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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem 9 Building Sleep Programs in Academic Health Centers CHAPTER SUMMARY New organizational structures for interdisciplinary sleep programs in academic health centers are necessary. This chapter makes the case for why interdisciplinary sleep programs are needed nationwide. It then offers a framework for establishing academic somnology and sleep medicine programs. Without being prescriptive, the chapter discusses operating principles gleaned from interdisciplinary somnology and sleep medicine programs that have flourished, as well as from others that have struggled. Finally, the chapter unveils the committee’s recommendation for a three-tier structure that ensures all academic health centers provide adequate interdisciplinary clinical care, with subsequent tiers also emphasizing training and research components. If these components and guiding principles are followed, interdisciplinary sleep programs can thrive, whether as a freestanding department or as a program within an existing department or division. Although not a trivial undertaking, it is necessary that all academic health centers strive to develop or transform their current sleep activities into interdisciplinary sleep programs. Some academic health centers are close to, or already have, achieved strong clinical programs. Once a sleep program is established, whether multidimensional or not, it can generate higher revenues than costs, according to a fiscal analysis presented in this chapter. To ensure improved care and scientific advances, the committee recommends clinical accreditation standards be updated to address patient care needs.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem Building sleep programs at academic health centers is not a matter of bricks and mortar. It is a matter of crumbling the organizational walls that separate a variety of traditional scientific and medical disciplines to function more appropriately to meet patient care needs and to facilitate research and training. In this chapter, the committee lays out a vision for each of the nation’s 125 academic health centers to formally establish an interdisciplinary somnology and sleep medicine program. Building sleep programs nationwide will strengthen Somnology and Sleep Medicine as a recognized medical specialty. There is too much at stake—a large patient population, high levels of underdiagnosis, and high public health toll—for inaction. RATIONALE FOR SLEEP PROGRAMS IN ACADEMIC HEALTH CENTERS The rationale for sleep programs has been presented throughout this report. This section of the chapter recapitulates those arguments concerning the magnitude of the public health problem and the lack of appropriate education at every level of academic instruction. It also answers the specific question—why is a sleep program optimally interdisciplinary? Public Health Burden Is High Chronic sleep loss and sleep disorders are serious and common problems, affecting an estimated 50 to 70 million Americans (NHLBI, 2003). These conditions have a bearing upon nearly every facet of public health— morbidity, mortality, productivity, accidents and injuries, quality of life, family well-being, and health care utilization. Earlier chapters of this report documented the prevalence of sleep problems and their health consequences. Sleep loss and sleep-disordered breathing, for example, are associated with obesity, diabetes, hypertension, cardiovascular disease, and stroke (Chapter 3). Nearly all types of sleep problems affect personal as well as public health (Chapter 4). The foremost symptom of sleep loss and most sleep disorders—daytime sleepiness—affects performance and cognition. When these functions are perturbed, whether at work, in school, or in the community, serious consequences can ensue. One of the most serious comes in the form of motor vehicle injuries. More broadly, the annual direct and indirect costs of sleep problems reach well beyond $100 billion (Chapter 4). Most Patients Remain Undiagnosed and Untreated Most individuals with sleep disorders remain undiagnosed and thus untreated. Two large epidemiological studies, each with thousands of subjects, found that the vast majority, up to 90 percent, of individuals with
