Summary

ABSTRACT It is estimated that 50 to 70 million Americans chronically suffer from a disorder of sleep and wakefulness, hindering daily functioning and adversely affecting health and longevity. The cumulative long-term effects of sleep deprivation and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. The Institute of Medicine (IOM) Committee on Sleep Medicine and Research concluded that although clinical activities and scientific opportunities in the field are expanding, awareness among the general public and health care professionals is low, given the magnitude of the burden. The available human resources and capacity are insufficient to further develop the science and to diagnose and treat individuals with sleep disorders. Therefore, the current situation necessitates a larger and more interdisciplinary workforce. Traditional scientific and medical disciplines need to be attracted into the somnology and sleep medicine field. Renewed and revitalized commitments to the field from the National Institutes of Health (NIH), academic health centers, private foundations, and professional societies are essential to ensure appropriate public and professional awareness, education and training, basic and clinical research, and patient care. Finally, the fragmentation of research and clinical care currently present in most academic institutions requires the creation of accredited interdisciplinary sleep programs in academic institutions.



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Summary ABSTRACT It is estimated that 50 to 70 million Americans chronically suffer from a disorder of sleep and wakefulness, hindering daily functioning and adversely affecting health and longevity. The cumulative long-term effects of sleep deprivation and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. The Institute of Medicine (IOM) Committee on Sleep Medicine and Research concluded that although clinical activities and scientific opportunities in the field are expanding, awareness among the general public and health care professionals is low, given the magnitude of the burden. The available human resources and capacity are insufficient to further develop the science and to diagnose and treat individuals with sleep disorders. Therefore, the current situation necessitates a larger and more interdisciplinary workforce. Traditional scientific and medical disciplines need to be attracted into the somnology and sleep medicine field. Renewed and revitalized commitments to the field from the National Institutes of Health (NIH), academic health centers, private foundations, and professional societies are essential to ensure appropriate public and professional awareness, education and train- ing, basic and clinical research, and patient care. Finally, the fragmentation of research and clinical care currently present in most academic institutions requires the creation of accredited interdisciplinary sleep programs in aca- demic institutions. 1

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2 SLEEP DISORDERS AND SLEEP DEPRIVATION Fitful sleep, restless nights, and hitting the alarm clock button for an additional 10 minutes of sleep are all too familiar manifestations of the interactions of life with one of the frontiers of science and clinical prac- tice—somnology1 and sleep medicine. It is estimated that 50 to 70 million Americans suffer from a chronic disorder of sleep and wakefulness, hinder- ing daily functioning and adversely affecting health. Hundreds of billions of dollars a year are spent on direct medical costs associated with doctor visits, hospital services, prescriptions, and over-the-counter medications. Almost 20 percent of all serious car crash injuries in the general population are associated with driver sleepiness, independent of alcohol effects. However, given this burden, awareness among the general public and health care pro- fessionals is low. In addition, the current clinical and scientific workforce is not sufficient to diagnose and treat individuals with sleep disorders. Six million individuals suffer moderate to severe obstructive sleep ap- nea, a disorder characterized by brief periods of recurrent cessation of breathing caused by airway obstruction. Chronic insomnia, which hampers a person’s ability to fall or stay asleep, occurs in approximately 30 million Americans. Restless legs syndrome and periodic limb movement disorder are neurological conditions characterized by an irresistible urge to move the legs and nocturnal limb movements; they affect approximately 6 million individuals, making it one of the most common movement disorders. The cumulative effects of sleep loss and sleep disorders have been asso- ciated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. At the same time, the majority of people with sleep disorders are yet to be diagnosed. Compared to healthy individuals, those suffering from sleep loss and sleep disorders are less productive, have an increased health care utilization, and have an increased likelihood of injury. In 2003 the NIH National Center on Sleep Disorders Research (NCSDR) published a research plan, which contained a set of research priorities for the field. However, recognizing that continued scientific and clinical advances will require a new coordinated strategy to improve public awareness and strengthen the field of Somnology and Sleep Medicine, the American Acad- emy of Sleep Medicine, the NCSDR at the NIH, the National Sleep Founda- tion, and the Sleep Research Society requested that the IOM conduct a study that would examine: (1) the public health significance of sleep, sleep loss, and sleep disorders, (2) gaps in the public health system and adequacy 1Somnology is the branch of science devoted to the study of the physiology of sleep, the behavioral dimensions of sleep, and the consequences of sleep loss and sleep disorders on an individual’s and the general population’s health, performance, safety, and quality of life. Sleep medicine is the branch of clinical medicine devoted to the diagnosis and treatment of individu- als suffering from chronic sleep loss or sleep disorders.

