Options and Evidence

1sleep Options and EvidenceSomnoMed MATRx™ and SomnoDent G2 head a rapidly evolving class of oral appliances and overnight study systems that bolster compliance and verify effectiveness.

Executives at Dallas-based SomnoMed (www.somnomed.com) are not afraid of evidence. On the contrary, they are making it easier to objectively measure effectiveness of the company’s oral sleep appliance portfolio. The result is a measure of certainty for sleep physicians who want the best therapy for their patients.

The vehicle that fuels this elusive certainty is the SomnoMed MATRx™ (pending FDA approval). Ralf Barschow, Global CEO of SomnoMed, touts the device as nothing less than a revolutionary breakthrough in the prediction of efficacy for the SomnoDent Mandibular Advancement Splint (MAS).

Responder or Non-Responder?

A typical MATRx scenario usually starts with a SomnoMed dentist taking an oral impression of the patient and fabricating a customized overnight oral appliance. From there, patients take the overnight appliance to a sleep lab where it is used with SomnoMed MATRx.

To conduct a study with SomnoMed MATRx, the overnight appliance is attached to a small motor (50 grams) that is remotely controlled by a sleep technician. “Using this process, sleep technicians can clearly see whether the patient is a responder or non-responder to SomnoDent therapy,” says Barschow, who also serves as president of SomnoMed North America. “The MATRx is analogous to a CPAP titration. For the first time, we are providing a means of predicting whether patients are suitable for an oral appliance. If they are, we can help determine optimal protrusive distance for their SomnoDent once they are returned to their SomnoMed dentist for further titrations.”

MAS Fosters Compliance

Loyal customers are already familiar with SomnoMed’s MAS treatments, each with different clinical indications aimed at OSA sufferers. These include the SomnoDent® Classic, SomnoDent® Flex, and SomnoDent® Edent for the Edentulous patient.

The SomnoDent® MAS is a custom-designed oral device that has been the subject of numerous stringent, independent, evidence-based studies that satisfy the need for safe and effective OSA treatment. The SomnoDent® MAS has a number of design features such as a streamlined design with minimal bulk, which maximizes lingual space, reduces gagging, and offers a comfortable treatment with a compliance rate of over 87% all night (Am J Respir Crit Care Med Vol 163. Pg 1457-1461, 2001).

The company touts an excellent fit in both upper and lower arches with anterior and posterior contact for a stable occlusion, which prevents tooth movement and minimizes temporomandibular joint (TMJ) discomfort and injuries.

The SomnoDent MAS is constructed in two separate pieces that allow patients to open and close their mouth. This allows clear speech, yawning, and drinking without requiring patients to remove the appliance. The ability to communicate clearly while wearing the device is particularly appreciated by patients and their partners.

G2 Builds on Legacy

Building on the considerable legacy of the SomnoDent MAS, Barschow and White introduced the SomnoDent G2 (pending FDA approval) oral appliance at this year’s American Professional Sleep Societies’ (APSS) show in Minneapolis. Like other SomnoDent products, the G2 is made with a proprietary SMH BFlex polymer lining material, which enhances comfort, stability, and durability. “When we launched SomnoDent Flex

2.5 years ago, it was a big surprise in the dental sleep medicine community and raised the quality standard considerably, hence a 3-year manufacturer’s warranty,” says Barschow. “I compare this to our feedback on the next SomnoDent generation G2, which has taken everyone by storm—whether it is the controlled forward protrusion mechanism or the smaller metal-free design.”

“Now for the first time, G2’s proprietary click-on, click-off technology provides certainty and standardization around the titration of an oral appliance,” adds Anthony White, vice president, SomnoMed Marketing & Academy. “This objective measure offers sleep physician’s certainty in prescribing SomnoDent therapy.”


2sleep Options and Evidence

Oral Appliances Here to Stay

Respect for oral appliance therapy remained high at this year’s APSS meeting in Minneapolis, echoing an inevitable trend that only seems to get stronger. Along with greater acceptance, foot traffic around the booth remained high, with serious inquiries outnumbering casual fact finders. “After Seattle and San Antonio, this is the third time we have had a strong presence at APSS,” says White. “The response has been overwhelming. Sleep lab managers and sleep physicians came and said, ‘The MATRx is the missing link here. The ability to prospectively predict which patients would be appropriate for SomnoDent therapy in a polysomno graphic environment means we can, with confidence, provide patients that cannot tolerate or adhere to CPAP a second chance at therapy.”

