA and the AHI does not meet reimbursement criteria. This is done just to ensure that the center receives some payment for the study. This is clearly insurance fraud and jeopardizes the integrity of the profession of sleep medicine.

PRACTICE #5: USE OF THE "CREDENTIAL" PSGT

Perhaps to foster a sense of "career" (ie, a job with advancement) versus "job," some sleep centers allow their unregistered polysomnographic technicians to use the letters PSGT after their name. The American Association of Sleep Technologists (AAST) recognizes three levels of increasing skill: "polysomnographic trainee" (a person who has 6 months or less of on-the-job training or who is enrolled in an associate degree program that emphasizes polysomnography); "polysomnographic technician" (a person who has 6 or more months of experience and has documentation of having passed competency requirements in scoring PSG records, CPAP/BPAP titration, etc); and "registered polysomnographic technologist"—a person who has passed the Board of Registered Polysomnographic Technologists (BRPT) registry exam and has earned the credential RPSGT. A sleep center should use these designations rather than PSGT to reflect a technician's level of skill.

Standard 3.1 of the Standards of Conduct established by the BRPT6 states: "The RPSGT applicant/certificant has the personal responsibility to conduct himself/herself in a manner that will assure the dignity and status of the profession. Examples of unacceptable behavior include, but are not limited to, misusing the certification credential … and misrepresenting one's capacity as a provider of service." The practice of using "PSGT" behind one's name, while not a blatant misuse of the credential RPSGT, is still misleading to patients who come to a sleep center and therefore is a subtle misrepresentation of one's true level of skill.

PRACTICE #6: REFUSING INDIGENT CARE

Indigence (ie, impoverishment) covers a wide range of people and situations. An indigent person may be homeless; an elderly person who can no longer work; a minimum-wage or low-wage worker whose job does not offer insurance; a disabled person; or a gainfully employed worker who is in a financial catch-22—too poor to pay for insurance but too "rich" to qualify for Medicaid or Medicare. Nevertheless, many people perceive an indigent person as a lazy person who depends solely on taxpayer support for subsistence, thereby draining the financial well-being of society. In a medical setting, indigent patients also are often viewed in terms of draining the financial well-being of a lab or center.

The AMA addressed the problem of indigent patients in 2001 by adding principle 9 to the preamble of the Principles of Medical Ethics.¹ It states: "A physician shall support access to medical care for all people."

Yet many sleep centers absolutely refuse to do sleep studies on indigent patients. This unwillingness means that an indigent patient may not get needed treatment for a sleep disorder. Lack of treatment can have catastrophic health consequences and therefore result in more expenditure of health care dollars. For example, untreated OSA may contribute to high blood pressure, which in turn may contribute to cardiovascular problems such as stroke or heart attack.

One approach to indigent care is to use community resources. For example, in 2004 the Harris County Hospital District Sleep Disorders Center was launched through the collaborative efforts of the Baylor College of Medicine and the University of Texas Medical School (both located in Houston).⁷ Faculty of the colleges were able to show that Harris County spent $1,000 to $2,000 more on each indigent sleep study patient because the patients were being sent to privately owned sleep centers. Harris County Hospital District Sleep Disorders Center now centralizes sleep disorders care in facilities funded by the county. This saves money while providing much-needed care to indigent patients.

PRACTICE #7: ABSENCE OF TREATMENT FOLLOW-UP

The AASM8 requires that a sleep center has an established long-term plan for following up with sleep disorders patients. Despite this requirement, patients who are diagnosed with OSA and prescribed CPAP are often never again contacted by the sleep center after being referred to a local home medical equipment company. Most home medical equipment companies follow up with a patient during the first 3 months, but their focus is primarily on equipment and insurance issues, not on managing the patient's sleep-disordered breathing. As a result, the patient remains indefinitely at a pressure that may become ineffective if they gain or lose a significant amount of weight. For this reason, a sleep center should routinely contact a patient during the year following an initial study to ensure that treatment continues to be effective.

PRACTICE #8: INDISCRIMINATE PRESCRIBING OF AUTO-ADJUSTING PAP SYSTEMS

In a sleep center, technologists manually adjust the pressure applied by a CPAP machine during a sleep study. The technologist increases or decreases the pressure until the patient's apneas and hypopneas are eliminated in all sleep stages and in all body positions. Disadvantages of technologist-titrated CPAP are: the final pressure may be slightly higher or slightly lower than a patient needs, depending on the technologist's skill in recognizing respiratory events; and technologist-titrated CPAP is costly and time-consuming.

An auto-titrating CPAP machine (APAP) counteracts these disadvantages since it automatically increases or decreases air pressure in response to fluctuations in airflow or airway resistance. It can make adjustments more quickly than a technologist. As a result, some centers indiscriminately prescribe APAP to avoid the need and cost of technologist-titrated CPAP. However, APAP machines are not beneficial for everyone.⁹ The AASM's Standards of Practice Committee does not recommend APAP for people who have central apnea, congestive heart failure, or chronic obstructive pulmonary disease (COPD); for people whose arterial oxygen desaturation is not related to OSA (eg, obesity hypoventilation syndrome); or for people who do not snore.¹⁰ Prescribing APAP to patients who will not benefit is a waste of health care dollars.