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3 SUMMARY of the current resources and infrastructures for addressing the gaps, (3) barriers and opportunities for improving interdisciplinary research and medical education and training in the area of sleep and sleep medicine, and (4) develop a comprehensive plan for enhancing sleep medicine and sleep research. In response to the request the IOM appointed a 14-member committee with expertise in academic and medical administration, adolescent medi- cine, cardiology, epidemiology, geriatrics, health sciences research, neurol- ogy, nursing, otolaryngology, pediatrics, psychiatry, and pulmonology. The committee met five times during the course of its work and held two work- shops that provided input on: (1) the current public health burden of sleep loss and chronic sleep disorders, and (2) the organization and operation of various types of academic sleep programs. This committee recognizes that with the continued leadership of the NCSDR and its advisory board a coordinated strategy, described below, is needed to ensure continued advances (Box ES-1). This strategy requires concurrent commitment to the following activities: • Establish the workforce required to meet the clinical and scientific demands of the field. • Increase awareness of the burden of sleep loss and sleep disorders among the general public. • Improve surveillance and monitoring of the public health burden of sleep loss and sleep disorders. • Expand awareness among health care professionals through educa- tion and training. • Develop and validate new and existing diagnostic and therapeutic technologies. • Expand accreditation criteria to emphasize treatment, long-term pa- tient care, and chronic disease management strategies. • Strengthen the national research infrastructure to connect individual investigators, research programs, and research centers. • Increase the investment in interdisciplinary sleep programs in aca- demic health centers that emphasize long-term clinical care, training, and research. THE NATIONAL INSTITUTES OF HEALTH LEADERSHIP IN RESEARCH AND TRAINING To a greater extent than most scientific and medical disciplines, the field of somnology and sleep medicine cuts across many clinical and basic research disciplines, including but not limited to cardiology, dentistry, endocrinology, epidemiology, geriatrics, molecular biology, neurology,

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4 SLEEP DISORDERS AND SLEEP DEPRIVATION neuroscience, nursing, otolaryngology, pediatrics, pharmacology, psychiatry, psychology, and pulmonology. In 2004, there were 331 sleep-related research project grants sponsored by 17 institutes at the NIH. The NIH has two entities to coordinate its sleep-related activities, the Trans-NIH Sleep Research Coordinating Committee and the NCSDR. However, major chal- lenges remain in involving all relevant NIH institutes, centers, and offices; developing a coordinated research and training program; and integrating the efforts of the NCSDR, its advisory board, and the Trans-NIH Sleep Research Coordinating Committee. Investment in sleep-related research has grown dramatically over the past 10 years; however, the growth in research and training programs have not kept up with the rapid pace of scientific advances. At the same time that the science and magnitude of the problem requires greater investment, NIH funding to sleep-related activities is reaching a plateau. This has partially overlapped the period when the overall NIH budget has plateaued. Conse- quently, the future outlook for somnology and sleep medicine is unclear. In 2004, for the first time since the NCSRD was established in 1993, there was a decrease in annual NIH expenditures for sleep-related programs, fewer research project grants were funded, and the number of new grants awarded decreased. Over the last three years the NCSDR has only sponsored two programs—one request for applications and one program announcement— a marked reduction since the inception of the NCSDR. This presents an even greater challenge for a field that requires growth in scientific work- force and technology. Thus, there must be incremental growth in this field to meet the public health and economic burden caused by sleep loss and sleep disorders. It is important that research priorities continue to be de- fined for both short- and long-term goals. To address this problem the com- mittee makes the following recommendation. Recommendation 8.1 The National Center on Sleep Disorders Re- search and its advisory board should play a more proactive role in stimulating and coordinating the field. The National Center on Sleep Disorders and Research (NCSDR) should have adequate staff and resources to ensure its ability to fulfill its mission of coordinating and stimulating training, research, and health information dissemination relevant to somnology and sleep disorders. All relevant institutes with significant sleep portfo- lios should become members of the Trans-NIH Sleep Research Coordinating Committee. Further, the NCSDR Advisory Board should take a more proactive role in advising the director of the NCSDR. On an annual basis, the NCSDR and its advisory board should:

