The Future of Sleep Medicine

It was natural that Alex Chediak would have a leadership role in medicine. At around the age of 15 Chediak became interested in the subject of medical science and with his father a physician and Professor of Hematology, the rest is history. Chediak is now President of the American Academy of Sleep Medicine (AASM) as well as Associate Professor at the University of Miami, Florida, and he also runs a privately owned sleep disorders facility, the Miami Sleep Disorder Center.

The AASM was founded in 1978. It has created a number of functions for sleep practitioners, but its main goal is to continue to be the leader in sleep healthcare. This means setting professional standards based on evidence, addressing public health needs, creating opportunities for medical education and public education in sleep medicine and addressing economic issues for health disparities and healthcare delivery. The organization currently has over 7000 members, of which 4500 are physicians. Among the various activities that the academy partakes in it accredits facilities for evaluation and treatment of sleep disorders medicine. The accreditation process is really one of the cornerstones of how they establish and set standards. By having facilities across the country that have both experts in sleep medicine, board certified doctors that practice sleep medicine, and have quality assurance standards for both diagnosing and treating sleep disorders medicine. The academy have established a rich and robust network of special expertise areas in this field.

The academy maintains the standards in part by producing standards of practice documents based on evidence and occasionally based on expert consensus. In using the documents the centers that participate are accredited and are the cream of the crop of sleep healthcare in the US. Currently there are around 1300 accredited sleep disorder facilities across the US and increasingly third parties who pay for healthcare services are requesting accreditation by the AASM as the prerequisite for doing tests and paying for them. In part this is due to the recognition of quality and outcome associated with the accreditation.

In Chediak’s role as President he hopes to expand on the efficiency and quality that the academy are currently bringing to the healthcare system. It is well known that there are wide disparities in all aspects of healthcare delivery systems that tend to make the system unstable and inefficient. “Part of the inefficiency is related to differences in practices that are not necessarily based on scientific evidence,” explains Chediak. “As medical societies, including the AASM, become more involved in developing evidence-based standards of practice papers, then we have an increasingly potent body of evidence to allow our clinicians to look at their practice parameters and introduce these to increase efficacy and decrease the variability of the treatment and in the outcomes of our patients.”

In order to achieve his aspirations as President, and enhance healthcare delivery systems to become more efficient, Chediak believes he needs to create two things. Firstly, a financial incentive needs to be in place for facilities to achieve quality standards, and then you need to create mechanisms and an environment among people to seek particular facilities and/or doctors that have special expertise and have achieved certain credentials. The first part of what Chediak has done is tie the accreditation process to reimbursement for sleep related diagnostic and treatment services. Secondly, Chediak suggests driving patients toward facilities that are better equipped to diagnose and deliver services and have improved healthcare outcomes.

Chediak highlights publications specifically related to healthcare, that being seen by a doctor who has a specialty certification and is at an accredited facility improves patient satisfaction, patient’s adherence to treatment and outcomes. Unfortunately, the studies have only been performed on 80 percent of sleep disorders. Chediak now wants to foster research to show that specialty services do provide better outcomes. “We want to translate this research into documents that are evidence-based, take it to third parties and say, “Patients seen by people with credentials will have a better outcome,” states Chediak.

Chediak also wants to continue to foster public education through campaigns and support research in fields of sleep medicine that are novel. He points to the gaps in technology and research that need to be filled to improve diagnosis and outcome. “It would be wonderful to have a quick, reproducible, simple, inexpensive test to determine how sleepy you are,” says Chediak. Currently the Multiple Sleep Latency Test is the best test to assess sleepiness, but it requires around 10 hours of time in a sleep facility where you have repeated opportunities to nap and see how fast you fall asleep. It’s cumbersome, tedious and expensive.

Areas for concern

In Chediak’s mind the most pressing areas of concern for sleep specialists is the ability to deliver sleep healthcare services in a uniform way across the country. According to Chediak there are geographic pockets of excellence for delivering healthcare and then there are areas with some disparities in their ability to meet the demands of the population.

