Author: Michael Kelley
Trucking industry reacts to Truck Crash research
ASBA members tent to spend a great deal of time reviewing literature to support clinical and practice management decisions. There is a great deal of peer reviewed information that guides the field of sleep disordered breathing. ASBA Diplomates are very much aware of how rigours of reading and understanding the foundational articles that form the basis for the practice. Bob Stanton Transportation editor for Sleepscholar.com wrote the below article as a rebuttal to an article that appeared in landline magazine. The practice of attacking the messenger that the Owner Operator Independent Drivers Association has undertaken recently after the first peer reviewed article on sleep apnea and truck crashes. Take a read and let me know what you think- ed The Owner Operator Independent Drivers Association (OOIDA) has, and will probably always be, one of the most vocal trucking industry groups opposing sleep apnea screening testing and treatment in trucking. One of their major valid points of opposition has been the lack of clear peer reviewed studies making a statistically valid correlation between untreated sleep apnea and increased risk of crash. This is a point I have made in previous Sleep Scholar articles. Recently Burks et al published a new study coming in the journal Sleep “Non-Adherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes.” Information requesting a pre-publication copy of the study can be found at http://www.aasmnet.org/articles.aspx?id=618. The Burks study is good research using both excellent medical criteria combined with the best of transportation accident analysis to make not only a clear crash risk correlation but make it in preventable crash where all reasonably confounding variable from a transportation crash research standpoint were also controlled. In an LandLine Magazine Article OOIDA questions the objectivity of the latest study. www.landlinemag.com/Story.aspx?StoryID=30846 Sleep Scholar readers might enjoy reading how good peer reviewed research is criticized in trucking industry press. The following was submitted as a letter to the Editor of Landline Magazine. Due to the length it is unlikely to be published by OOIDA. It is provided here for your reading pleasure. TO THE EDITOR – LANDLINE MAGAZINE The article “Ooida questions objectivity of latest Sleep Study” got it wrong. Instead of being critical OOIDA should be celebrating it as a victory. “They” finally did what we’ve been calling for. “They” published good research making a correlation between untreated sleep apnea and increased risk of crash in CMV operators in the US. Ever since the 2008 MRB-MEP report came out, the research cited to justify sleep apnea screening and testing has been a joke. BUT… here is the problem. Trying to argue against a sleep apnea crash risk correlation is like trying to argue that when it rains water will not flow downhill. Sleep apnea crash risk has been studied all over the world. It’s been studied in 4 wheelers and truck drivers. It’s been studied using insurance claims data, police accident data, and simulators. In Europe it is accepted as fact to the point that effective January of this year ALL drivers, not just CMV operators, have to be screened for sleep apnea. In the US when it’s been studied, it’s been like studying what happens to water when it falls on a perfectly flat truck stop parking lot. On a truck stop parking lot it doesn’t flow downhill. But, does that change the facts? On the other hand, if you want a truck stop to pay for an expensive storm water system, providing research it’s needed is just common sense. Demanding research like this is part of why public law 113-45 went through Congress with no opposition. The Parks study showing no sleep apnea crash risk (FMCSA Technical Report 125) looked at older experienced drivers doing local pickup and delivery work where more of them had sleep apnea and compared them to younger drivers doing interstate line haul work. Other studies showing no increased crash risk have just asked drivers “How many accidents have you have in the past (x) years.” Not a good research technique. This study not only used the most accurate method of testing for sleep apnea, it used reported accidents, DOT reportable accidents and analyzed them for preventability (eliminating accidents that clearly were not the fault of the driver). Drivers in the study had an option to appeal a preventable accident determination. I was a driver at Schneider during the study and was on an accident review board. This study went further than FMCSA has done in CSA. This study looked at accidents per mile driven and accounted for years of driving experience, type of work assignment, age of driver, practically any variable that was controllable that might statistically affect accident rates. The only variable they couldn’t account for was that drivers who refused treatment might have a more general disregard for safety regulations in general. It’s not ethical to conduct research that puts either the participants or the general driving public at risk. You can’t test drivers for sleep apnea and then let some drive without treatment to see what their accident rates are. This study used the best research methods available and did what good research is supposed to do. They discussed the limitations of the study in their conclusions. The lead author is a former truck driver. The study was funded by 10 different sources of which Schneider was only one. None were groups with an “agenda” like The John Lindsay Foundation, National Sleep Foundation, American Academy of Sleep Medicine, Road Safe America, CRASH, or other safety advocacy groups we are all familiar with. VTTI has published non-peer reviewed research showing sleep apnea crash risk. Fusion Sleep has also published data from their own testing programs. But VTTI is the “pet” researchers for FMCSA and Fusion Sleep publishing its own data is just sales material. This was peer reviewed research published in one of the most respected research journals in the world. I’ve written for the Journal of Clinical Sleep Medicine. Peer review means that other researchers with expertise look at EVERYTHING about your study and critique it. If it’s not correct your study never gets published. What’s sad is that Schneider has nothing to gain financially from a sleep apnea rule. Its program was actually started by a caring occupational health nurse Wendy Sullivan who was tired of doing return to work exams on drivers hospitalized for conditions aggravated by untreated sleep apnea. Wendy was saying the same thing