Muhammad Sayed, MD, helps open Charles George VA Medical Center’s new sleep disorders center.
Muhammad Sayed, MD, RST, RPSGT, attributes his decision to specialize in sleep medicine to two career-defining realizations. The first came as a neurology fellow at the State University of New York (SUNY) at Buffalo, where he studied stroke patients and learned that two-thirds suffered from untreated sleep apnea. He wasn’t surprised—the connection between sleep apnea and cardiovascular comorbidities was well established—but he was frustrated. “I need to see these people before they have strokes,” he says. “After they have a stroke, in many cases, all that I can do is just a kind of rehab. Why shouldn’t I try to prevent even the first stroke?”
The second realization came during a fellowship from the American Academy of Neurology that placed him at the United States Senate Health, Education, Labor & Pensions Committee, then chaired by Sen. Ted Kennedy. That experience gave him a bird’s-eye view of health and healthcare in this country, and he noticed an undercurrent running through many of the problems he saw: patients with sleep disorders not getting the help they needed.
So he’s been working in sleep medicine ever since, first as a fellow at the Cleveland Clinic and now as chief of sleep medicine at the Charles George VA Medical Center in Asheville, NC, part of the U.S. Department of Veterans Affairs. He was hired to design, build, and run its first sleep disorders center. Since its opening in January 2017, the four-bed facility has served over 2,000 clinic patients and is already expanding with the addition of home sleep testing and two more technician positions, Sayed says.
Previously, doctors at the Asheville medical center were referring patients with sleep concerns to other providers in the community, who had trouble keeping up with the volume, says Cynthia Breyfogle, director of the medical center. Plus, that arrangement was less than ideal for patients who prefer to see doctors with experience treating members of the military. “We typically make business decisions simply as any other private hospital,” Breyfogle says. “We look at the business plan. Does it make sense in terms of quality of care and the need of patients and, economically, is it a sound decision? And on opening the sleep disorders center, we felt the answer was ‘yes’ to all those questions.”
Sayed’s passion for sleep medicine is evident when he talks about the clinic.
“Here in the VA we are so committed to treatment like CPAP,” he says. “Building a whole program and looking at sleep disorders as part of overlapping comorbidities means that you say, ‘Hey, you know what, we’re going to take care of this here, so you don’t have to have a stroke, you don’t have to have a heart attack, you don’t have to have heart failure, and so on and so forth.’”
Sayed designed the space with veterans’ needs in mind. At 400 square feet, the rooms are spacious and Americans with Disabilities Act-compliant so veterans in wheelchairs can access any available room. The spaciousness also allows for the patient’s partner or service animal to accompany them overnight.
About 127 out of 170 VA medical centers now have sleep clinics, according to a VA spokesperson, and the VA is pushing better access to sleep medicine. For good reason: sleep disorders are increasingly reported among military personnel, with one study reporting four- to five-fold increases in the prevalence of insomnia and obstructive sleep apnea (OSA), respectively, among military personnel between 2005 and 2014. That may reflect rising awareness and diagnosis of these conditions in general, but Sayed notes that veterans are at increased risk of post-traumatic stress disorder (PTSD), traumatic brain injuries (TBIs), and other comorbidities that can affect pulmonary, brain, and sleep health.
The complex nature of caring for veterans with multiple comorbidities is eased by good communication between different departments within the medical center, Sayed says.
“When the primary care provider knows that the veteran has one of those disorders [such as PTSD or TBI], they might just send me a message that says, ‘Can you expedite the consult or the study for this particular veteran because of special needs,’” he says. The integration fosters a “spirit of collaboration,” he says, that benefits the patient.
It also keeps clinicians in other specialties informed about what’s going on in sleep medicine. When the results of ResMed’s SERVE-HF study—which advised against the use of adaptive servo-ventilation in patients with left ventricular ejection fraction less than 45%—came out, Sayed alerted the cardiology department that he’d soon be sending them more patients for echocardiograms, and explained why.
“The same thing applies to pulmonary and to neurological disorders associated with sleep disorders like Parkinson’s disease and REM behavior disorders,” he says. “A few times I’ve seen patients with REM sleep behavior disorder, which can be associated with Parkinson’s, so I’d do a consult with neurology and sure enough it was early Parkinson’s. So I think having a whole sleep program within the hospital or medical center, this is definitely rewarding for everyone because you have multidisciplinary care for your patients.”
A Growing Need
Increased awareness of sleep-disordered breathing and its consequences is a likely contributor to the rise in OSA diagnoses among active personnel and veterans. But a change in policy regarding disability benefits may play a role as well. In 2004, the federal government began allowing veterans who are eligible for retirement benefits to also collect disability benefits if they are at least 50% disabled by a service-related injury or condition. That has led some to question whether the financial benefit is contributing to the rise in veterans seeking sleep studies.
Bradley Hazell, associate director of field operations at nonprofit veterans service organization Veterans of Foreign Wars (VFW), doesn’t think there are many cases of veterans trying to play the system but does see confusion about what constitutes a disability claim. “I would think it’s not so much veterans that file it fraudulently but more of the veteran not understanding the full criteria for something to be service-connected. ‘My friend’s service-connected for sleep apnea, I also have it, therefore I should be connected,’” he says.
Despite existing demand, Armenthis Lester, a public affairs officer at Charles George, says outreach is still an important part of her job. “I don’t always take for granted that veterans are aware of the services we offer,” she says. So the clinic sends a sleep technician into the community to give presentations. The clinic also distributes brochures, shares news stories, and educates primary care physicians about the sleep services available in the hospital.
Lester notes that working for the VA system is a little different than working for a private hospital administration since the budget is set by Congress on a two-year cycle. “Our current dollars don’t always match our current needs,” she says. That’s why it’s important to document veterans using the sleep services in time for the next round of budget discussions, she says.
Plan for Success
So far, so good, both Lester and Sayed say. Sayed followed a careful business plan that included a SWOT (strengths, weaknesses, opportunities, and threats) analysis and says the return on investment is coming in as expected, with the medical center keeping patients it would otherwise have sent to private clinics.
Delineating goals and expectations and sharing that vision with leadership keeps things running smoothly, Sayed says. “If you know exactly your expectation and the guidelines, it’s easy to have a plan.”
Besides following a business plan, Sayed recommends that others starting a sleep clinic look to successful models for guidance. And for anyone working with the veteran population, he notes there are many resources to take advantage of in the VA library, at annual SLEEP meetings, and in the form of other physicians who have worked with veterans before. (The VFW also offers services for veterans navigating disability compensation.) Sayed himself is available to other physicians who are looking for a consultation about their business or treating sleep disorders. He can be reached at consult.sleep[at]gmail.com.
That’s because providing thoughtful, well-informed, and streamlined care is something that can’t be measured with dollars and cents, Sayed says. It’s priceless.
Rose Rimler is associate editor of Sleep Review.