Professional Attitudes about Sleep Technology Equipment: Part II

From the sleep doctor’s perspective, there are only a few resources from which they would typically gain new information to make decisions about selecting pertinent technology for their patients. The most common source in this day and age of alleged cost-consciousness would be how PAP modes are ranked by insurance reimbursements. As the vast majority of sleep physicians prescribe CPAP, and in most cases presume that all CPAPs are equivalent, then cost becomes the final arbiter in the decision for which brand of CPAP to select. Of course, a sleep doctor who is simply referring patients to a DME may show no preferences and leave it to the DME to determine the brand of CPAP, and we would expect in most instances the DME would also use cost as the final arbiter. The exception to this rule, for which there are no available data, arises when a sleep physician prescribes brand-specific PAP modes for whatever clinical, cost, or lifestyle reasons, the latter exemplified by travel considerations.

Beyond this straightforward decision-making process, we next find sleep physicians who regularly read the scientific sleep literature, from which they would again be reinforced with the idea that the use of other devices beyond CPAP provides no further benefits except in rare to occasional circumstances. Unfortunately, this view represents a gross misreading of the sleep literature as we described in a paper which is currently under review for publication. One specific point we make and have described elsewhere is that the literature on BPAP and ABPAP devices is heavily slanted toward studying patients who do not need these devices. In other words, no one that I am aware of is suggesting that BPAP or ABPAP devices are needed in straightforward or classic sleep apnea cases, yet the research studies comparing CPAP to BPAP or CPAP to ABPAP frequently declare the devices yield identical results, which I would argue tells us nothing. If BPAP or ABPAP are relevant, then they are relevant for patients who might need them, not for classic sleep apnea patients. Regrettably, only a very small amount of research has ever been conducted to test this theory; and, all the studies that have tested this idea indicate there are useful aspects to advanced technology (See references below for some of the best studies on the topic). 

Once sleep physicians develop entrenched opinions based on the scientific “evidence,” it would take stronger or more influential information to change their minds. One such piece of information, surprisingly or not, is word of mouth. Sometimes a sleep doctor treating one of his own patients might hear about a previously struggling patient at another center; this other patient (the one struggling with PAP) might be the brother or mother or friend of the patient speaking to the sleep physician. The story told might be that once the other patient was switched to advanced technology, provided by a competing sleep center or DME in the same city, the patient rapidly adapted to PAP. Despite the anecdotal case history, the sleep doctor in question may wonder whether or not consideration should be given to the advanced technology. And, if such circumstances were repeatedly played out, it would certainly affect most business-minded professionals to consider new treatment options.

On the other hand, the field of sleep medicine at the local level often suffers from a huge gap in follow-up knowledge. That is, it is incredibly common for patients to drop out of care at one center and then seek care at another center without the first center ever hearing or knowing what happened at the second center. With data just from our own center since 2003, we know of roughly 2500 patients who had attempted sleep disorders’ treatment at another facility before seeking care at our center, and more than 90% of these patients had already attempted and failed CPAP or were currently struggling with CPAP while continuing to use it, and it is very unclear to what extent other sleep centers in our locale hear about how we had switched these patients to ABPAP or ASV. Also, by comparison to those struggling, few patients would have sought care at our center simply to get new supplies or because they had moved to New Mexico.

Another way in which a sleep physician may be influenced would be at conferences with other sleep physicians. Regardless of what might be covered in the lecture halls, person-to-person interactions sometimes have the greatest influence, because someone may hear that BPAP or ABPAP is working much better in their more challenging OSA/UARS cases.

All these influences are highly relevant, each in their own way and their own circumstances, but the biggest factor in this whole process is the role of the technology manufacturers who make the products we use to treat our OSA/UARS. These companies are the biggest movers and shakers in the field of sleep medicine, because they have done more to enhance PAP compliance than any other entity in the this mix of professionals and institutions, just by their massive efforts to enhance mask technology.

By way of analogy, think back to a time when so many cancer patients rejected return trips to chemotherapy because of the horrible side effects of nausea and vomiting. What changed that world was newer drugs and integrated combinations of drugs that now markedly decrease these burdensome side-effects. New mask technology has rapidly changed the field of sleep medicine in a similar way by eliminating so many of the side-effects associated with older and less comfortable, if not painful masks.

In the next post we will delve further into the role of PAP manufacturers and their impact on professional attitudes towards sleep technology. 

References

  1. Ballard RD, Gay PC, Strollo PJ.Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure.J Clin Sleep Med2007; 3(7):706-712.
  2. Gulati A, Oscroft N, Chadwick R, Ali M, Smith I.The impact of changing people with sleep apnea using CPAP less than 4 h per night to a Bi-level device.Respir Med2015; 109(6):778-783.
  3. Krakow B, Ulibarri VA, Romero EA, Thomas RJ, McIver ND.Adaptive servo-ventilation therapy in a case series of patients with co-morbid insomnia and sleep apnea.Journal of Sleep Disorders: Treatment and Care2013; 2(1):1-10.
  4. Gentina T, Fortin F, Douay B, Dernis JM, Herengt F, Bout JC, Lamblin C.Auto bi-level with pressure relief during exhalation as a rescue therapy for optimally treated obstructive sleep apnoea patients with poor compliance to continuous positive airways pressure therapy--a pilot study.Sleep Breath2011; 15(1):21-27.
  5. Carlucci A, Ceriana P, Mancini M, Cirio S, Pierucci P, D'Artavilla LN, Gadaleta F et al.Efficacy of Bilevel-auto Treatment in Patients with Obstructive Sleep Apnea Not Responsive to or Intolerant of Continuous Positive Airway Pressure Ventilation.J Clin Sleep Med2015; 11(9):981-985.

Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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