Dr. John McElligott has been preaching to drivers since I first met him. Untreated sleep apnea is the engine driving many driver health problems. This is not to say there are not LOTS of other problems to address with sleep apnea rulemaking. Even something as simple as, Who Pays? Just Friday I dealt with another driver popped for a sleep study by a medical examiner. He got a sleep study from a local sleep lab but his insurance denied the claim. The sleep lab is now holding the paper copy of the results hostage until he pays the $ 800 bill. I referred him to a reputable sleep lab (not the one I work for) that will retest him for the OOIDA member price of $ 250. Working with medical examiners we need to develop screening criteria that meet insurance requirements for “medical necessity”. This study can do real good for drivers. A problem is that sleep apnea can be mild to severe. A problem is determining how bad a driver’s sleep apnea needs to be to warrant requiring treatment or a DQ on a medical card. I have severe sleep apnea. When I think back to what I was like before I got tested and treated it scares the begeebers out of me. But not everyone who has some level of sleep apnea poses the level of safety risk I did before treatment. This study now has accurate sleep study data with good accident records. Follow up research to help set the AHI requiring treatment will help drivers currently being forced into treatment by companies or medical examiners scared about liability, when medically it may not be required. Instead of trying to question the objectivity of the study, drivers and OOIDA should be chalking this up as a win. Anyone who knows a lot about a particular subject has to make a living. In my opinion the conflicts of interest and objectivity problems raised in the OOIDA article are not valid. If we use the logic of the story, Todd Spencer and Andrew King have conflicts of interest in their quotes as they both receive support from OOIDA. Let’s get real. Bob Stanton Conflict of Interest Statement: The author Bob Stanton is a working truck driver and OOIDA member who has been under treatment for severe sleep apnea since 2002. He is the Co-coordinator of Truckers for a Cause a volunteer patient support group for drivers with sleep apnea. He has received consulting fees from Safety First Sleep Solutions and The Center for Sleep Medicine. He currently is an advisor to Dedicated Sleep. He has received donations of CPAP and CPAP supplies from a variety of manufacturers for distribution to drivers in need at major trucking shows. He has authored a variety of articles and made multiple presentations to sleep medicine conferences and groups on the issues involved with sleep apnea screening and testing in CMV operators. See LinkedIn profile for details.
Feds seek input for DOT Sleep Apnea Screening Guidelines
ASBA Members are participating in this effort to establish guidelines for sleep diagnosis and therapy that will provide a standard for DOT and providers of care throughout the United States. There has been an effort over the last several years to establish some federal standards that would give some guidance regarding CPAP use and diagnostic testing procedures for commercial motor vehicle operators and rail crews. The article below was written by Bob Stanton for Sleepscholar. Bob has been very involved over the years as a working truck driver and patient activist in the transportation field. I really liked this article because it provides all the links to participate in the Department of Transportation’s Advanced Notice of Proposed Rule Making. This is a tremendous opportunity for ASBA members to not only educate themselves on sleep standards for commercial motor vehicle operators but to also participate in developing those standards. DOT begins rulemaking on sleep apnea for CMV operators and rail crews. The Department of Transportation (DOT) has issued an Advanced Notice of Proposed Rule Making (ANPRM) seeking information on sleep apnea in safety sensitive positions within the Federal Motor Carrier Safety Administration (FMCSA) and Federal Rail Authority (FRA). This link is to a press release on the ANPRM that will give you general information. https://www.fmcsa.dot.gov/newsroom/us-dot-seeks-input-screening-and-treating-commercial-motor-vehicle-drivers-and-rail-workers Links within the news release should let you access all 24 pages of the actual ANPRM. If you are not used to the alphabet soup of FMCSA rulemaking you need to understand this is the first step in a very long process. Elaine Papp former Chief of the FMCSA medical programs office feels that developing a final rule on sleep apnea will take 4-6 years. A major complicating factor will be the new White House administration that will take office. The Administrator of FMCSA is a White House appointment requiring Senate confirmation. Elaine just did an excellent driver friendly radio show podcast explaining this process if you are interested. http://www.blogtalkradio.com/truthabouttrucking/2016/03/24/driver-fatigue-what-you-need-to-know-about-fmcsa-rulemaking-for-sleep-apnea Another hurdle this rulemaking will have is passing a White House Office of Management and Budget (OMB) cost effectiveness analysis. Prior to Burks et al discussed later, good research establishing the rate of sleep apnea crash risk was not available. Even with this new data the OMB cost effectiveness analysis will be a hurdle. This ANPRM is open to public comments from anyone with an interest in the topic. Comments are not limited to medical groups or associations. As of writing there are already 113 comments submitted. While many are from drivers several are from either DOT medical examiners or sleep medicine professionals. The American Academy of Sleep Medicine (AASM) and American Sleep Apnea Association (ASAA) have both expressed plans to submit extensive comments. Comments are due by June 8, 2016. They can be submitted online via the Regulations.gov portal. Docket FMCSA-2015-0419. The DOT has included 20 questions they are seeking input from stakeholders on. Skip to page 19 of the ANPRM if you want. You can comment on any or all of the questions or just make general comments. Comments that cite specific research or evidence to support your comment often are given more weight in agency deliberations. Request for Comments The Agencies request public comment on the questions below. In your response, please provide supporting materials and identify your interest in this rulemaking, whether in the transportation industry, medical profession, or other. Questions Reprinted From DOT, ANPRM (public comment is described in the document) The Problem of OSA 1. What is the prevalence of moderate- to-severe OSA among the general adult U.S. population? How does this prevalence vary by age? 2. What is prevalence of moderate-to- severe OSA among individuals occupying safety sensitive transportation positions? If it differs from that among the general population, why does it appear to do so? If no existing estimates exist, what methods and information sources can the agencies use to reliably estimate this prevalence? 