Epidemiology and diagnostics of OSA
Sleep disorders are increasingly prevalent in the United States and are associated with reduced quality of life, increased health-care utilization, and numerous medical and psychiatric disorders (Edinger et al. Sleep. 2016;39[1]:237). The most common sleep disorder in the United States is obstructive sleep apnea (OSA). The major risk factor for OSA is obesity. As the obesity epidemic has grown, the prevalence of OSA has also increased (Romero-Corral et al. Chest. 2010;137[3]:711), and the need for sleep testing has, therefore, risen dramatically. OSA is traditionally diagnosed using attended in-laboratory polysomnography (PSG) conducted overnight. It requires special equipment, dedicated software for data processing, and trained technicians to conduct and later score the sleep study. A trained sleep medicine physician then interprets the data and provides a diagnosis.
A brief overview of the ACA
The Affordable Care Act (ACA) strives to provide high quality, affordable health care to all Americans. In our current health-care delivery model, primary care providers (PCPs) are often not involved with subspecialists in a coordinated process. This has resulted in fragmented patient care, leading to increased health-care delivery costs. In contrast, the ACA is gearing toward the patient-centered medical home (PCMH) model, where PCPs are at the heart of health-care delivery and provide comprehensive, patient-centered, coordinated care (Davis et al. J Gen Intern Med. 2011;26[10]:1201). The expression “medical neighborhood” is increasingly more popular where the PCMH is surrounded by specialty clinics and ancillary service providers with primary care at the core (Huang et al. N Engl J Med. 2014;370[15]:1376). Therefore, it is obvious that primary care will be an integral part of health-care delivery in the years to come, as opposed to current circumstances where primary care accounts for only 6% to 7% of total health-care spending (Phillips et al. Health Affairs. 2010;29[5]:806).
Impact of the ACA on sleep medicine delivery
With the provisions of the ACA now in place, its impact on sleep medicine delivery is substantial. Despite the increasing prevalence of sleep disorders, the sleep medicine field faces numerous challenges in sleep disorders diagnostics and management. It has confronted implementation of sizeable cuts in reimbursement rates for in-lab PSG. As a result, use of home sleep testing (HST) has increased rapidly. HST is a cost-effective alternative to in-lab testing and provides an expedited route of care for patients who usually have to wait months for in-lab PSG appointments in sleep centers (Masa et al. Sleep. 2013;36[12]:1799). The American Academy of Sleep Medicine (AASM) has endorsed HST as an alternative method to diagnosing OSA among appropriately screened individuals; however, it must be conducted in conjunction with a comprehensive clinical sleep assessment (Collop et al. J Clin Sleep Med. 2007;3[7]:737). Therefore, having a sleep program at the center of this process (vs independent referrals to home sleep testing companies) is crucial for enforcement of the HST parameters established by the AASM.
Yet, PCPs – in order to comply with insurance company requirements – often refer patients needing evaluation for OSA for HST via an independent HST company, that does not have a comprehensive sleep program. These patients are then prescribed automated treatment devices without appropriate education or access to follow-up with experienced sleep providers. This leaves PCPs, who often have limited training and access to sleep medicine resources, to manage problems with sleep apnea treatment devices, subsequently resulting in poor compliance to treatment and fragmented care. (Pack. Chest. 2015;148[2]:306). Therefore, it is imperative to identify segments in our current sleep practice model that require restructuring, and provide a model inspired by ACA provisions to improve sleep care delivery.
Why move toward the PCMH?
Several studies have shown that primary care-led care for moderate to severe sleep apnea is not inferior when compared with care provided by sleep specialists. In one study (Antic et al. Am J Respir Crit Care Med. 2009;179:501), patients with suspected moderate-to severe OSA were assigned to receive care from an experienced nurse, specialized in sleep disorders management, vs sleep-physician-directed care and laboratory PSG to confirm the diagnosis of OSA. Results showed that the simplified model of care was not inferior to the specialist sleep physician–led model, with no significant difference in continuous positive airway pressure (CPAP) adherence or Epworth Sleepiness Scale (ESS) score between the two groups. Costs were significantly less in the simplified model. Another study showed that primary care management of OSA in patients with moderate to severe OSA was not inferior to specialist management with regards to the change in ESS and showed no difference in OSA symptoms, adherence to CPAP, patient satisfaction, and health-care costs between the two groups (Chai-Coetzer et al. JAMA. 2013;309[10]:997). It is crucial to note, however, that although PCPs and community nurses were encouraged to take primary responsibility for patient management, prior experience, training, and education in sleep disorders management, as well as access to sleep specialists, were imperative in producing good outcomes in these studies.