Two major parts of any marketing plan are always exposure and education. A powerful means to grab the attention of niche market physicians or other health professional referral sources is to provide compelling research articles that show an association between obstructive sleep apnea (OSA) and diseases impacting patients within their subspecialty.

REACHING REFERRAL SOURCES WITH RESEARCH

Your key referral sources include, but are not limited to, anesthesiologists, surgeons, hospitalists, intensivists, pulmologists, radiologists, internists, nurses, therapists, primary care physicians, cardiologists, endocrinologists, pain management physicians, obstetricians, gynecologists, and physicians involved in stroke rehab or prevention. Get referrals rolling with the following list of articles that will help select sources grasp the intersection of sleep disorders within a variety of medical disciplines.

"Avoiding Adverse Outcomes in Patients with Obstructive Sleep Apnea (OSA): Development and Implementation of a Perioperative OSA Protocol" is a valuable reference article for anesthesiologists, surgeons, hospitalists and intensivists, pulmologists, radiologists, internists, nurses, therapists, and the rapid response team. The study demonstrates the importance of integrating a perioperative sleep apnea protocol to reduce the risk of an adverse event after receiving sedation.¹

This study contrasts three cases and the care management issues occurring prior to and after the integration of a sleep apnea protocol. Drugs that create respiratory suppression are commonly used in a perioperative and invasive procedural care plan—benzodiazepines for relaxation, opioids and narcotics for pain control, antiemetics for nausea, hypnotics for sleep, and antidepressants for mood.

Researchers defined the need for:

• Perioperative care providers to assess their patient for indications of undiagnosed OSA, since the majority of patients remain undiagnosed;
• Assessment for the impact of anesthesia, sedatives, and pain medications, which may exaggerate hypoxia and hypercapnia in the postoperative state;
• Guidelines developed to manage patients with OSA during the perioperative period in accordance with the American Society of Anesthesiologists Practice Guidelines and the American Academy of Sleep Medicine;
• Educating health care providers about sleep apnea and the need for an institutional protocol to manage sleep apnea patients perioperatively;
• Monitoring of ventilation for a prescribed duration of time as defined by the severity of the sleep apnea, the procedure completed, and the type of drugs being administered;
• Observation and monitoring of ventilation of patients with PAP therapy as oxygen desaturation was not prevented despite the use of PAP devices; and
• Integrating anesthesiologists in the care of OSA patients postoperatively to reduce untoward events.

The sleep apnea patient receiving drugs that cause sedation has an increased risk for other health risk factors such as hypoxia, hypercarbia, myocardial ischemia, cardiac arrhythmias, and death. With integration of a dedicated sleep apnea protocol, continuous monitoring of oxygenation and ventilation reduces the possibility of adverse events.

References

1. den Herder C, Schmeck J, Appelboom DJ, de Vries N. Risks of general anaesthesia in people with obstructive sleep apnoea. BMJ. 2004;329:955-9.
2. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology. 2006;104:1081-93.
3. Preventing and managing the impact of anesthesia awareness. Sentinel Event Alert, Joint Commission on Accreditation of Healthcare Organizations. October 6, 2004; Issue 32.
4. Bolden N, Smith CE, Anckley D. Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol. J Clin Anesth. 2009;21:286-293.

"Inflammation, Sleep, Obesity and Cardiovascular Disease" is a review of how alterations in sleep may be associated with cardiovascular disease through inflammatory mechanisms. This paper is valuable for primary care, cardiologists, nursing, and endocrinologists.

The paper will lead your referral sources to a greater understanding of evidence linking endocrine changes, immune function, cardiovascular disease, and their relationship with sleep deprivation. The findings are:

• Increased sleep deprivation contributes to increased risk for heart attack and stroke;
• The endothelial function of blood vessels may be affected by sleep behaviors;
• Age and gender differences have been observed to impact inflammatory markers;
• The prothrombotic state is affected by obesity and lack of sleep;
• Hormone regulation is affected by sleep behaviors;
• Obesity as a risk factor for sleep-disordered breathing is associated with an increased incidence of poststroke death; and
• Sleep-disordered breathing in pediatric populations contributes to increased levels of C-reactive protein or learning impairment.

Reference: Miller MA, Cappuccio FP. Inflammation, sleep, obesity and cardiovascular disease. Curr Vasc Pharmacol. 2007;5:93-102.

"Capnography Monitoring Enhances Safety of Postoperative Patient-Controlled Analgesia" is a study that will be valuable for any practitioner integrating pain management care plans.

The study, done with 634 patients receiving patient-controlled analgesia (PCA) for management of pain, compared a method for effective monitoring of ventilation with capnography and oximetry to promote earlier alerting of respiratory depression. Of the 634 patients studied, 38% received hydromorphone, 47% received morphine, and 15% received fentanyl. Nine patients with respiratory depression received supplemental oxygen.

