Sleep medicine in China: current clinical practice

Abstract

The modern practice of sleep medicine in China was introduced in the 1980s and has undergone significant development over the past few decades. The field has witnessed an increase in sleep laboratories, the publication of guidelines for the diagnosis and treatment of sleep disorders, and the establishment of several sleep medicine associations. Despite these achievements, there is still much to be done in this field. By utilizing original national survey data, this study comprehensively discusses the current practice of sleep medicine in China, including sleep medicine training, diagnostic capacity, multidisciplinary care, clinical competence and standardization, sleep telemedicine, barriers to the practice of sleep medicine, and costs of sleep medicine. It is imperative for the Chinese health care authorities to enhance their attention and investment in the field of sleep medicine. Urgent implementation of standardized training programs and accreditation systems is necessary to promote the diagnosis and treatment of sleep disorders in China.

Citation:

Xu S, Li Y, Ye J, Han D. Sleep medicine in China: current clinical practice. J Clin Sleep Med. 2023;19(12):2125–2131.

INTRODUCTION

China, spanning 9.6 million square kilometers, is presently recognized as the world’s second most populous country. According to the 2020 Census, the population reaches 1.41 billion, with 17.95% aged 0–14, 63.35% aged 15–59, and 18.70% aged 60 years and above. With 4.29 million doctors practicing in the country, the physician-to-patient ratio is 3.04 per 1,000 residents.¹ China’s health care system encompasses private and public sectors that are divided into primary, secondary, and tertiary care tiers. Primary care serves as the initial point of contact, but there is a shortage of general practitioners, with only 3.08 general practitioners per 10,000 residents, constituting 10.13% of practicing doctors.¹ The health care system in China operates on a multilevel payer system, primarily supported by basic medical insurance and supplemented by medical aid and commercial health insurance.

The modern practice of sleep medicine in China was introduced in the 1980s and this field has developed rapidly over the past few decades. However, several significant challenges persist within this domain. Hence, a first-ever national survey was jointly initiated by the sleep medicine branches of the China International Exchange and Promotive Association for Medical and Health Care (CPAM) and the Chinese Medical Doctor Association (CMDA) to assess the availability of clinical sleep medicine services and identify obstacles faced by health care professionals and institutions in China.

METHODS

A telephone survey aimed at primary hospitals was conducted from July 27 to July 31, 2022. One hundred twenty primary hospitals across China were randomly selected and hospital receptionists were asked about sleep-monitoring services, specialized sleep medicine clinics, and treatment of sleep disorders.

A comprehensive questionnaire-based survey was conducted targeting secondary and tertiary hospitals. The questionnaire covered the sleep medicine services provided in respondents’ hospitals, obstacles to initiating such services, and continuing education requirements. The questionnaire was disseminated electronically using WeChat (Tencent, China), a Chinese social network, and sent to members of the sleep medicine branches of the CPAM and the CMDA. Participants were encouraged to share the link with other health care professionals. This study was exempt from the institutional review board’s approval because it was an anonymous survey and no participants’ personal information was included. The link was active from July 27 to August 14, 2022. A total of 473 questionnaires were collected from various regions of China. After excluding incomplete and duplicate responses, 409 questionnaires were eligible (Figure 1 and Figure 2).

Figure 1. Flow diagram of the survey.

Figure 2. Numbers and percentages of respondents from different regions of China.

SLEEP MEDICINE TRAINING

Presently, China does not have a national standard for sleep medicine training and certification. The health care professionals involved in sleep medicine predominantly come from backgrounds in respiratory medicine, psychiatry, neurology, and otolaryngology, making it difficult to estimate their exact number. Consequently, the identification of sleep disorders often originates from their specific disciplinary perspectives, resulting in a certain degree of bias within the field. To tackle this, the Chinese Medical Association formulated the Specialized Physician Standardized Training Subject Catalog in 2019, which includes sleep medicine as an independent specialty. It specifies that residents who have completed training in internal medicine, psychiatry, neurology, otolaryngology, oral and maxillofacial surgery, or orthodontics can choose to participate in specialized training in sleep medicine. Nonetheless, it remains at the pilot stage, lacking a unified nationwide training and assessment system. As an example, Peking University Health Science Center introduced a pilot fellowship program in sleep medicine in 2021.² Participants undertake a 12-month rotation to acquire knowledge about sleep disorder theory, diagnosis, and treatment, which culminates in an objective structural clinical examination and a theory examination. However, such programs have recruited limited participants, as practicing physicians tend to specialize in sleep disorders of their specific discipline and lack incentive for comprehensive education in sleep medicine.

The training system for sleep technologists in China is also in its early stages. Since 2017, the CMDA has been organizing annual training courses on sleep-monitoring technology to enhance the professional competence of sleep technologists. Starting from April 2022, participants are required to take an examination organized by the National Health Commission. Candidates who passed the exam will be awarded a certification by the CMDA. Nevertheless, obtaining this certification is not obligatory for practicing as a sleep technologist.