PRACTICE #9: PERFORMING PSGS ON PATIENTS WITH GENERAL COMPLAINT OF INSOMNIA

Insomnia is the number one sleep complaint. It is usually a symptom of another problem such as stress or lifestyle issues.

Not all patients complaining of insomnia will benefit from a PSG study. A PSG study is not indicated for evaluation of transient or chronic insomnia; insomnia associated with fibromyalgia (since people with this disorder typically have alpha-delta sleep); or insomnia in people with dementia or psychiatric disorders. Yet some centers will study a person with a complaint of insomnia without fully assessing a potential patient's history to rule out lifestyle or psychological issues. This means health care dollars are wasted on an unnecessary, expensive test that is not diagnostically useful.

In 2003, the Standards of Practice Committee of the AASM¹¹ placed more emphasis on obtaining a thorough, detailed sleep history of a patient complaining of insomnia. The committee recommends that a PSG study be done for a person complaining of insomnia in these circumstances: 1) if a sleep-related breathing disorder or periodic limb movement disorder is suspected; 2) if arousals are associated with violent or injurious behavior; 3) if a person has a circadian dysrhythmia; 4) if a person has not responded to other treatment; or 5) if an initial diagnosis is unclear.

PRACTICE #10: TECHNOLOGIST BEHAVIOR DURING THE NIGHT

Once patients are asleep and things are going smoothly in the monitoring room of a sleep lab, the professional behavior of night shift technologists can degenerate. Behind the safety of closed doors of a monitoring room, technologists feel free to watch TV, view DVD movies, talk loudly, and "surf the net" on the data acquisition computer (but remembering first to minimize the patient's data into the background!).

These behaviors are not professional and can have potentially negative consequences for a patient since they distract a technologist from fully watching a patient's PSG record. Subtle, short-lasting, or episodic events can be missed while a technologist is being entertained by a TV show or DVD movie, surfing the Internet, or engaged in lively (often unwittingly loud) conversation with other technologists. Loud talking or laughing can awaken a patient or keep a patient awake and interfere with test results. Internet use on the data acquisition computer can potentially destroy a patient's data if a bug or worm enters the computer and crashes it. This means that the patient would have to come back for a restudy.

To avoid the negative consequences of such technologist behavior, a sleep center may need to limit Internet access to computers that are not for patient data acquisition. Visual distractors such as TV monitors on which technologists may watch TV programs or a DVD movie should ideally not be in the monitoring room. Technologists also need to be aware of their voice levels at all times.

Sleep workers always need to be concerned about ethics and the professionalism of the sleep medicine field. Without this concern, unethical sleep workers can quickly destroy the trust that has been so hard won in the field.

Regina Patrick, RPSGT, is a contributing writer for  Sleep Review. She can be reached at .

REFERENCES

1. American Medical Association House of Delegates. Health and Ethics Policies of the AMA. Principles of Medical Ethics: Preamble. June 2001. page 791. www.ama-assn.org/ama/pub/category/2512.html. Accessed March 27, 2008.
2. American Academy of Sleep Medicine. Bylaws of the American Academy of Sleep Medicine. Chapter 7: Discipline. February 2005. pages 11–12. www.assmnet.org/Resources/PDF/ByLaws.pdf. Accessed March 17, 2008.
3. Svetnik V, Ma J, Soper KA, et al. Evaluation of automated and semi-automated scoring of polysomnographic recordings from a clinical trial using zolpidem in the treatment of insomnia. Sleep. 2007;30:1562–1574.
4. Penzel T, Hirshkowitz M, Harsh J, et al. Digital analysis and technical specifications. J Clin Sleep Med. 2007;3(2):109–120.
5. Pittman SD, MacDonald MM, Fogel RB, et al. Assessment of automated scoring of polysomnographic recordings in a population with suspected sleep-disordered breathing. Sleep. 2004;27:1394–1403.
6. Board of Registered Polysomnographic Technologists, Professional Discipline Committee. Standards of Conduct. Responsibilities to Colleagues and the Profession. Item # 3.1 Dignity. July 6, 2006:5.
7. Harris County Hospital District. Hospital district hosts sleep center open house. March 21, 2005. www.hchdonline.com/about/publications/media/2005/Mar/sleepcenterrelease.pdf. Accessed March 27, 2008.
8. American Academy of Sleep Medicine. Standards for Accreditation of Sleep Disorders Centers. December 2007.
9. Husain AM. Evaluation and comparison of Tranquility and Autoset T autotitrating CPAP machines. J Clin Neurophysiol. 2003;20:291–295.
10. Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. Sleep. 2008;31:141–147.
11. Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for using polysomnography to evaluate insomnia: an update for 2002. Sleep. 2003;26:754–760.