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem sleep-disordered breathing had not been diagnosed (Young et al., 1997; Kapur et al., 2002). Narcolepsy and insomnia are also infrequently detected (Benca, 2005; Singh et al., 2005). All of the findings reported above are consistent with surveys indicating that primary care physicians infrequently ask questions about sleep problems (Chung et al., 2001; Reuveni et al., 2004). Patients with Sleep Loss and Sleep Disorders Require Long-Term Care and Chronic Disease Management Sleep disorders are chronic conditions with complex treatments. They are frequently comorbid with other sleep disorders, as well as other complex conditions (e.g., cardiovascular disease, depression, and diabetes) (Chapter 3). Sleep disorders also are dynamic, meaning that the underlying condition or its treatment changes with age and onset of new comorbidities. Despite the importance of early recognition and treatment, the primary focus of most existing sleep centers is on diagnosis rather than on comprehensive management of sleep loss and sleep disorders as chronic conditions. The narrow focus of sleep centers may largely be the unintended result of accreditation criteria, which emphasize diagnostic standards, as explained later, as well as a result of reimbursement, which is for diagnostic testing. There are numerous reasons for a paradigm shift to chronic disease management. Proper treatment for most sleep disorders—as for other chronic diseases such as congestive heart failure, diabetes, asthma, and depression— requires a period of time for fine-tuning, extended follow-up, and lifestyle changes. Sleep disorders cannot be adequately treated in a single visit. The need for chronic care management is even more pressing for the many patients (probably up to 30 percent) with combined sleep pathologies. These patients are difficult to manage without multiple clinicians being involved. For example, 20 to 50 percent of narcoleptics have obstructive sleep apnea (OSA); 40 percent of narcoleptics have insomnia; 40 percent of narcoleptics have periodic leg movements disorder (Baker et al., 1986; Cherniack, 2005; Chung, 2005). Residual daytime sleepiness is common in patients with sleep apnea adequately treated with continuous positive airway pressure (CPAP); it may require additional pharmacotherapy. Similarly, a large portion of patients with sleep apnea have insomnia and vice versa. Insomnia plus sleep apnea is a difficult combination, as it makes it more challenging for patients to tolerate CPAP and thus increases the likelihood of failure if the combination is not addressed. Sleep disorders are also common in patients with various medical and psychiatric conditions. For example, increased sleep apnea is found in obese subjects with or without the metabolic syndrome and in patients with stroke or various neurodegenerative disorders. Restless legs syndrome can occur in
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem the context of iron deficiency, renal failure, and pregnancy. Rapid-eye-movement (REM) behavior disorder is often an antecedent of Parkinson’s disease and Lewy body disease. Hypersomnia is a common symptom in Parkinson’s disease, depression, and various neurological conditions. Similarly, insomnia can occur in the context of various medical and psychiatric conditions and is associated with depression. These patients often require coordinated care across disciplines. As will be described below, interdisciplinary sleep programs provide the best structure to facilitate this type of care. Inadequate Numbers of Training and Research Programs Training of health professionals seldom deals with sleep hygiene, sleep loss, and sleep disorders (Chapters 5 and 7). Although there have been some improvements, challenges lie ahead for training of medical, nursing, and pharmacy students. Research opportunities for medical residents, sub-specialty residents, and doctoral and postdoctoral researchers are also limited. Most sleep researchers are clustered in a handful of institutions, according to the grants analysis presented in Chapter 7. Because mentoring is critical to success in clinical or basic research, the concentration of mentors at so few institutions leaves students elsewhere with few opportunities to successfully enter the field, thereby constricting the pipeline of new clinicians and researchers. Large Body of Knowledge Given the limited number of sleep experts nationwide and their clustering in a handful of institutions, is there a sufficient knowledge base and need to justify creation of an interdisciplinary somnology and sleep medicine program at each of the nation’s academic health centers? The simple answer is yes. Over the last 25 years, the field has grown to the point that a large base of knowledge now exists regarding diagnosis and treatment. Several recent milestones for the field attest to the achievement of a critical mass of knowledge. Sleep medicine is a medical subspecialty now recognized by the American Board of Medical Specialties. The Accreditation Council for Graduate Medical Education (ACGME) now accredits fellowship training programs. Numerous educational resources, including curriculum, are available from the American Academy of Sleep Medicine. The standard 1,500-page textbook, Principles and Practice of Sleep Medicine, is in its fourth edition. There is also a vibrant body of research, described in previous chapters, on the basic science of sleep and sleep disorders. The number of recipients of National Institutes of Health (NIH) R01 grants in sleep has risen from 100 to 253 over the last 10 years (Chapter 8).