Bright Future

In many ways, the APSS meeting in Minnesota reflected an industry on the cusp of change. Despite huge patient potential, lesser companies are falling by the wayside.

White believes clinicians will continue to embrace oral appliance sleep apnea therapies, but only patient-focused and evidence-based ideas will succeed. “Our products are backed by independent clinical studies validating their use,” says White. “Once our new products are available, they will all have the necessary medical device approvals and meet all regulatory standards.”

Viewed together, the MATRx (launch expected in Fall of this year) and G2 (release planned for beginning of 2012) are part of SomnoMed’s effort to be viewed as the evidence-based medical device company that provides more than just therapy. Instead, the company is looking for a way to determine efficacy and compliance—all while spreading knowledge. An educational arm called the SomnoMed Academy fosters this mission by generating continuing education credits for the dental and medical fraternity.

Dentists, physicians’ or sleep laboratory officials who wish to get involved can contact the company and purchase a starter program with collateral materials and sample devices. Participating dental professionals may choose to register for a Fundamentals Seminar, which is a 2-day continuing education event. The event is jointly presented by a physician and SomnoMed dentist that teaches dentists how to integrate dental sleep medicine and the SomnoDent therapy in their daily practice. “In accordance with the AASM guidelines, interested dentists learn why and how they need to interact with the medical community to get a proper diagnosis,” says Barschow. “However, we have always maintained, and will continue to maintain, that it is the physician’s role to treat and diagnose the patient. Once the SomnoDent therapy is deemed appropriate treatment, it goes to the dental arena for fitting. Patient care is for the physician, and diagnosis is for the physician.”

Demand for education figures to be high, considering that dental therapy has gained firm acceptance among many segments of the market. It was not too long ago that full PSGs were considered infinitely superior to home tests, just as it was once considered unthinkable that oral appliances could be an equal, or in some cases an even better choice, than CPAP.

Building Confidence

Ultimately, Barschow and White contend that all new products within — must focus on gaining the support and confidence of the patients, dentists, and physicians that will in turn improve crucial compliance rates. “The MATRx and G2 boost confidence among patients and clinicians,” says Barschow, who has more than two decades of experience with dental/medical materials and technology. “Patients are confident they are receiving the highest quality oral appliance treatment out there. That confidence brings them back into treatment, which improves compliance—and improves their lives.”

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For more information, visit  http://www.somnomed.com

CPAP Tubing Overlooked No More

Sleep Diagnosis and Therapy Vol 6 No 4 June-July 2011

ScreenShot040 CPAP Tubing Overlooked No More

Could a Different Tube Actually Make the Difference in the Battle for Compliance?

The CPAP compliance equation usually hinges on a common belief: find the right mask and comfort will follow. Comfort equals compliance, and compliance equals reimbursement. The strategy makes sense, but variables can complicate matters.

For example, what if the “best” mask is still too uncomfortable? Johan Verbraecken, MD, a pulmonologist and medical coordinator at the Belgium-based Sleep Disorders Centre, has seen this scenario on many occasions. One recent patient wanted to stop CPAP treatment after many failed attempts. “I asked him to try one more thing before he stopped,” says Verbraecken. “The only thing we changed was adding a heated tube. The patient was comfortable and happy with this intervention. We focus so much on changing masks, but tubes are often overlooked.”

Using the heated tube from the beginning, along with the heated humidifier, can also benefit sleep labs economically since fewer patients are likely to stop due to condensation. “Patients get moisture on their face at night, and it is not comfortable,” says Verbraecken. “The condensation can also make noise in the tube, similar to the sound of boiling water. This noise can often lead to stopping CPAP use, but the right tube can completely prevent it.”

New Respect

A few companies have been paying close attention to tubes, and clinicians are now looking to the technology in an effort to find any edge in the race to boost compliance. The transfer of air from machine to patient is no longer overlooked. In fact, the field is literally getting hotter with heated tubes reducing the pesky problem of condensation.

A company called Plastiflex Healthcare, a division of Plastiflex Group NV, decided to use its considerable experience manufacturing industrial flexible hoses and apply it to CPAP. Plastiflex contacted Verbraecken’s Centre about 2 years ago as it reached out to the European market.

