sleepdoctor

Sexual Behavior during Sleep

2008-07-08T18:51:00.000-07:00

Current Psychiatry has an article this month on "sexsomnia":
Sexual behavior during sleep (SBS)—or “sexsomnia” ...is more than a sensational defense for a high-profile court case. Sleep physicians are finding that sexual behaviors during sleep are real and more common than previously thought. Although SBS cases sound psychological in origin, it appears that the problem lies in the brain itself.
SBS can cause great distress to its initiators and recipients but often goes unreported and untreated because of embarrassment about seeking help. Among patients who report their symptoms, many say they experienced SBS 10 to 15 years before seeking help. SBS not only disrupts sleep but can damage relationships and lead to allegations of sexual assault and rape.

I have had only one case of this in my sleep practice- a woman with masturbatory behavior during sleep. She failed all the standard treatments- benzodiazepines, tricyclic antidepressants, and anticonvulsants. Her polysomnogram and EEG were essentially negative. I ended up referring to the local university sleep center for a second opionion. She didn't keep her follow up appt with me and I have no idea what happened to her.

Insomnia Tips

2008-06-30T06:31:00.000-07:00

5 tips on battling insomnia from Healthy Living, including:
Remove the television.

Running A Sleep Lab

2008-06-27T17:37:00.000-07:00

A key part of running a sleep lab is keeping on top of the constantly changing regulatory environment, on both the federal and state levels. This link does a good job of describing the new federal regulations for independent diagnostic and testing facilites (IDTF's) that went into effect January 2008 (though for pre-existing IDTF's, many of the provisions do not apply until January 2009). Every February the AASM gives a course on sleep lab management that is very useful for anyone running a sleep lab.

Treating OSA improves cognitive dysfunction in Alzheimer's disease

2008-06-18T20:14:00.000-07:00

Increases in total sleep time (TST) related to treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) are associated with improvements in cognition in patients with Alzheimer's disease, a new study shows.
The study is summarized on Medscape.

obstructive sleep apnea and diabetes

2008-06-18T18:37:00.000-07:00

The International Diabetes Federation reports on the close relationship between type 2 Diabetes and Obstructive Sleep Apnea:

Obstructive Sleep Apnea (OSA) is the most common form of sleep-disordered breathing, accounting for over 80% of cases.
Estimates suggest that up to 40% of people with OSA will have diabetes, but the incidence of new diabetes in people with OSA is not known.[i]
In people who have diabetes, the prevalence of OSA may be up to 23%[ii], and the prevalence of some form of sleep disordered breathing may be as high as 58%.[iii]
Overweight and obesity may play a role, but some recent studies show an association between the two conditions that is independent of overweight/ obesity.
OSA may have effects on glycemic control in people with type 2 diabetes.
OSA is associated with a range of cardiovascular complications such as hypertension, stroke and heart failure.
IDF calls on health decision makers to encourage further research into the links between the two conditions and urges healthcare professionals to adopt new clinical practices to ensure that a person with one condition is considered for the other.

More information about the relationship between diabetes and osa is available on the IDF website.

Memory dysfunction and obstructive sleep apnea

2008-06-15T21:15:00.000-07:00

Obstuctive sleep apnea is associated with cognitive dysfunction, including memory problems.
A study reports that key brain structures involved in memory, the mammilary bodies, are shrunken in patients with Obstructive sleep apnea:
A study using high-resolution magnetic resolution imaging (MRI) scans reports that mammillary bodies — brain structures involved in memory — were 20% smaller in patients with sleep apnea than in controls.

More from Baltimore

2008-06-11T18:20:00.000-07:00

Earlier this week preliminary data from the Sleep Heart Health Study was presented. It appears that in patients without significant preexisting cardiovascular disease, moderate to severe osa (apnea-hypopnea index of greater than 30 with events requiring a 4% desat) over a 10 year period led to only modest increases in the risk of incident coronary artery disease in men younger than 70 (about 1.35x risk), and no to minimal increased risk in older men and in women. The stroke risk however was significantly elevated in men, but not in women with an ahi of greater than 30. Sleepiness appeared to increase the risk of the development of coronary artery disease and stroke.