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem Why Is Somnology and Sleep Medicine Program Optimally Interdisciplinary? Medicine has historically drawn strength from compartmentalizing into distinct specialties and subspecialties. But sleep medicine is not an ordinary subspecialty; its purview spans multiple organ systems. Consequently, complications that arise as a result of sleep loss and sleep disorders require attention from health care professionals in many disciplines. Further, sleep cycles and perturbations exert physiological effects. The major circadian rhythm that originates in the brain influences body temperature, heart rate, muscle tone, and the secretion of hormones. There are also circadian clocks in the heart and other organs. Beyond maintaining proper health and normal cognitive and motor function, sleep is required for survival (Rechtschaffen et al., 1989). Disturbance of sleep or loss of sleep has widespread metabolic implications (Chapter 2). Finally, the scientific study of sleep loss and sleep disorders integrates the efforts of many disciplines, including but not limited to neuroscience, epidemiology, molecular and cellular biology, and genetics. Thus, by its very nature, the field is at the interface of many medical and scientific disciplines. Therefore, it is not surprising that board certification in sleep medicine is under the auspices of four different medical boards—the American Boards of Internal Medicine, Pediatrics, Otolaryngology, and Psychiatry and Neurology. To harness the needed specialties, sleep programs must be multidisciplinary. But being multidisciplinary is not sufficient. A true interdisciplinary program is an orientation, approach, or philosophy that seeks to go beyond the sum of the parts to build a new enterprise (Figure 9-1). It is not necessary for sleep medicine to be housed in a stand-alone department or division. Many interdisciplinary sleep programs thrive in a department (see below). However, sleep programs that are restricted to a single department that does not allow for interdisciplinary treatment and care tend to struggle. This is partly because they fail to provide a sense of identity; they lack a career path for faculty, which in turn, makes it difficult to recruit students and additional faculty—the very ingredients needed to establish and rejuvenate a field. Further, fragmented programs lack the collaborative spirit necessary for excellence in clinical care, training, and research. The field of somnology and sleep medicine is an excellent example of an interdisciplinary field because it strives to integrate ideas, tools, and perspectives from several disciplines in order to advance understanding beyond the scope of a single discipline or field of research practice. The field is being forged from existing fields of cardiology, dentistry, endocrinology, geriatrics, neurology, neuropsychopharmacology, neuroscience, nursing, otolaryngology, pediatrics, psychiatry, psychology, and pulmonology (Box 9-1). Although
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem FIGURE 9-1 Interdisciplinary and multidisciplinary research. SOURCE: NAS (2004). not all of these disciplines are essential for starting a sleep program, each enriches the sleep field in transcendent ways. Two of the most advanced and successful sleep programs, at Harvard University and the University of Pennsylvania, attest to the productivity and vibrancy of an interdisciplinary approach. The success of the program at the University of Pennsylvania also demonstrates that the success of an interdisciplinary sleep program is not dependent on it being its own stand-alone department. Many types of health professionals are needed to guide the chronic management of sleep disorders. Individuals with sleep loss and sleep disorders have a multitude of health-related problems that require attention from a number of medical disciplines. However, given the limited number of certified health care professionals in sleep medicine and depending on the size and structure of an interdisciplinary sleep program, an individual often may need to be referred to a specialist in another department who may not be certified in sleep medicine. These physicians come from a variety of medical specialties, including internal medicine, pediatrics, otolaryngology, pulmonology, neurology, and psychiatry. Psychologists are essential in behavioral management of sleep disorders. Nurses and nurse practitioners also play an important role in patient support, patient teaching (especially in sleep hygiene and use of CPAP), follow-up, and promoting adherence to prescribed medical therapies (Epstein and Bootzin, 2002; Lee et al., 2004b). For example, in one of the
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem BOX 9-1 Examples of Interdisciplinary Approaches to Somnology and Sleep Medicine Several major accomplishments of somnology and sleep medicine have critically depended on the insights and perspectives of disparate disciplines: Cardiology Contributions of cardiology and large cohorts such as the Framingham study led to the Sleep Heart Health Study. This large cohort study has shown that sleep apnea is a risk factor for hypertension, cardiovascular disease, and insulin resistance (Nieto et al., 2000; Shahar et al., 2001; Punjabi et al., 2004). Endocrinology Cumulative sleep loss led to reduced leptin and increased ghrelin and hence increased appetite (Spiegel et al., 2004; Taheri et al., 2004). This led to the hypothesis that a hormonally mediated increase in appetite may help to explain why short sleep is a risk factor for obesity. Pulmonary Pulmonologists, with their knowledge of pulmonary physiology and ventilators, led the development of nasal CPAP, the most efficacious and common treatment for OSA (Sullivan et al., 1981). Neurobiology and Genetics Contributions of neurobiologists led to the demonstration that the rest period in the fruit fly (Drosophila) is analogous to mammalian sleep (Shaw et al., 2000; Hendricks et al., 2000).This provides a powerful new genetic model to study sleep mechanisms. Nursing Nursing’s focus on quality of life led to development of the Functional Outcomes of Sleepiness Questionnaire (Weaver et al., 1997). This instrument, which measures functional capacity in relation to sleep, is now used in clinical trials. few studies of its kind, group education sessions with a pulmonary nurse practitioner were found to enhance CPAP compliance over a 2-year period (Likar et al., 1997). Other nursing interventions, such as appropriately timed exercise, relaxation, and meditation, have also been shown to have beneficial effects on sleep in patients with chronic illnesses such as cancer and those in the acute care setting (Davidson et al., 2001; Mock et al., 2001; Richards et al., 2003; Allison et al., 2004). The role that poor sleep plays in enhancing other symptoms such as depression, fatigue, and pain is also
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem receiving increased attention by nurse clinicians and researchers in an attempt to improve overall symptom management (Miaskowski and Lee, 1999; Lee et al., 2004a; Miaskowski, 2004; Parker et al., 2005). Despite its promise, the field, like any enterprise that strives to cut across traditional disciplines, is fragile—even in the most supportive environments (NAS, 2004). Sleep clinicians or researchers often face daunting obstacles and disincentives, most of which arise from the customs and practices of individual academic departments. Those obstacles are discussed later in this chapter. CONSTRAINTS FACING INTERDISCIPLINARY SLEEP PROGRAMS Many of the most promising new lines of academic pursuit fall outside of traditional disciplines (Ehrenberg and Epifantseva, 2001). Yet interdisciplinary programs, even under the best of circumstances, face barriers and impediments within the confines of academic or research institutions (Ehrenberg et al., 2003; Lach and Schankerman, 2003). A recent National Academies report focusing on ways to facilitate interdisciplinary research was unambiguous about the difficulties confronting these programs, despite their promise. The report observed that, “Researchers interested in pursuing [interdisciplinary research] often face daunting obstacles and disincentives.” Some of these obstacles take the form of personal communication or culture barriers; others are related to the tradition in academic institutions of organizing research and teaching activities by discipline-based departments—a tradition that is commonly mirrored in funding organizations, professional societies, and journals (NAS, 2004). This is a generic problem, regardless of whether the interdisciplinary research program deals with nanotechnology or the perception of pain. The problem of departmental silos permeates interdisciplinary programs within any setting: academic health centers, universities, national laboratories, or industry. The following section presents a series of constraints that together limit the achievement of interdisciplinary programs. These constraints were identified on the basis of an analysis of six sleep programs using methods from operations research that the committee commissioned (see below). Several of the other constraints described in the following sections stem from organizational structures that were established prior to the advent of interdisciplinary research: interdisciplinary programs challenge institutional reward systems; interdisciplinary requirements impose obstacles, different administrative jurisdictions, and lack of appropriately trained staff for sleep studies; and service demand outstrips service supply.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem Different Administrative Jurisdictions As a corollary of the interdisciplinary nature of sleep programs, another constraint is that the services offered by a sleep program often occur at different locations under different administrative jurisdictions. Coordinating all the different types of personnel, lines of authority, policy and procedures, and quality control measures across organizational boundaries is challenging. Who bears the costs and their alignment with benefits and the various revenue streams is neither obvious nor consistent. Interdisciplinary Programs Challenge the Institutional Reward System Most institutional reward systems are organized within traditional disciplines or academic departments. These are the units that control what most professionals covet: hiring capacity, tenure and promotion decisions, and space allocation. Interdisciplinary programs challenge this discipline-based reward system, as well as the culture accompanying each discipline (i.e., the customs and shared values that create group cohesion). The National Academies report on interdisciplinary research conducted three surveys of different groups either working within or overseeing interdisciplinary programs: individual professionals, provosts, and attendees of a conference on interdisciplinary research. In all, some 500 people responded to the surveys (NAS, 2004). The report acknowledges that the samples were not random. But since these are the only surveys of their kind, it is worth noting that the overwhelming majority of respondents (70.7 percent) reported that there were impediments at their institution. The leading barriers identified by individual professionals and provosts: promotion criteria, budget control, control on use of indirect costs, compatibility with university’s strategic plans, and space allocation (Figure 9-2). Interdisciplinary Requirements Impose Obstacles Interdisciplinary sleep programs, at a minimum, require multidisciplinary participation. As explained earlier, an interdisciplinary program moves beyond being multidisciplinary and is one in which multiple disciplines collaborate in a way that forges a new discipline or endeavor. Provision of clinical services in sleep medicine call upon professionals from internal medicine and its relevant subspecialties (e.g., pulmonology, cardiology, neurology, psychiatry, otolaryngology, pediatrics, and geriatrics) and other disciplines such as nursing, dentistry, and psychology. Research includes genetics, endocrinology, neuroscience, statistics, pharmacology, and epide-