3. Is there information (studies, data, etc.) available for estimating the future consequences resulting from individuals with OSA occupying safety sensitive transportation positions in the absence of new restrictions? For example, does any organization track the number of historical motor carrier or train accidents caused by OSA? With respect to rail, how would any OSA regulations and the current PTC requirements interrelate? 4. Which categories of transportation workers with safety sensitive duties should be required to undergo screening for OSA? On what basis did you identify those workers? Cost & Benefits 5. What alternative forms and degrees of restriction could FMCSA and FRA place on the performance of safety- sensitive duties by transportation workers with moderate-to-severe OSA, and how effective would these restrictions be in improving transportation safety? Should any regulations differentiate requirements for patients with moderate, as opposed to severe, OSA? 6. What are the potential costs of alternative FMCSA/FRA regulatory actions that would restrict the safety sensitive activities of transportation workers diagnosed with moderate-to- severe OSA? Who would incur those costs? What are the benefits of such actions and who would realize them? 7. What are the potential improved health outcomes for individuals occupying safety sensitive transportation positions and would receive OSA treatment due to regulations? 8. What models or empirical evidence is available to use to estimate potential costs and benefits of alternative restrictions? 9. What costs would be imposed on transportation workers with safety sensitive duties by requiring screening, evaluation, and treatment of OSA? 10. Are there any private or governmental sources of financial assistance? Would health insurance cover costs for screening and/or treatment of OSA? Screening Procedures & Diagnostics 11. What medical guidelines other than the AASM FAA currently uses are suitable for screening transportation workers with safety sensitive duties that are regulated by FMCSA/FRA for OSA? What level of effectiveness are you seeing with these guidelines? 12. What were the safety performance histories of transportation workers with safety sensitive duties who were diagnosed with moderate-to-severe OSA, who are now successfully compliant with treatment before and after their diagnosis? 13. When and how frequently should transportation workers with safety sensitive duties be screened for OSA? What methods (laboratory, at-home,split, etc.) of diagnosing OSA are appropriate and why? 14. What, if any, restrictions or prohibitions should there be on a transportation workers’ safety sensitive duties while they are being evaluated for moderate-to-severe OSA? 15. What methods are currently employed for providing training or other informational materials about OSA to transportation workers with safety sensitive duties? How effective are these methods at identifying workers with OSA? Medical Personnel Qualifications & Restrictions 16. What qualifications or credentials are necessary for a medical practitioner who performs OSA screening? What qualifications or credentials are necessary for a medical practitioner who performs the diagnosis and treatment of OSA? 17. With respect to FRA should it use Railroad MEs to perform OSA screening, diagnosis, and treatment? 18. Should MEs or other Agencies’ designated medical practitioners impose restrictions on a transportation worker with safety sensitive duties who self- reports experiencing excessive sleepiness while performing safety sensitive duties? Treatment Effectiveness 19. What should be the acceptable criteria for evaluating the effectiveness of prescribed treatments for moderate- to-severe OSA? 20. What measures should be used to evaluate whether transportation employees with safety sensitive duties are receiving effective OSA treatment? There are several efforts underway related to this ANPRM. The AASM leadership along with the AASM Transportation and Safety Task Force are developing comments internally. The American Transportation Research Institute (ATRI) the research arm of the American Trucking Association (ATA) has a data gathering effort among drivers being launched at the Mid America Truck Show in Louisville starting March 31. They will also have data gathering efforts for motor carriers. A special data gathering effort will be directed to sleep medicine testing and treatment firms. Question 9 in the ANPRM asks about testing and treatment costs. An issue that has already come out is that major firms with trucking company contracts are reluctant to share actual cost data, as that is proprietary competitive bidding information. ATRI has a reputation within the trucking industry for doing compilation and aggregation studies of confidential salary, freight rates, turn over, and other sensitive information to produce industry average data. Look for more information on this in future Sleep Scholar articles and in sleep medicine on line news outlets like Sleep Review. This was a major reason there were calls for FMCSA to clarify OSA issues. Another breaking news item on the transportation front has been the publication of Burks et al. in Sleep. This news release from the AASM on the study has information on how to request a pre-publication copy. http://www.aasmnet.org/articles.aspx?id=6186 Prior to the publication of Burks the research on sleep apnea crash risk was mixed at best. It has been the topic of a previous Sleep Scholar article of mine and a recent commentary in the Journal of Clinical Sleep Medicine. Burks used data from the Schneider National carrier long standing sleep apnea testing and treatment program. Taking drivers who refused or were never compliant on treatment it analyzed their accident records for the time between diagnosis and termination for cause for non-compliance. Improvements in compliance and removing unsafe non-compliant drivers more quickly has been done since. They used PSG sleep study data from 2005-2008 before HST was widely used. Using a matched pair methodology the study analyzed both sleep apnea and crash in a variety