Secondly, it is increasingly important to attract young scientific talent to sleep medicine. Chediak’s desired outcome is not necessarily more sleep doctors but more sleep doctors who become scientists in order to continue the work that has been started in order to become more effective and efficient in taking care of patients. “There is a huge problem across medicine right now with a lack of young quality scientists going into the sleep medicine field,” believes Chediak, “and that needs to be taken care of.”

The academy has addressed this problem by creating the American Sleep Medicine Foundation, which was designed to do many things, but in part was designed to help advance research in sleep medicine and encourage the growth of young scientists. “In the past year, the purpose has been to create opportunities to allow young scientists to find their way until such time that they can get proper funding from the National Institutes of Health and develop a long-term academic career in sleep medicine,” remarks Chediak. Specifically the foundation is paying for five sleep fellowship positions a year for full-time research.

The third issue for Chediak is around equitable reimbursement for physician services in sleep medicine. Currently there is no incentive for a doctor coming out of any subspecialties into sleep medicine. Chediak explains that after an extra year of training in sleep medicine, a doctor will take their board definite examination and go out in to the field with no advantage because they are specialists, than any other young physician other than greater knowledge. “When young physicians go back into the community after training they end up practicing sleep medicine because there is no sufficient opportunity for them yet, despite them doing the extra year,” says Chediak.

According to Chediak the way to create these opportunities is to limit who can provide the service, or guide those who can provide sleep related services to the patients. “Granted, you don’t want to limit access to patient care – that’s the opposite of what we are trying to achieve – but what we do want to achieve is patient care based on quality and additional education; and if you don’t give an incentive for this additional education then very few physicians will go into it,” says Chediak.

Pointing to an increasingly tighter link between reimbursement for services and aid and accreditation by the AASM, Chediak believes that sleep medicine will change for the better and attract new physicians. This will improve the practice of sleep medicine and create centers of excellence where patients can go and have confidence that they are being seen by an expert. It terms of creating more sleep scientists foundations, organizations and perhaps the National Institutes of Health all need to be financially supportive, suggest Chediak. “The public and private industries are of help and have been of help in the past. We need investments from people who have a vested interest in sleep healthcare outcomes, but what we don’t want is money from pharmaceutical companies for projects designed to foster realization of some molecule they manufacture.”

Outlook

If sleep medicine is going to continue on the exponential growth rate that it has experienced over the last decade, it’s going to need to achieve a number of goals. If there is a tighter link between reimbursement for services and facility accreditation by AASM, and young scientists to reinvigorate the field then there is hope that the sleep industry can move forward. “If we can achieve outcomes similar to our standard laboratory paradigms for diagnosing and treating selected sleep disorders and do it for less money,” believes Chediak, “then we can improve the efficiency of the system and it goes back to making this more valuable.”

About Alex Chediak

Dr. Alex Chediak, the 2007-2008 President of the American Academy of Sleep Medicine (AASM), is a leading sleep medicine clinician who is Chief of the Sleep Disorders Center at Mt. Sinai Medical Center in Miami Beach, the largest private, independent, not-for-profit teaching hospital in South Florida. He is also Medical Director of the Miami Sleep Disorders Center in South Miami and Associate Professor of Medicine at Mt. Sinai, where he specializes in teaching on the mechanisms of disease.

Respiratory medicine certification

In 1978, the American Academy of Sleep Medicine created a committee in order to develop a sleep certification examination, and it administered this examination until 1990. It became the American Board of Sleep Medicine, which continued to administer the examination until this year. In the US, medical specialties receive their board certification as experts in a specific field after they've completed special training in that field, and prerequisite training if necessary, and then take a certifying examination that testifies to not just their training but also that they have a minimum competency in order to be able practice effectively.

The body that has been administering nearly all of the well recognized medical specialty certifying examinations is called the American Board of Medical Specialties. The American Board of Medical Specialties only recognized sleep medicine as a specialty in 2006 and the first certifying examination was November 2007.

To find out more about the AASM log on to www.aasmet.org.

For resources on sleep disorders, www.sleepeducation.com is a patient education website provided by the AASM