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem FIGURE 9-2 Barriers to interdisciplinary research. SOURCE: NAS (2004). miology. Similar issues exist in teaching undergraduate, graduate, and physicians in their residencies, fellowships, and postdoctoral work. The unintended consequence is to produce barriers to interdisciplinary patient care, training, and research. Barriers include the length and depth of training in a single field necessary to develop scientists successful at competing for funds, the difficulty in forging a successful career path outside the single disciplinary structure, impediments to obtaining research funding for interdisciplinary research, and the perceived lack of outlets for the publication and dissemination of interdisciplinary research results. Lack of Appropriately Trained Staff for Sleep Studies By nearly universal consensus, one sleep technician can monitor at one time two uncomplicated diagnostic studies or one complicated study. Yet, the number of certified technicians nationally is inadequate to meet this need. As with any market in which the supply is less than demand, costs of certified technicians is rising faster than the average rate of inflation or the average rate of medical costs. This has two likely consequences: sleep programs are forced to provide on-the-job training for their technicians; and private-sector organizations are able to adjust their payment structures more readily than academic health centers. Thus, academic centers often provide training, but higher salaries in the private sector lure the experienced technologists. The
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem net consequence is that the lack of trained technicians can act as a serious structural impediment to developing interdisciplinary sleep programs. Demand Outstrips Supply Estimates suggest that 50 to 70 million Americans suffer from a chronic disorder of sleep and wakefulness (NHLBI, 2003). As discussed in detail in Chapter 6, the predicted number of individuals with sleep disorders greatly outstrips the ability to provide services using trained personnel (Tachibana et al., 2005). Although there are over 3,250 American Board of Sleep Medicine (ABSM) diplomats, inadequate staffing results in long wait time until next appointment. Analysis commissioned on behalf of the committee indicated that wait times could range by as much as 4 weeks to 4 months. KEY COMPONENTS AND GUIDING PRINCIPLES FOR BUILDING SLEEP PROGRAMS In this section, the committee offers guidance to academic health centers about the missions and roles of sleep programs. There is no single way to create or expand an interdisciplinary sleep program. The committee recognizes that every institution has established—often over many decades— its own policies, procedures, institutional organization, and lines of authority. The committee offers principles that can guide development of somnology and sleep medicine programs. For each of these key components and guiding principles, the committee draws on its experience with programs that have been successful, as well as those that have struggled. It also draws on the formidable barriers identified in the previous section. If these components and guiding principles are followed, interdisciplinary sleep programs can thrive, whether as a freestanding department or as a program within an existing department or division. Key Components of Interdisciplinary Sleep Programs Strong Linkages from Diagnostic Testing Centers to Comprehensive Care Diagnostic sleep centers need to establish strong linkages with treatment providers. The emphasis of sleep centers may be too narrowly focused on diagnosis. The committee heard testimony and anecdotal reports that many patients, once tested, are lost to follow-up. Once diagnosed, severe sleep apnea, for instance, optimally should be followed up by a physician certified in sleep medicine. Less severe forms of apnea may warrant watching or referral to a dentist for preparation of dental devices, if a dental problem is etiologically related.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem Finally, the absence of accreditation impedes sleep centers moving toward better care for patients (by embracing both diagnosis and treatment, rather than diagnosis alone). The overview to the standards indicates that accredited centers provide a comprehensive approach to patient care (AASM, 2006a). But this broad mission is not reflected in the actual criteria for accreditation. Accrediting criteria emphasize personnel, patient acceptance, facilities, and technical staff. The criteria lack specific emphasis on long-term disease management and improved outcomes provided by patient care. The committee heard testimony that many patients who are evaluated and diagnosed at centers are not systematically tracked in terms of follow-up care—either for treatment or for monitoring adherence with treatment. This testimony is consistent with research revealing that compliance with CPAP is poor (Kribbs et al., 1993; Reeves-Hoche et al., 1994). The committee could not find studies that directly address the extent to which diagnosed patients are not receiving treatment and follow-up care. The committee believes, however, that the accreditation procedure represents a unique opportunity to ensure that sleep centers are primarily focused on improving patient outcomes rather than diagnosis. Accreditation of Fellowship Training Programs in Sleep Medicine Starting in the mid-1990s, the AASM began to accredit sleep fellowship training