SLEEP : An Update The Village Sleep Lab Accredited by the American Academy of Sleep Medicine

1. SLEEP : An UpdateThe 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

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

3. Introduce Sleep Technologists • Melyssa Rivera • Jim Grazis • Anna Barker

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

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

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

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

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

9. Positive Pressure Devices • CPAP: Continuous Positive Airway Pressure one pressure over face, cheapest device for OSAS • AutoPAP or AutoCpap: 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

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

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

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

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

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

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

16. Medicare Advantage Plans: HMOs & Others • 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

17. Medicare Advantage Plans • 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

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

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

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

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

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

23. Websites • 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/HR2536.htm • Commercial: MyResmed.com • Commercial: Respironics.com • Commercial: talkaboutsleep.com • Commercial: ABCpap.com

24. Books • 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 LegsSyndromeby Robert H. Yoakum • Say Good Night to Insomnia by Gregg D. Jacobs