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Healthcare Uncovers Demand for Slumber

By Mark Green

Virtually everyone occasionally has trouble sleeping, but many unfortunate souls have problems every single night. Increasing awareness of medical issues involved, though, is spurring growth of healthcare facilities that diagnose and treat more than 80 underlying disorders in a nation of sleep-deprived Americans.

In Kentucky, the number of accredited medical facilities specializing in sleep disorders doubled in less than a decade from 25 in 2002 to 52 in 2011, according to the American Academy of Sleep Medicine (AASM). They range from dedicated areas in hospitals to free-standing buildings designed specifically for sleep disorder treatment.

Beyond making life miserable for the sufferer, poor quality sleep comes with an eye-opening price tag. Sleep disorders, sleep deprivation and sleepiness add an estimated $15.9 billion to the annual national healthcare bill, according to the National Center on Sleep Disorders Research. Other costs to society for related health problems, lost worker productivity and accidents can’t be calculated, but educated guesses begin at 10 times NCSDR’s healthcare cost tally.

Sleep disorders among their employees is the No. 2 health concern that Kentucky business and industry clients inquire about, ranking behind only substance abuse, according to an official with one major state healthcare system.

The NCSDR, part of the National Institutes of Health, reports about 70 million Americans suffer from sleep problems, nearly 60 percent of which are chronic.
And sufferers are demanding treatment.

The medical establishment has responded with major growth in sleep disorder clinics and other facilities the past decade. Nationwide from 2002 to 2011, the number of sleep centers more than tripled from 623 to 2,341.

Demand growth is a result of more physicians being better educated to recognize sleep deprivation symptoms as well as the public having more and better access to information and advertising that focuses on it. Changes in insurance reimbursement also is playing a major part in the accredited facility surge.

“Growth of the field comes from a number of factors such as education and marketing,” said Kathryn Hansen, executive director of the Kentucky Sleep Society. “And beginning Jan. 1, 2012, a new requirement for accreditation is required for sleep centers to receive insurance reimbursement from all federal insurances and third-party insurances. Centers that are an extension of a physician’s practice are not required to be accredited, so you’re only seeing about half of what is out there.”

The Kentucky Sleep Society is one of eight state-level organizations in the United States. Hansen, a clinician in the field for more than three decades, also owns Integration Consultants, a healthcare consulting firm that counsels clients in regulations, compliance, accreditation and education.

Sleep deprivation studies “became an official diagnostic tool in Kentucky in 1980,” she said. “The first in Kentucky was Louisville Sleep Medical Specialists, and I started the second with St. Joseph Hospital.”

More than 80 sleep disorders
Estimates show that nearly a quarter of Americans are living in a zombie-like state at least part of the time, caused by one or more of the 80-plus varieties of sleep disturbances. Unfortunately, most people have no idea they have a problem that can be addressed.

“Eighty-five percent of those who have a sleep disorder are undiagnosed,” said Hansen. “When we look at the most common sleep disorder, sleep apnea, we have evidence that demonstrates 25 percent of men are at risk and 9 percent of women are at risk.”

Putting a dollar figure on the collateral damage the conditions cause is virtually impossible.

“The direct effects of sleep disorders as well as the co-morbidity (additional related illnesses) with other substantial public health problems such as obesity, diabetes, stroke and depression, have a profound economic and social impact,” cites a 2006 publication from the Institute of Medicine of the National Academies. “Only minimal estimates of the economic impact of sleep disorders and their derivative consequences are possible because of underrecognition and underreporting.

“At a minimum, however, the total direct and indirect cost of sleep disorders and sleep deprivation in the United States is hundreds of billions of dollars. The magnitude of the effect of sleep pathology is shocking even to experts in the field of somnology and sleep medicine.”

‘I’m more aware of everything’
Jude Feld, who has held many professional jobs in the horse racing industry, says the difference in his health is “tremendous” since being diagnosed with sleep apnea and fitted with a continuous positive air pressure, or CPAP, machine a few weeks ago.

“The rejuvination is just amazing,” said the 54-year-old racing analyst for Horse Racing Radio Network.

