13th Annual Focus Conference
Niche Sleep Services That Can Be Added To
Your Sleep Program
May 12, 2013
Duane M. Johnson, PhD
Senior Partner, SCMI
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Why New Revenue Sources
Are Needed!
1.
2.
3.
4.
5.
Lower reimbursement pressures
More regulations
Greater sleep lab competition
Current national economy woes
Protect existing referral and patient
relationships
6. Attract more patients and new referral
sources
7. Increase financial results and future
business security
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Ten New Revenue Source
Opportunities
1. Oral Appliance Therapy for CPAP
failures
2. Cardiology/Catherization
Screenings
3. Sedation Apnea Management
(SAM) Screening and Service
4. Home Study Primary Care Ventures
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Ten New Revenue Source
Opportunities
5. Pain Clinic Services
6. Weight Loss Clinics/Bariatrics
7. Diabetes Specialty Sleep Initiatives
8. Business and Industry Safety
Programs
9. Insomnia Program
10. Women’s Sleep Services
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Dentistry’s Role in the
Diagnosis and Treatment of
OSA
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Dentistry’s Role in the Diagnosis
and Treatment of OSA
• Obstructive Sleep Apnea (OSA) is a
life threatening medical disorder
• Dentists are not medically qualified
nor legally permitted to diagnose
sleep disorders
• Diagnosis must be made by a
physician
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Dentistry’s Role
• Screening and referral
• Provide and monitor oral appliance
therapy as part of treatment team
with physician
• Monitor and treat potential side
effects of oral appliance
• Follow-up
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OSA Physical Exam Risk
Factors
•
•
•
•
•
BMI>30
Neck Circumference >16in
High arched palate
Micro/retrognathia
Mallampati class airway
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Oral Appliances
• “Oral appliances present a useful
alternative to continuous positive
airway pressure (CPAP), especially
for patients with simple snoring and
patients with obstructive sleep
apnea therapy who cannot tolerate
CPAP therapy.”
•
Wolfgang Schmidt-Nowara et al. Oral Appliances for the Treatment of
Snoring and Obstructive Sleep Apnea: A Review; Sleep, 1995;
18(8):501-510
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Practice Parameters
• Practice Parameters for the
Treatment of Snoring and
Obstructive Sleep Apnea with Oral
Appliances: An Update for 2005
•
An American Academy of Sleep Medicine Report.
•
SLEEP 2006; 29(2):240-243
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American Academy of Sleep
Medicine Clinical Guidelines
• Oral Appliances are indicated in:
– Patients with mild to moderate OSA
who prefer them to continuous positive
airway pressure (CPAP) therapy, or
who do not respond to, are not
appropriate candidates for, or who fail
treatment attempts with CPAP
–
SLEEP, Vol 29, No 2, 2006
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American Academy of Sleep
Medicine Clinical Guidelines
• Until there is higher quality evidence
to suggest efficacy, CPAP is
indicated whenever possible for
patients with severe OSA before
considering oral appliances.
–
SLEEP, Vol 29, No 2, 2006
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Other Indications for Oral
Appliance Therapy
• As an adjunct to CPAP
– For use during travel
– For use when electricity is not readily
available (camping, etc.)
• In combination with CPAP to help
reduce necessary pressure changes
or to eliminate head gear
• As a predictor of success of ‘bi-max’
advancement surgery
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American Academy of Sleep
Medicine Clinical Guidelines
• Diagnosis
– Medical Evaluation to Precede Appliance
Therapy
• Appliance Fitting
– Appliance Selection and Fitting by Qualified
Dental Personnel
• Follow Up
– Medical Assessment PSG for Moderate and
Severe OSA
– 6 Month/Annual Evaluation by Dentist
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Major Legal Concerns
• Compliance with local licensing
requirements (check with your state)
• Issues of professional liability
•
Due to the nature of oral appliance therapy, certain aspects of treatment
fall within the scope of practice of physicians and certain others dwell
within the scope of practice of dentists.
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CPAP and OA Treatment
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Oral Appliance Therapy
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How Do They Work?
• Oral appliances are utilized in the
mouth during sleep to prevent the
oropharyngeal tissues and the base
of the tongue from collapsing and
obstructing the upper airway.
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Oral Appliances May Function
in 3 Basic Ways
• Repositioning the mandible, tongue,
soft palate and hyoid bone
• Stabilizing the mandible, tongue and
hyoid bone
• Increasing the baseline
genioglossus muscle activity
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Functional Classification of Oral
Appliances
• Tongue Retaining Appliances
• Mandibular Repositioning
Appliances
• Combination Oral Appliances and
CPAP
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The Silent Sleep
• Non custom (less expensive)
• Easily fit with VPS (denture reline
material)
• No boiling
• Easy to alter position
• May be relined as many times as needed
• Excellent trial or temporary appliance
• May be used in youth or children
• May fit directly in the sleep lab
• Dental/TMJ uses as well
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Standard Protocol
•
•
•
•
•
•
•
Referral from phsyician
Initial exam
Records (study models, bite registrations, imaging, other)
Fitting of appliance
Follow up visits for comfort and efficacy
Follow up objective study (pulse ox, ambulatory unit)
Referral back to physician for consideration of follow up
PSG with titration of the appliance in the sleep lab
• Alteration of the appliance for long term success
• Long term follow up with regular maintenance and
replacement of the appliance
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How a Dentist might do things…
• Screen ALL patients for bruxism, snoring
and sleep apnea (Epworth, GASP,
Bruxism Questionnaire)
• Treat the patient with the Silent Sleep For
Bruxism
• Refer the patient to their family doctor for
consideration of a sleep study
• Follow up with the patient for creation of
a long term treatment plan
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Follow Up PSG or HST with
Titration
• Refer patient back to their physician for consideration of
follow up PSG or HST with titration of the appliance in the
sleep lab
• Need to provide the sleep lab with written protocols for
titration
• Have the patient return to review results and to determine
the next step
– Good position
– New treatment position?