of ways. What is most striking about this study is that it addressed confounding variables in trucking safety such as miles driven, type of driving, experience of driver, and crash preventability. This type of in depth of collaboration between sleep medicine researchers and experts in transportation safety is to be commended. The lead author Stephen Burks is a former truck driver. I am personally proud to have been a driver for Schneider under treatment for sleep apnea during the study period. Research ethics preclude the author confirming if my data was part of the study. Sleep medicine professionals should carefully address the questions relating to screening for OSA. A current recurring problem is that the screening criteria at times used by DOT medical examiners do not meet the definition of “medical necessity” for testing to be covered by insurance. This is especially true for tests negative for sleep apnea. Another issue sleep medicine professionals need to address in their comments is striking a balance between screening and testing to ensure no sleep apnea to a medical certainty versus screening and testing to establish a reasonable level of highway safety. Some commenter’s in previous recommendations to FMCSA on sleep apnea have recommended that with a high pre-test probability for OSA that no negative HST be accepted. All negative HST should be confirmed by a PSG. The reaction from trucking has been “After spending $4-500 on an HST that says I don’t have sleep apnea you want me to spend another $ 2,000 on an in-lab study to prove the same thing?” In my personal opinion if recommendations from the sleep medicine community retain this approach to negative testing, the rulemaking will not survive the OMB cost effectiveness analysis. All CMV drivers have to get a renewed DOT medical exam on a 1 or 2 year cycle depending on a variety of factors. Drivers who had screened high risk and were required to get a sleep study in the past which came back either negative or an AHI low enough to not require treatment (AHI or severity requiring treatment or disqualification for driving is another question) will often screen high risk again. The question requiring comments from sleep medicine will be how long should a negative sleep study be good for? This question was raised in public comments to the 2012 MCSAC-MRB recommendations. The MRB chose not to address it in the final recommendations. Fortunately, in a formal rulemaking like this, FMCSA is legally required to address all reasonable comments. Analysis of change in risk factors along with the type of original test (HST versus PSG) combined with research available on the progression on OSA over time in CMV operators may yield reasonable recommendations. Those involved with dental sleep medicine should take a careful look at question 16 regarding credentials. They also should look at question 14 about restrictions while undergoing treatment. For oral appliances to be a cost effective option the issues around safety sensitive position workers being able to work while an OAT is being titrated would need to be addressed. A major research gap dental sleep medicine may have is establishing that drivers being treated with OAT show the same or better actual safety performance than drivers under treatment with other methods such as CPAP. Potential research to address this issue has been discussed but accomplishing and publishing before the June 8 deadline is unrealistic. The problem is that since OAT was not a treatment option recommended by previous FMCSA expert medical panels the pool of study participants is limited. Additionally dental sleep medicine should offer its opinions if compliance monitoring of OAT should be required or just recommended. A question not even addressed in the ANPRM is: Why isn’t the Federal Aviation Administration (FAA) in this rulemaking? As noted in the preamble to the ANPRM the FAA already has OSA screening and testing requirements for pilots and others requiring Aeromedical exams (AME). The current FAA requirements do NOT require a pilot deemed high risk for OSA by the AME to undergo a sleep study. The pilot’s primary care physician can clear the pilot. Issues around how the Americans with Disabilities Act (ADA) may play into pre-employment screening or any screening outside of a DOT medical exam will have to be addressed. Those with expertise in sleep medicine may want to look at the base medical qualifications of DOT medical examiners. MD, DO, NP, PA and DC are allowed to train and test to enter the National Registry of Certified Medical Examiners (NRCME) which is required to conduct a DOT medical exam. How scope of practice regulations for Doctors of Chiropractic (DC) will play into screening should be commented on. Sleep medicine professionals should voice their opinion on the appropriateness of OSA screenings conducted by chiropractors. This may require FMCSA to revisit the issue of DC’s being able to conduct DOT exams at all. This is a topic hotly debated among occupational medicine professionals. In my home state of Illinois a DC offering an opinion on any medical condition not commonly treated by a course of chiropractic is a violation of the state chiropractic licensing legislation. On encountering a medical condition not treated by chiropractic a DC may only refer the patient to an appropriate medical professional and may not charge for their services. How this will play out with DC on the NRCME performing OSA screenings and conditional certifications pending a sleep study should be commented on by sleep medicine professionals. Truckers for a Cause the patient support group for truck drivers with sleep apnea will be doing extensive written comments. We will be developing a collaborative “Google Doc” which we will make accessible through truckersforacause.com. If you have research or objective data addressing any of the ANPRM questions start compiling them or send me an e-mail (truckerdad57@sbcglobal.net) Also please submit your thoughts directly via the regulations.gov portal. From previous rulemakings often vendors or others that due to their employment feel direct public comments might be construed as being an official opinion of their employer are at times reluctant to submit comments. We will attempt to provide an option for these types of commenter’s to provide anonymous input. We hope to have this up in mid May. Please pass this information on to others in sleep medicine. If you are having a meeting of conference before June, please consider adding this as a topic. Given how long this has been anticipated the next couple of months will be interesting.
