Sleep Disorders and Sleep Deprivation An Unmet Public Health Problem (2006) / Chapter Skim
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9 Building Sleep Programs in Academic Health Centers
9 Building Sleep Programs in Academic Health Centers
Pages 293-324
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From page 293... ...
It then offers a framework for establishing academic somnology and sleep medicine programs. Without being prescriptive, the chapter discusses operating principles gleaned from interdisciplinary somnology and sleep medicine programs that have flourished, as well as from others that have struggled.
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In this chapter, the committee lays out a vision for each of the nation's 125 academic health centers to formally establish an interdisciplinary somnology and sleep medicine program. Building sleep programs nationwide will strengthen Somnology and Sleep Medicine as a recognized medical specialty.
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For example, increased sleep apnea is found in obese subjects with or without the metabolic syndrome and in patients with stroke or various neurodegenerative disorders. Restless legs syndrome can occur in
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Several recent milestones for the field attest to the achievement of a critical mass of knowledge. Sleep medicine is a medical subspecialty now recognized by the American Board of Medical Specialties.
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But sleep medicine is not an ordinary subspecialty; its purview spans multiple organ systems. Consequently, complications that arise as a result of sleep loss and sleep disorders require attention from health care professionals in many disciplines.
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However, given the limited number of certified health care professionals in sleep medicine and depending on the size and structure of an interdisciplinary sleep program, an individual often may need to be referred to a specialist in another department who may not be certified in sleep medicine. These physicians come from a variety of medical specialties, including internal medicine, pediatrics, otolaryngology, pulmonology, neurology, and psychiatry.
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From page 299... ...
. Endocrinology Cumulative sleep loss led to reduced leptin and increased ghrelin and hence increased appetite (Spiegel et al., 2004; Taheri et al., 2004)
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. Several of the other constraints described in the following sections stem from organizational structures that were established prior to the advent of interdisciplinary research: interdisciplinary programs challenge institutional reward systems; interdisciplinary requirements impose obstacles, different administrative jurisdictions, and lack of appropriately trained staff for sleep studies; and service demand outstrips service supply.
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From page 301... ...
As explained earlier, an interdisciplinary program moves beyond being multidisciplinary and is one in which multiple disciplines collaborate in a way that forges a new discipline or endeavor. Provision of clinical services in sleep medicine call upon professionals from internal medicine and its relevant subspecialties (e.g., pulmonology, cardiology, neurology, psychiatry, otolaryngology, pediatrics, and geriatrics)
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From page 302... ...
Barriers include the length and depth of training in a single field necessary to develop scientists successful at competing for funds, the difficulty in forging a successful career path outside the single disciplinary structure, impediments to obtaining research funding for interdisciplinary research, and the perceived lack of outlets for the publication and dissemination of interdisciplinary research results. Lack of Appropriately Trained Staff for Sleep Studies By nearly universal consensus, one sleep technician can monitor at one time two uncomplicated diagnostic studies or one complicated study.
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From page 303... ...
Once diagnosed, severe sleep apnea, for instance, optimally should be followed up by a physician certified in sleep medicine. Less severe forms of apnea may warrant watching or referral to a dentist for preparation of dental devices, if a dental problem is etiologically related.
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Sleep disorders and sleep medicine should be covered in greater depth in residency and fellowship training programs in all primary care specialties, as well as specialties related to sleep (e.g., otolaryngology) , but without formal ACGME-accredited sleep fellowship programs.
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Participation in Proposed Research Network The committee recommended in Chapter 8 the creation of a National Somnology and Sleep Medicine Research and Clinical Network. The purpose of the proposed network is to advance the field by providing a means to connect individual investigators, research programs, and research centers.
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Such strategies give deans a very specific role in development of and support of somnology and sleep medicine as an interdisciplinary discipline. Transparent Policies and Procedures Sleep programs that are administered as divisions within individual departments may be at a disadvantage.
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Clinical services consist of obtaining a reliable clinical history from a patient, determining what studies to conduct and, based on findings, establishing a diagnosis and developing a treatment plan. Diagnostic sleep studies are constrained by the fact that a sleep technician simultaneously can run, at best, two studies.
