SLEEP An Update The Village Sleep Lab Accredited

SLEEP : An Update The Village Sleep Lab Accredited by the American Academy of Sleep Medicine Juan A. Albino, MD, FCCP Board Certified in Sleep Medicine 751 -4955; February, 2009

Thank You !!! l Phillip Ratliff, AWAKE Group l Lois Brach, AWAKE Group l Heather Ellington, Office Manager l Melyssa Rivera, Sleep Technologist l Jim Grazis, Sleep Technologist l Miyoshi Scott, Nurse l Lisa Grasso, Receptionist

Introduce Sleep Technologists Melyssa Rivera l Jim Grazis l Anna Barker l

Update on Sleep Apnea l Relationship with cardiovascular disease l Atypical presentation for sleep apnea l Positive pressure devices: types, monitoring l Home studies for diagnosis: insurance issues l Quality issues: physicians, facilities, technicians, vendors

Heart Attacks & Strokes l Studies on patients admitted to the hospital for heart attacks and strokes l After discharge had sleep studies l Heart attacks: at least one third had sleep apnea l Strokes: at least half had sleep apnea

Sleep Apnea: Risk Factor l Sleep apnea risk factor like hypertension, high cholesterol, diabetes, smoking l Metabolic Syndrome: obesity, borderline: hypertension, diabetes, cholesterol l Suggestion: add sleep apnea to the Metabolic Syndrome list

Presentation of Sleep Apnea l Snoring and Sleepiness and Apneas l Obesity and High blood pressure l Usually a combination of signs or symptoms l But sleep apnea: chronic disease that slowly worsens over time l Beware: women and over 65 do not have to be obese and often snore very little

Presentation of Sleep Apnea l First symptom or sign can be a heart attack or stroke l Day: fatigue and exercise intolerance l Night: restlessness and insomnia l Problem: spouse no longer sleeps in the same room l Problem: other illness has the same or similar symptoms

Positive Pressure Devices l l l CPAP: Continuous Positive Airway Pressure one pressure over face, cheapest device for OSAS Auto. PAP or Auto. Cpap: pressure varies depending on resistance, snoring, BIPAP: Respironics, Bilevel positive airway pressure, on inhalation higher pressure than on exhalation, more expensive Bilevel Auto, varies pressures Adaptive Servo Ventilation: SV device used for some types of difficult central sleep apnea, varies pressure continuously NIV Devices: Noninvasive ventilation

Medicare: CPAP Monitoring l Medicare mandating monitoring of PAP devices for sleep apnea begin: Jan 2009 l From day 31 to 90 of using CPAP there must be objective evidence of usage l Use over 4 hours, over 70% of nights l This is minimum usage necessary to see positive results, but the greater the compliance the greater the benefit

Home Studies for Sleep Apnea l Patient sent home with monitoring equipment to diagnose sleep apnea l Patient must be capable of understanding the equipment l Two visits to sleep facility: put on and take off l Who interprets the studies, judges their quality, Medicare wants sleep specialists

Home Sleep Studies l Not intended for patients with: heart disease, lung disease, neurological disease, little home support l Not intended for patients that may have: central apnea, periodic leg movements, behavior disorders l Artifacts or recording problems negate many studies

Home Sleep Studies l Intended for: young or middle aged obese males that snore loudly, with witnessed apneas, sleepy during day, and otherwise healthy l Intention of Medicare is to save money while not sacrificing quality care l But main intention of many companies is to sell equipment

Home Sleep Studies l Problem: once diagnose sleep apnea at home, how to treat l Either: bring to lab to titrate or do CPAP study, or give Auto-CPAP l But: if bring to lab for sleep study then no benefit over split night study l If use Auto-CPAP then must guess at the mask and machine expensive

Medicare Advantage Plans: HMOs & Others l Health Maintenance Organizations: very spotty record but push home studies l Medicare Part D in effect run like an HMO l Trying to come into Villages l Never been shown to improve health care l Never been shown to save money l Do make money for the administrators and owners who quickly move on

Medicare Advantage Plans: HMOs & Others l l Patients often do not know what they are getting into Told that this is Medicare but “better”: dental and eye care added, besides meds Ways of making money: cut back services to patients, cut back on brand name drugs, cut back on doctor & hospital reimbursements Real Goal: short term profits among profit making plans, some plans non-profit

Medicare Advantage Plans l l l Aggressively moving into the area Much positive advertising and endorsements Run by commercial insurance companies or business people False claim: save money, deliver better and more medical care (except: dental, eye) However these plans receive 12% more funds than regular Medicare, or over $10 billion/year

Quality Among Health Plans l National Committee for Quality Assurance (NCQA): www. ncqa. org: monitors health care quality among health plans l NCQA accreditation of health plans l Types: commercial, Medicare, Medicaid l NCQA with US News & World Report: ranking of best health plans 2008 -2009

NCQA: Accreditation and Ranking of Medicare Health Plans in Florida l Number 7: Capital Health Plan l Number 22: Health First Health Plans l Number 55: Av. Med Health Plans l Number 66: Health Options l Number 73: Universal Health Care l Number 75: Humana Medical Plan l Number 77: Freedom Health l Out of 78 ranked, accredited plans

Quality in Sleep Medicine: Certification of Physicians American Board of Sleep Medicine www. absm. org l American Board of Internal Medicine www. abim. org l American Board of Family Medicine, or Pediatrics, or Psychiatry & Neurology, or Otolaryngology l

Accreditation of Sleep Centers l American Academy of Sleep Medicine: www. sleepcenters. org or email: accreditation @aasmnet. org l Process is time consuming and expensive l The Village Sleep Lab: only accredited sleep center in the area l Medicare also lists: The Joint Commission as acceptable for payment purposes

Vendors: l DME: Durable Medical Equipment suppliers l Medicare generally prohibits physicians from providing CPAP equipment l Physicians and health care facilities highly regulated, quality monitored l Vendors have escaped close regulation: buyer beware, quality not monitored, room for improvement among many

Websites l l l l l The Village Sleep Lab: villagesleeplab. com National Sleep Foundation: sleepfoundation. org American Sleep Apnea Association: sleepapnea. org American Academy of Sleep Medicine: sleepeducation. com Restless Legs Syndrome Foundation: rls. org National Center on Sleep Disorders: healthfinder. gov/orgs/HR 2536. htm Commercial: My. Resmed. com Commercial: Respironics. com Commercial: talkaboutsleep. com Commercial: ABCpap. com

Books l l l The Promise of Sleep by William Dement Sleeping Well by Michael Thorpy No More Sleepless Nights by Peter Hauri A Woman’s Guide to Sleep Disorders by Meir H. Kryger Restless Legs Syndrome by Robert H. Yoakum Say Good Night to Insomnia by Gregg D. Jacobs