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Update on Licensure
In more than 15 states nationwide, the questions of who is licensed to diagnose and treat sleep disorders is being contested, debated, and, in some cases, finally put to bed.
After two solid years of national uncertainty, sleep technologists now are licensed in New Jersey, New Mexico, Louisiana, Tennessee and North Carolina.* In many other states, legislation amicable to both sleep and respiratory professionals is pending.
But according to Bruce Blehart, JD, government relations and health policy activities for the AASM, "The future is not going to be quiet on health policy."
In both Maryland and Georgia, licensure of sleep technologists has hit a snag. In order to be recognized by the state, technologists must graduate from a CAAHEP-accredited program. However, none exist in either state. Meanwhile, in both Kansas and Virginia, the law requires that the bills allowing medical licensure must be studied prior to implementation.
Awaiting the results of these latest obstacles are the more than 30 states that still have not considered this issue. So, will it become any easier to strike an agreement between state respiratory and sleep boards now that many states have agreements on the books?
"We're expecting sometime this summer to sit down with the AARC," Blehart said. "Hopefully, this resolution will make the next set of states go smoother."
-Kristen Ziegler
*A law granting licensure to sleep technologists was signed on Aug. 7, 2009.
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New choices
Opportunities to improve the health and quality of life for patients with sleep apnea exist outside of traditional CPAP therapy.
Over the past two years, clinicians increasingly have turned to adaptive servo-ventilation to treat patients with complex or emergent sleep apnea. Little research has been done on this relatively new modality, which is designed to adapt pressure support to the patient's rate and depth of breathing so as not to provoke apneas and arousals. One study found that it suppresses central sleep apnea and Cheynes-Stokes respiration and is well-tolerated by men with chronic heart failure.12"When used in the right patient population, it probably brings in more benefit than medications in other contemporary or comparable complex chronic diseases," said Sairam Parthasarathy, MD, chief of research at the Southern Arizona VA Healthcare System and associate professor at University of Arizona, Tucson. "What we are seeing is that patients upon follow-up are indeed using that particular device as opposed to in the past where we would just give them CPAP and hope that they would adapt to it."
Despite reported improvements in compliance, qualifying patients for these devices can be challenging. Medicare requires that the patient's central apnea index is greater than 10 per hour, CPAP and bilevel positive airway pressure have failed, and disruption from sleep was indeed ameliorated by this new device. That can be difficult to show in a split-night study, Dr. Parthasarathy said.
New on the market is a nasal expiratory positive airway pressure device, a disposable prescription device which incorporates a microvalve placed over the nostrils that opens during inhalation and closes during exhalation.
While preliminary research shows it is not as effective as CPAP therapy in ameliorating the apnea-hypopnea index in the sleep lab, the results are comparable to mandibular advancement devices and surgical approaches.13-15And this device may be better tolerated than the alternatives.
"The fact is compliance rates among patients who receive CPAP therapy is 50 percent," said Philip Westbrook, MD, emeritus professor of medicine at UCLA and chief medical officer for the medical device company developing the microvalve technology. "End-expiratory intranasal pressure may not lower AHI to zero, but it may lower it by 50 percent to 70 percent. Those patients likely will be a lot better off than those who don't use CPAP at all." A multisite, randomized clinical trial is under way that will look at 100 patients who use the device and their functional outcomes at three months. Some patients from this study will be followed for one year.
References
1. Global Industry Analysts Inc. Apnea monitors market to reach $382 million by 2015, according to new report by Global Industry Analysts Inc.
2. American Hospital Association. The impact of the economic crisis on health services for patients and communities. Washington D.C. Available from: URL: www.aha.org/aha/content/2009/pdf/090311econcrisisdatabank.pdf.
3. Wachovia Capital Markets LLC. Q4 2008 HME sleep & wound care survey. Dallas, TX: HME Business. Available from: URL: http://hme-business.com/Whitepapers/2008/10/Q4-2008-HME-Business-Wachovia-Sleep-and-Wound-Care-Survey.aspx.
4. Berry RB, Hill G, Thompson L, McLaurin V. Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. Sleep. 2008;31(10):1423-31.
5. Clinicaltrials.gov. Bethesda, MD: U.S. National Library of Medicine; 2009. Cost effectiveness of ambulatory management for veterans with sleep apnea (VSATT) Available from: URL: http://clinicaltrials.gov/ct2/show/NCT00880165. ClinicalTrials.gov Identifier: NCT00880165
6. Clinicaltrials.gov. Bethesda, MD: U.S. National Library of Medicine; 2009. Portable monitoring for diagnosis and management of sleep apnea (HomePAP) Available from: URL: http://clinicaltrials.gov:80/ct2/show/NCT00642486. ClinicalTrials.gov Identifier: NCT00642486
7. Kakkar RK, Berry RB. Positive airway pressure treatment for obstructive sleep apnea. Chest. 2007;132(3);1057-72.
8. Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep. 2007;30(5):635-40.
9. Means MK, Edinger JD. Graded exposure therapy for addressing claustrophobic reactions to continuous positive airway pressure: a case series report. Behav Sleep Med. 2007;5(2):105-16.
10. Clinicaltrials.gov. Bethesda, MD: U.S. National Library of Medicine; 2009. Evaluating behavioral treatments to improve adherence to continuous positive airway pressure (CPAP) therapy in people with obstructive sleep apnea (The BREATHE Study) Available from: URL: http://clinicaltrials.gov/ct2/show/NCT00623246. ClinicalTrials.gov Identifier: NCT00623246
11. Arzt M, Wensel R, Montalvan S, Schichtl T, Schroll S, Budweiser S, et. al. Effects of dynamic bilevel positive airway pressure support on central sleep apnea in men with heart failure. Chest. 2008;134(1):61-6.
12. Hwang D, Patel A, Chen G, Ayappa I, Rapoport DM. Nasal EPAP - physiologic mechanism of action. June 9, 2009, poster presentation at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies. Abstract 0591.
13. Abreu A, Doshi R, Loomas B, Westbrook P. Modeling the effectiveness of treatments for obstructive sleep apnea/hypopnea. June 09, 2009, poster presentation at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies. Abstract 0599.
14. Westbrook P, Doshi R, Loomas B. Success rates of nasal expiratory positive airway pressure (nEPAP) via expiratory resistive load for the treatment of obstructive sleep apnea. June 9, 2009, poster presentation at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies. Abstract 0570.
Contact Kristen Ziegler at kziegler@advanceweb.com.
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