Even in the population-dense region of Southern California, sleep labs used to be rare. When compared to 2011, sleep apnea awareness in the 1980s significantly trailed other conditions.
Officials at Hoag Memorial Hospital Presbyterian in Orange County, Calif, recognized early on that there was a need for a specialized center to evaluate and treat sleep disorders. The Judy & Richard Voltmer Sleep Center, backed by the resources at Hoag, filled this void back in 1987 in Newport Beach, Calif. More recently, the center moved to gleaming new quarters in an effort to modernize and accommodate more patients.
With considerable resources, expertise, and referrals flowing from Hoag, the state-of-the-art 8-bed facility never lacks for patients. Paul Selecky, MD, FACP, FCCP, FAASM, long-time medical director of the Voltmer Sleep Center, has tirelessly spread the message of sleep health among his colleagues. The result is that clinicians from diverse specialties appreciate the value of healthy sleep, and they don’t hesitate to ask for help when they need it.
Under the umbrella of Hoag Neurosciences Institute, the Voltmer Sleep Center is seamlessly integrated within the continuum of care. Sleep is not an afterthought. Neurologists, ENTs, pulmonologists, endocrinologists, and primary care physicians all readily send patients to the center.
Colleagues on Board
The evidence for the sleep/health connection seems to build each year, with ever-more co-morbidities related to poor sleep. The more apt question these days is what is not affected by sleep.
When the American Society of Anesthesiology (ASA) came out with its 2006 guidelines on peri-operative management of patients with known or suspected sleep apnea, clinicians at Voltmer Sleep Center were ready. “Our anesthesiologists asked if we could help them develop a program to screen patients who were coming in for elective surgery,” says Selecky. “That protocol has now grown, and nearly every admission coming into Hoag is evaluated for the risk factors of sleep apnea.”
Hoag has taken a proactive approach, and patients who come in for other ailments benefit from the extra attention. “About 70% of stroke patients have sleep apnea,” says Selecky. “It’s a chicken-egg type of thing, but at least they get sent here to lower that risk. Others who come in for total knee, hip, chest pain—we ask them about sleep and the patient is educated about serious breathing problems.”
Not surprisingly, about 90% of all referrals to Voltmer Sleep Center come from Hoag, but outside referrals are growing. If a patient is referred by a Hoag neurologist for sleep problems related to that neurologic problem, a neurologist working on staff at Voltmer Sleep Center is the one to see that patient.
If COPD was the primary problem, a pulmonologist would visit with the patient. “This is not just an independent sleep center,” explains Trish Stiger, BBA, RPSGT, CRT, manager of the Voltmer Sleep Center. “It is part of Hoag, and they refer from the Diabetes Center, the Cardiovascular Institute, and more. Even obstetricians are reminded that a snoring pregnant woman should not be ignored as if she merely has nasal congestion, as this can lead to complications of pregnancy.”
In line with the large body of evidence linking sleep apnea and congestive heart failure, Voltmer Sleep Center clinicians provide information and education to all Hoag cardiologists. “A lot of them have gotten the message,” says Selecky. “They ask every congestive heart patient, ‘Do you snore?’ If the patient snores, and has other features of sleep apnea, he comes to us.” Cardiologists will also send patients whom they are treating for resistant hypertension, as is recommended by the American College of Cardiology and American Heart Association because of the link with untreated obstructive sleep apnea.
Much the same can be said for diabetes management. Endocrinologists who prescribe several different medications for diabetes have referred their patients to the Center, again because of the link between diabetes management and sleep apnea . “The first thing that should be done is to rule out sleep apnea,” says Selecky.
Education and Follow-up
Every physician takes patients to the lab bedrooms to explain the diagnostic tests and procedures, and these in-person consultations provide vital information. Despite all the media attention on sleep, Selecky admits that some convincing is often part of the job. “Sometimes there is too much negative information out there,” laments Selecky. “People come in and say, ‘I don’t want that breathing machine. I know somebody that hated it.’ It gets a bad rap, so we must provide a lot of education.”
When it comes time to dispensing the actual CPAP machine, Selecky and Stiger work closely with trusted durable medical equipment (DME) providers who are known for their good service. “If they don’t provide good service, we don’t refer to them—it’s that simple,” says Selecky. “That means excellent follow-up, because if patients don’t have a positive experience in the first few weeks of CPAP use, they are more likely to abandon it. Nationally, the average for CPAP users is that 50% drop it by the end of the first year. We have several of the DME RTs spend time in the Center so patients can try a dozen different masks. It’s like buying a pair of shoes. If it doesn’t fit well, you are not going to use it.”
In addition to the familiar sleep apnea/CPAP combination, officials at Voltmer are keen to address all sleep disorders and treatments. “Insomnia is not a huge percentage of our patient population at this point, but it’s significant enough and our physicians treat it,” says Stiger. “Patients may need extensive cognitive behavioral therapy, sometimes with the aid of psychologists.
In addition to CPAP for apnea, we embrace dental sleep medicine as a valid option. “Oral corrective devices have been used throughout our history with the help of local dentists who started treating some of our milder patients, or those who could not tolerate CPAP,” adds Selecky.
Unlike the 1980s, Selecky says it seems as though these days there is a sleep lab on every corner. Favorable demographic trends suggest that won’t change, despite the furor caused last year when Medicare approved home sleep studies—much to the chagrin of lab owners. “People said that might be the end of all sleep centers,” says Selecky. “But as time has gone on, that has not occurred at all. Part of it is that reimbursement for home sleep studies is low. However, it has made every lab consider whether it should be involved in home sleep studies. The answer is yes for certain populations.”
In 2011, Selecky believes the keys to success looks a lot like the keys of the past. Education, clinical excellence, follow-up, and compliance must be the driving forces. As understanding of sleep medicine grows and physicians know more about it, they will inevitably order more sleep studies.
Those who have worked to be a full service center will remain in the black as they gain the trust of physicians and patients alike. “There is a difference between establishing yourself as a sleep center vs a sleep lab,” adds Stiger. “A center deals with everything. You educate, go out and teach the community, and work with all the other specialties to care for patients—which should always be the number one goal.”
Tradition of Excellence
Hoag Memorial Hospital Presbyterian is accredited by the Joint Commission on Accreditations of Healthcare Organizations (JCAHO), and home to Centers of Excellence in cancer, heart, orthopedics and women’s health services. Orange County residents named Hoag the “Hospital of Choice” in a National Research Corporation poll, as well as the county’s top hospital in a a local newspaper survey.
The Voltmer Sleep Center is an accredited member of the American Academy of Sleep Medicine, and features a Web site (http://www.hoag.org/services/neurosciences-institute/voltmer-sleep-center) where potential patients can view online sleep assessments, photos of the sleep center, and information about the physicians. “Many people simply don’t realize that an adequate night’s sleep is needed to maintain good health and stay fully alert throughout the day,” says Selecky. “We are excited about the opportunity to use the Internet to educate the public and to let them know there is help nearby.”