programs. These are 1-year programs for medical doctors, which may be taken after completion of a residency (e.g., internal medicine, neurology, otolaryngology, psychiatry, or pediatrics or fellowships such as pulmonary medicine). In 2003, the ACGME approved AASM’s application for transferring its fellowship training program to ACGME. AASM had actively sought approval in order to further elevate the standards for training and education. The newly established ACGME accreditation program began in June 2004. Accreditation criteria cover such areas as curriculum, qualifications of faculty, fellow competencies, scholarly activities, duty hours, and evaluation. By 2011, eligibility for board certification in sleep medicine will require attending an ACGME-accredited fellowship program in sleep medicine. Currently there are 24 ACGME-accredited fellowship programs and approximately 50 AASM accredited programs. Certification of Specialists in Sleep Medicine Since its inception, the AASM (or its predecessor organization) certified specialists by a specialty examination. By 1991, the AASM formed an independent body to serve that function, the American Board of Sleep Medicine. Certified professionals are known as diplomates in sleep medicine. The number of diplomates rose from 21 in the late 1970s to 3250 in 2005.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem One of the board’s major goals was realized in 2005, when it was accorded recognition as a bona fide subspecialty by the American Board of Medical Specialties. The timetable calls for a 6-year transition period. By 2011, board certification in sleep medicine will become available under the auspices of the American Boards of Internal Medicine, Pediatrics, Otolaryngology, and Psychiatry and Neurology. However, as discussed in Chapter 5, not all clinicians will be eligible to sit for the exam. The ACGME only permits accreditation of medical doctors; thus nurses, dentists, and doctorally prepared sleep specialists (e.g., psychologists and behavioral health specialists) in other fields will require alternative means of credentialing. It is possible that this may continue to be performed through the American Board of Sleep Medicine. Alternatively, other appropriate professional organizations may wish develop their own standards. Health Insurance Role in Improving Quality Health insurance, whether private or public (e.g., Medicare or Medicaid), is a driving force in health care delivery. Health insurance coverage drives the types of services that are offered and the incentives under which physicians operate. Health insurance coverage also influences who has access to services and how consumers select and use them (Hillman, 1991; Miller and Luft, 1994). Health insurance coverage also influences the quality of care, often in unintentional ways. For example, fee-for-service health insurance may promote overuse of services—ones may not be necessary or that may expose patients to greater harm than benefit. Conversely, managed care may promote potential underuse of services from which patients might benefit (IOM, 2001). A major recommendation of the IOM report, Crossing the Quality Chasm, was to use health insurance as a means to ensure development of programs in quality improvement. Payment policies, the report recommended, should be used to reward higher quality of care. The concept of using payment methods to reward better quality of care already has taken hold in many areas of medicine. It also is occurring in sleep medicine. In several regions, private health insurers require as a condition of reimbursement that sleep studies be conducted in accredited laboratories or centers (AASM, 2006a). NEXT STEPS Continued clinical advances and growth of the field depends on the appropriate emphasis and organization of academic sleep programs. These structures require special attention, not only to diagnosis, but also to long-term patient care that recognizes the need for chronic disease management
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem and strategies. The committee recommends a three-tier structure that ensures all academic health centers have at least a minimum set of organizational components that ensure adequate interdisciplinary clinical care, with subsequent tiers also emphasizing training and research components. Further, to ensure improved care and scientific advances, the committee recommends accreditation standards be updated to include patient care criteria. Proposed Organizational Guidelines for Interdisciplinary Sleep Programs As suggested throughout this chapter and the entire report, the current organizational structures at many academic health centers are not sufficient to ensure continued advances in clinical care and research. Consequently, the committee recommends that each health center strive to put in place an interdisciplinary sleep program. However, the committee recognizes that each of the 125 academic health centers has a different organizational structure and resources. Consequently, a three-tier model for interdisciplinary sleep programs is recommended, progressing from programs that emphasize clinical care and education, to programs with a considerable research capacity, advanced training, and public education (Table 9-2). The first tier TABLE 9-2 Guidelines for Interdisciplinary Type I, II, and III Academic Sleep Programs Attribute Type I (clinical) Type II (clinical, training, research) Type III (regionalized comprehensive centers) Structure and Composition Clinical specialties represented:a Internal medicine and relevant subspecialties x x x Neurology x x x Psychiatry and subdisciplines x x x Otolaryngology x x x Pediatrics and subspecialties (as necessary may be separate program) x x x Nursing x x x Psychology x x Dentistry x Medical director certification in sleep medicine (American Board of Medical Specialties or American Board of Sleep Medicine)b x x x Consultant services from specialties not represented x x x