Plastiflex offered the Hybernite® Rainout Control (ROC) System, which includes the proprietary Hybernite® Heated Breathing Tube (HBT) and Hybernite® Power Supply Unit (PSU). The HBT connects to the PSU via a plug-and-play connector, with copper wires embedded in the tubing wall.

The wires generate heat that maintains air temperature inside the tube, ultimately warding off problematic condensation. Verbraecken notes that the wires are positioned for uniform heating along the tube’s entire length, a system that avoids water droplets on the wall of the tube—and the resulting accumulation of moisture. The combination of the heated tube and the humidifier works to control condensation.

Ludo van der Poel, area manager at Netherlands-based Vivisol, a home care company that supplies Hybernite systems to patients, agrees that the seemingly minor detail of the tube can make a major difference. “The old saying about the weakest link in the chain also applies here,” says van der Poel. “If you have a superior mask and a superior CPAP device, but a bad tube, you will not get the best results.”

Important Accessory

Richard Webb, RRT, considers Hybernite a crucial add-on accessory, since it is not included with PAP devices. “The Hybernite is very beneficial for standardizing the humidification,” say Webb, CEO of Monitor Medical, a DME company with multiple locations throughout the United States. “We recommend it for most patients.”

Occasionally someone with severe allergies will request dry or cold air, but elevated humidity through increased temperature is usually the best remedy. Often the key is to mimic moisture conditions of the patient’s home state. “In a high humidity region, you get acclimated to 80% humidity, but if you are in a place like Colorado it is a lot dryer,” explains Webb. “The air you breathe with these PAP devices must be comfortable and not cause your tissues to swell. With swelling comes more resistance, and more resistance can lead to less effective pressure therapy. The humidity is not just for comfort. It is therapeutic.”

Universality is Key

With critical CE approval in hand, Verbraecken says the Hybernite’s appeal stems from its ability to be used with each kind of humidifier. Other heated tubes on the market can only be used on one machine. “This tube is universal,” says Verbraecken. “That is a major advantage.”

Some manufacturers choose to make tubes that are only compatible with their own machines—a mistake in Verbraecken’s eyes. “I think it’s the wrong decision,” he says. “You are obliged to use their machine, and it’s protection for them. The market is so huge that it does not make sense anymore.”

Titrations with Humidification?

At the moment, titration with humidification and heated tubing is not common. However, in cases involving chronic sinusitis and nasal obstruction, Verbraecken contends that the Hybernite could be an advantage. “You could eliminate specific side effects that could be disturbing and that could make a difference,” he says. “For many people, condensation feels as if the water is running from their nose and on to their face. It is like being in a swimming pool, and for many it is unacceptable.”

Better tubes have the potential to enhance CPAP and ultimately improve patient care, although studies must be done to back up this notion. “There is room to use these tubes in a routine setting and not just as an escape tool,” says Verbraecken. “We need large trials to look at the effects of routine application, which has the potential to enhance the objective of compliance.”

Nuts and Bolts

Close proximity to Plastiflex’s European headquarters fostered a relationship with officials at Vivisol who were able to give advice during Hybernite’s development. “We discovered this product before it was launched,” reveals van der Poel. “We were involved in the early stages, giving input from the field to the developers at Plastiflex to further refine the product prior to its launch.”

Years prior to contacting Verbraecken, Plastiflex officials also underwent an exhaustive fact-finding period that took them to numerous trade shows and visits with industry professionals. Designers narrowed down CPAP tubing complaints to condensation and comfort, and refining technology to deal with these two problems has remained the top priority.

After taking into account all this information, engineers developed a Hybernite® ROC that essentially consists of two main parts; one is a heated breathing tube and the other is a power supply. With standard conical connectors, company engineers claim that the Hybernite® ROC can fit the role of a universal solution that can be fully integrated into any humidifier—including all types of masks that use standard tubes. “We like the flexibility of the tubing and the high quality plastic,” adds van der Poel. “A tube that is not flexible or long enough could prevent patients from moving in an easy way. Poor quality can also lead to breakage.”

The system itself does not take power or require power to be taken from the humidifier. It takes the energy straight out of the socket in the wall via the Power Supply Unit (PSU). The system works with all humidifiers that currently use standard tubing—which is 99% of the market.

Johan Verbraecken, MD, is a pulmonologist and medical coordinator at the Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp. He also serves as vice president of the Belgian Association for Sleep Research and Sleep Medicine.

Richard Webb is CEO of Monitor Medical, a DME company with locations throughout the United States.