The findings revealed:

• 1.4% of patients had respiratory depression with bradypnea: 67% were receiving hydromorphone and 33% were receiving morphine;
• All respiratory events occurred within the initial 24 hours of receiving PCA;
• In all cases, capnography rather than oximetry detected respiratory depression;
• In patients receiving supplemental oxygen, capnography was more effective to alert of impending respiratory depression; and
• Capnography and automatic pausing of PCA increased patient outcomes to promote increased safety with use of opioids to manage pain.

The study will assist all practitioners in making an earlier decision about referring to a sleep medicine specialist for diagnosis and treatment of sleep-related breathing disorders to reduce the risk and impact of sedation.

Reference: McCarter T, Shaik Z, Scarfo K, Thompson LJ. Capnography monitoring enhances safety of postoperative patient-controlled analgesia. American Health and Drug Benefits. June 2008.

"Is Sleep Apnea an Independent Risk Factor for Prevalent and Incident Diabetes in the Busselton Health Study?" is a community-based study in Busselton, Australia, to quantify OSA as a risk factor for diabetes. This article is relevant for primary care, endocrinologists, nurse practitioners, and physician assistants.

The targeted population consisted of a 295-participant sleep apnea cohort without diabetes at baseline. Patients were studied in their home to define their respective respiratory disturbance index. Diabetes was either diagnosed by physician or defined with a fasting blood glucose level of >/= 7 mmol/L.

Findings reveal:

• OSA is a univariate risk factor for diabetes;
• OSA is an independent risk factor for nine incident cases observed longitudinally over 4 years; and
• The confidence intervals in this study are wide and other community-based studies will be required to validate the relationship between sleep apnea and the incidence of diabetes.

Reference: Marshall NS, Wong KK, Phillips CL, Liu PY, Knuiman MW, Grunstein RR. Is sleep apnea an independent risk factor for prevalent and incident diabetes in the Busselton Health Study?. J Clin Sleep Med. 2009;5:15-20.

"Postmenopausal Women and the Health Consequences of Obesity" will guide your referral source through a review of the relationship between obesity and menopause on developing chronic diseases such as heart disease, sleep apnea, hypertension, and diabetes. It is a relevant article for primary care, nursing, nursing practitioners, obstetricians and gynecologists, and internists.

The researcher reviews data collected by the National Health and Nutrition Examination Survey, which has been used since 1960 to gauge prevalence of overweight in ages 20 to 74. The prevalence of overweight in women increased from 41% to 62% from 1980 to 2000, with the greatest impact on non-Hispanic black women. This is the basis for the need to understand the health consequences of obesity and integrate preventive strategies for postmenopausal women.

Findings demonstrate:

• The need to understand the impact of obesity on health;
• Obesity impacts the morbidity and mortality associated with coronary heart disease and cardiovascular disease;
• Type 2 diabetes is a serious risk factor manifested when weight gain occurred over time in adults;
• At the basis of defining impact is the relationship with sleep deprivation as a causal agent;
• Overweight postmenopausal women have increased risk for some types of cancer due to increased circulating estrogens;
• Osteoarthritis increases prevalence in women's overweight; and
• Lifestyle choices in the overweight such as reduced physical activity impact the health care dollars expended to address the physical, psychological, and emotional care required.

Reference: Dennis KE. Postmenopausal women and the health consequences of obesity. J Obstet Gynecol Neonatal Nurs. 2007;36:511-519.

"Impaired Cerebral Autoregulation in Obstructive Sleep Apnea" would be a compelling study to pass along to physicians involved in stroke rehab or prevention. The study found obstructive sleep apnea decreases blood flow to the brain, elevates blood pressure within the brain, and eventually harms the brain's ability to modulate these changes and prevent damage to itself. The findings may help explain why people with sleep apnea are more likely to suffer strokes and to die in their sleep.

Study participants were an average of 47 years of age and free of cardiac disease, and had not experienced any strokes. A control group, who did not have sleep apnea but was similar in most other ways, was also included. Researchers found that the sleep apnea group:

• had lower cerebral blood flow velocity;
• had significantly lower blood oxygen levels during sleep;
• took longer to recover from a drop in blood pressure; and
• took longer to normalize blood flow to the brain.

Reference: Urbano F, Roux F, Schindler J, Mohsenin V. Impaired cerebral autoregulation in obstructive sleep apnea. J Appl Physiol. 2008;105:1852-1857.

Creative development of niche sleep service referral source marketing is the wave of the future. Use powerful research article data along with technology advances in portable monitoring, miniaturized equipment, remote tracking of patient compliance, and patient-focused/patient-first personalized service to grow your sleep service referral base.

Kathryn Hansen, BS, REEGT, CPC, is a senior consultant on the Sleep Center Management Institute's advisory team. Her work with SCMI focuses on sleep apnea management programs, sleep lab accreditation, and health care professional sleep training. For more information, visit the SCMI Web site at www.sleepcmi.com. The author can be reached at .