ASBA Members supporting NFLPA 2016 Former Players Conference
I was invited by David Gergen Executive Director of the American Sleep and Breathing Academy (ASBA) to attend the NFLPA 2016 Former Players Convention. I was there to demonstrate the value of home sleep testing in evaluating sleep disordered breathing using the Nox T3 by Carefusion. This is the second year that David has invited me to participate and I am grateful for the opportunity to contribute. I continue to be impressed with the effort the NFLPA takes to foster the community atmosphere for the former players. This year the ASBA added the oral appliance treatment component with the attendance of Eugene Azuma DDS. Dr Azuma and his daughter Erin participated by consulting former players, who were previously diagnosed with OSA but were untreated, on the benefit of oral appliance therapy. Dr Azuma is an Oahu HI dentist and member of the ASBA. He has participated in the ASBA Study Study Club, taken the Diplomacy review course and is writing his Diplomacy Exam on April 17th 2016. I really appreciated the energy and enthusiasm he brought to the meeting in Maui. I’m sure that other ASBA members want to start working with the NFLPA former players. There is a program to help former players with regional meetings at NFLPA Former Player chapters, this will begin after the April conference (contact David Gergen, David@myasba.com for details). Andre Collins Director of former player services really went above and beyond to help us communicate the importance of sleep apnea diagnosis and treatment. The light that the NFLPA has shone on the sleep apnea condition over the last 10 years has been very bright. David Gergen has developed many close friendships with former players including Roy Green, Derrik Kennard and Eric Dickerson to name a few. Eric Dickerson has confirmed his attendance at the 2016 Sleep and Wellness conference this April 15 and 16, 2016. Click Here to Register Eric Dickerson has become a real fan of the work that the American Sleep and Breathing academy has been doing and has even become an avid reader of Sleep and Wellness magazine the official magazine of the ASBA. The Agenda for the ASBA meeting is very strong with a little something for everyone. We have a 101 level breakout session lead by Dr. Erin Elliott, for dental teams new to the field. On the main stage we will have a presentation by Dr Jerry Weisfogel the first Cardiologist in the country to be board certified in sleep. His presentation will cover sleep from the perspective of the practicing cardiologist and Sleep apnea as a chronic disease requiring chronic care management. Click Here for the Agenda
Medicare and Private insurers raise rates for Sleep Apnea Dentistry
Sleep therapy continues to receive scrutiny by regulators and payors. Centers for Medicare and Medicaid have been monitoring patient outcomes and clinical yield for patients. There has been no formal announcement as to their findings however CPAP reimbursement continues to be cut while Oral Appliance Therapy reimbursement has officially been increased by Medicare. Revenue from code E0486 has doubled in recent months according to reports by ASBA members, Industry leaders predict that private insurance will follow Medicare reimbursement guidelines. Supporting this trend is the recent announcement by Cigna the first private insurer to develop a national policy for Oral Appliance Therapy, settling on $2500 as a bundled fee. In other regions fees have increased by 25 to 100%. Jurisdiction “D” reimbursement rates has remained unchanged. Insurers are expected to work with industry to monitor outcomes data to balance revenue and patient care expectations. It is also very significant and important to note that evidence of post graduate training and Diplomacy has become a method that some insurers use to deny insurance claims (this is new and bears watching). The American Sleep And Breathing Academy continues to monitor insurance reimbursement, and policies through its relationships with Washington DC insiders like Congressman Marty Russo and others. “In June of 2015 the ASBA was the first organization to warn Dentists of the risk to using the “S” code for billing TMJ Splints. Advance notice of this change saved ASBA members thousands of dollars in hard costs associated with billing errors and uncollected revenue.” – David Gergen CDT The latest opportunity identified by the American Sleep And Breathing Academy team of lobbyists is a new government protocol for chronic care management. CCM has the potential to contribute a strong revenue stream for sleep apnea dentists in 2016. The physician who developed the Chronic Care Program will be speaking at the Sleep and Wellness conference in Scottsdale AZ April 15 and 16. Make sure you attend this presentation, this may be one of the strongest new sources of revenue yet for dentists practicing sleep apnea dentistry.-ed CMS Bets on Oral Appliance Therapy a blog post Gergensortho.com A running discussion for the last 6 years here at Gergens Orthodontic Lab has been the CPAP as Gold standard of sleep therapy vs Oral Appliance therapy debate. These discussions usually go for hours and have gone on for years. The strongest debate has been between David Gergen President of Gergens Orthodontic Lab and executive director of American Sleep and Breathing Academy (ASBA) and Randy Clare from ASBA. Back and forth compliance vs treatment efficacy. David Gergen has been back and forth to Washington working with congressman Marty Russo trying to get some traction within the federal government on this issue. The key point of distinction of course is what drives medical care in the United States is reimbursement. The story for CPAP in the reimbursment arena since competitive bidding became an issue has slowly restricted access to care and fed a consolidation of providers. Fewer providers to provide care and the care they can afford to provide is less personal which results in lower compliance rates which results in lower reimbursement. January 1 2016 CMS cut CPAP reimbursement by 25%. Will this affect a diagnosed OSA patients ability to get great care of course it will. On the other side of the ledger Oral Appliance therapy has not been a focus for CMS. The OAT program has been way underfunded. This has made access to oral devices for sleep apnea difficult for medicare patients. Dentists were not finding it easy to provide care for these patients because reimbursement was so low. January 1 2016 CMS raised reimbursement for OAT to $3700 in jurisdiction B (see attached EOB) If you don’t know your jurisdiction for medicare I have also added a map for your use. I expect that this will increase access to care significantly. I feel it indicates a trend and perhaps insurers are ready to consider higher compliance rates and better return on sleep therapy dollars. After all the dental team sees the patient at minimum every six months which is a much better way to manage a lifelong condition with severe health implications.