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308 SLEEP DISORDERS AND SLEEP DEPRIVATION BOX 9-2 Areas Addressed in Semistructured Interviews 1. A description of the program's revenue stream(s)
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and clinical encounters, teaching revenue streams (student tuition fees, graduate medical education [GME] funding, and NIH training grants)
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Training grants support the education of fellows during their research training. Support of the fellows' clinical education is derived from a variety of sources and therefore differs from one institution to another.
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Under the disaggregated organizational structures, all the complications and barriers exist to multidisciplinary collaboration in clinical, teaching, and research activities. Even more relevant to the purpose of this report, the ability to reinvest net revenues generated by the various sleep programs' revenue streams is dependent on individual initiative, personal relationships, and historical fiscal arrangements.
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ACCREDITATION AND CERTIFICATION ARE ESSENTIAL TO QUALITY CARE Although somnology and sleep medicine is a relatively new field, it is coming of age during this transformative period in medicine as a whole. Sleep medicine needs to be committed to the same high standards and evolving system of care influencing other fields of medicine, starting with the basics -- accreditation and certification.
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The centers are described as having a "comprehensive or full-service sleep disorders program" (American Academy of Sleep Medicine, 2006b)
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The committee believes, however, that the accreditation procedure represents a unique opportunity to ensure that sleep centers are primarily focused on improving patient outcomes rather than diagnosis. Accreditation of Fellowship Training Programs in Sleep Medicine Starting in the mid-1990s, the AASM began to accredit sleep fellowship training programs.
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It also is occurring in sleep medicine. In several regions, private health insurers require as a condition of reimbursement that sleep studies be conducted in accredited laboratories or centers (AASM, 2006a)
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Structure and Composition Clinical specialties represented:a Internal medicine and relevant x x x subspecialties Neurology x x x Psychiatry and subdisciplines x x x Otolaryngology x x x Pediatrics and subspecialties (as x x x necessary may be separate program) Nursing x x x Psychology x x Dentistry x Medical director certification in sleep x x x medicine (American Board of Medical Specialties or American Board of Sleep Medicine)
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centers) Sleep specialists provide consultant services x x x Single accredited clinical sleep center x x x Comprehensive program for diagnosis x x x and treatment of individuals Training Program Training program for health care x x x professionals and/or researchers Medical school training and education x x x Education for residents in primary care x x x Residents in neurology, psychiatry, x x otolaryngology, and fellows in pulmonary medicine rotate through sleep program Accredited fellowship program for physicians x x Research training for clinical fellows x x NIH-sponsored training grants for graduate x x and postgraduate researchers Research Program Research areas of emphasis:c Neuroscience x x Epidemiology/public health x x Pharmacology x Basic or clinical research program x Basic and clinical research program x Member of proposed national somnology xd x x and sleep medicine research and clinical network Regional coordinator for: Core facilities for basic research x Multisite clinical trials x Core facilities for clinical research x Mentoring of sleep fellows x Public education x Data coordinating site x aThis list is not meant to be exclusive or exhaustive and should be modified as relevant specialties and training programs emerge.
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From page 318... ...
Finally, comprehensive patient care will also be facilitated through the creation of accreditation standards for interdisciplinary academic programs in Somnology and Sleep Medicine that cover the diagnosis, treatment, and long-term follow-up of individuals with sleep disorders. As discussed previously in this chapter, the AASM has a demonstrated track record and the expertise to develop these criteria, which could be expanded to include the overall management of sleep disorders.
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From page 319... ...
Academic medical centers with a commitment to interdisciplinary training are encouraged to train sleep scientists and fellows in sleep medicine, which would require at least a Type II training and re search interdisciplinary sleep program. Research-intensive medical centers should aspire to become Type III regional interdisciplinary sleep programs and coordinators of the National Somnology and Sleep Medicine Research Network.
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Type III Regional Interdisciplinary Sleep Program A Type III Regional Interdisciplinary Sleep Program includes the characteristics of Type I and II programs; however, in addition, a Type III program is designed to serve as a center for public health education, training for clinical care and research, basic research, patient-oriented research, translational research, and clinical care. As described in Chapter 8 the committee envisions that this type of program would act as a regional coordinator for the proposed National Somnology and Sleep Medicine Research and Clinical Network for education, training, mentoring, clinical care, research, clinical research studies, and large-scale population genetics studies.
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REFERENCES AASM (American Academy of Sleep Medicine)
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1993. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea.
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2003. National Sleep Disorders Research Plan, 2003.
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Journal of Clinical Sleep Medicine 1(1)
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