In the past he rarely dreamed while sleeping, Feld said, but had no idea this was related to a major health issue. He wasn’t sleeping enough.

“I had my (sleep study) test done at St. Joseph East (Hospital in Lexington),” he said. “During a 151-minute span, I woke up 162 times.

“I had been functioning at a really high level for years on virtually no sleep and didn’t know it,” Feld said. “The difference in how I feel now is so dramatic – it’s changed so many aspects of my life. It’s improved my concentration level, and I’m more aware of everything around me. I had literally been walking through life asleep. Even my handicapping has gotten better.”

Something as simple as being able to drive distances without dozing off is again possible.

“I hadn’t been able to drive for three hours by myself for 11 years,” he said. “Now I’m not restricted to just driving around (Lexington’s) New Circle Road.”

Traveling specialist sees lack of recognition
Dr. Pam Combs is a bit of a rarity among sleep doctors, working independently and even performing sleep studies in patients’ homes. A cardiologist, Combs said she has been studying sleep issues since the 1990s.

“I have a passion about sleep studies, and I think in cardiology,” Combs said. “I think a lot of people are missing the boat.”

While the awareness of sleep problems is growing, it still has a long way to go, she said. “The diagnostics still aren’t where they need to be,” and the public still often doesn’t think of sleep disturbances as a serious health issue that can be addressed.

“A typical patient is a male, in his 50s, slightly overweight,” she said. “They don’t think about sleep problems as the problem. They just think they’re getting old and tired.”

Combs’ company, Cardiovascular and Sleep Consulting Services, is based in Paris, with additional clinics in Frankfort, Winchester and St. Joseph East in Lexington.

“I contract with hospitals for sleep studies,” she said. “They have the best and newest equipment, certified technicians and, since I tend to have the sicker patients, doing the studies in a hospital allows me to monitor additional things like blood gas levels.”

She is also the medical director of sleep labs in hospitals in Frankfort, Paris and Winchester.

“I’m in each facility a couple of days a month and review studies weekly,” Combs said.

Home visits aren’t nearly as complete as those done in the hospital, she said, but offer at least some results for patients unwilling or unable to leave home.

“We have portable monitors, and our staff shows the patient how to hook them up,” Combs said. “They wear it overnight, and a credentialed technician goes over the data. Often it gives the answer, although it’s not nearly as detailed. In the hospital we have 16 channels to monitor and in a home (study) only four.”

Sleep and mental vitality affect productivity
Whether psychological issues are the result of sleep disturbances or vise-versa is much like the question of which came first – the chicken or the egg?

“Our sleep cycles are regulated by our behavior,” said Dr. Ryan Wetzler, a clinical psychologist certified in behavioral sleep medicine with Louisville’s Sleep Medicine Specialists. “It’s futile to try to separate which causes the other. They are very much intertwined.

“There’s increasing recognition of the part sleep plays on our health,” he said. “Not sleeping is associated with a myriad of health conditions, and mental health conditions, and it undoubtedly affects productivity.”

Wetlzer deals exclusively with insomnia, one of only a few in Kentucky who does.

“There’s so much focus and awareness of sleep apnea that it’s kind of pushed insomnia back in the shadows,” he said. “But we get referrals from virtually every sleep center in the city. Drug company advertising for products such as Lunesta has pushed prescription sleep drug sales through the roof.”

Wetlzer prefers to treat the condition through other means.

“My part in this is addressing insomnia without drugs. They don’t work well, they cause other health issues, and they have side effects,” he said. “For years, insomnia was considered to be a symptom rather than a condition and was frequently dismissed.

“When you get a patient who has taken two hours to go to sleep for years or even decades, getting maybe four hours of sleep a night, and then with treatment they fall asleep quickly and get seven hours a night, it’s a huge difference. I’ve had people say we’ve saved their lives,” Wetzler said.

Better conditions today but less sleep
“People don’t sleep as well as they did 100 years ago,” said Dr. Tom Westerfield, who co-owns the Sleep Disorders Center in Lexington along with neurologist Dr. James M. Thompson. “It’s interesting when you think that our ancestors slept on rock-hard beds, in drafty rooms, sometimes with several people in the same bed.