– OA not effective – combination therapy?
• Annual follow up
• Replace appliance every 2 to 3 years
• Oral appliance therapy in LIFETIME therapy for most
patients
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The Bottom Line
• Sleep Apnea is a serious health concern
with a high prevalence in our society
• Dentists can play an important role in the
diagnosis and treatment of sleep
disordered breathing (SDB).
• Oral appliances are useful in the
treatment of SDB and are often better
tolerated that CPAP and can be used
adjunctive to CPAP or in combination
with CPAP.
• You Can Do It!!!!
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Keys to Success: Cardiology
• Make it easy for Cardiologists to refer
SDB patients
• Screen for SDB before Cardiologists
see patients in clinic (who, what and
when)
• Streamline Process (i.e. EMR/Paper
Charts)
• Education: Physicians, Extenders,
Staff and the Patients
• Time Line to start Treatment
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Three Landmark Conclusions
from the Latest Research:
1. Up to 50% of cardiologist’s patients
suffer from Sleep Disordered Breathing
(SDB).
2. Treatment of SDB has therapeutic
value for many types of cardiac
pathology.
3. Sleep Centers have a diagnostic value
in the detection of cardiac pathology.
Many patients exhibit cardiac
abnormalities only during sleep.
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Indications for a Sleep Study
1.
2.
3.
4.
5.
6.
7.
8.
Congestive Heart Failure
Refractory Hypertension
Refractory Angina
Left Ventricular Systolic Dysfunction
Ischemic Heart Disease
Arrhythmia
Myocardial Infarction
Stroke
IMPORTANT: These diagnoses allow
reimbursable sleep studies to be performed.
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SDB Co-Morbidities
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Samples from Current Literature
Lung Biology in Health and Disease
The leading medical text book on Sleep & CVD
by TD Bradley and JS Floras; Marcel Dekker, Inc, New York, 2000
In the chapter entitled:
Sleep Apnea: Implications for Cardiovascular and
Cerebrovascular Disease
Links the Comorbidities of SDB and:
 Drug-Resistant Hypertension = 80%
 Hypertension
= 45%
 Congestive Heart Failure
= 50%
 Stroke
= 60%
 Coronary Artery Disease
= 30%
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Conclusion
The detection and treatment of
Sleep Disordered Breathing no
longer lies entirely in the realm
of the pulmonologists.
It is a must for cardiologists
and their patients.
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Sedation Apnea
Management
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Reasons to Integrate a Sleep
Apnea Management Program
•
•
•
•
•
•
•
•
Improve patient care
Increasing prevalence for sleep apnea
ASA Practice Guidelines
Reimbursement changes
Pain Management focus
Joint Commission focus
Reduce adverse events
Reduce liability claims
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Reduction of costs
• Never Events - Hospitals tear up
bills for medical mistakes
– The Seattle Times
2008
January 29,
• Nationally the movement to stop
paying for unexpected medical
events
• RAC audits
• Reduce length of stay
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Joint Commission
• Requirements to manage patients at risk
– The process for effective hand-off interactive
communication for questioning between the
giver and receiver of patient information.
Includes updating the patient’s medications
– For surgical patients, describe the measures
that will be taken to prevent adverse events
in surgery
– Improve recognition and response to
changes in a patient’s condition
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Scope of the Program
• Reduce risk in patient with sleep
apnea who receives sedation, pain
control, medication for nausea,
anxiety, and depression
• Reduce Adverse Events
• Requires support of extended
clinical and administrative team
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How to Start
• Obstructive Sleep Apnea
Perioperative Screening and Post
Operative Care Protocol
• Pre-operative screening for OSA –
Pre-Admission Services
• Pilot a scoring tool
• Focused review of Adverse Events
using Root cause analyses
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How to Start
• Define protocol for at risk patients
– AHI
– Sleep study
– Practice Guidelines
• Develop discharge instructions/plan
• Develop a Quality Management
Process
– Outcome data
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Opportunities
• Expansion of service line
• Increased referral network
– Send letters to PCP and patient
•
•
•
•
Reduction of risk
Reduction of medical liability
Improved clinical outcomes
Integrate DME communication
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Monitoring to Define:
• Impaired arousal response
– Increased with COPD
– Bariatric patients at risk
– Orthopedic procedures
– May be at risk 6-24 hours after surgery
due to residual effects from anesthesia
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SAM Summary
• Determine the need for a program
– Prevalence data
• Define the benefits for establishing
a program
• Demonstrate how to integrate the
program into an established care
continuum
• Revenue sources require careful
planning
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New Revenue Source
Opportunities
Home Study Primary Care
Ventures
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New Revenue Source
Opportunities
PAIN CLINIC SERVICES
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New Revenue Source
Opportunities
WEIGHT LOSS
CLINICS/BARIATRICS
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New Revenue Source
Opportunities
DIABETES SPECIALTY
SLEEP INITIATIVES
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New Revenue Source
Opportunities
BUSINESS AND INDUSTRY
SAFETY PROGRAMS
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New Revenue Source
Opportunities
INSOMNIA PROGRAM
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New Revenue Source
Opportunities
WOMEN’S SLEEP SERVICE
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Opportunities
Exist,
ACTION
Produces
RESULTS
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QUESTIONS
Should you have questions about this
presentation please contact the
SCMI office at 1-888-556-2203
Email djohnson@sleepcmi.com or
info@sleepcmi.com
Visit our website at
www.sleepcmi.com
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