New Roadblocks Can Slow Treatment of Sleep Apnea
By BETH SIMKANIN
Insurance Limitations Can Be an Obstruction for Patients
Despite recent advancements in sleep medicine, Mid-South sleep specialists are facing new challenges when diagnosing and treating patients with sleep apnea.
Insurance regulations and restrictions, along with a lack of awareness of new therapies in the medical community, sometimes create additional hurdles for local sleep specialists, according to three Memphis physicians.
Neal Aguillard, MD
When treating patients with sleep apnea, it has become common for sleep specialists to use a team-based approach with other physicians as a result of alternative therapies, said Neal Aguillard, MD, a pulmonologist and medical director at the Methodist Sleep Disorders Center.
However, the team approach can sometimes be problematic due to a lack of awareness of new sleep therapies. The general public and some physicians aren't always aware that newer surgical treatments are available.
Additionally, sleep specialists and their patients at times are forced to deal with new insurance restrictions that either limit or do not cover the costs of tests or procedures.
"Technological advancements have made a difference in treating sleep apnea over the past decade," Dr. Aguillard said. "There are more customized options that make treatment more comfortable and effective for patients."
According to Dr. Aguillard, head of one of the largest hospital-based sleep centers in the nation, 80 percent of the patients treated at the Methodist Sleep Disorders Clinic have some form of sleep apnea, which occurs when a person's breathing stops and starts repeatedly during sleep.
The American Sleep Apnea Association, a nonprofit organization that promotes awareness, reports that 22 million Americans have obstructive sleep apnea.
The majority of patients who are diagnosed with obstructive sleep apnea are treated with a continuous positive airway pressure machine (CPAP) so they can breathe easier during sleep. A CPAP machine is a mask that covers the nose and mouth and increases air pressure in patients' throats so the airway doesn't collapse when they breathe during sleep. A patient must use the machine every night during sleep, and it is considered an effective, noninvasive way to treat sleep apnea.
Dr. Aguillard says 75 to 80 percent of his patients diagnosed with sleep apnea use a CPAP machine.
"CPAP machines are very sophisticated now," he said. "A decade ago when a patient used it at home, it gave the highest pressure for air flow all of the time. Now CPAP machines can sense when the air pressure should be higher or lower as the patient moves in his or her sleep. They allow us to download information to find out right away how the patient is doing and if the machine is effective. The ability to analyze the data has taken out a lot of guesswork."
Additionally, Dr. Aguillard says there are many types of masks available to fit a patient comfortably. Also, CPAP machines are now more compact and can be charged with a small battery, making it easier for patients to travel with one.
Boyd Gillespie, MD
Although the use of CPAP machines provides results for most patients with obstructive sleep apnea, some don't find relief and must seek alternative surgical treatments, according to Boyd Gillespie, MD, an otolaryngologist with UT Methodist Physicians.
"CPAP machines are the gold standard for treating sleep apnea," he said. "It works the majority of the time, yet one-third of the patients who use a CPAP have trouble tolerating it for various reasons. These patients usually try the CPAP for three to six months and do not improve. Surgery is an option for these patients. We can determine where the airway closes and fix that."
Dr. Gillespie is the only board-certified physician in the Mid-South in both sleep medicine and otolaryngology. He has performed about 150 surgical procedures on patients with severe sleep apnea during the past year. He says once it is determined that a patient isn't responding to a CPAP machine, he or she is evaluated for the best approach. This is done with drug-induced sleep endoscopy. The patient is put under anesthesia and the physician inserts a scope through the patient's nose to determine where the airway closes during sleep.
"Performing this procedure improves outcomes because we can determine the exact problem," Dr. Gillespie said.
There are many alternative surgical treatments for sleep apnea patients, but two new advancements in the field are transoral robotic surgery (TORS) and upper airway stimulation therapy.
The TORS procedure uses the assistance of a surgical robot to reduce the size of a patient's tongue. According to Dr. Gillespie, a patient's tongue can be too large in some cases and can block the patient's airway. The TORS procedure eliminates the need for breathing devices and the recovery time is minimal.
Upper airway stimulation therapy is a recently approved treatment for sleep apnea by the U.S. Food and Drug Administration. It involves placing an implant inside the body, which stimulates the hypoglossal nerve, which sends messages to the tongue. The implant is timed with the patient's breathing and provides electrical stimulation to prevent the tongue from blocking the airway.
According to both Dr. Aguillard and Dr. Gillespie, there are other solutions available for patients with mild sleep apnea. Dr. Aguillard says he uses a team-based approach and works with other specialists to treat patients.
"We take a multidisciplinary approach and work with psychologists, ENTs and dentists to treat patients with sleep apnea. Not everyone needs a CPAP," he said. "There are many ENT or dentist options for patients, and their solutions are helpful.
"For instance, I will refer a patient to a dentist to receive a retainer that slowly moves the patient's jaw forward over time if there is a problem with the patient's skull. Also, if a patient tells me he or she is claustrophobic and can't wear a CPAP, I will send the patient to a psychologist for help before the patient wears one."
James Adams, MD
Both Dr. Aguillard and James Adams, MD, a pulmonologist and sleep lab director at Delta Medical Center, have noticed a change in the public's awareness over the past few years.
"I see more awareness among the general public to be vigilant," Dr. Adams said. "We are more aware of how important sleep is to the body, and it's become more acceptable for people to use a CPAP machine. People used to have a sleep study because their doctor or spouse sent them. Now the patients come in knowing they aren't getting enough sleep."
However, Dr. Gillespie says the general public and some physicians aren't as aware of other treatment options besides using a CPAP machine.
"There isn't as much awareness in the medical community and general public that there are alternative treatments after CPAP," he said. "There are many people suffering, and they don't know there are other options. This can put the patient and others at risk.
"A person with obstructive sleep apnea has the delayed reflexes of someone who has had two or three drinks. It impairs a person's motor skills, which are used to drive a vehicle. Also, patients are at risk for other health problems such as heart disease or stroke."
Despite collaborative efforts between physicians and technological advancements in treatment, insurance restrictions can be an issue for physicians wanting to perform sleep studies inside of a sleep center laboratory.
"An overnight sleep study performed in a lab is very expensive," Dr. Aguillard said. "Insurance companies won't always cover it and will opt to cover a home sleep study instead. While these are helpful, they are not as comprehensive."
In a home sleep study, a patient's sleep is monitored and his or her oxygen level, heartbeat, air flow and chest movement are measured. In addition to these measurements, an overnight sleep study performed in a sleep center records and monitors a patient's brain waves as well as muscle activity.
"It's tough to get insurance to pay for a full sleep study," Dr. Adams said. "We have more open beds at the center because a third party won't pay, and this can hurt patients and put others at risk."