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5 SUMMARY • Identify specific objectives that address each of the three NCSDR missions and evaluate specific actions taken to accomplish each objective. This assessment should be reported in an annual meet- ing to the NIH-Trans Sleep Coordinating Committee, the insti- tute directors of its members, and to the director of the NIH. • Directors of the other federal agencies that fund significant sleep- related activities, such as Department of Defense, Department of Commerce, Department of Education, Department of Labor, and Department of Transportation should report annually on their activities to the NCSDR Advisory Board. • The NCSDR Advisory Board should annually review the cur- rent NIH portfolio of sleep-related grants, as well as requests for applications, and program announcements, assess them for re- sponsiveness to the program plan and identify gaps in research and training. • The NCSDR Advisory Board should annually recommend new, or modify existing, requests for applications that can be pre- sented to appropriate NIH institutes and other federal agencies including the Centers for Disease Control and Prevention and Department of Defense. Multiple members of the Trans-NIH Sleep Coordinating Committee are encouraged to continue to cosponsor sleep-related grants. ESTABLISHING A SUFFICIENT WORKFORCE One of the most pressing needs recognized by this committee is to create an infrastructure capable of developing the workforce required to meet the clinical and scientific demands of the field. This will entail in- creased investment by the NIH, academia, professional societies, private foundations, and industry. In 2004 there were only 151 researchers who had a clinical sleep-related research project grant (R01), and only 126 in- vestigators focused primarily on basic sleep-related research projects, a de- crease from the number of R01 awards in 2003. Further, of the top aca- demic institutions that received the greatest number of grants from the NIH, less then half had career development or training grants in somnology or sleep medicine. Only 54 doctorates were awarded with a focus on som- nology or sleep medicine in 2004. This workforce is insufficient given the burden of sleep loss and sleep disorders. The NIH support of career development awards has decreased. Over the period encompassing 2000 to 2004 there was a decrease in the number of career development awards. Further, since 1997 there have been no new requests for application (RFAs) or program announcements (PAs) for sleep- related fellowship (F), training (T), or career development (K) programs. Given

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6 SLEEP DISORDERS AND SLEEP DEPRIVATION these statistics, creating an infrastructure to develop a workforce capable of meeting the clinical and scientific demand is a challenge for the field. Compared to other fields the current number of clinicians and scientists in the field is not sufficient, given the public health burden of sleep loss and sleep disorders. Further, NIH, academia, and private foundations have not sufficiently supported the development of an adequate workforce. To strengthen the interdisciplinary aspect of the field it is not only important to attract new investigators to the field, but also to expand the number of trained scientists in other relevant disciplines electing to focus on sleep- related research. Therefore, the committee makes the following recommen- dation designed to improve training and mentoring activities. Recommendation 7.1: The National Institutes of Health and private foundations should increase investment in interdisciplinary somnology and sleep medicine research training and mentoring activities. The National Institutes of Health, foundations, and professional societies should utilize and develop further funding mechanisms to attract young investigators into the field of somnology and sleep medicine. As a reflection of the interdisciplinary nature of som- nology and sleep medicine, members of the Trans-NIH Sleep Re- search Coordinating Committee should be encouraged to combine resources to sponsor grants for disciplinary and cross-disciplinary training and mentoring activities (T, F, and K funding mechanisms) of medical students, graduate students, postdoctoral fellows, clini- cal fellows, and junior faculty. To implement this recommendation the following should be considered: • The Trans-NIH Sleep Research Coordinating Committee should establish a somnology and sleep medicine career development program. This program should support trainees for a significant number of years, spanning research training in fellowship and research career development as a faculty member. It should also facilitate midcareer training opportunities (e.g., K21, K24), the Academic Career Award for Education and Curriculum Devel- opment program (K07), and research education grants (R25). • Existing training grants or large research programs in disciplines related to somnology or sleep medicine (e.g., internal medicine, neurology, psychiatry, psychology, otolaryngology, nursing, epi- demiology, neuroscience, health services research) should allow for the addition of a sleep medicine trainee. Where pertinent expertise is not available on-site, remote mentoring at other in- stitutions should be encouraged.