Sleep Apnea Treatment- The Canadian Experience
So, you’re tired of feeling tired or hearing from your spouse about your snoring. You go to your family physician, which refers you to a Sleep Specialist. After the Sleep Study results are available you are told that you stop breathing in your sleep 30 times an hour, something that would concern most people. You are then told about lifestyle modifications that you may want to consider, and various therapeutic approaches. But the one they highly recommend, and that the government sponsored Health Plan covers is CPAP. Continuous Positive Airway Pressure, which involves blowing the appropriate level of air pressure up your nose on a continuous basis preventing your airway from collapsing during sleep. You simply breathe with and against the constant stream of air. This therapy is effective in preventing the airway from collapsing and eliminates snoring for virtually everyone. So, all is good! Until you take it home… About 1/3 of patients take to CPAP very well, and actually become missionaries telling everyone around them how it’s changed their lives. About 1/3 struggle with it daily and although they wear it to some degree, it is not all night and may not even be every night. For the remaining 1/3, you will find their CPAP stored under their bed or in their closet for a variety of reasons. Adherence studies have shown that after 6 years of prescription, 54% of patients are still wearing their CPAP. So, what happens to the other 46%? Mostly, they remain untreated. Let’s look at the reasons: Some do not feel it worth their while to return to their Sleep Specialist because they feel that CPAP is the only option available there, and they’ve already tried that. So, they remain untreated. Some return to their CPAP dispenser, which typically encourage them to try alternative masks and to stick with CPAP, explaining that it is the only worthwhile therapy, discouraging them from considering any alternatives. So, they remain untreated. Some, ask their family physician for guidance, often being referred for an ENT consultation for palatal surgery which has a success rate of <50%, consequently, few of these procedures are performed. So, they remain untreated. This of course is no fault of the family physicians because even when they attend CE courses promoted as “Current Management of Sleep Disorders: A Comprehensive Update”, all they hear about is CPAP. Some, go to the drug store and pick up an oral appliance over the counter that states the following on the label, “FDA Approved for Mild to Moderate Sleep Apnea”. Imagine that, the Regulatory Boards in Canada currently allow patients to manage their own Sleep Apnea! This of course ends up failing for a variety of reasons, so they remain untreated. The information these patients need is this, The American Academy of Sleep Medicine AND the American Academy of Dental Sleep Medicine Joint Guidelines state that an oral appliance is an appropriate therapy for All Severities of Sleep Apnea if the patient prefers an oral appliance to CPAP. This is the current “Standard of Care”. Adherence studies show us that long term oral appliance adherence ranges from 85-95% and that patients typically wear their oral appliance longer each night when compared to CPAP wear. Although oral appliances may not be as effective in reducing the apnea level in some patients, for most, the fact that patients wear them more often and for longer seems to make their overall benefit similar, current studies evaluating both Efficacy and Actual Use suggesting that they have a similar Mean Disease Alleviation as CPAP. Yet, patients often don’t hear about oral appliances as a viable option or are simply misinformed about their efficacy and or side effects. So, they remain untreated. Adding insult to injury, 30% of patients referred for a Sleep Study simply don’t go, 50% of these patients citing that they don’t want to wear CPAP as their reason. Considering that 82% of them would have tested positive had they gone, this increases the number of patients with OSA needing our help to an even higher level. What happens to these additional patients? They remain untreated. In countries like USA, France and Sweden, where government sponsored health plans cover oral appliance therapy. Many oral appliances are being delivered on a regular basis, even before trialing and or failing the use of CPAP. I guess for those countries, the answer for what happens to the other 46% is, they get an oral appliance! But in Canada, what happens to the other 46%? Unfortunately, all too often, they remain untreated! John Viviano DDS D ABDSM Links to the pertaining articles… https://www.linkedin.com/pulse/time-dentists-invited-front-room-john-viviano-dds-diplomate-abdsm?trk=pulse_spock-articles https://www.linkedin.com/pulse/cautionary-tale-physicians-dentists-regulatory-boards-john?trk=pulse_spock-articles
ASTHMA a Predictor of CHRONIC MIGRAINE ATTACKS
Pre-existing asthma may be a strong predictor of future chronic migraine attacks in individuals experiencing occasional migraine headaches, according to researchers from the University of Cincinnati (UC), Montefiore Headache Center and Albert Einstein College of Medicine, and Vedanta Research. The findings were published online in November in the journalHeadache, a publication of the American Headache Society. “If you have asthma along with episodic or occasional migraine, then your headaches are more likely to evolve into a more disabling form known as chronic migraine,” said Vincent Martin, M.D., professor of medicine in UC’s division of general internal medicine, co-director of the Headache and Facial Pain Program at the UC Neuroscience Institute, and lead author of the study. Dr. Martin teamed with Richard Lipton, M.D., and Dawn Buse, Ph.D., both of Montefiore Headache Center and Albert Einstein College of Medicine; and Kristina Fanning, Ph.D.; Daniel Serrano, Ph.D.; and Michael Reed, Ph.D., all from Vedanta Research, to study about 4,500 individuals who experienced episodic migraine or fewer than 15 headaches per month in 2008. “Migraine and asthma are disorders that involve inflammation and activation of smooth muscle either in blood vessels of in the airways,” said Richard Lipton, M.D., director of Montefiore Headache Center and vice chair of neurology, and the Edwin S. Lowe Chair in Neurology, Albert Einstein College of Medicine, and founder of the American Migraine Prevalence and Prevention Study. “Therefore, asthma-related inflammation may lead to migraine progression.” About 12 percent of the U.S. population experiences migraine, according to the American Migraine Prevalence and Prevention (AMPP) Study. This