The practice of sleep medicine faces many challenges, from increasing health care costs for an increasing number of patients in the face of reduced reimbursements, to higher standards of care for all, increased patient expectations, and an ever-expanding (and at times confusing) array of diagnostic and treatment tools. Which treatment protocol is best? And for which patient? What is the best way to ensure compliance and benefit of treatment while staying financially afloat in hostile seas? To excel in today’s sleep profession, it is imperative to understand and educate your patients and to know your tools as well as how to apply them.
To prepare your sleep business for the future, you could follow up with these essential areas in order to ensure success and maintain high levels of service.
Technology and product mix: What types of devices are being offered, and what modes are often used to improve adherence? This may include use of pharmaceuticals as well as consumer-type products. This also would include diagnostics and therapeutic systems, combining the elements of all resources in a collaborative fashion.
Business solutions: Data management and patient follow-up.
Accreditation: Preparing for and complying with new quality standards in order to bid on contracts.
|Table 1: Modes of therapy commonly used with SDB patients.|
Education and marketing: Programs and services focused on internal as well as external efforts to increase awareness and educate people on the issues surrounding SDB.
Each one of these components could take pages and pages to explore, so for the purpose of this article, we will focus on the toolbox and tools that sleep specialists have at their disposal, as well as future trends. This is an overview of the toolbox and its main components.
Humidification: Humidification has been shown through clinical trials to improve comfort and reduce nasal resistance. By far, heated humidifiers are preferred for most patients. Although some payors do not cover them, cool humidifiers are still offered by manufacturers. Heated wire and tubing insulators made from Polar Tech-style materials also are available to reduce rainout and improve comfort when using PAP therapy.5,6
MAD (mandibular advancement device): An oral appliance is an alternative for some patients and has been endorsed by the AASM. The popularity of this option has led to the establishment of the Academy of Dental Sleep Medicine. A wide variety of oral appliances have been developed with varying degrees of success. The most widely used appliances increase the posterior airway space by advancing the lower jaw forward. These devices are typically reserved for milder forms of SDB or for snoring reduction.
Pharmaceutical options used with PAP: It is not uncommon for patients with SDB to have comorbid insomnia. In addition, the initial adaptation to positive airway pressure may be disruptive to sleep with resulting transient insomnia. Both of these factors may hinder treatment compliance. Given these factors, hypnotics have been considered as an option in the treatment of these patients. Newer hypnotics are less likely to suppress breathing or exacerbate SDB than older hypnotics such as barbiturates. Although anecdotal experience favors the use of hypnotics in helping patients with insomnia using positive airway pressure, there are no large controlled clinical trials published. A placebo-controlled clinical trial of hypnotics compliance measurements of patients newly treated with positive airway pressure recently has been started at Stanford.
Pharmaceutical options without PAP: The use of medications as a primary treatment for obstructive sleep apnea is no longer part of routine clinical care. In the past, antidepressant agents such as protriptyline were advocated as an alternative treatment option. Hormonal agents also have been considered. The putative mechanisms of action included increasing upper airway tone, increasing respiratory drive, and suppressing REM sleep. The use of medications as a sole primary treatment has fallen on disfavor for patients with clinically significant OSA. However, as milder forms of SDB come to medical attention, a potential role for medications may arise in the future.
|Table 2: Subsets of modes used to treat SDB.|
There is a shortage of qualified sleep technicians across the country; high demand for sleep physicians; and increased pressure on manufacturers to produce high-quality, feature-rich products at lower prices in order to supply products to home care providers, who are in turn being told to sharpen their pencils when bidding on sleep contracts. How can we turn this pile of lemons into lemonade? For starters, we need to understand that differing solutions may apply to different patients in different situations. Patient compliance is usually determined within the first 7 to 10 days of therapy. If compliance is not achieved, the hard work, patient benefit, and cost savings may not be fully realized. Thus, sleep specialists have to use every tool at their disposal to improve outcomes and patient adherence while still making a reasonable profit.
Ron F. Richard is senior vice president of strategic marketing initiatives for ResMed Corp, Poway, Calif. He can be reached at . Del Henninger, MD, FCCP, FASM, is owner/medical director of Complete Sleep Solutions, Murrieta and Riverside, Calif. He can be reached at . Rafael Pelayo, MD, FAAP, DABSM, has been treating children and adults for more than a dozen years at the Stanford Sleep Disorders Clinic, Stanford, Calif. He can be reached at .
- Masa JF, Jimenez A, Duran J, et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Resp Crit Care Med. 2004;170:1218-1224.
- Massie CA, McArdle N, Hart RW, et al. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Resp Crit Care Med. 2003;167:20-23.
- Planes C, D’Ortho MP, Foucher A, et al. Efficacy and cost of home-initiated auto-nCPAP versus conventional nCPAP. Sleep. 2003;26:156-160.
- Smith CE, Dauz ER, Clements F, et al.Telehealth services to improve nonadherence: a placebo-controlled study. Telemed J E Health. 2006;12:289-296.
- Massie CA, Hart RW, Peralez K, Richards GN. Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest.1999;116:403-408.
- Rakotonanahary D, Pelletier-Fleury N, Gagnadoux F, Fleury B. Predictive factors for the need for additional humidification during nasal continuous positive airway pressure therapy. Chest. 2001;119:460-465.