The implications of this large (over 6000 subjects) prospective cohort study is that osa may not increase the risk of developing cardiovascular disease (angina, coronary artery disease, congestive heart failure) as much as previously thought, though the risk of developing ischemic stroke is increased in younger men (about 2.7x).
Patients without significant cardiovascular disease should be treated if symptomatic (significant sleepiness). This study does not change the need to aggresively treat osa in patients with preexisting cardiovascular disease.

Greetings from Baltimore

2008-06-10T18:59:00.000-07:00

Went to an interesting session today at SLEEP 2008 on portable home testing. Not much has changed over the last several months. Most Medicare carriers are still writing Local Coverage Determinations for home testing. It appears that the old code for home testing with a type 3 device (95806) is being replaced with a G code (G0399) with additional G codes for Type 2 and Type 4 devices. Trailblazer, the Medicare carrier for New Mexico and several neighboring states apparently won't cover home testing, though that decision is still under review.
Everyone is talking about home testing, but no one appears to be doing it yet to any great extent. It doesn't appear that home testing will be done to any great extent until 2009; it will take at least that long for the local Medicare carries to decide their policies regarding home testing, and more importantly, get the payment mechanisms/codes in place for home testing

SLEEP 2008

2008-06-08T17:16:00.000-07:00

I just arrived at the SLEEP annual meeting, in Baltimore. Hope to be inspired at this meeting and post about it this week.

Congratulations to Top Sleep Technicians

2008-05-27T07:07:00.000-07:00

Congratulations to the recipients of ADVANCE magazine's sixth annual National Sleep Achievement Awards.
The winner for Best Tech was Diana Chesnut, RRT, RPSGT.
Honorable Mention
Best Tech
Robert Parks, RPSGT Somnus Sleep Clinic, Flowood, Miss.
Roger Scott Dr. Zzzs Sleep Center Tulsa, Okla.

Sleepy

2008-05-21T14:34:00.000-07:00

Sometimes I feel this way, after staying up too late the night before:
It's no secret our economy has reached the point that my eyelids…are drooping. Face…falling toward keyboard. Energy level…sinking fast, but cannot stop now! Must…keep…typing op-ed piece. Deadline…looming! Article due! Cannot allow…self to sleep…precious, precious sleep… until finished….

Hypnotic Prescribing Trends

2008-05-07T07:19:00.000-07:00

A new survey finds that latency to sleep onset (rather than sleep maintenance) is what Primary care doctor's consider the most important attribute in selecting a hypnotic:
Decision Resources, a research and advisory firm focusing on pharmaceutical and health care issues, finds that a drug's effect on latency to sleep onset is the attribute that most influences the prescribing decisions of surveyed primary care physicians (PCPs) in the treatment of insomnia.
I prescribe Ambien, which is good for helping a person fall asleep, much more than Ambien CR, which is better for sleep maintenance. Ambien is also now generic and much cheaper than Ambien CR.

Pills don't cure Obstructive Sleep Apnea

2008-05-03T14:18:00.000-07:00

The life sciences company BTG is developing a pill that will supposedly treat obstuctive sleep apnea:

BGC20-0166 is a novel combination of two marketed serotonin modulating drugs being developed for the treatment of OSA.

Various sertonergic and serotenergic/noradrenergic antidepressants, including Prozac and protriptyline, have been used to treat OSA. These medications have a mild effect on osa. They slightly improve osa by increasing upper airway tone and also possibly by decreasing REM sleep. The effects are mild and antidepressants are not considered to be an effective treatment for OSA.

I don't recommend buying stock in BTG.

Starting a Sleep Lab, part three

2008-04-29T17:40:00.000-07:00

There are 3 basic types of sleep labs: hospital associated, extension of a physician practice, and independent diagnostic and testing facility (IDTF).
Assuming that a physician is not starting a sleep lab in association with a hospital, the basic choice comes down to IDTF or extension of a physician practice.
In my case, I started Somnus Sleep Clinic with some non-physician owners, so IDTF was the only option.
For a physician or physician group, either form could be appropriate. The key difference is how patients are referred to the sleep lab.

For an IDTF, the Feds mandate that most of the referrals for sleep studies come from outside physicians. Practically, what this means is that the outside physicians refer the patients directly for the sleep study. The sleep physician then sees the patient (if the patient is going to be seen by the sleep physician) after the sleep study (within 3 months will meet AASM guidelines). You need to put some type of statement on the psg order form (which should be signed by the outside referring physician) that a cpap titration will be performed if clinically appropriate- then both studies will count as ordered by the outside physician.

