El-Solh AA, Moitheennazima B, Akinnusi ME, Churder PM, Lafornara AM.
Source
The Veterans Affairs Western New York Healthcare System, Medical Research, Bldg. 20 (151) VISN02, 3495 Bailey Avenue, Buffalo, NY, 14215-1199, USA, solh@buffalo.edu.
Abstract
BACKGROUND:
The high efficacy of continuous positive airway pressure (CPAP) in treating obstructive sleep apnea (OSA) is limited by poor compliance often related to pressure intolerance. Mandibular advancement devices (MADs) are proven alternative therapy although not universally effective. A combination of nasal CPAP and MAD may provide another option for CPAP-intolerant patients with incomplete response to MAD.

METHODS:
Ten patients with residual apnea/hypopnea events on MAD who were intolerant to CPAP were recruited prospectively from the sleep clinic. After a washout period of 1 week off MAD, subjects were asked to use an auto-CPAP unit along with their prescribed MAD for three consecutive nights. Oxygen desaturations were obtained from overnight oximetry. Efficacy of the combination therapy was evaluated by the Epworth Sleepiness Scale and Smartcard data recordings.

RESULTS:
The combination of MAD and nasal CPAP was well tolerated by all participants. Compared to CPAP alone, the optimal CPAP pressure required to eliminate all obstructive events on the combination therapy was reduced from 9.4 ± 2.3 to 7.3 ± 1.4 cm H(2)O (p = 0.001). The residual apnea hypopnea index on the MAD decreased from 11.2 ± 3.9 to 3.4 ± 1.5 on the combination therapy (p < 0.001). The number of oxygen desaturations was also less with the combination therapy than with MAD (p < 0.001). Both the MAD and the combination therapy were effective in reducing daytime sleepiness from 12.7 ± 2.1 at baseline to 9.7 ± 3.1 (p = 0.04) and 7.5 ± 4.1 (p = 0.007), respectively.

CONCLUSIONS:
Combination therapy of MAD and nasal CPAP is effective in normalizing respiratory disturbances of sleep apnea in selected OSA patients who are intolerant to CPAP.

Sleep Breath. 2011 May;15(2):203-8.

Mador MJ, Nadler J, Mreyoud A, Khadka G, Gottumukkala VA, Abo-Khamis M, Mehboob S.
Source
Western New York Veteran Affairs Healthcare System, University at Buffalo, Buffalo, NY, USA, mador@buffalo.edu.
Abstract
BACKGROUND:
Patients with sleep apnea (OSA) have an increased risk of perioperative complications.

AIM:
The purpose of this study is to assess whether OSA increases the risk of cardio-respiratory complications in patients undergoing endoscopic procedures with conscious sedation.

METHODS:
A prospective study over a 7-month period was performed. All patients undergoing upper, lower, or combined endoscopy were asked to fill in the Berlin questionnaire. The questionnaire was scored, and patients were classified as high or low risk for sleep apnea based on the suggested scoring criteria. Patients who had previously undergone a sleep study were excluded. Demographics and co-morbidities were identified from the electronic medical record. Procedure type, amount of sedation, and minor and major complications were identified from the endoscopy flow sheet. The minor complications were defined as hypertension, hypotension, bradycardia, tachycardia, hypoxemia, and bradypnea (respiratory rate <8 breaths/min). Major complications included chest pain, arrhythmia, altered mental status, respiratory distress, and a minor complication that required a significant intervention, such as use of a reversal agent, atropine, up-titration of oxygen for hypoxemia, or prolonged observation.