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7 SUMMARY PUBLIC AND PROFESSIONAL AWARENESS A well-coordinated strategy to improve sleep-related health care is re- quired, owing to the public health burden of sleep loss and sleep disorders coupled with the low awareness among the general population, health care professionals, professional societies, and policy makers. Increasing the awareness and improving the diagnosis and treatment of sleep disorders requires a multipronged effort that includes three key components: public education, surveillance and monitoring of the burden of sleep loss and sleep disorders, and training for health professionals. The preeminent goal of these activities is to create and sustain a broad societal commitment to adopting proper sleep habits as a primary tenet of health. Such a commit- ment will require participation by those individuals and organizations in a position to educate the public at national, state, local, and community levels—including K–12 education, colleges and universities, medical schools, nursing schools, hospitals, community clinics, local health departments, private industry, and entertainment media. This will necessitate simulta- neous investment in public education campaigns for all age groups and a sustained effort to integrate sleep-related content into curricula of under- graduate education. Recommendation 5.1: The National Center on Sleep Disorders Research and the Centers for Disease Control and Prevention should establish a multimedia public education campaign. The National Center on Sleep Disorders Research—working with the Centers for Disease Control and Prevention, the proposed Na- tional Somnology and Sleep Medicine Research Network, private organizations and foundations, entertainment and news media, and private industry—should develop, implement, and evaluate a long- term national multimedia and public awareness campaign directed to targeted segments of the population (e.g., children, their parents, and teachers in preschool and elementary school; adolescents; col- lege students and young adults; middle-aged adults; and elderly people) and specific high-risk populations (e.g., minorities). Improve Surveillance and Monitoring of the Public Health Burden Adequate public health education not only requires informing public and health care practitioners, but also adequate monitoring of the pub- lic health burden. The development of adequate surveillance and monitor- ing systems is important for informing policy makers, health care providers,

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8 SLEEP DISORDERS AND SLEEP DEPRIVATION researchers, and the public about the effectiveness of health care services, programs, rules and regulations, and policies. However, there is currently very little ongoing nationwide surveillance. Thus existing national and state- wide databases should be amended to allow for improved surveillance and monitoring of the burden of sleep loss and sleep disorders in the United States population. Recommendation 5.3: The Centers for Disease Control and Pre- vention and National Center on Sleep Disorders Research should support additional surveillance and monitoring of sleep patterns and sleep disorders. The Centers for Disease Control and Prevention, working with the National Center on Sleep Disorders Research, should support the development and expansion of adequate surveillance and monitor- ing instruments designed to examine the American population’s sleep patterns and the prevalence and health outcomes associated with sleep disorders. Increasing Awareness Among Health Professionals Increasing education and training of health care professionals in som- nology and sleep medicine will improve the awareness of the associated public health burden and attract a new pool of clinicians and scientists interested in the field. Time devoted to sleep-related material in health and life sciences curricula is inadequate given the magnitude of the morbid ef- fects that sleep disorders have on the most common diseases (e.g. obesity, hypertension, heart attack, and diabetes) and accidents. Focused training about sleep can positively influence the performance of health care provid- ers. In particular, medical, nursing, dentistry, and pharmacy students re- quire greater exposure to the public health burden of sleep loss and sleep disorders. Thus the committee makes the following recommendation to in- crease sleep-related content in health sciences curricula. Recommendation 5.2: Academic health centers should integrate the teaching of somnology and sleep medicine into baccalaureate and doctoral health sciences programs, as well as residency and fellow- ship training and continuing professional development programs. The subjects of sleep loss and sleep disorders should be included in the curricula of relevant baccalaureate and graduate educational