condition is three times more common in women than men, including 18 percent of American women and 6 percent of American men. Individuals with chronic migraine have headaches occurring 15 or more days per month; this condition affects one percent of the U.S. population and takes a severe toll on sufferers who often miss work and social events. The World Health Organization (WHO) rates migraine as the world’s seventh most disabling medical condition. The researchers analyzed data from the AMPP Study. Study participants completed written questionnaires both in 2008 and 2009. Based on responses to the 2008 questionnaire, they were divided into two groups—one with episodic migraine and coexisting asthma and another with episodic migraine and no asthma. They were also asked about medication usage, depression and smoking status. The 2008 and 2009 questionnaires included questions about their frequency of headache, which enabled the authors to identify the participants who had progressed to chronic migraine. Here are MD Spiro we feel that we are living in an era where we have new biological knowledge and new targets for therapy that can support patient management and care through diagnostics. It is the right time for healthcare professionals to take bold steps and move aware from historical diagnoses that are impeding modern medicine. References: http://www.mdspiro.com http://www.news-medical.net/news/20151130/Pre-existing-asthma-may-strongly-predict-future-chronic-migraine-attacks.aspx http://www.headachejournal.org/view/0/index.html http://www.who.int/en/ http://www.achenet.org/resources/ampp_studypub/
Public Awareness Provides Patients for ASBA Diplomates
David Gergen President of the ProPlayer Health alliance and executive director of the American sleep and breathing academy lead the team to victory last Tuesday night in Phoenix Arizona. Initially the idea of NFL football, Sleep Apnea and the Phoenix Police foundation don’t seem to fit together very well. It is important to understand that Sleep Apnea is a pervasive disorder that affects all walks of life and whose impact on performance at every level is real and measurable. Sleep apnea affects over 20% of the US population and unfortunately elevated body mass is a big part of the condition. The condition reached prominence with the death of Reggie White at age 43 he was a 13 time pro bowler who played at weights topping 290 pounds it was his size that put him in a group susceptible to sleep apnea. A study in the New England Journal of Medicine found linemen accounted for 85% of sleep apnea cases among the more than 300 NFL players tested. Sleep apnea is considered by some to be an occupational hazard for NFL linemen. So what is the connection with the Police force? After Studying 5,296 law enforcement officers in North America, a Harvard Medical school group reported that 40% of active duty officers suffered from sleep abnormalities. These include Apnea, Insomnia, shift work disorders, restless legs syndrome and narcolepsy. Yet sleep disorders in cops often go undiagnosed and largely untreated, according to Dr. Rudi Ferrate. For example, “almost half the individuals diagnosed with obstructive sleep apnea [a dangerous condition in which impaired breathing can lead to a heart attack or stroke] do not regularly take treatment,” he says. The sleep apnea event Padre Murphy’s in Phoenix January 26th 2016 was really a triumph of timing and execution. The Arizona Cardinals football team and its Executive Director and owner Nicole Bidwill chose to cosponsor a public sleep apnea awareness event with the ProPlayer health alliance and the Phoenix Police foundation. The publicity for the event was electric, driven by a season that saw the Cardinals win a franchise high 13 regular season games and earned their third NFC West division title. Cardinal superstar Larry Fitzgerald and Retired Cardinal Roy Green lead the event with David Gergen. I have been attending sleep apnea events for over 20 years and have never seen more than 400 people (and that was a ProPlayer Health Alliance event in Tacoma Washington). Imagine my surprise when I arrived at the event in Phoenix and saw crowd control in the parking lot and out on the street. There was a huge parking lot overflowing with cars and people thronging into Padre Murphy’s Sports Grill. The Phoenix Police reported that there were over 3000 people in attendance. The main area was so packed that people were being turned away at the door. At a certain point entrance to the parking lot was blocked off to new traffic. Inside the event everyone was excited to see Larry Fitzgerald and Roy Green. David Gergen in his roll as Master of Ceremonies was moving things along and the crowd seemed to really be enjoying themselves especially when they had the opportunity to get an autograph or participate in the phoenix Police Foundation auction (which offered many great autographed items). This was a huge night with many great moments. A few of my favorites were when Phoenix Police Chief Joseph Yahner presented Larry Fitzgerald and Roy Green with honorary Police officer awards. The crowd yelled Larry…Larry…Larry and surged forward sparking some concerned glances by security however the mood was great and everyone was having a great time. Eric Dikerson was really great when he put his hand on David Gergen’s shoulder and said to the crowd “Thanks to David Gergen for waking up the world to the dangers of Sleep Apnea” Mark Brnovich Arizona Attorney General who wears and oral appliance for his sleep apnea and Secretary of Transportation Alberto Gutier were also in attendance and wanted to make sure that the everyone understood the perils of sleepy driving and the importance to public safety of a good and restful night’s sleep. They are very impressed with the Sleep Herbst as an alternative to CPAP for commercial drivers including emergency response. I was very impressed to learn that 8 of the 40 Phoenix police officers made appointments with ASBA diplomate Mark Castle at Koala of Arrowhead, to be treated for their sleep apnea In Summary I think this event was really important milestone in the education of the public to the dangers of sleep apnea. The NFL players current and retired certainly had a great event. I understand from David Gergen Roy Green that he and Nicole Bidwill are in fact working on another sleep apnea event to kick off the 2016 season. I also heard that other teams around the league are considering adding sleep apnea awareness to their calendar. Congratulations to David Gergen and Roy Green for planning an excellent event that I’m sure laid a foundation for bigger and better public education events in the future.