“Now we have climate control, Tempur-Pedic mattresses, high-end bedding – but we sleep 90 minutes less a night on average than we did at the turn of that last century.

“We’re trying to be a 24-hour society,” he said. “And we’re not being active. In the office, you don’t even have to walk down the hall to get a file. It’s right on your computer. We’ve become more sedentary at home, too.”

Westerfield, a pulmonologist, said acknowledging a problem and seeking solutions is beneficial for employees and employers.

“Addressing the problem means less illness, less missed work and more productivity,” he said. “It is a huge problem; 10 percent of the adult population in Kentucky has sleep apnea.”

The Sleep Disorders Centers in Lexington is a four-room facility. Two technicians each monitor two patients during an overnight study via computer and camera. The physicians also partner with hospitals and other providers in London, Corbin, Frankfort, Mt. Vernon and Danville.

A free-standing facility, such as theirs in the Beaumont area of southwest Lexington, is not inexpensive to operate.

“It costs $20,000 to outfit a (testing) room,” Westerfield said. “Sleep technicians earn between $16 and $25 an hour, and there are ongoing costs such as replacing equipment.”

The cost for the testing in their facility runs between $900 and $1,500, he said.
“That includes the consultation, the testing and interpretation, and follow-up,” he said. “The same services based in a hospital can be two or three times higher.
Even so, the hospitals are siphoning away business.

“When we first opened (in 2000) there wasn’t a sleep lab in every hospital,” Westerfield said. When the testing became available locally, “people wanted to stay close to home. That’s one reason we started the outreach (consulting in hospitals).”

Specialty gains respect and then abusers
Standalones also receive less in insurance reimbursements than hospitals, Westerfield said.

Dr. Barbara Phillips, director of the Sleep Center at the University of Kentucky Good Samaritan Hospital, has been heavily involved in the field for a long time. She has served as president of the American Board of Sleep Medicine, and on the board of directors of the AASM and American Sleep Foundation. She is also a professor of pulmonary, critical care and sleep medicine with UK’s Department of Internal Medicine.

She’s seen plenty of advances in the field during her tenure.

“During the nearly three decades that I have been directing a sleep lab of one sort or another at UK’s College of Medicine, I’ve seen many changes and trends in the field of sleep medicine,” Phillips said.

“Among these are recognition of the field as a legitimate entity, with a recognized board exam, journals, formal training programs and an NIH center. I’ve also seen a growing awareness by physicians and the lay public that sleep apnea is dangerous, and is an important risk factor for cardiac events, impaired quality of life, and death.

“Perhaps more importantly, it’s a public health problem of some magnitude, since untreated sleep apnea is clearly a risk factor for crash. This makes the condition risky not only for those who have it but also for those on the roads and in the car with them,” she said.

Not all the changes have been positive, though.

“We’ve also seen the rise and fall of ‘apnea mills,’ where the focus is on lucrative testing, and actual patient care and follow-up get shortchanged,” she said. “And there is a distressing tendency to lump all ‘sleep disorders’ together, and to ascribe the well-documented consequences of sleep apnea to all sleep disorders. Sleep apnea kills, but I seriously doubt that bedwetting, restless legs syndrome or insomnia do.”

Another emerging trend is the diagnosis and treatment of sleep apnea in children and teenagers.

“There is an increasing awareness of the role of sleep apnea in causing behavioral problems and cognitive dysfunction in children,” said Phillips.
Westerfield also treats youngsters in his practice.

“We’re seeing a lot more children,” he said. “Some of the problems come from large tonsils, but face it: Little Johnny is fat; he’s on the computer or watching TV instead of getting exercise.”

Sleep medicine is a growing, changing field, but one that has already made an impact on the health of many people. In addition to addressing the underlying problem, treating the sleep disorder helps greatly diminish other health problems.

“Our legacy may be the reduction in cardio-vascular problems,” said Westerfield. “The No. 1 thing to remember about the subject is pure and simple:?We are just not getting enough sleep.”