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9 SUMMARY and research programs of all the health sciences. Similarly, post- graduate, residency, and fellowship training programs, as well as continuing professional development programs, must include this content. The curriculum should expose students in the fields of medicine and allied health fields to the etiology, pathophysiology, diagnosis, treatment, prevention, and public health burden of sleep loss and sleep disorders. Relevant accrediting bodies and licensing boards ought to define sleep-related curriculum requirements and expectations for knowledge and competency (e.g., Liaison Com- mittee on Medical Education, Accreditation Council for Graduate Medical Education, American Board of Medical Specialties, the National League for Nursing, the Commission on Collegiate Nurs- ing Education, and the Council on Education for Public Health). Further, a means for credentialing nonphysicians should be main- tained by the American Board of Sleep Medicine, or new mecha- nisms should be developed by relevant organizations. TECHNOLOGY DEVELOPMENT AND ACCREDITATION As awareness increases, greater investment in the development and vali- dation of new and existing diagnostic and therapeutic technologies is required to meet the anticipated demand. Today, the capacity needed to serve the population seeking diagnosis and treatment is inadequate. The wait time for a polysomnogram, the procedure used to diagnose sleep disorders, can be up to 10 weeks. Most American communities do not have adequate health care resources to meet the clinical demand; therefore, millions of individuals suffering from sleep disorders remain undiagnosed and untreated. It has been estimated that sleep apnea alone, a diagnosis that necessitates polysomnography to meet current criteria set out by third-party payers, annually requires at least 2,300 polysomnograms per 100,000 population. However, on average, only 425 polysomnograms per 100,000 population are performed each year in the United States, a level far below the need. In fact, 33 states perform fewer than 500 polysomnograms per 100,000 people annually. This shortfall will exacerbate as awareness of the clinical consequences and public health burden of sleep loss and disorders increases, particularly with the aging of the United States population. Given the cumbersome nature and cost of the diag- nosis and treatment of sleep disorders and sleep loss and the resultant inequities with regard to access, in order to ensure future quality care the committee recommends greater investment in the development of new and validation of existing diagnostic and therapeutic technologies.

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10 SLEEP DISORDERS AND SLEEP DEPRIVATION Recommendation 6.1: The National Institutes of Health and the Agency for Healthcare Research and Quality should support the validation and development of existing and new diagnostic and therapeutic technologies. The National Center on Sleep Disorders Research—working with the Trans-NIH Sleep Research Coordinating Committee, the Agency for Health Care Policy and Research, other federal agen- cies, and private industry—should support the evaluation and vali- dation of existing diagnostic and therapeutic technologies. Further, development of new technologies such as ambulatory monitoring, biological markers, and imaging techniques should be vigorously supported. Establish Sleep Laboratories in the NIH Clinical Research Program The intramural clinical research program at the NIH does not have a sleep laboratory. Consequently, many experimental sleep therapies and the relationship between sleep processes and disease development are not being examined. If there is adequate investment in extramural sleep-related pro- grams, the field can continue to make great strides; therefore, the commit- tee does not support use of limited resources to invest in an intramural somnology and sleep disorders research program. However, because appro- priateness of sleep patterns is one of the basic tenets of health, the committee strongly urges the NIH intramural clinical research program to ascertain the need for establishing a sleep study laboratory so that evaluation of sleep may be integrated into ongoing relevant clinical research protocols at NIH. Recommendation 8.3: The National Institutes of Health should ascertain the need for a transdisciplinary sleep laboratory that would serve as a core resource in its intramural clinical research program. The Director of the National Institutes of Health Intramural Re- search Program should ascertain the need for a transdisciplinary sleep laboratory within the intramural clinical research program that would serve as a core resource for the community of intramu- ral clinical investigators across all institutes.

