Ilene M. Rosen

An official american thoracic society statement: Continuous positive airway pressure adherence tracking systems the optimal monitoring strategies and outcome measures in adults

BACKGROUND Continuous positive airway pressure (CPAP) is considered the treatment of choice for obstructive sleep apnea (OSA), and studies have shown that there is a correlation between patient adherence and treatment outcomes. Newer CPAP machines can track adherence, hours of use, mask leak, and residual apnea-hypopnea index (AHI). Such data provide a strong platform to examine OSA outcomes in a chronic disease management model. However, there are no standards for capturing CPAP adherence data, scoring flow signals, or measuring mask leak, or for how clinicians should use these data. METHODS American Thoracic Society (ATS) committee members were invited, based on their expertise in OSA and CPAP monitoring. Their conclusions were based on both empirical evidence identified by a comprehensive literature review and clinical experience. RESULTS CPAP usage can be reliably determined from CPAP tracking systems, but the residual events (apnea/hypopnea) and leak data are not as easy to interpret as CPAP usage and the definitions of these parameters differ among CPAP manufacturers. Nonetheless, ends of the spectrum (very high or low values for residual events or mask leak) appear to be clinically meaningful. CONCLUSIONS Providers need to understand how to interpret CPAP adherence tracking data. CPAP tracking systems are able to reliably track CPAP adherence. Nomenclature on the CPAP adherence tracking reports needs to be standardized between manufacturers and AHIFlow should be used to describe residual events. Studies should be performed examining the usefulness of the CPAP tracking systems and how these systems affect OSA outcomes.

Sleep apnea and commercial motor vehicle operators: statement from the joint Task Force of the American College of Chest Physicians, American College of Occupational and Environmental Medicine, and the National Sleep Foundation

M edical research supports the finding that obstructive sleep apnea (OSA) is a significant cause of motor vehicle crashes (MVCs) resulting in twoto sevenfold increased risk. Recent reports indicate OSA is present in a greater prevalence in operators of commercial motor vehicle (CMV) operators than in the general population. Although U.S. commercial drivers are required by federal statute to undergo medical qualification examinations at least every 2 years, the most recent OSA recommendations for medical examiners were prepared during a 1991 conference sponsored by the Federal Highway Administration (FHWA). Since then, the clinical diagnosis, evaluation, treatment, and follow-up criteria have changed significantly. Lacking current recommendations from the U.S. Department of Transportation (DOT), commercial driver medical examiners (CDMEs) must rely on outdated guidance and are thus forced to fill in the many existing gaps when evaluating CMV operators for this safety-sensitive type of work. In addition to causing difficulties for the medical examiner, the current guidelines, or lack thereof, foster an environment in which drivers who possibly have OSA are afraid to be evaluated because it might result in their removal from work. This set of circumstances may lead to the underrecognition of this condition and an increase in MVCs. From OccuMedix, Inc. (Dr Hartenbaum), Dresher, Pennsylvania; the Department of Medicine, Division of Pulmonary/Critical Care Medicine (Dr Collop), Johns Hopkins University, Baltimore, Maryland; the Department of Medicine, Divisions of Sleep Medicine and Pulmonary, Allergy & Critical Care Medicine (Dr Rosen), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; the Division of Pulmonary Critical Care and Sleep Medicine (Dr Phillips), University of Kentucky College of Medicine, Lexington, Kentucky; the Department of Medicine, Division of Respirology (Dr George), University of Western Ontario, and the Sleep Laboratory, London Health Sciences Centre, South Street Hospital, London, Ontario, Canada; the Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine (Dr Rowley), Wayne State University School of Medicine, Harper University Hospital, Detroit, Michigan; The Sleep and Behavior Medicine Institute and Pulmonary Physicians of the North Shore (Dr Freedman), Bannockburn, Illinois; Biobehavioral and Health Sciences Division (Dr Weaver), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; the Department of Medicine, Divisions of Sleep, Pulmonary and Critical Care Medicine (Dr Gurubhagavatula), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; the Department of Medicine, Director (Dr Strohl), Center for Sleep Disorders Research, Case Western Reserve University School of Medicine, Louis Stokes DVA Medical Center, Cleveland, Ohio; the IHC Health Services to Business (Dr Leaman), Intermountain WorkMed, Salt Lake City, Utah; and Arkansas Occupational Health (Dr Moffitt), Springdale, Arkansas; Alertness Solutions (Dr Rosekind), Cupertino, CA. Address correspondence to: Natalie Hartenbaum, MD, MPH, FACOEM, President and Chief Medical Officer, OccuMedix, Inc., P.O. Box 197, Dresher, PA 19025; E-mail: occumedix@comcast.net. Copyright

Health and Health Care Among Housestaff in Four U.S. Internal Medicine Residency Programs

AbstractBACKGROUND: Although there have been many studies of the health care services that resident physicians provide, little is known about the health care services they receive. OBJECTIVE: To describe residents’ perceptions of the health care they receive. DESIGN: Anonymous mailed survey. SUBJECTS: All 389 residents in four U.S. categorical internal medicine training programs. MAIN RESULTS: Three hundred sixteen residents responded (83%). In aggregate, 116 (37%) reported having no primary care physician, and 36 (12%) reported that they are their own primary care physician. These figures varied substantially across the four programs. Most residents reported receiving basic screening and preventive services; however, their attitudes toward their health and health care differed across postgraduate level, gender, and program. Many residents reported that their long and unpredictable hours interfered with their ability to schedule clinician visits, that their health had declined because of residency, that programs and other residents were unsupportive of residents’ health care needs, and that residency raised special issues of privacy that limited access to health care. CONCLUSIONS: Despite high rates of receipt of preventive services, these internal medicine residents identified several barriers that limited their access to health care. Program directors should explore these barriers and, at the same time, reevaluate the messages being sent to resident physicians about maintaining their health and health care.

Sleep behaviors and attitudes among internal medicine housestaff in a U.S. university-based residency program.

Purpose. Physicians-in-training are susceptible to fatigue given their prolonged duty hours. Sleep deprivation has been shown to alter perceptions of sleepiness and performance. This study examined the state of sleepiness and attitudes about sleep and performance of work- and non–work-related tasks among incoming and current housestaff; and how rotation, call cycle, and call status are related to acute and chronic sleep deprivation and perceptions of sleepiness. Method. A survey instrument was administered in June 2001 to 53 incoming interns and 79 current housestaff at the University Pennsylvania School of Medicine, a university-based internal medicine residency program. Results. All 132 participants (100%) completed the instrument. Acute sleep deprivation was experienced by 34% of the current housestaff and 64% of current housestaff were chronically sleep deprived. Current housestaff admitted to the possibility of dozing while performing various work-related tasks such as writing notes in charts (69%), reviewing medication lists (61%), interpreting labs (51%), and writing orders (46%). At least half of all respondents felt their patients received good care despite residents’ sleepiness and as many believed sleep deprivation was a necessary part of training. Nearly half (48%) of current housestaff rotating on a ward service reported acute sleep deprivation, as did 81% of those who were postcall. Over two-thirds of the housestaff on wards and in the ICU reported chronic sleep deprivation. Subjective sleepiness did not vary much across rotations, call cycle, and call status. Conclusion. Chronic and acute sleep deprivation contribute to residents’ fatigue. Education could be targeted at attitudes. Further investigation of factors contributing to chronic sleep deprivation in this population is warranted.

Confronting Drowsy Driving: The American Academy of Sleep Medicine Perspective

ABSTRACT Drowsy driving is a serious public health concern which is often difficult for individual drivers to identify. While it is important for drivers to understand the causes of drowsy driving, there is still insufficient scientific knowledge and public education to prevent drowsy driving. As a result, the AASM is calling upon institutions and policy makers to increase public awareness and improve education on the issue, so our society can better recognize and prevent drowsy driving. The AASM has adopted a position statement to educate both healthcare providers and the general public about drowsy driving risks and countermeasures.

Confronting drowsy driving: The American academy of sleep medicine perspective: An American academy of sleep medicine position statement

ABSTRACT Drowsy driving is a serious public health concern which is often difficult for individual drivers to identify. While it is important for drivers to understand the causes of drowsy driving, there is still insufficient scientific knowledge and public education to prevent drowsy driving. As a result, the AASM is calling upon institutions and policy makers to increase public awareness and improve education on the issue, so our society can better recognize and prevent drowsy driving. The AASM has adopted a position statement to educate both healthcare providers and the general public about drowsy driving risks and countermeasures.

The Changing Landscape of Adult Home Noninvasive Ventilation Technology, Use, and Reimbursement in the United States

There has been an exponential increase in the use of home noninvasive ventilation (NIV). Despite growing use, there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies and coding. This article aims to provide a practice management perspective for clinicians providing home NIV, including Local Coverage Determination reimbursement criteria for respiratory assist devices, Durable Medical Equipment coding, and Current Procedural Terminology coding to optimize clinical care and minimize lost revenue. It highlights the need for further research and development of evidence-based clinical practice standards to ensure best practice policies are in place for this rapidly evolving patient population.

Delaying Middle School and High School Start Times Promotes Student Health and Performance: An American Academy of Sleep Medicine Position Statement

ABSTRACT During adolescence, internal circadian rhythms and biological sleep drive change to result in later sleep and wake times. As a result of these changes, early middle school and high school start times curtail sleep, hamper a students preparedness to learn, negatively impact physical and mental health, and impair driving safety. Furthermore, a growing body of evidence shows that delaying school start times positively impacts student achievement, health, and safety. Public awareness of the hazards of early school start times and the benefits of later start times are largely unappreciated. As a result, the American Academy of Sleep Medicine is calling on communities, school boards, and educational institutions to implement start times of 8:30 AM or later for middle schools and high schools to ensure that every student arrives at school healthy, awake, alert, and ready to learn.

Impact of Protected Sleep Period for Internal Medicine Interns on Overnight Call on Depression, Burnout, and Empathy

BACKGROUND Patient safety and sleep experts advocate a protected sleep period for residents. OBJECTIVE We examined whether interns scheduled for a protected sleep period during overnight call would have better end-of-rotation assessments of burnout, depression, and empathy scores compared with interns without protected sleep periods and whether the amount of sleep obtained during on call predicted end-of-rotation assessments. METHODS We conducted a randomized, controlled trial with internal medicine interns at the Philadelphia Veterans Affairs Medical Center (PVAMC) and the Hospital of the University of Pennsylvania (HUP) in academic year 2009-2010. Four-week blocks were randomly assigned to either overnight call permitted under the 2003 duty hour standards or a protected sleep period from 12:30 am to 5:30 am. Participants wore wrist actigraphs. At the beginning and end of the rotations, they completed the Beck Depression Inventory (BDI-II), Maslach Burnout Inventory (MBI-HSS), and Interpersonal Reactivity Index (IRI). RESULTS A total of 106 interns participated. There were no significant differences between groups in end-of-rotation BDI-II, MBI-HSS, or IRI scores at either location (P > .05). Amount of sleep while on call significantly predicted lower MBI-Emotional Exhaustion (P < .003), MBI-Depersonalization (P < .003), and IRI-Personal Distress (P < .006) at PVAMC, and higher IRI-Perspective Taking (P < .008) at HUP. CONCLUSIONS A protected sleep period produced few consistent improvements in depression, burnout, or empathy, although depression was already low at baseline. Possibly the amount of protected time was too small to affect these emotional states or sleep may not be directly related to these scores.

Medical cannabis and the treatment of obstructive sleep apnea: An American Academy of sleep Medicine position statement

ABSTRACT The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. Positive airway pressure (PAP) therapy remains the most effective treatment for OSA, although other treatment options continue to be explored. Limited evidence citing small pilot or proof of concept studies suggest that the synthetic medical cannabis extract dronabinol may improve respiratory stability and provide benefit to treat OSA. However, side effects such as somnolence related to treatment were reported in most patients, and the long-term effects on other sleep quality measures, tolerability, and safety are still unknown. Dronabinol is not approved by the United States Food and Drug Administration (FDA) for treatment of OSA, and medical cannabis and synthetic extracts other than dronabinol have not been studied in patients with OSA. The composition of cannabinoids within medical cannabis varies significantly and is not regulated. Synthetic medical cannabis may have differential effects, with variable efficacy and side effects in the treatment of OSA. Therefore, it is the position of the American Academy of Sleep Medicine (AASM) that medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA due to unreliable delivery methods and insufficient evidence of effectiveness, tolerability, and safety. OSA should be excluded from the list of chronic medical conditions for state medical cannabis programs, and patients with OSA should discuss their treatment options with a licensed medical provider at an accredited sleep facility. Further research is needed to understand the functionality of medical cannabis extracts before recommending them as a treatment for OSA.