1. 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 751-4955; February, 2009

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

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

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

5. Heart Attacks & Strokes Studies on patients admitted to the hospital for heart attacks and strokes Studies on patients admitted to the hospital for heart attacks and strokes After discharge had sleep studies After discharge had sleep studies Heart attacks: at least one third had sleep apnea Heart attacks: at least one third had sleep apnea Strokes: at least half 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 Sleep apnea risk factor like hypertension, high cholesterol, diabetes, smoking Metabolic Syndrome: obesity, borderline: hypertension, diabetes, cholesterol Metabolic Syndrome: obesity, borderline: hypertension, diabetes, cholesterol Suggestion: add sleep apnea to the Metabolic Syndrome list Suggestion: add sleep apnea to the Metabolic Syndrome list

7. Presentation of Sleep Apnea Snoring and Sleepiness and Apneas Snoring and Sleepiness and Apneas Obesity and High blood pressure Obesity and High blood pressure Usually a combination of signs or symptoms Usually a combination of signs or symptoms But sleep apnea: chronic disease that slowly worsens over time 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 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 First symptom or sign can be a heart attack or stroke Day: fatigue and exercise intolerance Day: fatigue and exercise intolerance Night: restlessness and insomnia Night: restlessness and insomnia Problem: spouse no longer sleeps in the same room Problem: spouse no longer sleeps in the same room Problem: other illness has the same or similar symptoms 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 CPAP: Continuous Positive Airway Pressure one pressure over face, cheapest device for OSAS AutoPAP or AutoCpap: pressure varies depending on resistance, snoring, AutoPAP or AutoCpap: pressure varies depending on resistance, snoring, BIPAP: Respironics, Bilevel positive airway pressure, on inhalation higher pressure than on exhalation, more expensive BIPAP: Respironics, Bilevel positive airway pressure, on inhalation higher pressure than on exhalation, more expensive Bilevel Auto, varies pressures Bilevel Auto, varies pressures Adaptive Servo Ventilation: SV device used for some types of difficult central sleep apnea, varies pressure continuously Adaptive Servo Ventilation: SV device used for some types of difficult central sleep apnea, varies pressure continuously NIV Devices: Noninvasive ventilation NIV Devices: Noninvasive ventilation

10. Medicare: CPAP Monitoring Medicare mandating monitoring of PAP devices for sleep apnea begin: Jan 2009 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 From day 31 to 90 of using CPAP there must be objective evidence of usage Use over 4 hours, over 70% of nights 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 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 sent home with monitoring equipment to diagnose sleep apnea Patient must be capable of understanding the equipment Patient must be capable of understanding the equipment Two visits to sleep facility: put on and take off Two visits to sleep facility: put on and take off Who interprets the studies, judges their quality, Medicare wants sleep specialists Who interprets the studies, judges their quality, Medicare wants sleep specialists

12. Home Sleep Studies for patients with: heart disease, lung disease, neurological disease, little home support Not intended for patients with: heart disease, lung disease, neurological disease, little home support for patients that may have: central apnea, periodic leg movements, behavior disorders Not intended for patients that may have: central apnea, periodic leg movements, behavior disorders Artifacts or recording problems negate many studies 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 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 Intention of Medicare is to save money while not sacrificing quality care But main intention of many companies is to sell equipment But main intention of many companies is to sell equipment

14. Home Sleep Studies Problem: once diagnose sleep apnea at home, how to treat Problem: once diagnose sleep apnea at home, how to treat Either: bring to lab to titrate or do CPAP study, or give Auto-CPAP 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 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 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 Health Maintenance Organizations: very spotty record but push home studies Medicare Part D in effect run like an HMO Medicare Part D in effect run like an HMO Trying to come into Villages Trying to come into Villages Never been shown to improve health care Never been shown to improve health care Never been shown to save money Never been shown to save money Do make money for the administrators and owners who quickly move on 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 Patients often do not know what they are getting into Told that this is Medicare but “better”: dental and eye care added, besides meds 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 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 Real Goal: short term profits among profit making plans, some plans non-profit

17. Medicare Advantage Plans Aggressively moving into the area Aggressively moving into the area Much positive advertising and endorsements Much positive advertising and endorsements Run by commercial insurance companies or business people Run by commercial insurance companies or business people False claim: save money, deliver better and more medical care (except: dental, eye) False claim: save money, deliver better and more medical care (except: dental, eye) However these plans receive funds than regular Medicare, or over $10 billion/year 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 National Committee for Quality Assurance (NCQA): www.ncqa.org: monitors health care quality among health planswww.ncqa.org NCQA accreditation of health plans NCQA accreditation of health plans Types: commercial, Medicare, Medicaid Types: commercial, Medicare, Medicaid NCQA with US News & World Report: ranking of best health plans 2008-2009 NCQA with US News & World Report: ranking of best health plans 2008-2009

19. NCQA: Accreditation and Ranking of Medicare Health Plans in Florida Number 7: Capital Health Plan Number 7: Capital Health Plan Number 22: Health First Health Plans Number 22: Health First Health Plans Number 55: AvMed Health Plans Number 55: AvMed Health Plans Number 66: Health Options Number 66: Health Options Number 73: Universal Health Care Number 73: Universal Health Care Number 75: Humana Medical Plan Number 75: Humana Medical Plan Number 77: Freedom Health Number 77: Freedom Health Out of 78 ranked, accredited plans 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 Sleep Medicine www.absm.org www.absm.org American Board of Internal Medicine www.abim.org American Board of Internal Medicine www.abim.org www.abim.org American Board of Family Medicine, or Pediatrics, or Psychiatry & Neurology, or Otolaryngology 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 American Academy of Sleep Medicine: www.sleepcenters.org or email: accreditation @aasmnet.org www.sleepcenters.org Process is time consuming and expensive Process is time consuming and expensive The Village Sleep Lab: only accredited sleep center in the area The Village Sleep Lab: only accredited sleep center in the area Medicare also lists: The Joint Commission as acceptable for payment purposes Medicare also lists: The Joint Commission as acceptable for payment purposes

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

23. Websites The Village Sleep Lab: villagesleeplab.com The Village Sleep Lab: villagesleeplab.com National Sleep Foundation: sleepfoundation.org National Sleep Foundation: sleepfoundation.org American Sleep Apnea Association: sleepapnea.org American Sleep Apnea Association: sleepapnea.org American Academy of Sleep Medicine: sleepeducation.com American Academy of Sleep Medicine: sleepeducation.com Restless Legs Syndrome Foundation: rls.org Restless Legs Syndrome Foundation: rls.org National Center on Sleep Disorders: healthfinder.gov/orgs/HR2536.htm National Center on Sleep Disorders: healthfinder.gov/orgs/HR2536.htm Commercial: MyResmed.com Commercial: MyResmed.com Commercial: Respironics.com Commercial: Respironics.com Commercial: talkaboutsleep.com Commercial: talkaboutsleep.com Commercial: ABCpap.com Commercial: ABCpap.com

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