OUTCOMES: The Value of Sleep Medicine Services & The Future of Sleep Medicine

1. Raghu Upender, MD Assistant Professor in Neurology Medical Director Vanderbilt Sleep Disorders Center OUTCOMES:The Value of Sleep Medicine Services &The Future of Sleep Medicine

2. Sleep Disorders& Obesity Epidemic • Referrals for sleep services have increased 12-fold in the last 10 years. • Obesity epidemic and aging population are driving demand for sleep services. • 1/5 Americans has mild sleep apnea. • 1/15 has moderate or severe sleep apnea. • 70% of men and 56% of women over 50 have moderate to severe sleep apnea.

3. Growth of Sleep Services • AASM accredited labs • 337 in 1996 • 2,461 in 2012 • Medicare expenditure on sleep testing • $62 million in 2001 • $235 million in 2009

4. Sleep Medicine in the News “We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value.” -Dr. Fred Holt Medical Director BCBS, NC NPR news-Jan 2012

6. Sleep Medicine in the News "This is a good example of something where we have technology, we have financial incentives to use more of it ... You have enough problems, including a growing obesity epidemic, and you sort of put together the so-called perfect storm for driving up overuse and health care costs.” -Helen Darling President National Business Group on Health

8. Sleep Medicine in the News • "I believe lab tests, as opposed to the home tests, are being wildly overprescribed…it should be 70 percent at home and 30 percent in the lab.” Michael Backus VP of American Imaging Management WellPoint

9. Sleep Medicine Promise Treat wide range of sleep disorders with an aim to: • Improve sleep quality and daytime functioning • Prevent fatigue related accidents/errors • Prevent or reduce risk of chronic medical conditions (hypertension, heart disease, diabetes, stroke, headaches) • Improve overall quality of life

10. Objectives • Review interconnection between • Sleep and health • Sleep and chronic illnesses • Review sleep apnea treatment outcomes • Review the cost of untreated sleep apnea • The future of sleep medicine • Vanderbilt strategy

11. Sleep loss and Functional Impairment • Daytime sleepiness • Fatigue related accidents • Medical errors • Depressed Mood • Decreased Productivity • Increased absenteeism

12. Sleep & obesity in the U.S. 9 35% 30% 8 25% 20% Sleep (hours) Obesity Prevalence 7 15% 10% 6 Sleep 5% Obesity 5 0% 1950 1960 1970 1980 1990 2000 2010 Fred Turek

13. Obesity and Sleep Apnea • Obesity is the strongest risk factor for obstructive sleep apnea (OSA) • Each increase of 10 kg in weight doubles the risk of OSA • OSA contributes to weight gain causing a vicious cycle Obesity OSA

14. Sleep Apnea and Chronic illness • Diabetes • Hypertension • Heart disease • Stroke • Cancer

15. OSA and Hypertension Pepard et al. NEJM 2000;342(19) 1378-1384

16. OSA and Blood PressureMeta-Analysis

17. CPAP Therapy and Hypertension Bottini et al. Respiratory Medicine (2012)106, 1329-1334

18. Sleep Apnea &Cardiovascular Disease FATAL EVENTS NON-FATAL EVENTS Marin JM et al Lancet 2005;365:1046-53

19. OSA and Stroke Martınez-Garcıa et al. Eur Respir J 2012; 39: 906–912

20. OSA and Stroke Martinez-Garcia et.al. Eur Respir J 2012; 39: 906–912

21. OSA and Diabetes Aronsohn, RS et al. Amer J of Resp and Critical Care Medicine 2010; 181: 507–513

22. OSA and Diabetes Diabetes & Metabolic Syndrome: Clinical Research & Reviews 6 (2012) 176–179

23. OSA and Cancer Nieto et al Am J Respir Crit Care Med2012;186: 190–194

24. Neuropsychologic Outcomes • Attention and Vigilance • Memory function • Frontal lobe executive functions • Motor function

25. Neuropsychologic Effects of OSA Reaction Times Principles and Practices of Sleep Medicine 2011

26. Neuropsychologic Outcomes • Motor function • Attention and Vigilance • Memory function • Frontal lobe executive functions

27. Cost of Untreated OSA

29. Sleep Medicine 2.0F0cus on Outcome • Short-Term • Patient satisfaction • Quality of life measures • Productivity measures • Health measures • Weight & BP • Glucose control (HgA1c) • Lipid control • CRP

30. Sleep Medicine 2.0F0cus on Outcome • Long-Term • Hospitalization rates • Cardiovascular events • Cancer incidence • Dementia Incidence • Mortality rates

31. Patient-Provider-Health Plan Partnership • Patient engagement • Care coordination • Outcomes measurements • Cost-benefit analysis • Iterative Process

32. Vanderbilt Strategy • Care Coordinator • Patient Education • Patient Engagement • Partnership with Primary Care Physicians • Medical Home • Medical neighbor • Partnership with Vanderbilt Health Plan • Cost-sharing • Cost-benefit analysis • Web-app to Coordinate activity of Program

33. Conclusion • The future of our field will be dictated by our ability to show how our services add value to the healthcare enterprise. • We must focus on short and long-term outcomes and design our practices to maximize best outcomes. • We must see the evolving changes as an opportunity to fulfill the promise of better sleep.