For a sleep lab that is an extension of a physician practice, most of the sleep study referrals (85% is a figure I've heard several times before) need to come from inside the practice. Practically, what this means is that the sleep studies need to come from either the practice's own patients and/or patients referred to the practice for a sleep evaluation (and seen by the practice prior to the sleep study). The order for the sleep study needs to come from a physician in the practice.

There are some other differences between IDTF's and physician practice sleep labs, more to come later.

Postpolio syndrome

2008-04-29T17:20:00.000-07:00

ADVANCE magazine has an interesting article about Postpolio syndrome, focusing on respiratory disturbances:

Disordered breathing is among the most misdiagnosed and misunderstood symptoms polio survivors face later in life. Too often their breathlessness and inefficient coughs are misdiagnosed as asthma or chronic obstructive pulmonary disease. For many aging polio survivors, it largely has been up to them to initiate their care and educate their doctors on the medical literature.

One-third to one-half of polio survivors experience new or increased weakening and pain in the muscles later in life. This typically occurs 10 to 40 years after recovering from original polio. This weakening can affect the diaphragm and breathing muscles, causing such disorders as obstructive sleep apnea, central sleep apnea, pneumonia, pulmonary restriction, shallow breathing, pneumonia, and diffuse muscle twitching during sleep.

He warns that split-night sleep studies are not appropriate for polio survivors I agree with this; home testing is not appropriate either.

Polio survivors should be given portable volume-pressure ventilators to use with nasal interfaces for ventilatory assistance rather than CPAP or bilevel positive airway pressure, Dr. Bach said. Polio survivors do not benefit from the expiratory positive pressure, he said, and it detracts from the positive inspiratory pressure in assisting the inspiratory muscles.
I disagree, many do have some element of obstructive sleep apnea and benefit from BiPAP. Typically these patients do require a wide differential between the EPAP and IPAP.

A few patients still use the iron lung, a form of negative pressure ventilation. Negative pressure ventilation can predispose to or worsen obstructive sleep apnea, but is very effective in some patients with postpolio syndrome.

"Moderate" does not mean "Mild"

2008-04-22T19:39:00.000-07:00

I was in clinic most of the day. I told 2 of the patients that their sleep studies showed "moderate sleep apnea". Both of them looked relieved and said almost exactly the same thing, "so it's not that serious?" This necessitated additional time to explain that moderate obstructive sleep apnea is indeed a significant condition that usually affects daytime functioning as well as cardiovascular health.

I'm not sure why this confusion occurred. Maybe "moderate" means something different to lay people than physicians.

I guess I should change my classification, when speaking with patients, to "mild obstructive sleep apnea", "obstructive sleep apnea," and "severe obstructive sleep apnea" to promote clarity.

The Latest on Home Testing

2008-04-20T10:37:00.000-07:00

I want to thank everyone who's been leaving comments about home testing. Currently the situation is unclear. It seems like a new LCD is written every week. If you have questions about what is covered in your state/Medicare region, I would encourage you to contact your local Medicare carrier or your state sleep society.

If anyone out there has successfully qualified a patient for cpap using home testing and/or has successfully billed for home testing, please leave a comment and share your experience.

A reader asked the following question:

I have some questions reguarding who will or who will be required to give a sleep study at home? Can a sleep technican hook up a patient at their home, by himself? Are can only a sleep technologist hook the patient up, in there home? This just seems like a slippery slope for sleep medicine. To me at the minimal a sleep technican, but what about Nurses or Respritory Therapist? Thank you for responding.

I don't think there are any standards for the hook up. The patient can hook himself up, or he could be hooked up by a technician, nurse, or secretary. I agree with your concerns.

I will be getting a type 3 home testing device in about 2 weeks. I'll let the readers of this blog know how things work out.

Military Sleep Interventions

2008-04-11T16:37:00.000-07:00

This month's issue of Focus Journal has an interesting article about interventions that various branches of the military use to promote alertness (PDF file).
I wish caffeinated gum was available for civilians.