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11 SUMMARY Improved Accreditation Standards Are Required Sleep disorders are chronic conditions frequently associated with other comorbidities (e.g., cardiovascular disease, depression, diabetes), which often require complex treatments. Despite the importance of early recognition and treatment, the primary focus of most existing sleep centers appears to be on diagnosis, rather than on comprehensive care of sleep loss and sleep disorders as chronic conditions. This narrow focus may largely be the unintended result of compliance with criteria for accreditation of sleep laboratories, which em- phasize diagnostic standards and reimbursement, for diagnostic testing. To address this it is recommended that accreditation criteria for sleep centers, in which are imbedded sleep laboratories, be expanded to emphasize treatment, long-term patient care, and management strategies. Recommendation 9.2: Sleep laboratories should be part of accred- ited sleep centers, the latter to include long-term strategies for patient care and chronic disease management. All private and academic sleep laboratories should be under the auspices of accredited sleep centers and include adequate mecha- nisms to ensure long-term patient care and chronic disease manage- ment. Accreditation criteria should expand beyond a primary focus on diagnostic testing to emphasize treatment, long-term patient care, and chronic disease management strategies. INTERDISCIPLINARY SLEEP PROGRAMS IN ACADEMIC HEALTH CENTERS Accelerating Scientific Advances A coordinated and integrated strategy requires bolstering clinical and basic research efforts, catalyzing collaborative research efforts, and at- tracting the breadth of talented researchers who can provide leadership to advance research and clinical care in sleep loss and sleep disorders. Key to accelerating progress in the treatment of chronic sleep loss and sleep dis- orders is the development of a coordinated, focused, and centralized net- work that connects individual investigators, research programs, and re- search centers; facilitates collaborative projects; encompasses relevant research from diverse fields; and builds on the unique strengths of each research effort to move toward effective therapy, prevention, and treat- ment. Somnology and Sleep Medicine Research Centers of Excellence would spearhead these translational research efforts and promote collabo- rations among all sites conducting research relevant to somnology and

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12 SLEEP DISORDERS AND SLEEP DEPRIVATION sleep medicine. Similar to cancer centers, the Somnology and Sleep Medi- cine Centers of Excellence would act as local, regional, and national re- sources for the scientific community and the community at large. These centers would provide the interdisciplinary environment that is essential to accelerate the development of therapies for chronic sleep loss and sleep disorders. In addition, these centers would facilitate interactions among basic, clinical, and population-focused scientists. These would not only be research centers, but somnology and sleep medicine centers that empha- size the close association among research, clinical care, and education. The committee further envisions a sustained network for somnology and sleep medicine in the United States that would facilitate public education, career development opportunities, translational research, and implemen- tation of multicenter clinical trials. Although in aggregate, sleep loss and sleep disorders are prevalent, among these are many rare conditions that would benefit from a national data collection system and clinical network. Despite the limited size of the field, the committee believes that the somnology and sleep medicine field is now sufficiently mature for the estab- lishment of a national somnology and sleep medicine research network. Scientific advances and a number of large academic interdisciplinary sleep programs place the proposed network in position to successfully compete for funding from the National Heart, Lung, and Blood Institute and other members of the Trans-NIH Sleep Research Coordinating Committee. Recommendation 8.2: The National Institutes of Health should establish a National Somnology and Sleep Medicine Research Network. The National Center on Sleep Disorders Research in collaboration with the Trans-NIH Sleep Research Coordination Committee should establish a National Somnology and Sleep Medicine Re- search Network. Type III regional interdisciplinary sleep programs designated by the National Institutes of Health would act as re- gional centers working with basic research laboratories and sleep cores at NIH-designated clinical translational research centers. It is envisioned that the networks would do the following: • Coordinate and support the current and future cadre of basic and clinical researchers. • Train new investigators and fellows. • Provide core capabilities for basic, clinical, and translational research. • Support multisite clinical research in children, adolescents, adults, and elderly.

