What Is the Future of Sleep Medicine in the United States?

EDITORIALS selective induction of vascular cell adhesion molecule-1 and amplification of interleukin-6 production. Blood 1994;84: 13. Woltmann G, McNulty CA, Dewson G, Symon FA, Wardlaw AJ. Interleukin-13 induces PSGL-1/P-selectin-dependent adhesion of eosinophils, but not neutrophils, to human umbilical vein endothelial cells under flow. Blood 2000;95:3146–3152. 14. Park SH, Chen WC, Esmaeil N, Lucas BEG, Marsh LM, Reibman J, Grunig G. Interleukin 13- and interleukin 17A-induced pulmonary hypertension phenotype due to inhalation of antigen and fine particles from air pollution. Pulm Circ 2014;4:654–668. 15. Daley E, Emson C, Guignabert C, de Waal Malefyt R, Louten J, Kurup VP, Hogaboam C, Taraseviciene-Stewart L, Voelkel NF, Rabinovitch M, et al. Pulmonary arterial remodeling induced by a Th2 immune response. J Exp Med 2008;205:361–372. Copyright © 2015 by the American Thoracic Society What Is the Future of Sleep Medicine in the United States? Obstructive sleep apnea (OSA) is a highly prevalent condition that is a major risk factor for many prevalent, resource-draining conditions. Furthermore, OSA endangers not only those who are afflicted with it but also innocent bystanders, because it is a clear risk factor for motor vehicle crashes (1). Treatment of OSA is associated with improved outcomes from many of its consequences, including motor vehicle accidents (1), atrial fibrillation (2), hypertension (3), and overall mortality in men (4), women (5), and the elderly (6). Thus, access to diagnosis and management of OSA would be expected to improve outcomes for many patients and has been demonstrated to be cost-effective (7). Most recent estimates of OSA prevalence conservatively suggest 13% of men and 6% of women have clinically important OSA (defined by an apnea–hypopnea index . 15/h) (8), as do 2 to 4% of school-aged children (9). A recent Swiss study found up to 50% of men had OSA with clinical consequences (10). Assuming a conservative estimate of 10% population prevalence suggests that about 30 million people in the United States alone have clinically important OSA, with many more at risk. Currently, up to 4 to 5 million people in the United States are receiving treatment for OSA, suggesting that the vast majority of OSA remains undiagnosed and undertreated (11). There are multiple reasons for this situation. Many third-party payers require diagnosis in an accredited laboratory and involvement of a physician who is board certified in sleep medicine (which requires an additional year of training) for reimbursement. As a result, many in the current generation of pulmonologists have forgone involvement in the management of OSA or even development of expertise in the use of positive pressure ventilation for other indications. To a large extent, the minimal involvement of pulmonologists in the care of patients with OSA derives from their inability to get reimbursed for delivering care. This is likely to change because: d Currently, the number of board-certified sleep specialists is dwindling rapidly. The numbers probably peaked around 2013, after large-scale grandfathering before the implementation of the American Board of Medical Specialties examination in sleep medicine. However, in the 2013 sleep medicine fellowship match, 64 programs offered 129 training positions starting in July 2013. About one-fourth of these positions went unfilled, and an even higher percentage went unfilled in 2014 (12). With the imminent retirement of the current cohort of grandfathered sleep specialists and a very small pipeline of future board- certified sleep specialists, the number of sleep specialists is expected to plummet over the next several years. The situation is Editorials d even more serious in pediatrics, because there are currently fewer than 300 certified pediatric sleep practitioners, and fewer than 10 pediatricians enroll annually in accredited sleep medicine fellowships. Current insurance and industry reimbursement policies in the United States require “face-to-face” visits within 30 to 90 days after continuous positive airway pressure (CPAP) initiation, followed by annual visits (13). Although not unreasonable, this requirement is simply not feasible with the current supply of sleep-board–certified physicians available, and that pipeline is shrinking. Something needs to change. Some potential solutions are: 1. Increased training and empowerment in the management of OSA in adult and pediatric pulmonary fellowship programs. As experts in breathing, pulmonologists are well equipped to manage sleep-disordered breathing and already have alliances with respiratory care practitioners, natural partners in this endeavor. Pulmonologists should be able to manage sleep- disordered breathing on completion of a pulmonary fellowship, given that a full 10% of the American Board of Internal Medicine pulmonary medicine examination focuses on sleep, including nonrespiratory sleep (14). The idea that a respiratory specialist is incapable of managing sleep apnea needs to change and is at odds with many other countries with high-quality healthcare. 2. Elimination of the requirement for board certification and center accreditation for reimbursement for routine OSA management. Although controversial (15), evidence (16–18) suggests that nonspecialist care is as effective and less expensive than specialist care for OSA. 3. Simplification or elimination of the Home Medical Equipment and insurance regulations/paperwork for provision of CPAP equipment and supplies. With the advent of required “face-to-face” visits and annual follow up and compliance documentation to obtain CPAP or supplies through insurance (13), accredited sleep clinics have experienced sharply increased demands for routine follow up simply for documentation purposes. 4. Increased training for generalist clinicians, including nonphysicians, in the diagnosis and chronic management of symptomatic, uncomplicated high pretest probability OSA, similar to the approach currently implemented for other chronic medical conditions such as COPD or asthma. This approach has already begun to happen in the diagnosis