In the absence of formal sleep medicine fellowship programs, continuing education programs and workshops play a crucial role in sleep medicine education. Some top-tier hospitals will occasionally organize sleep medicine workshops for interested physicians to enhance their knowledge and skills. Regarding continuing education requirements, our survey found online and offline training were favored as effective methods (Figure 3A). Among the topics covered, respondents expressed their interest in guideline studies, new progress in the field, typical case analysis, and the relationship between sleep disorders and other diseases (Figure 3B). Understanding physicians’ needs would be beneficial for the further development of continuing education.

Figure 3. Demands for continuing education.

(A) The preferred forms of continuing education. (B) The preferred contents of continuing education.

PRACTICE AND STRUCTURE OF SLEEP MEDICINE

Diagnostic capacity

China faces a high prevalence of sleep disorders. A meta-analysis revealed that approximately 15% of the general population experience insomnia.³ Furthermore, the burden of obstructive sleep apnea (OSA) is significant, affecting an estimated 176 million individuals, among whom approximately 66 million are categorized as having moderate to severe OSA.⁴ Presently, the estimated number of medical institutions in China capable of conducting sleep monitoring ranges from 2,000 to 3,000, resulting in a ratio of 0.14 to 0.21 sleep laboratories per 100,000 population.^2,5 In the present survey, among 409 secondary and tertiary hospitals, 178 had sleep laboratories equipped for polysomnography (PSG), and nearly half of them were established after 2016 (Figure 4A). However, none of the primary hospitals surveyed could perform PSG. Despite the increasing number of sleep laboratories, many face limitations in terms of staffing and available beds, resulting in a low number of daily PSG cases. Specifically, 83% of the surveyed sleep laboratories reported conducting no more than 5 PSGs per workday (Figure 4B). Additionally, 48% of the sleep laboratories indicated that their patients frequently complained about long waiting times for PSG. The monitoring capacity was significantly correlated with the number of designated PSG beds, followed by the number of technologists and doctors (Figure 4C), suggesting a great demand for facilities and staff. Among 271 hospitals capable of performing home sleep apnea tests (HSATs), only one was a primary hospital. Eighty-five percent of them completed no more than 5 cases per workday, 7% performed 6 to 10 cases per workday, and the remaining 7% conducted more than 10 cases per workday.

Figure 4. Sleep laboratories: establishment time, staff, beds, and workloads.

(A) The establishment time of the sleep laboratories. (B) Number of staff, beds, and workloads of the sleep laboratories. (C) Scatterplots and Spearman’s rank correlation test results for the number of PSGs performed per workday and other variables. PSG = polysomnography.

In terms of sleep clinics, a mere 2% of primary hospitals had specialized sleep clinics, while 37.5% could treat sleep disorders in their outpatient clinics. Among secondary and tertiary hospitals, 76% had clinics for sleep disorders. Of these, 66% were able to treat multiple sleep disorders, and 23% had specialized clinics of other specialties that could also treat specific types of sleep disorders. Only 11% of clinics were focused on a single type of sleep disorder.

Multidisciplinary care

Patient-centered, multidisciplinary sleep clinics and laboratories can improve care coordination, reduce duplication, and enhance cost-effectiveness. Our survey revealed that multidisciplinary services could be provided in many sleep laboratories, including referral or consultation, transfer of patients with poor blood pressure control, and joint rescue programs for emergencies (Figure 5A). However, in terms of administrative affiliation, only 12% of sleep laboratories were managed by specialized sleep medicine departments, while the majority were managed by other clinical departments or jointly administered by multiple departments (Figure 5B).

Figure 5. Practice of sleep laboratories.

(A) Multidisciplinary diagnosis and treatment. (B) Administrative affiliation. (C) Professional competence and scope of service. (D) Patient follow-up and telemedicine service. CBT-I = cognitive behavioral therapy for insomnia, HBP = high blood pressure, MSLT = Multiple Sleep Latency Testing, PAP = positive airway pressure, PSG = polysomnography.

Clinical competence and standardization

There are variances in clinical competence among different sleep laboratories. Apart from PSG, other clinical services such as multiple sleep latency testing, positive airway pressure (PAP) titration, and cognitive behavioral therapy for insomnia also play a crucial role in the accurate diagnosis and effective management of sleep disorders. Unfortunately, our survey revealed that approximately 30% of sleep laboratories lack the ability to perform these tests and therapy (Figure 5C). In order to standardize the construction of sleep medicine centers, a guideline, drafted by domestic experts in this field, was officially released at the national conference organized by the Chinese Medical Association and the Chinese Society of Psychiatry in 2021.⁶ It provides comprehensive insights into site construction, staff requirements and standardized training, sleep-monitoring equipment and operational protocols, and emergency contingency plans, among other related topics. In the future, an accrediting system will be imperative to ensure the implementation of this guideline.