Home Testing not covered in many states

2008-04-04T14:39:00.000-07:00

The AASM just linked to a new Local Coverage Determination for the following states:
Illinois, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska and Wisconsin.

Here is the link

http://www.aasmnet.org/Resources/PDF/WPSIC.pdf

Based on a quick read of the LCD, it appears that home testing will not be covered in the above states.

Starting a Sleep Lab, part two

2008-04-03T19:30:00.000-07:00

Yesterday, I briefly touched upon the necessity of having patients for your sleep lab. And I am not talking about patients with restless legs or insomnia. Though I find those 2 conditions interesting and challenging to treat, they will not generate a large number of sleep studies. You can't support a million dollar sleep lab billing evaluation and management codes for insomnia!

So where will the sleep apnea patients, the bread and butter of sleep medicine come from?
If you are a pulmonlogist and part of a pulmonary group, you have a head start. If you are a psychiatrist/neurologist/non-pulm internist/FP, read on.

Most likely you will need to be part of a "network/association," and I use these words loosely and am not implying an insurance network. Let me give some examples:

1. You could run a sleep lab for a large multi-specialty group, and get referrals from the physicians in the group. If you choose this route, you will most likely get the professional fee for reading the studies, while the profit from the technical component will go to the group as a whole.

2. You could associate yourself with a hospital, perhaps formally and either be employed by the hospital or you could own the sleep lab with the hosptial as a joint venture. Alternatively you could have a less formal association with the hospital (perhaps do ER call for your primary specialty for the hospital with the understanding that sleep patients from the hospital will be directed to your private sleep lab). If you are associated with a hospital, either formally or informally, you can get referrals from other doctors/groups associated with the hospital.

3. You could sell part of your sleep lab to local physician groups (primarily IM/FP, but also cards, ENT). This strategy can work both in the initial stages of starting a sleep lab or for an established sleep lab.

disclaimer: before putting any of these ideas into practice, consult an attorney. Stark doesn't apply to sleep labs (though it does apply to DME), but anti-Kickback rules do.

ADVERTISING: You probably need to do some advertising to patients, but don't rely on this to generate a large number of sleep studies. And aim your advertising towards osa, not insomnia. More important than advertising to patients is hiring someone to promote your sleep practice to other physicians (this can be done on a part-time basis).

More later..

Starting a Sleep Lab, part one

2008-04-02T17:39:00.000-07:00

I have had several physicians email/call/PM me recently about how to start a sleep lab, and whether it is still possible with the new CMS decision on home testing.

Regarding home testing: this will have a negative financial impact on sleep physicians, but I don't think it precludes a physician from starting a sleep lab. A lot is still up in the air, however, and the full financial implications of home testing are uncertain.

Even before the CMS decision, starting a sleep lab was a difficult process. I would encourage any physician (or technician or business person) who is interested in starting a sleep lab to attend the annual February American Academy of Sleep Medicine Management Course (see the AASM website for details).

Some things for a physician to think about in starting a sleep lab:

1. Where are the patients going to come from? If you are a pulomonologist and part of a pulmonary group, your group can probably generate enough sleep patients to sustain a sleep lab (roughly 1 sleep bed/pulmonologist). If you are a solo psychiatrist or neurologist, things are going to be tough.

2. Are you established in an area? It's easier to start a sleep lab if you are already a practicing physician in an area and a member of insurance networks.

3. Do you have a million dollars sitting around? The start-up costs for a 6 bed sleep lab are $500,000 to 1 million.

4. Who's going to manage the lab (hire/train technicians, get the lab in network/accredited, etc)? There are companies that you can work with in this regard. There are several companies that both own sleep labs and that partner with physicians and hospitals to run sleep labs- United Sleep Medicine, SleepWorks.

5. Don't even think about becoming involved in DME if you are an inexperienced physician just coming out of sleep fellowship. If you do eventually get involved in DME, make sure the situation is reviewed by a lawyer who is knowledgeable about Stark/anti-kickback rules.

More later.

State of Sleep Medicine 2008, Part one

2008-04-01T17:36:00.000-07:00

This is the first in a series of posts in which I discuss sleep industry trends. I'll start with a familiar topic, home testing for Obstructive Sleep Apnea.

