Why has sleep breathing management not been integrated into cardiology care pathways?
The increased awareness and broad acceptance of the role of sleep apnea in cardiac disease, and the main studies and scientific statements published by the European Society of Cardiology, American Heart Association, and American College of Cardiology were the drivers behind the American Sleep Academy’s “Sleep Apnea Hurts Hearts” campaign.
The remaining questions are:
If the link between sleep apnea and several main cardiovascular diseases such as Atrial Fibrillation and hypertension has been broadly accepted, why do most heart patients remain undiagnosed? And why are the majority of cardiologists not integrating this factor into their care pathways?
There are two main barriers that we hear about from practitioners:
The first obstacle is awareness among cardiologists and their patients about how prevalent sleep apnea is and the fact that most will not be visually detected. Most cardiologists “eyeball” patients to assess obvious signs of sleep apnea, such as a thick neck, visually high BMI, chronically blocked nose, etc.
This results in a significant under-diagnosis of sleep apnea, as demonstrated in a recent study conducted in Montefiore Medical Center in New York City by Dr. Wharton and Dr. Zaremski. Their conclusion was that systematic and broad screening is recommended in cardiology clinics: 84% of their patients screened positive for sleep apnea, while they found that BMI was a poor predictor of screening results.
The second obstacle lies in the dynamics of referring a patient to a sleep medicine physician. To start with, cardiology patients are preoccupied with their heart condition and do not understand the link between their sleep apnea and their heart. If not given a motivational explanation by the cardiologist or pressed hard to show up at the sleep doctor, most will not make the extra effort this requires. Furthermore, when patients finally overcome this obstacle and wish to have a sleep study, they encounter a lack of sufficient sleep certified physicians, resulting in inconvenient wait times, sometimes reaching months, combined with geographical accessibility limitations driven by the tendency to diagnose simple OSA with full in-lab polysomnography (PSG) as a first-line procedure, which has a host of barriers embedded in it.
For example, more and more healthcare insurers are requiring Home Sleep Apnea Testing (HSAT) before authorizing PSG. Sleep physicians, preferring PSG, require the patient to undergo two procedures or challenge the insurance company. A not-insignificant portion of the patients refuse to undergo in-lab PSG because they are worried about being hospitalized or fear the financial impact of the co-pay. Sleeping at a sleep lab is typically perceived to be an unpleasant experience.
HARNESSING THE SIMPLICITY OF HOME SLEEP TESTS
Cardiology and sleep need to be integrated differently. Home sleep tests, which revolutionized
sleep medicine and made sleep studies available to all patients, whether they lived far away, had a disability, or simply liked sleeping in their own beds have the potential to enable the cardiology patient population to easily manage their sleep by either moving the point of dispatch to the cardiology practice or even to direct shipment just like Amazon did with retail.
How do we solve these challenges?
Recently Itamar® Medical launched the Total Sleep Solution program that has all the components necessary to successfully integrate sleep medicine into cardiology patient care. It has:
- A. Cardiology oriented screening tools combined with patient education materials to achieve efficient accessibility for all patients while maintaining a seamless and pleasant patient experience.
- B. Unique, Home Sleep Test-enabling technology with the WatchPAT® home sleep test offers an unparalleled, simple user experience and requires only a finger sensor and a watch instead of all the cumbersome home sleep tests available. It’s FDA approved, listed as technically adequate in the AASM guidelines for HSATs,1 and fully reimbursed.*
- C. Remote Sleep Expert Interpretation. Cloud-based technology enables immediate transmission of the test report to a sleep specialist for interpretation and diagnosis.
- D. Connection to sleep apnea management service providers of high quality that understand the standards cardiologists are expecting and help ensure patient compliance and adherence.
To learn more about Total Sleep Solutions, you may always contact your local Itamar® Sales Representative or leave your details at [email protected]
1. Kapur VK, et al. 2017 “Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline.”J Clin Sleep Med. 13(3):479–504.
*Please verify with your insurance mix as local policies varies.