The Third Pillar of Health

 

Richard K. Bogan, MD, has worked diligently in the field of sleep medicine for a long time. It seemed inevitable that the medical community would eventually come to realize what Bogan and his colleagues have known for a long time: sleep is no less important than diet and exercise when it comes to overall health.

From the occasional article in the mass media in years past to a recent headline in Time magazine proclaiming sleep the “new health frontier,” it’s clear that physicians and patients understand the importance of sleep. As chief medical officer of Sleep Med Inc, Columbia, SC, Bogan has seen awareness blossom, and these days he is more confident than ever about the future of sleep medicine. Ultimately, that future must encompass all of sleep disordered breathing, from obstructive sleep apnea to insomnia.

Sleep Diagnosis & Therapy chatted with Dr. Bogan about growing awareness and the need to respect all sleep disorders.

How would you Characterize the level of Awareness about Sleep Apnea in 2014?

Richard K. Bogan, MD, chief medical officer, Sleep Med Inc, Columbia, SC: The general awareness of not only sleep apnea, but all sleep disorders, is certainly increasing. The world has begun to recognize that sleep is one of the three legs of health, and there’s a lot of awareness from the consumer perspective, but certainly from the
clinical perspective, moving beyond sleep apnea.

How much did the Fatal Train Accident in the Bronx–where the Driver was Diagnosed with Severe Sleep Apnea–put the Spotlight on the Occupational side of Sleep Health?

The industry is beginning to figure this [occupational benefits] out. Not only large employers, but national providers and third party administrators–those people are thinking in terms of employee wellness. They are interested. They have been interested in nutrition and exercise, and now all of a sudden sleep is beginning to be very important for these sort of national players, as well as consumers.

Does this Concern Extend Beyond the Commercial Transportation Aspects?

Yes. People who snore, people who have insomnia, and people who may have other sleep disorders can have productivity issues. This can lead to mood disturbances, even substance abuse. All those things are downstream effects. So the employers are now incorporating concepts of employee wellness with some screening measures.
This is obviously important in the transportation industry where we are well aware of the liabilities of poor sleep. It’s not just an adequate quantity of sleep, but the quality of sleep, and its continuity.

What Drives Real Change in the Work World?

Some of it has been legislated, particularly in the trucking industry. The truckers still have to have a physical done to get their commercial drivers license, and at the moment at least, it’s up to physicians whether the individual should go on and have a sleep study. The intent is not to remove people from their jobs—it’s to recognize the disorder and treat it to improve functionality. Functionality, alertness, attentiveness, and productivity all lead to reduced health care costs and an improved bottom line.

What Should Sleep Clinicians be Concentrating on these day?

There is a focus on sleep apnea, but it really should be on sleep disordered breathing. It just so happens that sleep apnea is the more prevalent form of abnormal breathing during sleep.

However, we could have obesity hypo ventilation syndrome, or patients with underlying neurologic abnormalities—particularly individuals who have weak muscles, extrinsic lung disease, and underlying lung disease that can affect breathing. during sleep. When you start mixing all those up, you can have all kinds of abnormal breathing that can occur. We should be thinking in terms of sleep disordered breathing, not just sleep apnea.

From the Perspective of Chronic Disease Management, how Should Sleep Clinicians be Handling Sleep Disordered Breathing and/or Insomnia?

There is a tendency to make the diagnosis and initiate therapy, and it’s all oriented toward making the diagnosis. There has not really been chronic disease management and assessment. The sleep industry is moving in that direction, which is a good thing. By now, the issue is, what’s your diagnosis, do you have sleep apnea or not, and what’s your number? And then what’s your CPAP level? After that, there is no real follow up of a chronic disorder, which likely will get worse, by the way. As you get older, it can change, and as weight changes, it can change. The downstream effect is the significant potential worsening of a patient’s cognitive executive function.

Manufacturers of CPAP and CPAP Masks are Constantly Striving for Enhanced Comfort. How well have they done Judging Strictly by Compliance Numbers?

With the newer CPAP devices, we have better measurements of compliance and adherence to CPAP therapy. We’ve begun to recognize that there is a certain percentage of patients who can’t or won’t wear the device, and that may be as high as 25%. When we look at adherence, which is the term I prefer rather than compliance, we know that the numbers can drop even lower.

How Receptive are Sleep docs to Oral Appliances?

It is natural for clinicians to consider alternative therapy, and it’s clear that in some patients,
alternative therapy may be benefi cial. Even if it’s suboptimal therapy, maybe sub optimal therapy is
better than none, and adherence might be better–and it might not. There is some evolving data that shows that while upper airway appliances may be sub optimal, at least patients wear the device.

