It is now recognized that sleep disorders affect at least one-third of society on some level. Problems range from insomnia on an occasional basis to excessive daytime sleepiness to the point of falling asleep behind the wheel. In 1991The National Commission on Sleep Disorders Research reported to Congress that over $30 billion is lost every year as a result of sleep-related issues in the United States. The field of Sleep Disorders Medicine has evolved extensively over the past twenty years, but unfortunately, there is a significant lack of education and awareness amongst most healthcare professionals. In a study published in 1993, all 126 American Medical Schools were surveyed to determine how much time is spent teaching medical students anything on the topic of sleep: researchers found that on average only two hours are spent on the topic of sleep during the four years of medical school.
It is also now recognized that obstructive breathing during sleep, which causes snoring, is interrelated to the jaw and tongue position during sleep. Movement of the jaw can either help or hinder the breathing process. Many patients who grind and clench their teeth at night do so in an attempt to help keep the airway open and prevent obstructive respirations. Treatment devices for patients with obstructive Sleep Apnea consist of dental appliances that maintain the mandible in a forward position during sleep and help with breathing.
Educating dentists is another way to make a significant impact on sleep education within our society. If Dentists knew what to look for and were motivated to make an assessment of the airway, then many patients with sleep-related breathing disturbances could be diagnosed at an earlier stage and the overall negative impact of their abnormal breathing could reduced by earlier intervention. Therefore, another major goal of the Sleep Education Consortium is to educate Dentists on sleep disorders.
Public education is also clearly necessary in order to motivate primary care physicians who have to address their patient's health questions. Enhancing the education of the general public on sleep problems will also help achieve the overall goal of the Sleep Education Consortium by creating a more educated population base, which will then bring their questions and concerns to their primary care physician.
The National Sleep Foundation is directed to enhance public awareness of sleep-related issues and has done a phenomenal job along these lines. Activities such as Sleep Awareness Week have helped bring to light how extensive sleep-related problems affect our society. Therefore, the National Sleep Foundation has been named as the organization that would receive supplementary dollars from the Sleep Education Consortium if available.
The Need for Academic Sleep Centers
by William C. Dement, MD, PhD, and Robert Koenigsberg
Medical school programs are key to increasing sleep disorder research, diagnosis, and treatment.
There is a great need to maintain continuous assessment of the role of OSA, as well as other sleep disorders, in the health of the American public and to track the savings in lives and dollars of diagnosis and treatment. The cost of cardiovascular disease, for example, is in the range of $500 billion per year, and OSA alone may account for 25% or more of these costs. Unfortunately, at present, there are no truly accurate and compelling data on the number of people in the United States currently in need of OSA treatment. In fact, we do not even have data on how many currently are being treated. Informal estimates suggest that we treat around 1 million new OSA patients per year. However, Terry Young's original study of the prevalence of OSA extrapolated that 30 million people in the United States may have the disorder, with possibly 2 million new cases developing each year. Given these figures, treating 1 million patients per year is inadequate.
It is obvious that our ability to diagnose and treat sleep disorders must continue to expand. As we have said here and elsewhere, this may be best achieved by simplifying the diagnostic and treatment procedures and lowering their costs. The main purpose of this editorial, however, is to emphasize that there is a great deal more to learn about OSA, as well as other sleep disorders, including predisposing factors, natural history, better treatments, and so on. It is therefore mandatory that we maintain our academic sleep centers as they can perform the needed research into these topics. Indeed, we should attempt to develop such programs in every medical school. At the present time, our 125 medical schools have very few comprehensive sleep-disorders training programs. Of the 63% of medical schools that offer curricula including sleep disorders, the time devoted averages only 2.11 hours.
Although strong support for sleep-research education is still lacking in our society and among medical and public policy professionals, it is clear to sleep specialists that sleep-disorders medicine must have an adequate representation in medical school curricula. The current rate of change is inadequate to accomplish this goal. There must be an additional impetus brought about through legislation and through the education of professional societies and the general public.
The best way to produce the needed teaching and research is through sleep centers that are affiliated with medical schools. However, to support teaching and research in clinical practice, it is necessary to maintain sufficient income normally provided by grants and teaching remuneration. One way, therefore, of protecting the academic sleep center is to introduce to the Centers for Medicare and Medicaid Services (CMS) a payment system that encourages patients to go to academic centers as opposed to independent private sleep laboratories.
This is exactly what is currently happening in diagnostic imaging. CMS will pay ambulatory surgery centers (i.e., independent laboratories) at 62% of hospital-based outpatient departments.
If a similar system made academic sleep centers more profitable, sleep physicians who are now operating independently might be motivated to leave the private laboratories in favor of the academic centers. This, in turn, will help medical schools add a sleep component. If all medical schools included a comprehensive educational program on sleep disorders and sleep deprivation, we could produce a greater number of sleep specialists who could significantly expand clinical care and drive discoveries far beyond our current abilities.
We also must continue to improve methods of providing all physicians with the basic understanding and tools for proper identification and treatment of sleep disorders. If academic sleep centers could take on the responsibility to develop courses that would keep physicians abreast of new methods and treatments for sleep disorders, more undiagnosed and misdiagnosed individuals would be identified. In addition, by allowing physicians to choose between portable and in-laboratory testing on the basis of patients' symptoms, we would be able to diagnose and hence treat thousands more than we presently can.
If primary care physicians are being asked to take on responsibility for diagnosing and treating patients with heart disease and diabetes, there is no reason why sleep disorders should not be given equal importance. In California, primary care physicians seem to be content with referring sleep patients to sleep centers rather than managing sleep care as they would other common diseases. The sleep physician's knowledge of sleep disorders is respected as the equivalent of a brain surgeon who has the necessary specialized knowledge to perform highly complex and difficult operations. It is time to empower primary care physicians with the knowledge to manage their sleep patients' care and use both the sleep center and the sleep physician to optimize that care. Because of high costs, primary care physicians would benefit from financial incentives to manage the care of their sleep patients, just as they do with hypertensive or diabetic patients. These primary care physicians would most likely prefer to have at their disposal either portable or in-laboratory testing depending on the type of disorder they suspect, the cost of the test, the turnaround time from diagnosis to treatment, and the personal preference of the patient.
If academic sleep centers were to focus on training primary care physicians to identify sleep disorders, the rate of sleep disorder identification, diagnosis, and treatment would improve. As the medical profession and the population at large begin to recognize the widespread impact of sleep disorders, the same effort put into raising awareness of heart disease and diabetes will undoubtedly be applied to sleep disorders.
William C. Dement, MD, PhD, is a professor of psychiatry and behavioral sciences at the Stanford University School of Medicine, Stanford, CA., as well as chief of the newly established Division of Sleep Medicine. Robert Koenigsberg is president and CEO of SleepQuest Inc, Redwood City, CA. Contact them at email@example.com.
Since the time this study was published there have been some improvements in the Medical School education process; however most physicians in practice today attended medical school prior to any enhancement in sleep medicine education, and they subsequently suffer from a severe lack of understanding when it comes to properly identifying and treating patients with sleep-related issues.
One of the main goals of the Sleep Education Consortium is to provide continuing medical education (CME) courses for physicians that will help them identify and treat patients with the most common sleep disturbances.