ScreenShot039 CPAP Tubing Overlooked No More

All About Options

The owner of Austin InstaTech carries many CPAP/mask brands, but she favors one brand in particular when it comes to humidification.

As the owner of a DME and sleep lab “with a twist,” Debbie Downey, RRT, RPSGT, works with physicians to -provide their patients with sleep testing and medical equipment as needed. Sleep docs want to know that their patients are being well taken care of, and anything less is bound to mean reduced referrals.

Austin InstaTech is a subcontractor that physicians rely on, and Downey’s experience has taught her that one size does not fit all when it comes to boosting patient compliance. Patients typically are prescribed one of three different types of CPAP, APAP, BiPAP, and masks. “Every patient is different, not one mask fits everyone and not one machine fits all,” she says. “The need for better humidification is a constant. Without it, CPAP can be a miserable experience. For a long time, Fisher & Paykel in particular has preached that humidification matters, and I agree with them.”

As a respiratory therapist, Downey first encountered Calif- based Fisher & Paykel’s humidification technology within the world of ventilators. Similar to its effects in ventilation, efficient humidification wards off excessive drying and swelling. When F&P rolled humidification into PAP therapy, Downey established a relationship with the company that she maintains to this day.

Downey usually opts to put out units with heated humidification and heated tubing if it becomes necessary. “We don’t put out dry PAP devices,” says Downey. “When we have patients with excessive dryness, or excessive reactive mucosa due to dryness, we verify a good mask fit and switch them to the heated tubing to increase humidification.”

ICON Aims for Aesthetics

Fisher & Paykel Healthcare’s ICON is designed to push the aesthetic envelope, while weaving in proprietary ThermoSmart™ technology to match clinical effectiveness with sleek design.

Engineers designed the ICON™ using input culled from in-depth patient and clinician feedback. On the global market for more than a year, the ICON is aiming to capture market share in a highly competitive niche.

When F&P remodeled their PAP device to the ICON platform, Downey gave the unit another look and liked what she saw. “In the past, the F&P design had been rather bulky even though their humidification was elegant,” says Downey. “We have a mobile population these days, and the bigger the CPAP, the less likely it is to travel with the patient on business or vacation. They made the footprint smaller, and patients like that less of their bedside table gets taken up. It is lighter, less cumbersome and the humidifier chamber drops down into the top of the machine, which also makes it easier to use.”

Downey was one of the first sleep professionals in the United States to carry the ICON. According to Masoud Vahidi, senior product manager, Fisher & Paykel, Irvine, Calif, the reception in Australia, New Zealand, and Europe has been enthusiastic. “At CPAPTalk.com, every discussion we have seen has been very positive,” says Vahidi. “Respiratory therapists and sleep technicians are wowed. We, as well as our customers, get daily calls from patients asking when ICON is going to be available, so there is great excitement.”

Clinicians have embraced the ICON’s ThermoSmart™ technology which mimics the ability of the nose to heat and humidify the air to prevent symptoms such as dryness and congestion caused by CPAP use. A recent bench study found that ThermoSmart™ delivered average absolute humidity levels greater than 27 mg/L, and without causing condensation.1

Appealing to Patients

With neutral colors, Vahidi believes the ICON can discreetly blend into the bedroom environment. Since it also comes with full digital clock and alarm capabilities, it can free up limited space on the nightstand.

Downey initially pegged the digital clock and alarm additions as non therapeutic “hooey,” but now she admits with a chuckle that it was a good idea. “In Austin, Texas, we have a lot of 30-something guys who come in for CPAP therapy, and it’s not very sexy,” she says. “You have the ability to download music to the ICON. It’s not a therapeutic thing, but this type of ‘cool technology’ makes it more approachable to them. I did not think it would be popular, but when I tell them they can download different ring tones and alarm tones, it’s a feature they like. If it can boost compliance, I am for it. It goes to show that it is not always about therapeutic applications.”

“The ICON will fit in well in a patient’s bedroom,” adds Vahidi. “It has a forward facing display and a clock that blends in well. If you look at what people usually have on their nightstand— a radio, clock, phone, a book—the ICON fits right in and replaces the need for a clock. In the past, many patients have felt uncomfortable being on CPAP therapy and elected to take their CPAP units off the nightstand and hide it underneath the bed while not in use. With the ICON, they can feel comfortable leaving it out.”

