The Future of Sleep Medicine

Abstract

Dr. Strollo has received research support from ResMed. Dr. Kushida has received research support from Philips-Respironics and ResMed via grants to Stanford and royalties from patent licensed to Philips-Respironics. The other authors have indicated no financial conflicts of interest. In July of 2010, at the request of Patrick J Strollo Jr, MD (AASM President 2010-2011), the Board of Directors of the American Academy of Sleep Medicine (AASM) approved a year-long presidential task force designed to examine the future of sleep medicine in the care of adult patients. This initiative was an extension of a workshop convened by Susie Esther, MD (AASM President 2008-2009), in December of 2009 at the request of Clete Kushida, MD, PhD (AASM President 2009-2010). The project was designed to survey current trends, project the ability of sleep medicine specialists to best treat patients with sleep disorders in the future, and identify areas for further exploration. The topics that were identified for further examination included: 1) frameworks for healthcare delivery such as the patient-centered medical home model, 2) patient registries, and 3) new outcomes measures and tools for diagnosis and treatment of sleep disorders. The Affordable Care Act1 has put healthcare delivery in a state of flux. Possible future healthcare delivery models were discussed, and the patient-centered medical home was chosen as being the most viable. In this model, the development of “coordinated sleep care centers” acting as good “neighbors” to the primary care physician and others in the medical home appeared to be an effective position for the sleep medicine practitioner in the future. Both patients and their physicians will benefit from the focus on patient-centered care when effective communication, care coordination, and long-term care management, including the integration of electronic health records, are implemented. Patient registries will also play a part in the future of sleep medicine because of their value in clinical, scientific, and policy domains. Clinical registries in particular can help to describe the natural history of a disease, determine the clinical effectiveness or cost-effectiveness of healthcare products and services, monitor safety, and measure quality of care. Funding is the main barrier to implementation. If they are to be successful, registries should begin on a small, pilot scale to facilitate establishment and manageability. This includes identifying the standard outcomes measures to be collected. Outcomes-based care is emerging as an effective way to measure value of care as well as treatment efficacy. New polysomnographic and metabolic outcomes measures are currently under investigation, from new measures based on innovative polysomnographic data analysis to novel cardiovascular- and metabolic-related biomarkers. Similarly, well-validated tools to assess behavioral, neurocognitive, and quality of life outcomes such as daytime sleepiness and psychomotor vigilance are available and await validation and incorporation into daily practice. A variety of other tools fall into this category as well, including portable monitoring and transcutaneous CO2 monitoring. The exercise of stepping out of everyday practice and considering the future of sleep medicine has been useful, and will continue to bear fruit if it is continued in a periodic manner. Additional items for further consideration of future thought leaders include: The role of telemedicine, including remote monitoring; The impact of health care reform will have on practice; Development of disease management programs for sleep disorders beyond OSA; Strategic research needs in sleep medicine; and Partnership with industry to advance the science and practice of sleep medicine. There were several steps involved in creating this white paper. In the summer of 2010, the AASM Board of Directors identified the need to host a forum for thought leaders in sleep medicine, sleep research, and allied fields to discuss the future direction of clinical care and scientific investigation. The first meeting of the AASM's Future of Sleep Medicine Task Force was held at the AASM national office in Darien, IL on October 11, 2010; 53 thought leaders attended. The chair of the Task Force, AASM President Patrick J. Strollo Jr., led the discussion, with 16 speakers (including Dr. Strollo) presenting their ideas. Topics were divided into three areas of concentration: Tools, Integrated Care, and Accreditation. The Tools section included presentations on current and emerging technologies in sleep: actigraphy, nasal endoscopy, portable monitoring, high definition EEG, phenotyping of the upper airway, and circadian rhythms testing. The Integrated Care section focused on care delivery models, notably the Patient Centered Medical Home; patient services, including positive airway pressure (PAP) accommodation and behavioral interventions; and data management and clinical registries. The Accreditation section outlined existing and future models for accreditation. These ideas were discussed and key information was identified for further investigation. Based on the discussion, the Steering Committee broadened the areas of concentration and established workgroups to address Tools, the Patient Centered Medical Home, and Patient Registries and Outcomes. Members of the Future of Sleep Medicine Task Force were identified as participants on the workgroups based on their clinical and research expertise. Each of the three workgroups held several conference calls during the winter of 2011 and wrote draft reports (one from each workgroup), the contents of which were presented to all workgroup members at a second meeting on February 19, 2011, in La Jolla, California. The draft reports were refined subsequent to the presentations and ensuing discussions that resulted in the present report. This report was presented to the membership in June 2011 at the 25th Annual Meeting of the Associated Professional Sleep Societies in Minneapolis, Minnesota. The Patient Protection and Affordable Care Act (PPACA)1 was signed into law on March 23, 2010. The PPACA and the Health Care and Education Reconciliation Act of 2010,2 which were signed into law on March 30, 2010, comprise the health care reform of 2010. Several provisions outlined in the PPACA have been enacted already; additional provisions take effect January 1, of 2012, 2013, 2014, and January 1, 2017 and 2018. Several states have challenged the constitutionality of the law, and these cases might affect implementation. Additionally, efforts are underway in Congress to repeal healthcare reform legislation. These developments may affect implementation of the PPACA and healthcare reform in general. It is uncertain how reform will be implemented fully; the healthcare system is changing with the advent of new technology and introduction of new care delivery models. Historically, sleep medicine has been practiced as a subspecialty by physicians with backgrounds in internal medicine, family practice, pulmonary, psychiatry, neurology, otolaryngology and pediatrics. With the recognition of sleep as a designated subspecialty, the accreditation of fellowship training programs in sleep medicine, and the certification examination offered by the American Board of Medical Specialties, physicians increasingly designate sleep medicine as their primary practice discipline. Sleep medicine practitioners need to consider how they want to interface with other physician specialties in the healthcare realm. The concept of the patient-centered medical home (PCMH) represents a useful framework for chronic management of patients with sleep disorders. The PCMH model of care may provide the required transformation of the current, fragmented system of health care delivery. The key feature of the PCMH is an ongoing healing relationship between the physician and the patient rather than an episodic relationship based on illness and complaints. The National Committee on Quality Assurance (NCQA)3 offers the following background on the PCMH model: The American College of Physicians, the American Academy of Family Practice, the American Academy of Pediatrics and the American Osteopathic Association have jointly defined the medical home as a model of care where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. The physician-led care team is responsible for providing all the patient's health care needs and, when needed, arranges for appropriate care with other qualified physicians. A medical home also emphasizes enhanced care through open scheduling, expanded hours and communication between patients, physicians and staff. The PCMH focuses on care coordination, where a primary care physician (PCP) generally acts as the center point for all care. In addition to patient care, this responsibility includes relating to institutional providers, acting as a referral source for specialized care with affiliated specialist physicians, and coordinating follow-up care. Three tracks for specialists in this model were reviewed, including principal provider, selective principal provider, and major provider. It was determined that none of these tracks is ideal for the typical sleep physician. Instead, the sleep physician is best described as a “partner” or “neighbor” in the care process, interfacing and communicating with the PCMH-N,4,5 and providing specialty sleep care in close collaboration with the patient's designated PCP. The NCQA has developed standards6 for certification as a PCMH. Briefly, these standards address the following areas: 1) access and communication; 2) patient tracking and registry functions; 3) care management; 4) patient self-management support; 5) electronic prescribing; 6) test tracking; 7) referral tracking; 8) performance reporting and improvement; and 9) advanced electronic communication. A few of these areas will be highlighted, including communication, long-term care management, electronic health records, and patient registries. Effective communication between the sleep physician, the patient, the PCMH PCP, and other physicians and health care entities is essential for optimal care delivery. Effective communication with patients will facilitate their being able to co-manage their own conditions, but must be done in a manner that is culturally and linguistically appropriate. The sleep physician needs to communicate with the patient in a variety of ways to improve the self-management of their sleep disorder for attainment of optimal outcomes. Elements of these communications include: 1) participation of patients in decision-making; 2) enhancement of patient education by providing access to educational resources including print and other media; 3) identification of communication needs and barriers; and 4) participation of patients in quality improvement activities. In addition to patient-specific support, the system should facilitate engagement with community resources, such as patient advocacy organizations and tools for community education. In addition, communications have to be ramped up to coordinate care with the patient's designated PCP and other physicians and health care entities. 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