Tips and Tricks for Implementation of Sleep Dentistry into your Practice
I have been attending entry level Dental CE courses for snoring and sleep apnea for over 20 years. It has always been fascinating to me that a dentist can take hundreds of hours of course hours but never really manage to get Sleep Apnea Dentistry implemented into his or her practice. This is an all two common occurrence and I thought the article below by Dr Erin Elliott does a great job setting out some really clear, real world. tips for beating “Wednesday Morning Syndrome”. The condition that some staff members find themselves in when the Dr gets back from a course with lots of new ideas is this generally results in the staff going home late until the Dr gets back on the program. Dr Elliott managed to avoid Wednesday morning syndrome and has built a tremendous footprint in Sleep Apnea Dentistry in her community and as President of the American Sleep and Breathing Academy. -ed Golf and dental sleep medicine – This article previously appeared in Dental Economics January 2016 What I have learned from 6 years of bad shots That’s right your next six months don’t have to be like my six years in dental sleep medicine. You have skills. Here are some tips to help you avoid some of the pitfalls that come with integrating anything new into your practice. Following these tips will let you spend more time on the fairway and less time looking for an errant drive. Fore! I have an amazing team. Gosh, I think they know me better than my best friends do. They also know that I love continuing education and dentistry. Therefore, over the years they’ve developed “Wednesday morning syndrome”. This means that when I come back from a course and I’m ready to implement a new program on Monday morning, all they have to do is avoid eye contact with me until Wednesday, and I’ll give up. Unfortunately for them (or so they thought at the time) this didn’t happen with dental sleep medicine. I know it would be hard to navigate the medical world, and I knew trying to get paid from medical insurance would be an uphill climb. But I loved being able to screen otherwise undiagnosed patients and treat a life threatening disease. I was helping patients get their lives back. So I kept it simple for a while. One main assistant and I did all of the dental sleep medicine. The other team members were happy to avoid all matters of sleep apnea because it was still very foreign, and I was afraid to “force” anything on them. Then came the turning point and the whole team had to jump in. We were busy- patients were calling and doctors were referring sleep medicine patients. The best decision I made was taking an afternoon off to teach dental sleep medicine to my entire team. This enabled them to answer questions over the phone. Thereby saving the fate of hundreds of sticky notes. The hygienists learned how to screen for undiagnosed sleep apnea, and the office manager learned the tricks of billing medical insurance. As in any dental office however, there was team turnover. Team members started showing up with baby bumps moving and of course, we had to terminate the rare team member who just wasn’t a good performer. How did I teach the new employees years of experience and get them treating sleep apnea patients in a short time? My answer I didn’t. I had two chairside assistants for general dentistry and one main dental sleep medicine coordinator. My golf partner Julie was an ortho assistant with 25 years of ortho experience and zero years of general dentistry experience. When my chairside assistant left for maternity leave, I asked Julie to fill in. She became a permanent employee when my assistant decided to stay home with her bundle of joy. General dentistry was foreign to Julie but she caught on quickly. Even though she was what we can call a “veteran” (i.e., older), she knew her way around computers, and she became a mama bear to the younger team members. As a bonus, she was able to help with my Six Month Smiles patients. She was always willing to help take impressions for our sleep apnea patients, but when it came time to do follow-up visits or deliveries, she bolted. She said she didn’t want to look like an idiot or like she was too old to learn anything new. She said there wasn’t enough room in her brain to add sleep apnea. I gave her the bad news. We were moving to two and a half days of fulltime sleep apnea, so there was no avoiding it. She had to learn it. If a patient needed an appliance adjusted, she could easily perform it, as she was comfortable working with nightguards. But what if a patient came in with a (gasp) side effect? How could I teach Julie the ins and outs of the paperwork and familiarize her with medical billing? Can you see why it was the path of least resistance to have my already trained and willing dental sleep medicine coordinator take care of it all? I needed to give Julie a systematic approach to helping the team treat sleep apnea. It is an entirely different beast. I had her watch some of my past webinars to get the basics of dental sleep medicine, but more importantly, I sat down with her to go over how to do a consult, how to deliver, how to adjust and calibrate an appliance, and how to troubleshoot on follow-up visits. This was a perfect analogy for the whole basis of our relationship— golf. She grew up on a golf course, and she was good at it and comfortable with it. I reluctantly learned golf as an adult, and I had been a beer cart girl for a local golf course in dental school. (I was a tutor and a beer cart girl. Isn’t that an interesting combination?) I didn’t want to learn golf because it didn’t come naturally to me, and I wasn’t instantly good at it. Besides, I grew up playing soccer. Now that was in my wheelhouse. Why learn something new now? The biggest mistake I made was allowing many amateurs to coach me, and I practiced a horrible swing over and over again. I just jumped into it and got frustrated. But like any golfer, the one Ladies Professional Golf Association-type shot I managed to pull out once in a while is what brought me back for more, even though I had 100 other wayward shots. Plus, golf was a necessity with my family and friends. I couldn’t give up. After 10 years, I finally took lessons from a professional, and my favorite sound in the world is my golf ball dropping into the cup. I love golf! But what if I had started with lessons from a professional immediately rather than listening to amateurs? I would have loved the game that much more. I wouldn’t have gotten frustrated, and I wouldn’t have wanted to give up. What’s my advice on becoming a good golfer? Take lessons from the start. Although I’m a far from perfect golfer, I can pull off a KP (closest to the pin) or longest drive award in my community golf tournaments. I can play a round with confidence. I can perform. Just as the professional coach gave me confidence in my golf game, I have given Julie confidence in the dental sleep medicine world. I have even given her a few mulligans as she was learning. She speaks with authority and can answer any questions patients throw her way. She is capable of getting a “hole in one.” The only reason I was able to coach her was because I gained confidence by taking the best courses in dental sleep medicine and continue to learn. It’s persistence and practice, just like in golf. Become trained and get your team trained now. Don’t give them a choice like I did. It’s never too late to learn something new, and it’s way better to learn how to do it correctly from the start. Change from an attitude of frustration (all of those missed shots!) to one of “I can do this!” LPGA, here I come! ERIN E. ELLIOTT, DDS, is a practicing general dentist in Post Falls, Idaho, where she has successfully integrated dental sleep medicine into her practice. She has lectured extensively, educating dentists on the benefits of incorporating this growing field of dentistry into their practices. She is an active member of her local and state American Dental Association components and is a member of the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine. She is the president and diplomate of the American Sleep and Breathing Academy. She can be contacted at erinelliottdds@gmail.com.