Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit

Abstract

Challenges exist in access to high-quality care for insomnia disorder. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults, the American Academy of Sleep Medicine (AASM) hosted a 1-day virtual Insomnia Summit in September 2022 to discuss improving care for patients with insomnia disorder. Fifty participants representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the event. Videos highlighting patient perspectives on insomnia and an overview of current insomnia disorder treatment guidelines were followed by thematic sessions, each with 3 to 4 brief, topical presentations by content experts. Breakout groups were used to brainstorm and prioritize issues in each thematic area. Top barriers to care for insomnia disorder include limited access, limited awareness of treatment options, low perceived value of insomnia treatment, and an insufficient number of trained clinicians. Top facilitators of high-quality care include education and awareness, novel care models to increase access, expanding the insomnia patient care workforce, incorporating research into practice, and increasing reimbursement for psychotherapies. Priorities for the future include increasing awareness among patients and providers, increasing the number of skilled behavioral sleep medicine providers, increasing advocacy efforts to address insurance issues (eg, billing, reimbursement, and performance measures), and working collaboratively with multidisciplinary organizations to achieve common goals. These priorities highlight that goals set to improve accessible, high-quality care for insomnia disorder will require sustained, coordinated efforts to increase awareness, improve reimbursement, and grow the necessary skilled health care workforce.

Citation:

Schotland H, Wickwire E, Aaronson RM, et al. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med. 2024;20(3):455–459.

INTRODUCTION

Insomnia disorder is a clinical sleep disorder defined as frequent (≥ 3 nights/wk), persistent (≥ 3 months) difficulty falling or staying asleep or waking earlier than desired that is accompanied by daytime consequences.¹ Insomnia disorder impacts 10–20% of the adult population in the United States, with rates higher among women (vs men), older adults (vs younger adults), and patients who identify as members of racial/ethnic minoritized groups (vs not).² Insomnia disorder is often comorbid with medical conditions, mental health problems, and other sleep disorders, including obstructive sleep apnea (OSA), and it is associated with substantial economic costs. Although clinical practice guidelines exist for pharmacological and nonpharmacological treatment of insomnia disorder (see Table 1),^3,4 this sleep disorder is often unrecognized, and access to guideline-concordant care is challenging for many patients. Prior research highlights barriers to care, including a lack of knowledge among primary care professionals and an insufficient number of board-certified behavioral sleep specialists and mental health professionals trained to deliver cognitive behavioral therapy for insomnia (CBT-I).^5,6

Table 1.

Summary of AASM clinical practice guidelines on treatment of chronic insomnia disorder in adults.^3,4

Strength (and Direction of Recommendation)	Pharmacological Therapies3	Behavioral and Psychological Therapies4
Strong (for)	None	Cognitive behavioral therapy for insomnia (multicomponent)
Conditional (for)	Eszopiclone (onset, maintenance) Ramelteon (onset) Temazepam (onset, maintenance) Triazolam (onset) Zaleplon (onset) Zolpidem (onset, maintenance) Doxepin (maintenance) Suvorexant (maintenance)	Brief therapies for insomnia (multicomponent) Stimulus control (single component) Sleep restriction therapy (single component) Relaxation therapy (single component)
Conditional (against)	Diphenhydramine Melatonin Tiagabine Trazodone Tryptophan Valerian	Sleep hygiene (single component)
Strong (against)	None	None

AASM = American Academy of Sleep Medicine.

Historically, the American Academy of Sleep Medicine (AASM) has held gatherings of key stakeholders and thought leaders to discuss sleep-related issues in the context of an ever-changing health care climate. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults,⁴ the AASM Board of Directors convened an Insomnia Summit Task Force to develop a 1-day virtual AASM Insomnia Summit. The 12-member task force included representatives from the AASM, American Academy of Family Physicians, American Academy of Neurology, American Academy of Pediatrics, American College of Physicians, American Psychiatric Association, and Society of Behavioral Sleep Medicine.

