Raghu Upender, MDRaghu Upender, MDAssistant Professor in Assistant Professor in Neurology Neurology Medical DirectorMedical DirectorVanderbilt Sleep Disorders Vanderbilt Sleep Disorders CenterCenter

Referrals for sleep services have increased 12-fold in the last 10 years.

Obesity epidemic and aging population are driving demand for sleep services.

1/5 Americans has mild sleep apnea.

1/15 has moderate or severe sleep apnea.

70% of men and 56% of women over 50 have moderate to severe sleep apnea.

Obesity in Tennessee

2011 2030

29 % 63%

AASM accredited labs 337 in 1996 2,461 in 2012

Medicare expenditure on sleep testing $62 million in 2001 $235 million in 2009

“We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value.”

-Dr. Fred HoltMedical Director

BCBS, NC NPR news-Jan 2012

"This is a good example of something where we have technology, we have financial incentives to use more of it ... You have enough problems, including a growing obesity epidemic, and you sort of put together the so-called perfect storm for driving up overuse and health care costs.”

-Helen DarlingPresident

National Business Group on Health

"I believe lab tests, as opposed to the home tests, are being wildly overprescribed…it should be 70 percent at home and 30 percent in the lab.”

Michael BackusVP of American Imaging

ManagementWellPoint

Treat wide range of sleep disorders with an aim to:

Improve sleep quality and daytime functioning Prevent fatigue related accidents/errors Prevent or reduce risk of chronic medical

conditions (hypertension, heart disease, diabetes, stroke, headaches)

Improve overall quality of life

Review interconnection between Sleep and health Sleep and chronic illnesses

Review sleep apnea treatment outcomes Review the cost of untreated sleep

apnea The future of sleep medicine Vanderbilt strategy

Daytime sleepiness Fatigue related

accidents Medical errors Depressed Mood Decreased Productivity Increased absenteeism

5

6

7

8

9

1950 1960 1970 1980 1990 2000 2010

Slee

p (h

ours

)

0%

5%

10%

15%

20%

25%

30%

35%

Obe

sity

Pre

vale

nce

SleepObesity

Sleep & obesity in the U.S.

Fred Turek

Obesity is the strongest risk factor for obstructive sleep apnea (OSA)

Each increase of 10 kg in weight doubles the risk of OSA

OSA contributes to weight gain causing a vicious cycle

Obesity OSA

DiabetesHypertensionHeart diseaseStrokeCancer

Pepard et al. NEJM 2000;342(19) 1378-1384

Bottini et al. Respiratory Medicine (2012)106, 1329-1334

FATAL EVENTS NON-FATAL EVENTS

Marin JM et al Lancet 2005;365:1046-53

Martınez-Garcıa et al. Eur Respir J 2012; 39: 906–912

Martinez-Garcia et.al. Eur Respir J 2012; 39: 906–912

Aronsohn, RS et al. Amer J of Resp and Critical Care Medicine 2010; 181: 507–513

Diabetes & Metabolic Syndrome: Clinical Research & Reviews 6 (2012) 176–179

Nieto et al Am J Respir Crit Care Med2012;186: 190–194

Attention and Vigilance

Memory function Frontal lobe

executive functions

Motor function

Reaction Times Principles and Practices of Sleep Medicine 2011

Motor functionAttention and

VigilanceMemory function Frontal lobe

executive functions

Short-Term Patient satisfaction Quality of life

measures Productivity measures Health measures▪ Weight & BP▪ Glucose control (HgA1c)▪ Lipid control▪ CRP

Long-Term Hospitalization

rates Cardiovascular

events Cancer incidence Dementia

Incidence Mortality rates

Patient engagement Care coordination Outcomes

measurements Cost-benefit analysis Iterative Process

Care Coordinator Patient Education Patient Engagement Partnership with Primary Care Physicians Medical Home Medical neighbor Partnership with Vanderbilt Health Plan Cost-sharing Cost-benefit analysis Web-app to Coordinate activity of

Program

The future of our field will be dictated by our ability to show how our services add value to the healthcare enterprise.

We must focus on short and long-term outcomes and design our practices to maximize best outcomes.

We must see the evolving changes as an opportunity to fulfill the promise of better sleep.