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem Attribute Type I (clinical) Type II (clinical, training, research) Type III (regionalized comprehensive centers) Sleep specialists provide consultant services x x x Single accredited clinical sleep center x x x Comprehensive program for diagnosis and treatment of individuals x x x Training Program Training program for health care professionals and/or researchers x x x Medical school training and education x x x Education for residents in primary care x x x Residents in neurology, psychiatry, otolaryngology, and fellows in pulmonary medicine rotate through sleep program x x Accredited fellowship program for physicians x x Research training for clinical fellows x x NIH-sponsored training grants for graduate and postgraduate researchers x x 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 Member of proposed national somnology and sleep medicine research and clinical network xd x x 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 specialties and training programs emerge. bCurrently this is American Board of Sleep Medicine. It is anticipated that in 2007 the examination would be supplanted by the American Board of Medical Specialties. cThis list is not meant to be exclusive or exhaustive. Other research areas could be involved (e.g., genetics, systems neurobiology, and bioengineering). dType 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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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem represents a comprehensive program that emphasizes diagnosis and patient care. Type II and III interdisciplinary programs require a progressively larger commitment to clinical care, research, and training. It is the belief of the committee that, if these components and guiding principles are followed, interdisciplinary sleep programs can thrive, whether as a freestanding department or as a program within an existing department, division, or unit. There is the danger that establishing stand-alone centers will result in the formation of additional barriers. Therefore, academic sleep programs must be organized to limit the formation of silos and facilitate interdisciplinary care and research. In most academic health centers, faculty participating in a sleep program will likely continue to have their primary appointment in departments, programs, or centers. To ensure interdisciplinary research and care, as well as prevent the formation of additional silos, faculty appointed in sleep programs are encouraged to maintain a connection with both the sleep program and their primary appointment. Many academic health centers have in place the components to establish these types of programs. However, organizing and coordinating the components to reach the committee’s vision is not an inconsequential task. Not all academic health centers are currently positioned to create interdisciplinary sleep programs. The committee recognizes that there must be incentives to facilitate this transition. To achieve this lofty goal will take great effort by the leaders of sleep programs and support and commitment from academic leadership. Establishing Type II and Type III interdisciplinary programs will require additional support from the NIH. As discussed in Chapter 8, the increased availability of training grants and program project grants will also help aid the establishment of these programs. However, simply increasing the funding available for these activities may not be effective. It is important to also establish comprehensive interdisciplinary sleep programs that will provide an environment conducive for interdisciplinary sleep-related research, training, and career development. Finally, comprehensive patient care will also be facilitated through the creation of accreditation standards for interdisciplinary academic programs in Somnology and Sleep Medicine that cover the diagnosis, treatment, and long-term follow-up of individuals with sleep disorders. As discussed previously in this chapter, the AASM has a demonstrated track record and the expertise to develop these criteria, which could be expanded to include the overall management of sleep disorders. The need to establish novel structures for Somnology and Sleep Medicine within academic health centers is in line with current changes occurring in many other areas of science and medicine. The organization of basic science departments in academic health centers has been in a continuing state of transition in recent years, according to new data analysis
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem from the American Association of Medical Colleges (AAMC). Medical schools are restructuring their basic science departments by consolidating the number of traditional departments and adding new departments to reflect scientific complexity and opportunity, as well as the changing nature of interdisciplinary biomedical research. The number of traditional discipline-based departments decreased from 2000 to 2004, but the overall number of departments has remained steady (Bunton 2006; Mallon et al., 2003). The creation of viable interdisciplinary sleep programs by the medical school leadership should benefit from ongoing experimentation in parallel areas. Recommendation 9.1: New and existing sleep programs in academic 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. Academic medical centers with a commitment to interdisciplinary training are encouraged to train sleep scientists and fellows in sleep medicine, 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 programs and coordinators of the National Somnology and Sleep Medicine Research Network. The American Academy of Sleep Medicine should develop accreditation criteria for sleep programs specific to academic health centers. Type I Clinical Interdisciplinary Sleep Program The Type I Clinical Interdisciplinary Sleep