The 6-hour virtual AASM Insomnia Summit was held on September 23, 2022. Fifty attendees representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the summit. It began with a 10-minute video featuring the personal perspectives of 4 patients with chronic insomnia. Their stories highlighted the diversity of patient experiences and the challenges of treating chronic insomnia. Following the video, Jack Edinger, PhD, discussed the current recommendations for the treatment of chronic insomnia, focusing on the AASM’s clinical practice guidelines for insomnia, including behavioral and psychological treatments and pharmacologic therapy.^3,4

The remainder of the summit was structured around 3 thematic sessions: (1) Barriers to Insomnia Care, (2) Facilitators of High-Quality Insomnia Care, and (3) Future Directions and Innovations. Each session began with 3 or 4 brief, topical presentations by content experts. Presentations during the Barriers session were as follows: Provider Knowledge and Attitudes, Patient Awareness and Expectations, Perceived Importance/Value (Health System Barriers), and Pediatric Barriers. The Facilitators session comprised lectures on Practice Models that Work, Workforce Development, and Technology and Telehealth. The Future Directions and Innovations presentations were How to Influence Payer Policies, Public Health Principles, and Implementation Science.

Following each didactic, thematic session, participants were split into 7 breakout rooms for a 30-minute discussion of the presentations and to brainstorm and prioritize ways in which the AASM, partnering organizations, and the sleep medicine community should respond. Breakout room facilitators asked participants to consider key questions for the brainstorming sessions.

SESSION 1: BARRIERS TO INSOMNIA CARE

The first segment of the summit comprised 4 brief presentations on the following topics.

Provider knowledge and attitudes

David Neubauer, MD, began this session by discussing the challenge of underdiagnosis of insomnia disorder in primary care and other clinical settings. He noted challenges in access to CBT-I and a need for personalized prescribing models to improve outcomes.

Patient awareness and expectations

Eric Zhou, PhD, provided an overview of patient awareness and expectations regarding treatment of chronic insomnia. He noted that patients often obtain information about treatment from nonscientific sources, and therefore are likely to have incomplete or inaccurate information as they seek insomnia care. Additional patient barriers include underappreciation of the consequences of insomnia on health and well-being as well as low confidence in health care professionals to deliver effective insomnia treatment.^7,8 Finally, Dr. Zhou noted that many skilled CBT-I providers do not accept insurance as reimbursement for psychotherapy, which has not kept pace with inflation. This makes it difficult for patients to access affordable care and differentially impacts individuals of low socioeconomic status, increasing disparities.

Perceived importance/value (health system barriers)

Michelle Drerup, PsyD, discussed both the administrative and financial barriers to delivering high-quality care for insomnia disorder, including challenges of incorporating behavioral health into physician-led care models and downstream challenges in care coordination that result. She also discussed the lack of health system knowledge in mental health billing as a barrier to implementation of behavioral and psychological interventions. Dr. Drerup highlighted potential electronic health record solutions as well as telehealth expansions as possible solutions.

Pediatric barriers

Although the summit primarily focused on care for adult patients with insomnia disorder, Roberta Leu, MD, provided an overview of issues that limit access to high-quality insomnia care for pediatric patients. She discussed the problem of underdiagnosis and the lack of available sleep clinicians with pediatric expertise, as well as the paucity of safety and efficacy data for pharmacological interventions in pediatric patients. Dr. Leu also highlighted societal issues that negatively impact sleep in children, including early school start times that truncate sleep opportunity and extracurricular/social engagements that interfere with healthy sleep. She noted that provider, educator, and parent education can help to prioritize sleep among children while motivating increased access to high-quality care for those with sleep disorders, including insomnia.

Breakout groups

At the conclusion of these presentations, participants broke into 7 breakout groups. During these sessions, participants were asked the following:

1. What stood out as the most important “take home” message?

2. Are there any critical issues that were not discussed regarding barriers to high-quality care?

3. Where there any surprises based on the presentations?

4. What are the important barriers in treating insomnia disorder for patients, for clinicians, and for health systems?

The participants identified their top 3 barriers to care and then reconvened with all the other summit participants to share their thoughts (see Table 2).

Table 2.

Summary of Session 1: Barriers to Insomnia Care.

