Raghu Upender, MDRaghu Upender, MDAssistant Professor in Assistant Professor in Neurology Neurology Medical DirectorMedical DirectorVanderbilt Sleep Disorders Vanderbilt Sleep Disorders CenterCenter
Referrals for sleep services have increased 12-fold in the last 10 years.
Obesity epidemic and aging population are driving demand for sleep services.
1/5 Americans has mild sleep apnea.
1/15 has moderate or severe sleep apnea.
70% of men and 56% of women over 50 have moderate to severe sleep apnea.
Obesity in Tennessee
2011 2030
29 % 63%
AASM accredited labs 337 in 1996 2,461 in 2012
Medicare expenditure on sleep testing $62 million in 2001 $235 million in 2009
“We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value.”
-Dr. Fred HoltMedical Director
BCBS, NC NPR news-Jan 2012
"This is a good example of something where we have technology, we have financial incentives to use more of it ... You have enough problems, including a growing obesity epidemic, and you sort of put together the so-called perfect storm for driving up overuse and health care costs.”
-Helen DarlingPresident
National Business Group on Health
"I believe lab tests, as opposed to the home tests, are being wildly overprescribed…it should be 70 percent at home and 30 percent in the lab.”
Michael BackusVP of American Imaging
ManagementWellPoint
Treat wide range of sleep disorders with an aim to:
Improve sleep quality and daytime functioning Prevent fatigue related accidents/errors Prevent or reduce risk of chronic medical
conditions (hypertension, heart disease, diabetes, stroke, headaches)
Improve overall quality of life
Review interconnection between Sleep and health Sleep and chronic illnesses
Review sleep apnea treatment outcomes Review the cost of untreated sleep
apnea The future of sleep medicine Vanderbilt strategy
Daytime sleepiness Fatigue related
accidents Medical errors Depressed Mood Decreased Productivity Increased absenteeism
5
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9
1950 1960 1970 1980 1990 2000 2010
Slee
p (h
ours
)
0%
5%
10%
15%
20%
25%
30%
35%
Obe
sity
Pre
vale
nce
SleepObesity
Sleep & obesity in the U.S.
Fred Turek
Obesity is the strongest risk factor for obstructive sleep apnea (OSA)
Each increase of 10 kg in weight doubles the risk of OSA
OSA contributes to weight gain causing a vicious cycle
Obesity OSA
DiabetesHypertensionHeart diseaseStrokeCancer
Pepard et al. NEJM 2000;342(19) 1378-1384
Bottini et al. Respiratory Medicine (2012)106, 1329-1334
FATAL EVENTS NON-FATAL EVENTS
Marin JM et al Lancet 2005;365:1046-53
Martınez-Garcıa et al. Eur Respir J 2012; 39: 906–912
Martinez-Garcia et.al. Eur Respir J 2012; 39: 906–912
Aronsohn, RS et al. Amer J of Resp and Critical Care Medicine 2010; 181: 507–513
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 6 (2012) 176–179
Nieto et al Am J Respir Crit Care Med2012;186: 190–194
Attention and Vigilance
Memory function Frontal lobe
executive functions
Motor function
Reaction Times Principles and Practices of Sleep Medicine 2011
Motor functionAttention and
VigilanceMemory function Frontal lobe
executive functions
Short-Term Patient satisfaction Quality of life
measures Productivity measures Health measures▪ Weight & BP▪ Glucose control (HgA1c)▪ Lipid control▪ CRP
Long-Term Hospitalization
rates Cardiovascular
events Cancer incidence Dementia
Incidence Mortality rates
Patient engagement Care coordination Outcomes
measurements Cost-benefit analysis Iterative Process
Care Coordinator Patient Education Patient Engagement Partnership with Primary Care Physicians Medical Home Medical neighbor Partnership with Vanderbilt Health Plan Cost-sharing Cost-benefit analysis Web-app to Coordinate activity of
Program
The future of our field will be dictated by our ability to show how our services add value to the healthcare enterprise.
We must focus on short and long-term outcomes and design our practices to maximize best outcomes.
We must see the evolving changes as an opportunity to fulfill the promise of better sleep.