I think the adjustable oral appliances have certainly improved in terms of comfort and to some extent, efficacy. They still can’t predict who is going to respond, and that’s the problem. It is a bit of trial and error, so there are some problems with this system in terms of comfort and adherence and efficacy. But the upper airway appliances have increased in relevance in the sleep therapy arena.

Are there any new Devices that you Find Interesting?

The Winx system is evolving. This is an oral appliance that creates negative pressure. All of us have our eye on it as they look to newer generation devices that might be more predictable in terms of effi cacy. It creates negative pressure at the junction of the soft palate. Its function is to keep tissue from collapsing. It’s FDA approved, and it does not have broad distribution.

What is the State of Cooperation Among Sleep docs and Dentists, and how can it be Improved?

I think that’s very regional. My impression is that when you have a local sleep expert that has a lot of interest, and personally develops relationships with dentists—that is a very favorable situation because they work together as a team. Again, this is a chronic disorder. It goes beyond just the upper airway obstruction.

How Informed are Dentists about Sleep Disorders?

They are improving in terms of their knowledge base through the American Academy of Dental Sleep Medicine, but it’s not just a matter of relieving the upper airway obstruction. Patients may have functional abnormalities, executive cognitive changes, narcolepsy, and all of those feed in to impact the sleep process, and it’s not always
sleep disorder breathing. Narcolepsy, for example, can be diffi cult to diagnose and treat, and it requires a sleep physician with experience.

There may be co-morbidities, maybe even insomnia associated with the disorders, so I worry that dentists are thinking in terms of “What’s your AHI number, and what’s your age, based on some measurement— whether it’s a home study or an in-lab study. And then they create an upper airway appliance with different ways of following up. But they are not physicians, and they are not intimately aware of the severity of the disease and the co-morbidities that dictate the need for dentists and the sleep physicians to work together.

But you Agree that Oral Appliances Should be the Purview of Dentists?

I wouldn’t try to make an upper airway appliance, and I don’t think a dentist should be treating a medical disorder without some help. When we see patient, not only are the patients presenting to us with a complaint, we’re in the business of helping them feel better by finding the cause. We do risk ratifi cation. I’m not sure that dentists are fully equipped to do that.

What Areas of Sleep Medicine do you Believe are most Ripe for Research?

We now are recognizing that sleep is necessary for us to exist. Sleep apnea, insomnia, and narcolepsy can all affect our crucial sleep patterns. So with employers now recognizing this, I think we’re ripe for doing research in terms of fi nding which models we should adopt to help consumers and employers recognize individuals who are suffering. Is it a sleep wellness program? What impact does it have on the outcomes?

Are there quantitative measures that we can look at in terms of the downstream effects on comorbidities and health care costs? The ability to look at functional, as well as health care delivery costs when we intervene, is a very ripe process. And sleep medicine is looking into that. We’re developing our Sleep Med network of clinicians with whom we will work to make sure that we have high quality accurate assessment of out patients, appropriate delivery of care, and effective outcomes—and we have a system that allows us to look at the diagnosis and therapy and outcome measures and big data basically to asses all of these processes to see what the outcome is.

How does your Company Address these Problems?

We have well over 400 sleep experts who are tightly affi liated with us and growing. Through the development of our broad network, and coordination of our IT platform, we can assimilate all this data. We actually are doing some early pilot studies with industry, some national payers as well as a large employer. This will be great for the sleep community.

How long have you been Involved with Sleep Medicine?

A long time. I’ve always been interested in regulation of breathing. As a medical director of respiratory therapy at a large hospital, I started a sleep lab in the early 1980s. My lab was actually accredited in the late 80s. I was one of the fi rst labs to be accredited. None of us really realized the relevance all of these sleep disorders, and it eventually became apparent that there were not enough people to take care of these folks.

Pulmonary positions at that time were more oriented towards taking care of people when they’re awake, and not thinking about what happened to them when they were asleep.

Estimates about the Numbers of Undiagnosed People can be Enormous. Do you Believe those Figures?

It’s still the majority who have not been diagnosed. So maybe we have diagnosed 20% by now. I think it still is grossly under diagnosed. How well have Sleep Physicians and Sleep Labs Capitalized on the Business Potential of Sleep? The sleep business arena is huge, and the current health care delivery system is trying to fi gure it out
and determine the value.

How well have Sleep Physicians and Sleep Labs Capitalized on the Business Potential of Sleep?

The sleep business arena is huge, and the current health care delivery system is trying to figure it out and determine the value.

 

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