As a physician assistant who treats sleep disorders, I am concerned about how a recent study published in the Journal of the American Medical Association might affect the field of sleep medicine.

The study by Chai-Coetzer  et al posits that nurse-led primary care teams demonstrate non-inferior outcomes for sleep apnea treatment and management compared with a specialist model.

Insurance companies already challenge claims from sleep specialists, stating a preference for home sleep studies and auto continuous positive airway pressure (CPAP). Now we are seeing yet another group who wants to get into the sleep medicine field without proper training, but this time it is our own peers and colleagues. 

Up until the late 1990s anyone who wanted to be a sleep specialist could start his or her own sleep medicine practice with relatively little oversight. Unfortunately, I’ve heard horror stories from patients who have had bad experiences treated by providers that were not certified sleep specialists.

Thankfully, the American Medical Association and the American Board of Sleep Medicine established criteria to become a sleep specialist, and a one-year fellowship is now required. The nurses in the JAMA study completed just a six-hour education program on obstructive sleep apnea and its management. This hardly compares to a one-year sleep-medicine intensive fellowship.

Having worked in the field, I know that there is so much more that goes into a laboratory sleep study than simply determining if someone has sleep apnea. We also look at the patient’s EEG, sleep efficiency, oxygen levels, cardiac status and sleep architecture. This is done to rule out central sleep apnea, a more serious condition that may be more difficult to observe during a home sleep study.

Let’s not forget about other potential complications, such as upper airway resistance and periodic limb movements of sleep. Periodic limb movements are difficult to pick up using  a home sleep study, as is REM sleep behavior disorder, because most home sleep studies do not include EEG monitoring.   

Despite the overall study findings in support of primary care nurse-led sleep apnea management, more patients assigned to the primary care group withdrew than those in the sleep specialist group – 17 vs. 8. This was mostly attributed to patients’ inability to tolerate CPAP. Perhaps the presence of a sleep specialist could have reduced this number.

I am also unsure why primary care clinicians, who are already very busy, would want to add one more aspect of care to their plates. I understand that our population is getting older and more obese, and as a result there will be a higher demand for additional tests. But why not leave sleep medicine up to those of us who practice it everyday?

If a patient has a neurological, gastrointestinal or gynecological problem, where do you send them? I’m sure you already have the specialists’ names that you would refer them to there in your mind. Why then wouldn’t you choose to call a sleep specialist to treat obstructive sleep apnea?

I understand managing sleep apnea in the primary care setting may offer some cost savings for the patient, and I am all about making healthcare affordable for everyone. But when you compare the costs of one full night of patient monitoring for a polysomnogram to some of the costs these other specialists charge for procedures, and this argument does not hold up in my mind.

The study researchers themselves pointed out that patient outcomes in clinical setting may “not be as good as those observed in this study,” and that  “caution needs to be exercised in extrapolating these findings to actual practice” because “primary care physicians may not be as skilled and motivated as those who participated in this randomized controlled trial.”

There are about 100 different sleep disorders. Are you prepared to recognize them all? I hope there is no question among primary care providers, when it comes to who should evaluate patients with sleep disorders.

Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.

References

  1. Chai-Coetzer, Ching Li et al. “Primary Care vs. Specialist Sleep Center Management of Obstructive Sleep Apnea and Daytime Sleepiness and Quality of Life.” JAMA. 2013. 309(10):997-1004.