The high-tech look goes well with a computer-driven interactivity that features more menus that patients can access. The menus provide familiar ways for patients to look at data and get feedback on how they are doing with the therapy. “In this day and age, where patients are relatively computer savvy, this can be really helpful,” enthuses Downey. “When you tell patients they can turn to this menu and see how many apneas they had last night they can correlate that to the type of mask they were using, because that might affect results.

What were the circumstances in the home that may have changed the numbers?”

Feedback allows patients to become active participants in their care. “Instead of guessing, they have empirical data that is right there on the screen,” says Downey. “You give patients some measure of control, and they know we want a certain number. They become more compliant, accepting more responsibility for therapy outcomes.”

Ultimately, Downey evaluates every new advance based on the holy grail of compliance and therapeutic results. She appreciates the ICON’s improved ability to allow a greater range of internal temperature settings for heated humidification, a feature that allows her to bracket low, medium, and high temperature ranges. If patients don’t get enough humidity, they can choose a low, medium, or high temperature range.

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1 Virag R. Evaluation of the performance of CPAP heated humidifiers for use in sleep apnea therapy: a comparative study of humidification effectiveness Sleep 2008; 31: A382.

ScreenShot038 All About Options

Three Big Questions

The president of the American Academy of Craniofacial Pain tackles cost, efficacy, and results.

Dentists with experience in sleep medicine hear the same three questions over and over again: 1) Why are oral appliances so expensive?; 2) Are oral appliances ever covered by insurance?; and 3) How do I know if oral appliances are effective? As a fol- low-up to number three, physicians usually want to know why patients they refer for oral appliance therapy rarely, if ever, come back for follow-up.

Cost
The fee that most dentists charge—and that most insurance companies pay—usually takes into account everything that dentists do for patients. These services often include x-rays, examinations, treatment planning, dental impressions, and model fabrications. Factor in a laboratory bill for custom appliances (which can be as high as $600), plus fitting and 90-day follow-up, and the typical fee by a dentist who knows what he is doing can be about $2,000 to $3,000.

Jamison Spencer, DMD, MS, president of the American Academy of Craniofacial Pains, knows that sleep physicians don’t always refer to dentists who have extensive experience with oral appliance therapy. “An assumption is often made that all dentists are equally proficient in dental sleep medicine and oral appliances,” says Spencer, a dentist with practices limited to dental sleep medicine and craniofacial pain in Boise, Idaho. “This is absolutely not the case. Dentists receive virtually no education regarding dental sleep medicine in dental school, and many dentists will choose appliances based on dental magazine advertisements rather than education or training.”

Spencer concedes that less experienced dentists may charge a few hundred dollars less than clinicians with hundreds of hours of continuing education, but outcomes will often be less than satisfactory. “I have had many patients referred to my office after being fit with an inferior appliance by a well-meaning dentist who didn’t really understand oral appliance therapy,” laments Spencer. “In the end, the patient pays more than if he had been referred to my office in the first place.”

Coverage
Sleep physicians are often surprised to learn that oral appli- ance therapy is generally covered by medical insurance, as long as the patient meets criteria for treatment—and Spencer confirms that this criteria is the same as CPAP. While insur- ance coverage usually exists, including through Medicare, most dentists are not aware of how to work with medical in- surance companies or Medicare.

It usually ends up that only dentists who are serious about oral appliance therapy to acquire the knowledge and resourc- es necessary to work with third party payers, Medicare, and Tri- care. Spencer is contracted with many insurance companies, including Medicare and Tricare. He acknowledges that it took years to make it happen.

Efficacy
Sleep docs know the literature regarding oral appliance ther- apy and AASM guidelines. Most are also aware that oral appliances are effective, particularly in mild to moderate OSA. The problem is that patients often do not receive appropriate and objective follow-up.

Once again, this may have to do with whom the sleep doc- tor is sending his patients . Most dentists have their patients’ best interests in mind, but good intentions are not enough. “They usually will not even be aware that their patient should be evaluated in the sleep lab to confirm that the oral appliance is effectively treating the patient’s sleep apnea,” says Spencer. “The only way to know if the oral appliance therapy is work- ing is for the patient is to get back to the sleep lab. While this often requires some patient education, to convince them to go in for yet another sleep study, most patients understand the importance of confirming that the appliance is helping.”

Most insurance companies and Medicare will pay for these follow-up studies, but what about those who don’t have insur- ance coverage, or those who have high deductibles? For these patients, Spencer has developed an oral appliance called the Silent Sleep that is non-custom, but fits in a unique way.