RESULTS:
Procedures were performed in 904 patients: colonoscopies, 68.0%; upper endoscopies, 22.8%; and combined procedures, 9.2%. Five hundred fifty-three patients were identified as low risk (61.2%), and 351 were identified as high risk (38.8%). The mean age was 59.5 ± 10.5 years, mean body mass index was 28.9 ± 6.6, mean neck circumference was 16.2 ± 6.3 in., and 91.4% were males. The median Charlson co-morbidity index was 1 (25-75% percentage range 0-2). All patients received midazolam and fentanyl during endoscopy. The median and 25-75% range for midazolam and fentanyl dosages were 5 mg, 4-6 mg and 100 μg, 75-125 μg, respectively. Minor complications were observed in 10.56% of low-risk patients and 10.63% of high-risk patients (p = not significant (NS); odds ratio, 1.01; 95% confidence interval 0.65-1.56). Major complications were observed in 3.25% of low-risk patients and 1.9% of high-risk patients (p = ns; odds ratio, 0.6; 95% confidence interval 0.26-1.46).

CONCLUSION:
For patients undergoing endoscopy procedures under conscious sedation, the presence of OSA does not clearly increase the risk of cardiopulmonary complications.

Sleep Breath. 2011 Jun 27

The accreditation simplification movement that is sweeping through healthcare evaluation circles today has had a profound impact on all sectors of our healthcare delivery system. Indeed, in many important ways, the focus has shifted from a monolithic, one size fits all approach to accreditation, to more nuanced customizable programs that help healthcare providers alter their everyday business operations to meet specific healthcare sector patient care quality measures.

In recent years, as a way of urging these reforms forward, the Centers for Medicare and Medicaid Services (CMS) has adopted plain language, product-line and service specific, accreditation quality standards for the durable medical equipment, prosthetics, orthotics, supplies (DMEPOS) industry.

Indeed, no sector of our healthcare delivery system has felt the effects of accreditation simplification more acutely than the DMEPOS industry. Competition between the various CMS “deemed” private sector accreditation organizations has not only helped streamline and simplify the accreditation process, it has effectively lowered implementation times and all associated costs across the board. This is especially true for sleep center DMEPOS accreditation; bringing benefits to both provider organizations and patients alike.

Let there be no misunderstanding, sleep center DMEPOS accreditation is not the same as the accreditation process for a diagnostic sleep center facility. Whereas facility-wide accreditation looks at the entire organizational structure and the daily operations that are needed to conduct successful sleep studies, sleep center DMEPOS accreditation is much more narrowly focused on the activities surrounding patient set-up and usage of a limited number of product types; most notably CPAP and Bi-PAP devices.

What follows are some caveats that I believe should be closely adhered to in order to assure that sleep DMEPOS accreditation becomes synonymous with the exemplary care that every patient deserves:

1. Medicare’s DMEPOS Supplier Standards as well as product specific accreditation quality standards must be met in order to maintain a facility’s Medicare billing privileges.
2. Written policies for sleep center DMEPOS need to be understandable to all staff members; not just administrators and compliance officers.
3. Policies and Procedures should reflect an operations perspective when addressing specific business functions such as: Administration, Human Resources, Equipment Management etc. By formulating policies according to the functions and tasks of the DMEPOS department it makes it easier for the staff to utilize it as a true resource.
4. Comprehensive instruction on Plans of Care and the close monitoring of product use compliance through diligent follow-up procedures brings with it many patient care benefits.
5. Patient care services are best evaluated by experienced sleep professionals. These professionals must be properly credentialed, and participate in a continuous education regimen.
6. Sleep DMEPOS staff should be able to demonstrate a thorough knowledge of the full range of products as well as their set-up and delivery requirements.
7. As experts in Equipment Management- sleep DMEPOS professionals add value to the patient’s plan of care goals.
8. CPAP/ Bi-PAP devices have built-in compliance monitoring functions that are designed to track compliance and give feedback to the sleep physician.
9. Sleep DMEPOS equipment experts often do the most thorough job of product instruction.
10. Sleep DMEPOS departments should demonstrate expertize in staff training in the exercise of universal precautions to prevent cross-contamination from blood or other bodily fluids.
11. Cleaning, storage and maintenance of equipment is critically important as an infection control measure. E.g. Using appropriate disinfection techniques. Proper hand washing.
12. Patient follow-up is an integral part of the DMEPOS accreditation process and is a special area of interest during the accreditation on-site evaluation or survey visit.
13. Inventory tracking is an important component of the accreditation process as a measure of recovery readiness in the event of a product recall. (A good inventory tracking mechanism also helps maintain profitability by preventing thief or product “shrinkage”.)
14. Medical Record reviews are an important aspect of the sleep DMEPOS accreditation process. During an on-site evaluation/ survey while looking at patient records we want to see documentation of all patient interactions that transpired as well as the LCD/insurance requirements of the billing provider.