HOME TESTING- WHERE ARE WE 3 WEEKS AFTER THE BIG DECISION:

3 weeks ago, CMS approved home testing for OSA on a national level. Currently the Medicare Regions are implementing the national decision via Local Coverage Determinations (LCD), which are not expected to veer too far from the National Coverage Determination (NCD). Specifically, either Type 3 (at least 4 channels) or Type 4 devices with 3 channels (not all Type 4 devices have 3 channels) will be acceptable for diagnosing OSA and qualifying the patient for CPAP. Certain type 3 devices have been, and will continue to remain elgible for reimbursement by Medicare under the following CPT code:

CPT code 95806 (unattended sleep study) by definition involves the absence of a technologist. Unattended sleep studies must meet the CPT definition in order to bill CPT code 95806.95806SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, UNATTENDED BY A TECHNOLOGIST.

The Medicare reimbursement for 95806 is slightly over $200 (for the combined technical and professional component of billing).

Commercial insurers are expected to follow Medicare's lead in the upcoming months. Aetna is following Medicare's NCD closely.

American Academy of Sleep Medicine accredited sleep centers/labs that offer home testing will need to use Type 3 devices to stay within AASM guidelines.

At least for now, there has been no change in the coverage for in-lab polysomnography (Medicare and all major insurers cover standard polysomnography and do not require portable testing to be done). CPAP titration studies also remain covered. An in-lab CPAP titration study is not required to prescribe CPAP. In the long-term, it is possible that insurers will try to cut down on the number of the more expensive in-lab studies done.

UNCERTAINTIES IN HOME TESTING:
To what extent will home testing replace in-lab studies? Will primary care doctors move into the sleep apnea business and start to offer home testing? To what extent will home auto-cpap titrations (there is no reimbursement for performing this type of study) replace standard in-lab cpap titrations? Will primary care doctors in rural areas try to treat osa without the involvement of a sleep lab by doing portable testing followed by home auto-cpap titrations?

A FINAL QUESTION TO THINK ABOUT:
Will Auto CPAP replaced fixed-pressure CPAP???? Rather that performing a titration study (either in a lab or at home), will it become standard practice just to prescribe an auto-cpap machine set with a range of 4-20 for permanent use, and then perhaps narrow the pressure range over time???? This would be the most economical strategy for insurance companies, and I think that this is where the sleep industry is headed over the next 5-10 years. I don't think that this is the best strategy for patient care, however.

Symphony of Destruction

2008-03-31T21:11:00.000-07:00

Sleep Review Magazine has a Podcast series on portable monitoring. The series starts off with a talk by Mary Susan Esther, MD, President-elect of the AASM. Dr. Esther's talk is followed by that of Dr. Chediak, current AASM President. In the coming days, talks will be added by industry representatives.

Local Coverage Decision for Home Testing for OSA

2008-03-31T15:53:00.000-07:00

The local coverage decisions that will implement Medicare coverage for home testing are starting to come out. The following "Future LCD" appears to cover Indiana, New Jersey, New York, and Kentucky:
The diagnosis of sleep apnea may be made using the following modalities:
polysomnography (PSG) performed in a sleep laboratory; or
unattended home sleep monitoring device of Type II; or
unattended home sleep monitoring device of Type III; or
unattended home sleep monitoring device of Type IV, measuring at least three channels (CAG-00093R2)

CPT code 95806 (unattended sleep study) by definition involves the absence of a technologist. Unattended sleep studies must meet the CPT definition in order to bill CPT code 95806.
95806
SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, UNATTENDED BY A TECHNOLOGIST

I expect LCD's covering other regions to be similar. The bottom line is that Type 4 devices can be used to diagnose osa and obtain coverage for cpap, but there is no reimbursement for the actual study. The reimbursement for a type 3 study (95806) is about $200.

Get 8 hours of sleep to lose weight

2008-03-23T17:19:00.000-07:00

I have previously posted on the relationship between sleep deprivation and weight gain.

Carnie Wison agrees with me:

"Ever since I had my daughter, my focus is not on me; it's on her," says Wilson, who is currently a size 16. "For the past two-and-a-half years, I haven't slept. I am convinced there has to be a link between sleep deprivation and a slower metabolism ... the past year, my workouts have been lazy. I've been snacking on the wrong foods and not drinking enough water."