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13 SUMMARY • Create and support virtual networking centers to facilitate the standardization and sharing of data and resources online and enhance collaborations with researchers not working in research centers. • Create a data coordinating center that includes an Internet-based clearing house for the publication of all data produced in coop- eration with the research and clinical network. • Together with the Agency for Healthcare Research and Quality develop standards for research, outcomes, and clinical practice. • Work with the Center for Disease Control and Prevention to integrate and support surveillance and population-based research. Criteria for Interdisciplinary Sleep Programs in Academic Health Centers Somnology and sleep medicine is an emerging interdisciplinary field that is being forged from several disciplines and clinical specialties. How- ever, the limited investment and organization of sleep programs in aca- demic health centers do not favor interdisciplinary research efforts and con- tinued advances in clinical care. Consequently, the committee recommends a three-tier model for interdisciplinary sleep programs, which lays down the guiding principles for their organization in all academic health centers— progressing from programs that emphasize clinical care and education to programs with a considerable capacity for research, advanced training, and public education (Table S-1). It is the belief of the committee that, if these components and guiding principles are followed, interdisciplinary sleep pro- grams can thrive, whether as free-standing departments or as programs within an existing department, division, or unit. Status as a Type I interdisciplinary sleep program is achievable by many academic health centers nationwide; it primarily focuses on clinical care. This type should highlight the importance of increasing awareness among health care professionals by offering educational programs for medical students and residents in primary care. The Type I interdisciplinary sleep program is a single accredited center that emphasizes a comprehensive diag- nosis and treatment program. A Type II interdisciplinary sleep program includes the characteristics of a Type I program but in addition is designed to provide optimal education, training, and research in somnology and sleep medicine for scientists and physicians, including an accredited sleep fellowship program for physicians. A Type III regional interdisciplinary sleep program includes the characteris- tics of Type I and II programs; however, this type of program would act as a regional coordinator for the proposed National Somnology and Sleep

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14 SLEEP DISORDERS AND SLEEP DEPRIVATION Medicine Research Network for education, training, mentoring, clinical care, research, and clinical trials. Recommendation 9.1: New and existing sleep programs in aca- demic health centers should meet the criteria of a Type I, II, or III interdisciplinary sleep program. New and existing sleep programs should at a minimum conform to the criteria of a Type I clinical interdisciplinary sleep program. Aca- demic medical centers with a commitment to interdisciplinary train- ing are encouraged to train sleep scientists and fellows in sleep medi- cine, which would require at least a Type II training and research interdisciplinary sleep program. Research-intensive medical centers should aspire to become Type III regional interdisciplinary sleep pro- grams and coordinators of the National Somnology and Sleep Medi- cine Research Network. The American Academy of Sleep Medicine should develop accreditation criteria for sleep programs specific to academic health centers. PRIORITIES TO ADVANCE SOMNOLOGY AND SLEEP MEDICINE The field is particularly well suited to interdisciplinary and translational strategies. NIH’s Roadmap identified a number of initiatives that aim to foster the development of interdisciplinary research and training. The growth of this field fits in with the framework of the Roadmap and thus could serve as a prototypical program for these new cross-institute initiatives. Recognizing the current fiscal restraints at the NIH and the prerequisite requirements for the field, the committee recommends the following priori- tized strategy. Of primary importance is • improving awareness among the general public and health care professionals, • increasing investment in interdisciplinary somnology and sleep medi- cine research training and mentoring activities, • validating and developing new and existing technologies for diagno- sis and treatment. Transforming academic health centers is also an important part of the strategy. Although many health centers have the components to establish interdisciplinary sleep programs, many do not, and it will take time and energy to develop successful programs. Therefore, it is important that academia and accrediting bodies begin facilitating this transformation.

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15 SUMMARY Finally, although there are only a limited number of academic institu- tions that currently have the capacity to be a Type III regional interdiscipli- nary sleep program, this should not delay the establishment of the research network. Initially the network could consist of a limited number of pro- grams. The network would benefit greatly from cultural, ethnic, and envi- ronmental diversity. Therefore, a long-range goal should be to have 8 to 10 geographically distributed Type III regional interdisciplinary sleep pro- grams. In this report the committee does not recommend any research pri- orities. It is the committee’s belief that the strategies outlined in the report will generate the appropriate mechanisms for generating a research agenda for the future of somnology and sleep medicine. TABLE S-1 Guidelines for Interdisciplinary Type I, II, and III Academic Sleep Programs Type II Type III (clinical, (regionalized Type I training, comprehensive Attribute (clinical) research) centers) Structure and Composition Clinical specialties represented:a Internal medicine and relevant x x x subspecialties Neurology x x x Psychiatry and subdisciplines x x x Otolaryngology x x x Pediatrics and subspecialties (as x x x necessary may be separate program) Nursing x x x Psychology x x Dentistry x Medical director certification in sleep x x x medicine (American Board of Medical Specialties or American Board of Sleep Medicine)b Consultant services from specialties x x x not represented Sleep specialists provide consultant services x x x Single accredited clinical sleep center x x x Comprehensive program for diagnosis x x x and treatment of individuals continued