Moving Forward

New rulings by CMS are happening all of the time and they often change what is required of sleep professionals; to the point where keeping up with the ever-evolving world of government regulatory matters becomes a critical business function. Case in point, Medicare Part B now requires that beneficiaries return to their doctor for a CPAP compliance (usage) test 60 days after set-up, but before 90 days from the dispensing date.

Another rapidly evolving arena that is affecting diagnostic sleep center business models is the status of home sleep studies. Now that home testing is CMS reimbursable, patient safety and the appropriateness of the sleep study device being used in a home environment must be taken into account.

Given the general leveling effect that CMS’ product-line and service specific quality standards have brought to the DMEPOS accreditation world, it is easier than ever for diagnostic sleep centers to meet these nettlesome challenges. Much of the credit for these advancements should also go to the emergence of the new era of healthcare accreditation simplification. Sleep DMEPOS professionals can bank on it.

Sandra C. Canally, RN is the Founder and President of The Compliance Team, Inc., a CMS approved accreditation organization with deeming authority for DMEPOS. In addition, her firm offers a full line-up of proprietary Exemplary Provider™ accreditation programs including ones for: Diagnostic Sleep Center, Infusion/ Specialty/ and LTC Pharmacy, Critical Access Hospital, Rural Health Clinic, Physician Practice/ Medical Home, Long Term Care, Home Health/ Hospice Agency, Private Duty Homecare, Ocularist/ Anaplastologist.

 This is a reprint of a letter recently published at www.BRPT.org By Cindy Altman, RPSGT, R.EEG/EP T., President-Elect, BRPT .

What are your thoughts?:

Did the AAST have prior knowledge of the AASM/ABSM decision to develop a credentialing exam that by design is easier to pass? Did the AAST ask the AASM/ABSM to develope such an exam and credential?

Did/Are certain members of te AAST Board of Directors (present or past) participating in the development of such a credentialing process while serving on the AAST Board of Directors? If they are/did, are you OK with that?

Has sufficient information been released to the professional sleep community by either the AAST/AASM/ABSM to support the claims made about the pass rate of the RPSGT exam or the skills sets of the new RPSGT’s?

If you are an RPSGT, are you yourself planning on supporting the new credential by paying the ABSM $25 to be grandfathered in to the new credential?

Do you think that this is all meaningless and that an influx of newly credential sleeptechs will have no impact on your current salary or employment opportunites?

By Cindy Altman, RPSGT, R.EEG/EP T.
President-Elect, BRPT

“I recently attended an American Board of Sleep Medicine (ABSM) technologist examination information
session at the American Association of Sleep Technologists (AAST) program in Minneapolis. Most
technologists went to lunch, but a hundred or so were present.

Dr. Richard Rosenberg gave the presentation. Dr. Nathaniel Watson was also there. He was introduced
as president of the ABSM and he sat next to Dr. Rosenberg on the stage but really didn’t say much.

Dr. Rosenberg is a full-time American Academy of Sleep Medicine (AASM) employee, and Dr. Watson
is on the AASM board of directors. How can the ABSM be “an independent, nonprofit, self-designated
board” separate from undue influence by the AASM? The relationship between the two groups is not
transparent.

On several occasions Dr. Rosenberg let the audience know that he trained in sleep with Dr.
Rechtschaffen, and he serves on the Committee for Accreditation of Polysomnographic Technologists
Education (CoA PSG). He talked of all the good the AASM has done for sleep technologists and
education. He forgot to mention the role that the AAST and the Board of Registered Polysomnographic
Technologists (BRPT) played in advancing technologists’ professional status, or in the formation and
continued support of the CoA PSG.

