by Kym S. Wambold

July 2012 – I just returned from my third healthcare conference in 12 months and must admit I am increasingly surprised by the lack of discussion around “Sleep Health” in general and Obstructive Sleep Apnea (OSA) in particular. I recognize that managing chronic conditions, such as diabetes and heart disease, and addressing wellness and prevention issues, such as obesity and smoking cessation, are extremely important. However, intuitively we also know, and the literature confirms, that adequate sleep is certainly one of the pillars of good health.

In part this apparent lack of attention around sleep is because sleep medicine has been somewhat of a niche specialty. In fact, when I recently spoke with the CEO of a large national health insurance company, I asked his opinion of why sleep is not on the radar (or conference agendas) of health plans, when there is such a drive toward health improvement. He stated that, while he understands the importance of educating about diabetes and smoking cessation, he doesn’t know anything about sleep!

Another case in point, there are literally hundreds of research articles and studies showing that lack of sleep is costly, both financially and clinically. Yet the journals in which they are published, Behavioral Sleep Medicine, Sleep Medicine, Sleep Review Magazine, Journal of Clinical Medicine, and SLEEP Journal, are unfamiliar to healthcare providers outside the field of sleep medicine.

How important is this?

There are nearly 20 million people in the U.S. that suffer from OSA. That is roughly the same amount as have diabetes, and we all know the attention that diabetes receives. Additionally, as a result of an aging and obese population, OSA is on the rise.

Research shows that OSA is associated with multiple high-cost co-morbidities. People that have OSA very commonly will also have diabetes, hypertension, heart disease, and erectile dysfunction.
Fortunately, there is a therapy available that is widely considered the gold standard for treating OSA. Continuous Positive Airway Pressure (CPAP) therapy, when done 4 hours per night and 5 nights per week, is the most effective way to control the condition, keeping these individuals healthy, reducing unnecessary healthcare utilization, and lowering costs.

The literature shows that chronic conditions will be better managed, and potentially even improved, if people reliably treat their OSA. People with both diabetes and OSA would have improved insulin resistance, and those with both hypertension and OSA could lower their blood pressure by 10 points, if they are diligent about managing their OSA. Several studies have demonstrated that people that have, but don’t treat, OSA will have twice as many doctor visits, hospitalizations, and motor vehicle accidents as their compliant counterparts. They also will have twice the medical expense level.

So, What’s the Problem?

Unfortunately, only 50% of those who initiate CPAP therapy will be using their CPAP device at the end of one year. Commenting on medication adherence, former US Surgeon General, C. Everett Coop, once said, “Drugs don’t work in people who don’t take them.” Well, the same could be said about CPAP therapy. And let’s all agree: learning one is faced with wearing a Darth Vader-like contraption every night can be daunting. It is a treatment that is significantly more complex and challenging than popping a pill. It’s a complete lifestyle adjustment and it’s complicated. There are literally hundreds of CPAP devices, supplies, styles, makes, and models. The average Joe isn’t prepared to sort through all that.

Another obstacle to long-term CPAP adherence is the current process of diagnosis and treatment. It leads people to be “lost to follow-up.”

It starts with a Primary Care Physician (PCP) determining there may be OSA and directing the patient to get a sleep study. Most PCPs are not well versed in sleep medicine – during your annual well visit, you are more likely to be asked if there is a gun in your house than how you are sleeping. So the PCP refers the patient to a Sleep Specialist to be tested and then steps out of the process. The Sleep Specialist coordinates a Polysomnogram in a Sleep Lab or a Home Sleep Test and makes an OSA determination. With a positive OSA diagnosis, the Specialist refers the patient to a Durable Medical Equipment (DME) company. Now the Specialist steps out of the process, and the DME gets the patient set up on the CPAP device. Once that’s done, the patient is “lost to follow-up”. Each entity has completed its part of the process, and the patient is now pretty much on his/her own.

It seems to me that this situation is tailor-made for the health & wellness / care management space, in which the focus is on changing behaviors through education, coaching, and support. For example, programs that incorporate Cognitive Behavioral Theory, Transtheoretical Models (e.g. readiness-to-change), and Motivational Interviewing are highly successful in engaging and encouraging individuals who struggle with chronic conditions and poor lifestyle habits.

So let’s put sleep and improving adherence to CPAP therapy on our radar, and let’s talk about how you slept last night.

About the Author

Kym S. Wambold has been on the business side of healthcare for more than 30 years, with an extensive background in the area of disease and care management, and a strong understanding of the clinical and financial implications of health care delivery. She has been involved with business development, sales channel development, marketing, sales training, sales management, sales strategy, operations and new product development with both private and publicly traded healthcare companies. Currently Vice President of Business Development at American HomePatient®, Kym has created the population-based CPAP Adherence Program to help improve the financial and clinical outcomes of health plan members with Obstructive Sleep Apnea and to help mitigate the health plan’s risk from this population.

You can reach Kym Wambold at (615) 866-8635 or kym.wambold@gmail.com.