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16 SLEEP DISORDERS AND SLEEP DEPRIVATION TABLE S-1 continued Type II Type III (clinical, (regionalized Type I training, comprehensive Attribute (clinical) research) centers) Training Program Training program for health care x x x professionals and/or researchers Medical school training and education x x x Education for residents in primary care x x x Residents in neurology, psychiatry, x x otolaryngology, and fellows in pulmonary medicine rotate through sleep program Accredited fellowship program for physicians x x Research training for clinical fellows x x NIH-sponsored training grants for graduate x x and postgraduate researchers Research Program Research areas of emphasis:c Neuroscience x x Epidemiology/public health x x Pharmacology x Basic or clinical research program x Basic and clinical research program x xd Member of proposed national somnology x x and sleep medicine research and clinical network Regional coordinator for: Core facilities for basic research x Multisite clinical trials x Core facilities for clinical research x Mentoring of sleep fellows x Public education x Data coordinating site x aThis list is not meant to be exclusive or exhaustive and should be modified as relevant special- ties and training programs emerge. b Currently this is American Board of Sleep Medicine. It is anticipated that in 2007 the exami- nation would be supplanted by the American Board of Medical Specialties. c This list is not meant to be exclusive or exhaustive. Other research areas could be involved (e.g., genetics, systems neurobiology, and bioengineering). d Type I programs would be responsible for generating and submitting data to the national data registry established by the proposed National Somnology and Sleep Medicine Research and Clinical Network.

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17 SUMMARY BOX S-1 Summary of Committee’s Recommendations to Address and Remedy the Unmet Public Health Need The following is a summary of the committee’s recommendations. Com- plete text of each recommendation can be found in the corresponding chapters. NATIONAL INSTITUTES OF HEALTH LEADERSHIP IN RESEARCH AND TRAINING The National Center on Sleep Disorders Research and its advi- sory board should play a more proactive role in stimulating and coordinating the field. (Recommendation 8.1) The National Institutes of Health and private foundations must increase investment in interdisciplinary somnology and sleep medicine research training and mentoring activities. (Recommen- dation 7.1) The National Institutes of Health should ascertain the need for a transdisciplinary sleep laboratory that would serve as a core re- source in its intramural clinical research program. (Recommen- dation 8.3) PUBLIC AND PROFESSIONAL AWARENESS The National Center on Sleep Disorders Research and the Cen- ters for Disease Control and Prevention should establish a multi- media public education campaign. (Recommendation 5.1) Academic health centers should integrate the teaching of som- nology and sleep medicine into baccalaureate and doctoral health sciences programs, as well as residency and fellowship training and continuing professional development programs. (Recommendation 5.2) SURVIELLANCE AND MONITORING The Centers for Disease Control and Prevention and National Cen- ter on Sleep Disorders Research should support additional sur- veillance and monitoring of sleep patterns and sleep disorders. (Recommendation 5.3) continued

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18 SLEEP DISORDERS AND SLEEP DEPRIVATION BOX S-1 continued TECHNOLOGY DEVELOPMENT The National Institutes of Health and the Agency for Healthcare Research and Quality should support the validation and devel- opment of existing and new diagnostic and therapeutic tech- nologies. (Recommendation 6.1) INTERDISCIPLINARY SLEEP PROGRAMS IN ACADEMIC HEALTH CENTERS New and existing sleep programs in academic health centers should conform to meet the criteria of a type I, II, or III interdisci- plinary sleep program. (Recommendation 9.1) Type I clinical interdisciplinary sleep program Type II clinical, research, and training interdisciplinary sleep program Type III regional comprehensive sleep program It is recommended that the National Institutes of Health establish a national somnology and sleep medicine research network. (Recommendation 8.2) Sleep laboratories should be part of accredited sleep centers, which include long-term strategies for patient care and chronic disease management. (Recommendation 9.2) NOTE: For ease of reference, the committee’s recommendations are numbered according to the chapter of the main text in which they appear followed by the order in which they appear in the chapter.