Program, which if not already in existence, is achievable by the majority of centers nationwide and focuses on clinical care specialties. It further highlights the importance of increased awareness among health care professionals by requiring educational programs for medical students and residents in primary care. This minimum commitment to training is so important because of the sheer commonality of sleep disorders in primary care. Optimally, each academic health center should have a single Type I Clinical Interdisciplinary Sleep Program accredited center that emphasizes a comprehensive diagnosis and treatment program and includes representation from internal medicine and its relevant subspecialties, such as pulmonary medicine, neurology, psychiatry, otolaryngology, pediatrics, and nursing. Often pediatrics and its relevant subspecialties—especially in large, freestanding children’s hospitals—may be better served by a separate program. Further, this list of participating
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem specialties is not meant to be exclusive or exhaustive but should be modified as relevant specialties and training programs emerge. Although it is important that generalists and the key specialists are capable of treating individuals with sleep disorders, programs should also ensure that patients are referred to relevant specialists as needed. The medical director of each program should be certified in sleep medicine, and it should be a goal of each program that all physicians also be certified. Type II Training and Research Interdisciplinary Sleep Program A Type II Training and Research 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. Nurses and psychologists should be included in the programs. Further, a Type II program should have an accredited fellowship program for all eligible physician rotations through the sleep program for all pulmonology, neurology, otolaryngology, and psychiatry residents. In addition, as described in Chapter 8, a Type II program would serve as an active member of the proposed National Somnology and Sleep Medicine Research and Clinical Network through at least an active basic or clinical research program. Research areas of emphasis should include, but not be limited to, science in the biological basis of sleep and population-based research on sleep patterns and problems. Type III Regional Interdisciplinary Sleep Program A Type III Regional Interdisciplinary Sleep Program includes the characteristics of Type I and II programs; however, in addition, a Type III program is designed to serve as a center for public health education, training for clinical care and research, basic research, patient-oriented research, translational research, and clinical care. As described in Chapter 8 the committee envisions that this type of program would act as a regional coordinator for the proposed National Somnology and Sleep Medicine Research and Clinical Network for education, training, mentoring, clinical care, research, clinical research studies, and large-scale population genetics studies. The committee does not recommend a specific number of Type III programs but recognizes that only a minimum number of programs currently have the necessary resources. However, as the field grows, more programs should develop the resources necessary to become a Type III program. Establishing these programs will not only require a significant investment from academic programs, but also, as described in Chapter 8, a long-term commitment by the NIH.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem Chronic Care Accreditation Standards As described earlier in this chapter, sleep disorders are chronic conditions with complex treatments. However, despite the importance of early recognition and treatment, the primary focus of most existing sleep centers is on diagnosis rather than on comprehensive management 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 emphasize diagnostic standards and reimbursement, for diagnostic testing. Clinical accreditation standards should be updated to address patient care needs. Chronic disease management models, such as those used to provide optimal care for individuals with diabetes, asthma, congestive heart failure, and depression, have been proven to be effective at providing better-integrated care (Tsai et al., 2005). Therefore, the committee recommends that accreditation criteria for all sleep centers, embedded in either academic health centers or private sleep laboratories, be expanded to emphasize treatment, long-term patient care, and management strategies. Although sleep laboratories may face a financial burden implementing the changes, the committee believes this is the most effective way to ensure optimal patient care. Such criteria should be subject to further analysis and a demonstration that chronic care is a worthwhile investment. If such studies demonstrate a benefit, this may then change reimbursement patterns. Recommendation 9.2: Sleep laboratories should be part of accredited 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 mechanisms to ensure long-term patient care and chronic disease management. Accreditation criteria should expand beyond a primary focus on diagnostic testing to emphasize treatment, long-term patient care, and chronic disease management strategies. REFERENCES AASM (American Academy of Sleep Medicine). 2006a. Standards for Accreditation of Sleep Disorders Centers. [Online]. Available: http://www.aasmnet.org/PDF/CenterStandards.pdf [accessed January 3, 2006]. AASM. 2006b. Accreditation Standards. [Online]. Available: http://www.aasmnet.org/centerLab.aspx [accessed January 18, 2006]. Allison PJ, Nicolau B, Edgar L, Archer J, Black M, Hier M. 2004. Teaching head and neck cancer patients coping strategies: Results of a feasibility study. Oral Oncology 40(5):538–544.
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Representative terms from entire chapter: