Industry Inspiration: Richard Simon, Kathryn Severyns Dement Sleep Disorders Center
Dr. Richard D. Simon Jr. is the medical director at Kathryn Severyns Dement Sleep Disorders Center at St. Mary Medical Center in Walla Walla,Wash. He has been in sleep since 1993.
How prevalent is sleep screening at the physician level?I don’t think it’s prevalent at all. I don’t think it’s done. In a 2004 study, a standardized patient was incorporated into the practice of 30 primary care MDs. Only 10 percent asked three or more sleep questions. Ten percent asked two questions and 30 percent asked one question. Fifty percent asked no sleep questions. In the Wisconsin CoHort Study, Dr. Terry Young reported in 1997 that 93 percent of middle-aged women and 82 percent of middle-aged men who had moderate to severe OSA had not been diagnosed by their doctors.
What do you think that is?I think doctors don’t know about sleep. The reason they don’t know is because sleep physiology is not really covered in medical school to any meaningful degree, nor is it covered in residency.
Why is it important that more physicians screen for obstructive sleep apnea?Obstructive sleep apnea, at least in its mild forms, affects up to 25 percent of men and 10 percent of women — that’s based on Terry Young’s studies — and these are people who previously thought they were fairly healthy. Additionally, there are multiple studies suggesting that obstructive sleep apnea probably causes hypertension, or at least is one of the causes of hypertension. From studies such as that, we also find that the risk of heart attack increases two- to threefold in patients with obstructive apnea compared to patients who don’t have apnea, and that treatment of apnea seems to lower that risk. Obstructive sleep apnea probably increases the risk of stroke. Untreated obstructive sleep apnea clearly increases the risk of fall-asleep car accidents; and in several studies, CPAP seems to lower this risk. Obstructive apnea is associated with insulin resistance.
We’re in the last stages of a huge study where we’re looking at 1,100 patients with obstructive sleep apnea. We’ve randomized them to either effective CPAP or sham CPAP, and we’re following them for six months doing repetitive measures of neuro-cognitive functioning. That study should be completed in February 2008, and this will be the definitive study on sleep apnea. It’s called the APPLES (Apnea Positive Pressure Long-term Efficacy Study) project.
As awareness of sleep apnea increases, do you think physicians are starting to realize that it’s a problem and that they need to start screening?I think they realize it’s a problem, but they’re still not screening. Fifteen years ago, a bed partner would usually bring her husband in and say he snores. The primary care doc would go, “Snoring is normal. Don’t worry about it.” Now, they’re saying it could be sleep apnea and they refer. But that’s not really screening. Screening is when you’re talking to an asymptomatic person or the person who hasn’t brought it up. A routine screening exam should include questions about what time do you go to bed, what time do you wake up, are you satisfied with your sleep, do you get sleepy in the daytime? Everybody should be asked do you snore? And if the answer is yes, do you snore every night? If the answer is yes, they need a sleep study of some sort. End of discussion.
Do you support in-home sleep testing?The first 400 sleep studies we did, we did at home before Medicare disallowed it. We did full polysomnograms at a patient’s home. They worked fine. The difficulty with the screening technology is where you just get limited channels, where you get maybe an airflow channel, maybe a heart rate and oxygen saturation channel, where you actually don’t get the sleep. An abnormal study such as that does diagnose sleep apnea. A normal study does not exclude sleep apnea. The only way to exclude sleep apnea is a full polysomnogram. The screening studies don’t come anywhere close to that. We have many patients — I would say hundreds — that would show minimal to no apnea on a screening study that actually have clinically significant, if not severe apnea. What if they didn’t sleep that night? When they’re awake, every sleep apnea patient looks normal. The problem with the screening studies is that the abnormal ones almost assuredly all have apnea, but don’t be fooled that the normal patient does not have apnea.
This article originally appeared in the Respiratory Management Sept/Oct 2007 issue of HME Business.