Typical “boil and bite” appliances are difficult to fit, lack retention, are bulky, uncomfortable, and often ineffective. The Silent Sleep is fit using an impression-type material that is odorless, tasteless and durable. “The time for the dentist to fit the appliance is less than 10 minutes, and the complete cost to the dentist is low,” says Spencer. “This is opening up treatment to those who can’t afford CPAP or custom appliances, and is also a great option for those diagnosed as primary snorers.”

Spencer believes that sleep professionals owe it to their pa- tients to coordinate care with dentists who are trained and ex- perienced in dental sleep medicine. A good way to ensure this is for sleep physicians to look for dentists credentialed by the American Academy of Dental Sleep Medicine and the Ameri- can Academy of Craniofacial Pain (AADSM.org and AACFP. org). These dentists will understand dental sleep medicine, TMJ, and facial pain issues, which is crucial to avoiding and treating possible side effects of oral appliance therapy.

Ultimately, sleep physicians and trained dentists working together can provide effective and affordable treatment op- tions for patients suffering with OSA—including combination therapy where oral appliances are used to help patients to bet- ter tolerate CPAP. Many patients may benefit from oral appli- ance therapy, and the three common concerns can be easily resolved by working with knowledgeable dentists.

“Knowing the facts and seeking answers is the first step,” adds Spencer. “The fact is that oral appliances are reasonably priced considering everything that is included. Medical in- surance will typically cover the therapy, and trained dentists will encourage patients to return to the sleep lab for objective follow up. Knowing these facts will hopefully motivate sleep professionals to find trained dentists to work with.”

In addition to his role as president of the American Academy of Craniofacial Pain, Jamison Spencer, DMD, MS, is a dentist with practices limited to dental sleep medicine and craniofacial pain in Boise, Idaho. He also serves as chief technical officer for Cadwell Therapeutics,Inc., a company that manufacturers the Silent Sleep appliance and helps connect sleep physicians and sleep labs with trained dentists, including helping with the challenges of billing third party payers for payment of oral appliance therapy (www.ctisleep.com).

Can the RST and RPSGT Credentials Co-Exist?

Posted by Anglee Leviner Aug 28, 2011

Introduction

The Registered Sleep Technologist (RST) credential from the American Board of Sleep Medicine (ABSM) in March 2012 will represent the first time since 1979 that two credentialing bodies are available for sleep technology professionals. The original credential, the Registered Polysomnographic Technologist (RPSGT) was introduced by the American Board of Registered Polysomnographic Technologist (BRPT), the education and examination board of the Association of Polysomnographic Technologists (APT).  This article presents my personal viewpoints on whether or not two sleep technology credentials can co-exist.

Perspective

I’ve read a lot of grossly misinformed statements about the ABSM and their intentions. Until taking the time to research the concerns of those opposing the new credential, I had not made up my own mind on the matter of whether I would make an application for the RST. I feel it is important to present key facts rather than hearsay about the RST credential. Below is a summary of my findings.

Some believe, or are of the opinion that the RST exam is intended to be easier for skilled and trained technologists to pass. However, according to the ABSM, topics the BRPT fails to include in it’s RPSGT exam, such as Multiple Sleep Latency Testing (MSLT) questions and pediatric questions lead to a less prepared work force. If anything, the BRPT increased their pass rates in 2010 and 2011 by removing difficult content such as MSLT and pediatric questions. The ABSM states, “The primary goal of the American Board of Sleep Medicine is to offer a certification examination for sleep technologists based on a blueprint reflective of the day-to-day professional responsibilities of sleep technologists in the sleep center setting and instruction received from available didactic programs. We believe this methodology fairly and responsibly evaluates professional competence (1).” It seems very clear that the newly offered RST exam will be aimed to coincide with the curriculums of the Committee on Accreditation for Polysomnographic Technologist Education (CoA PSG) programs. However, until the first testing window for the RST exam in November 2011, and until which time a copy of that exam is released, all opinions on the ease of the test are poorly informed assumptions.

Another public opinion of the RST exam is that of “greed”. Among the various forums and discussion areas for sleep techs, some say that the doctors (i.e, ABSM Board Members) are doing this to raise their profits because Medicare cut the reimbursement. Actually, reimbursements were put on hold, not cut. On December 8th 2010 legislative processes decided to postpone the medicare cuts (2). While some continue to rant about how it will eventually happen, I remind you this threat has been looming for years, and has yet to come to pass. This is a common fear and tease game seen on the national level of politics and government. So these accusations of greed are unfair, and meant to undermine any true intentions had by the ABSM.

Finally, to argue that two allied health credentials could not run in parallel is largely biased. I admit, finding the truth of the matter was not easy, and also a lucky accident. Recently, I discovered that nurse practitioners can choose from two different credentialing bodies. While that might not be quite as similar to our profession as some would like, there is a better example. Electrodiagnostic technologists are very similar to our own profession; I would dare to call it a sister profession. They function in their jobs, education, and credentialing very similarly to the sleep technology profession. Therefore, we have the great fortune of comparing our current predicament to one that happened to them only two years back.

The American Association of Electrodiagnostic Technologists (AAET), was the sole credentialing body for the profession. The AAET was founded in 1974 to register nerve conduction study (NCS) technologists, although back then they were called electrodiagnostic technologists. The AAET is a technologist driven credentialing group, much akin to our BRPT. In 2010, the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), an organization of physicians which employ NCS technologists, offered to absorb the AAET into their organization. The AAET explained to it’s members that, “TheAANEM proposal requires the AAET to ‘dissolve and transfer its assets, including the examination, to theAANEM (3).” With the offer, the AANEM agreed to grandfather in current NCS techs registered by AAET, and to include current AAET board and council members in the AANEM standing committees. However, the AAET refused this gracious offer. In response to the refusal, the AANEM launched their own credentialing exam. The physicians from the American Board of Electrodiagnostic Medicine (ABEM) designed a separate credentialing exam, with a “grandfather” option, that was in direct competition with the professional technologist developed exam. “The ABEM is creating a written and practical examination for NCS technologists. We believe the examination will soon be recognized as the premiere certification for NCS technologists.”(4) Does this sound familiar? Of course it does. This is exactly what is happening to the sleep technology profession as we speak. Based on their numbers, it appears one third of the NCStechs took the grandfather option extended to them. Luckily we have the AAET conflict with the AANEMto learn what effects a second credentialing option will have on the profession. Although it’s still early for them and the effects are yet to be seen, I hope we learn something from their results soon.

So is the RST trying to replace the RPSGT credential for which many of us worked so hard to achieve? At this time, logical deduction points to the coexistence of two credentials, not the elimination of one. While their may be some initial bias to hire or not hire the new RST credential holders, ultimately they should coexist. The amount of lobbying and work we are talking about to remove the RPSGT from CMS guidelines and state laws is not reasonable. It is unrealistic to believe that the RPSGT will be replaced, no matter what quotes are attributed to the AASM/ABSM situation. Moreover, to determine which pathway is more challenging when considering to sit for each exam is still being fiercely debated. This may be due to the fact that there are various opinions on which means of training and education lead to the best qualified technologists. Whichever educational temple you pray to, it is incorrect to state that little effort will be required to sit for the new RST exam. Indeed, many people who have spoken on the matter may not have actually reviewed the pathways that lead to sitting for the ABSM credentialing exam. You can make up your own mind on the appropriate difficulty levels of the various pathways. These pathways for the ABSM and BRPT can be found online at:http://absm.org/resources/sleeptechregapp.pdf andhttp://www.brpt.org/default.asp?contentID=85 respectively.

Summary

I find most concerns all root back to the same fear, a drop in pay. All unfounded fears aside, can two credentials co-exist? They can and they will. Should two credentials co-exist? You bet they should, and this will likely benefit the technologists of the sleep medicine world. We come out on top thanks to the structure of free market capitalism. The introduction of the RST will likely be the stimulus for change needed to incite the long awaited improvements in credentialing called for by techs, managers, and doctors around the world. Both the ABSM and BRPT are important and necessary in their own right. At the very least, they will have to work more diligently to please us and keep our best interests in mind, or else we will pay our money to a different credentialing body!

Randy Clare

Randy Clare

Randy Clare brings to Sleep Scholar more than 25 years of extensive knowledge and experience in the sleep field. He has held numerous management positions throughout his career and has demonstrated a unique view of the alternate care diagnostic and therapy model. Mr. Clare's extensive sleep industry experience assists Sleep Scholar in providing current, relevant, data-proven information on sleep diagnostics and sleep therapies that are effective for the treatment of sleep disorders.

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