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Sleep-disordered breathing (SDB) is a well-recognized medical problem but often not appropriately viewed as the chronic disease process that it truly represents. The estimated costs directly related to diagnosis and treatment—in addition to the financial and societal burden due to associated medical co-morbidities, accidents, and lost work—total in the billions of dollars. Given the strong care demands of SDB parallel to those of other chronic conditions, there are compelling reasons to develop a comprehensive treatment plan paradigm similar to those in place for such conditions as hypertension, type 2 diabetes, stroke, and COPD. Sleep centers, primary caregivers, and home care providers offer counseling and support for SDB patients in their own self-designed patterns since there are no widely accepted evidence-based or national consensus guidelines to guide them. In order to better serve these patients and meet the challenges of the necessary optimal self-management, the sleep medicine profession should establish a model and credentialing process for clinicians who specialize in the overall health outcomes for patients with SDB. Such a process would give birth to a new role much needed in sleep medicine—the sleep educator.
MIMICKING PRIOR MODELS
Patients presenting with sleep complaints do so for a variety of conditions, including insomnia, restless legs syndrome, narcolepsy, obstructive sleep apnea (OSA), and other parasomnias. In the population at large, insomnia is by far the most common sleep complaint, while OSA is clearly the most prevalent condition diagnosed in patients presenting to sleep clinics. A specialized sleep educator should be trained to have expertise in personalized trouble-shooting, education, and preparation for testing such as polysomnography, in addition to treatment needs for the continual care of OSA.
Many sleep centers are now providing comprehensive approaches to diagnosing and treating the more than 83 classified sleep disorders. This commonly involves a multidisciplinary team of sleep specialists consisting of pulmonologists, psychologists, neurologists, ENTs, dentists, and bariatric and obesity management experts. With this multidisciplinary system, resources are available for patient assessment by a team of medical practitioners who have an understanding of the core problems related to sleep disorders as well as the links to other co-morbidities. The next step within the care continuum is helping people with diagnosed sleep-related disease to lead healthier lives.
Chronic health conditions can negatively affect quality of life and contribute to declines in function and inability, but many chronic condition treatments can limit progression or modify outcomes with behavioral interventions. The Robert Wood Johnson Foundation made the following statement: “Many of the services essential to caring for the chronically ill or disabled person may be non-medical in nature, provided at home, and require health care workers other than physicians. …” Patients need to understand that making healthy lifestyle changes is often harder than accepting a diagnosis of a disease. By incorporating the sleep educator into the continuum of care for SDB patients, such patients can better accept and cope with their disorder.
A care continuum solution requires that a connection and rapport be established between a health care professional and a patient. The need for a specialist trained in the long-term care of patients suffering from sleep disorders is predicated on models already in place and showing effective outcomes in areas such as cost reduction, improving quality of life, and reducing morbidity. Often, SDB prevalence has been compared to that of asthma and diabetes. Both of these conditions have clinical positions associated with the support and long-term management of the patient. These positions are also reimbursed by payors on a per-visit basis or under a plan that includes a set number of patient and clinician appointments during the initial 3 to 6 months of treatment. These appointments ensure that the patient gets started with appropriate support and education related to managing their condition. Similar to the diabetes and asthma educators, the sleep educator would work with people, one-on-one, to achieve their health goals one step at a time.
Diabetes educators have had enormous success in terms of care improvement by assisting diabetics to better understand the need for frequent diagnostic measures to minimize organ failure associated with their disease. The results of the Diabetes Prevention Program study of 2002 demonstrate the impact education has on diabetes prevention. As part of the study, a lifestyle intervention program, including counseling on effective diet, exercise, and behavior modification, was developed and issued to a group of individuals who were at risk of developing type 2 diabetes. According to results of the study, the study participants lowered their risk of developing the disorder by 58%. The sleep educator also could offer counseling and behavior modification techniques and ensure that SDB patients would have access to a medically trained professional who is familiar with a wide variety of sleep disorders.
Another educational role similar to that of the diabetes educator is the asthma educator, who plays a vital role in managing patients with airway disease. The implementation of the asthma educator has aided in reducing morbidity in this area over the past several years. As with the Certified Asthma Educator (AE-C) program, sleep educator candidates would sit for an examination as demonstration of proficiency in managing and counseling patients and their families in the knowledge and skills necessary to minimize the impact of their sleep disorders. Licensed health care professionals who may meet the requirements could include respiratory therapists, sleep technologists, physician assistants, nurse practitioners, social workers, and health educators. Like the AE-C, sleep educator certification would be voluntary and is not required by law for employment in the field.
Similar to asthma, the prevalence of OSA has been proposed to be 5% of the US population. The burden of care, coordination, and patient self-empowerment to build positive clinical outcomes to manage SDB patients will require a broad-spectrum approach within a medical community of scarce resources. The future of US health care may depend on its ability to successfully redesign care systems—and incorporate such roles as that of the sleep educator—that can meet the needs of the growing population of chronically ill patients.
SLEEP EDUCATOR MODEL
The sleep educator should work with each patient to develop a care plan, which serves as the foundation to provide disease-specific education, build self-awareness, and encourage and promote self-management. Disease-specific education is aimed at helping participants understand how their sleep-disordered conditions develop and progress; how the controllable risk factors impact their health; signs and symptoms of disease progression; and the role of prescribed therapy and medications. For example, patients would learn about the importance of sleep hygiene and adherence to positive pressure therapy, as well as the benefits of healthy eating and regular exercise to improve their condition. The sleep educator would work with the patient to address areas of concern, and improve communications with their physicians, and together, they would develop realistic goals to improve overall health and well-being. In addition, the educator would provide information about SDB and care management outcomes to communities, insurers, physicians, and home care providers.
The future of sleep presents the industry with a big challenge. The number of treated SDB patients is growing at around 15% per year and will continue to do so for several years. However, as this population expands, so do the opportunities to provide support and the resources needed to accomplish treatment goals. If one could assume that the positive impact witnessed with the implementation of asthma and diabetes educators would be similar with the introduction of sleep educators, it would seem prudent for the sleep industry to begin the process of creating a sleep educator position. Unfortunately, the sleep industry suffers from a highly fractured and less than partisan approach to patient care, thus turf issues may get in the way of seeing the big picture; and ultimately, patients suffer from the inefficiencies of the system and fragmented approach to managing SDB. However, if the sleep community were willing to recognize the importance of establishing the role of the sleep educator, patients suffering from SDB would have much needed support from individuals who are dedicated to properly managing their disorder.
Ron Richard is senior vice president of sales and marketing for SeQual Inc, San Diego. Peter C. Gay, MD, is an associate professor of pulmonary, critical care, and sleep medicine at the Mayo Clinic, Rochester, Minn. Pamela K. Fry, RRT, is vice president of product development for AirLogix Inc, Dallas. You can reach the authors at [email protected].
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