Dr. Rosenberg said there was absolutely no financial motivation, as rumors implied, behind the
development of the new technologist exam. He said the ABSM simply wants to offer a technologist
examination that is relevant for all “stakeholders.” And they want a pass rate that is higher than the
RPSGT exam…for the good of the profession. In other words, for the good of the physicians who employ
the techs who are unable to pass the RPSGT exam. After all, he implies, the problem in passing the
RPSGT exam is with the exam itself, and not the individuals or educational pathways.

To them, it doesn’t matter that the BRPT works with a well-respected professional testing company,
or that the BRPT uses best practices for developing, maintaining, reviewing, delivering, and scoring
the RPSGT examination. Or that it uses a geographically and professionally diverse group of Subject
Matter Experts. Or that at every step along the way, the RPSGT examination is checked for validity
and relevance not only by the professionals in the field, but by professionals in the testing community.
What matters is that the ABSM believes it has produced a better technologist exam that will result in a
higher pass rate. After all, the ABSM knows “some psychometricians” who help with the exam. What
matters is that the ABSM will do what the AASM asks.

Dr. Rosenberg said the ABSM would apply for NCCA accreditation for the technologist examination.
He fumbled with the terms and relationship between the Institute for Credentialing Excellence
(ICE), the National Commission for Certifying Agencies (NCCA), and the National Organization for Competency Assurance (NOCA), which is now ICE. I hope he gets these organizations straight for his
next presentation.

Dr. Rosenberg blamed the RPSGT exam pass rate on “stifling” the development of formal sleep
technology education programs across the country. He based this on a conversation with a dean at a
school in the Chicago area. Dr. Rosenberg talked about the dissatisfaction physician’s have with the
RPSGT credential, yet he has no data to support that. The AASM is certainly capable of surveying a
large number of people and institutions to determine the extent of this dissatisfaction…if they were
interested.

Dr. Rosenberg repeatedly referred to outdated RPSGT exam pass rates and did not discuss the
difference in pass rates based on educational pathway or over time, or compare the pass rates of similar
examinations with multiple pathways. When program directors from two different schools challenged
the assertion that the exam was too difficult for CAAHEP students, Dr. Rosenberg indicated their schools
were the exception, not the norm.

Dr. Rosenberg told us that the RPSGT requirement for AASM sleep center accreditation would still stand.
Yet when asked if he would put that statement in writing, he let the audience know it wouldn’t have any
weight. When asked if the new examination should be viewed as a mid-level credential, with the CPSGT
on the lowest level and the RPSGT on the highest level, he made it clear that the new credential was to
be on equal terms with the RPSGT.

Dr. Rosenberg reminded the audience that the AAST supports the new exam. He let us know AAST’s
immediate past president and current president have been involved in the development of the ABSM
technologist exam. The audience was already aware of AAST’s position to support “all” technologist
examinations—even those not yet developed or evaluated—but it was surprising that AAST leaders
were actually assisting in the exam development. This was news to current AAST board members as
well. Did Dr. Rosenberg let the cat out of the bag?

When it was time for questions and comments at the end of the presentation, not one person stood
up to voice support for the new exam. However, many stood in line to question or comment on the
purpose of it. At times those in attendance clapped enthusiastically in support of the techs or physicians
who challenged the ABSM. Suffice it to say, the new ABSM technologist examination was not well
received.

So why, exactly, is the ABSM getting involved in technologist credentialing? Could it be that the BRPT is
truly an independent organization adhering to best practices in credentialing, and the AASM does not
like that?

The RPSGT is the Gold Standard. Don’t let grandfathering into the new credential confuse you. While
it is “only $25” and you may think that you have nothing to lose, you do. You risk losing the professional
identity that technologists have worked for over 32 years to achieve. As technologists we can stand
united to keep the RPSGT credential strong. Don’t let the AASM divide and conquer. That is really what
this is all about.” 

Neuroendocrinology. 2011 Apr 5.