Sleep telemedicine

Sleep telemedicine enhances treatment strategies by exchanging patient information, improving accessibility, and containing costs. It effectively manages chronic sleep disorders like OSA and insomnia, while improving patient adherence to PAP therapy.^7–9 However, only half of the surveyed sleep laboratories could perform remote PAP treatment monitoring and data transmission (Figure 5D). This is consistent with another survey from China indicating that only approximately one-fourth of sleep centers provided telemedicine services.¹⁰ Given the scarcity and uneven distribution of sleep medicine resources among different levels of hospitals, developing telemedicine is crucial to improve patient access and extend the reach of sleep medicine in the future.

BARRIERS TO THE PRACTICE OF SLEEP MEDICINE

Modern sleep medicine in China has experienced exponential growth in recent decades, supported by actively involved associations. The Chinese Sleep Research Society, founded in 1994, is a multidisciplinary association that brings together professionals from diverse fields. The Assembly of Sleep Disordered Breathing, established in 2000 as part of the Chinese Thoracic Society, focuses specifically on the diagnosis and treatment of sleep-related breathing disorders. Furthermore, the integration of sleep medicine branches within prominent professional associations such as the CMDA and the CPAM has further propelled the growth and development of the field in China. In addition, the publication of multiple guidelines has facilitated standardized diagnosis and treatment for insomnia, OSA, and other sleep disorders.^11–14 In terms of research programs, the National Natural Science Foundation of China approved 399 sleep research projects from 1988 to 2019, exhibiting an upward trend in both project approvals and funding amounts, especially since 2010 after the National Natural Science Foundation of China specifically established funding programs for sleep research, namely sleep-disordered breathing (code H0113) and sleep and sleep disorders (code H0916).¹⁵

Despite these achievements, 9% (37/409) of the secondary and tertiary hospitals in our survey did not offer any sleep medicine services, and we asked these respondents about the obstacles that hinder such services (Figure 6A). The first major challenge pertains to the lack of sleep specialists and technologists. As mentioned above, China currently lacks a standardized training and certification system for sleep medicine specialists, which greatly limits the cultivation of talent in this field. The second major obstacle reported by respondents is the cost of equipment. The devices for sleep monitoring and treatment are expensive and require frequent maintenance. On the other hand, the charge for PSG in Chinese public hospitals is mostly determined by the government. Although the low cost makes PSG more accessible for patients, the lack of revenue poses a huge financial burden on sleep laboratories, undermining their incentives to initiate such services. The third obstacle involves a shortage of patients, as reported by one-third of the respondents. Despite the high prevalence of sleep disorders in China, public awareness of sleep health is relatively low. Many patients with sleep disorders would not consider visiting a sleep specialist as an option.

Figure 6. Main obstacles and future directions of the hospitals without sleep service.

(A) The main obstacles of providing sleep medicine services. (B) The sleep medicine service wished to be developed in the future.

In terms of future directions, 62% of the respondents expressed their interest in performing HSATs, while 51% indicated their desire to conduct PSG. Only 19% of the respondents reported their intention to establish a sleep center that includes both a sleep laboratory and a sleep clinic, which also reflects that sleep medicine services in China are still in the early stages of development (Figure 6B).

COSTS OF SLEEP MEDICINE

Sleep medicine in China is generally affordable for the majority of the population, with fee standards varying across regions based on the government-determined price list for medical services. PSG typically ranges from 250 to 600 yuan (∼35–82 US dollars [USD]), with an average cost of approximately 500 yuan (∼69 USD), compared to 1,000–7,000 USD per PSG in the United States. HSATs are priced between 50 and 300 yuan (∼7–42 USD), with an average cost of approximately 100 yuan (∼14 USD). In most regions of China, both PSG and HSATs are reimbursed at a rate of 50–90% by basic medical insurance. Medical insurance also covers common surgical treatments for OSA, including uvulopalatopharyngoplasty, adenotonsillectomy, and septoplasty. According to the Diagnosis Related Groups payment standard, the cost of inpatient treatment for surgery is approximately 6,000 to 10,000 yuan (∼837–1,395 USD). Nonetheless, insurance coverage in China does not extend to durable medical equipment for home use, including continuous PAP (ie, CPAP) machines, which have high upfront costs (3,000–8,000 yuan, ∼418–1,116 USD) and ongoing maintenance expenses. As a result, a considerable number of patients with OSA might choose surgical interventions over noninvasive positive-pressure ventilation as their preferred treatment option. The absence of long-term cost-effectiveness data on noninvasive positive-pressure ventilation in China also deters the government from approving the proposals to insure CPAP machines. Similarly, oral appliances used for OSA treatment cost 100–1,000 yuan (∼14–140 USD) and are not covered by medical insurance.

CONCLUSIONS

Sleep medicine is a relatively new field in the Chinese medical community and has experienced tremendous development over the past few decades. However, diagnostic capacities remain limited, and hospitals’ competence in managing sleep disorders requires further development. Standardized training programs and accreditation systems are urgently needed to promote the diagnosis and treatment of sleep disorders in China.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. Work for this study was performed at Beijing Tongren Hospital, Beijing, China. This research was supported by the National Natural Science Foundation of China (81970866). The authors report no conflicts of interest.