Domain/Theme	Description of Barrier
Limited access to care	Barriers include a shortage of trained specialist providers, nonstandardized care referral pathways, and patient-level barriers including variable health literacy, out-of-pocket treatment costs, and cumbersome treatment formats.
Limited awareness of insomnia and treatment options	Stakeholders are unaware and thus do not appreciate the burden of insomnia disorder or availability of treatment options. Much work remains to increase public health and clinical awareness.
Limited treatment formats	Patient-centered insomnia care requires personalized treatment plans and flexibility, both of which are limited within common, time-based treatment formats. Nonexpert clinicians lack easy-to-use tools to screen, assess, triage, or treat insomnia.
Low perceived value of insomnia treatment	Payers, providers, and even patients are unclear on the benefits and value of high-quality insomnia care. Reimbursement for insomnia care is low, with downstream effects on access to care and workforce development.
Insufficient number of trained clinicians	In the United States and worldwide, the demand for insomnia care far exceeds available supply of trained specialist clinicians. In the United States, fewer than 350 board-certified behavioral sleep specialists cannot possibly care for the millions of adults with insomnia.

SESSION 2: FACILITATORS OF INSOMNIA CARE

Following this discussion, the focus shifted to innovative and effective practice models. This segment began with 3 presentations on the following topics.

Practice models that work

Kristin Daley, PhD, provided a conceptual framework highlighting that effective models include tools that meet the needs of most patients with sleep disorders, including embedded behavioral sleep medicine services within sleep disorder centers. She highlighted that this enables coordination of care and provision of multiple levels of care (ie, low-, medium-, and high-intensity interventions), the ability to address behavioral sleep medicine concerns beyond insomnia disorder, and the capacity to provide high-quality training to multiple provider types. The major limitations of this model include practice costs and billing challenges. She then discussed the collaboration between sleep centers and outside behavioral sleep medicine providers, noting that this can be a lower-cost option for practices but can lead to less-integrated care, and it can be difficult to sustain these relationships over time. Finally, she discussed private practice models in which the CBT-I provider works independently. This has no financial impact for sleep centers and is often the most financially viable option for mental health providers; however, this can further limit integration of care for patients requiring ongoing sleep medicine services.

Workforce development

Loretta Colvin, ACNP, discussed the role that advanced practice providers can play in improving access and quality of care for insomnia disorder. She noted that the number of advanced practice providers practicing in sleep medicine centers is increasing, and billing for their services can be seamlessly incorporated into clinical workflows. She noted that development of training models for advanced practice providers is needed and could create an opportunity to improve access to some nonmedication interventions, such as behavioral therapies for insomnia, and for coordinated care with sleep medicine physicians.

Technology and telehealth

Jason Ong, PhD, discussed the positive role that technology and telehealth can play in improving access to high-quality care for insomnia disorder. He discussed ways in which technology can be used to facilitate care, such as by improving scalability of treatments, improving cost-efficacy, and leveraging technology to monitor and promote adherence. Dr. Ong highlighted the growing evidence that CBT-I is similarly effective when delivered in person or via telehealth, and that the evidence that digital CBT-I can benefit some patients is growing. He noted that a combination of approaches may facilitate technologic innovations that align the need for insomnia treatments and the availability of those interventions for patients.

Breakout groups

At the conclusion of these presentations, participants broke into 7 breakout groups. During this session, participants were asked the following:

1. What stood out as the most important “take home” message?

2. Are there any critical issues that were not discussed regarding facilitators of high-quality care?

3. Where there any surprises based on the presentations?

4. What are the simple solutions that would be easy to implement?

5. What are the complex solutions that would have a big impact?

Breakout group participants identified their top 3 facilitators and shared their findings with the larger summit group (see Table 3).

Table 3.

Summary of Session 2: Facilitators of Insomnia Care.

Domain/Theme	Description of Facilitator
Comprehensive care models	Give greater attention to insomnia that is comorbid with other sleep disorders and develop “Insomnia Centers of Excellence.” Disseminate stepped care models in primary care and psychiatric care clinics and in other settings such as workplaces and senior communities.
Expanded workforce	Educate and train primary care physicians (including pediatricians and geriatricians), psychologists, advanced practice providers, and registered nurses. Expand eligibility for behavioral sleep medicine certification and develop new insomnia certificate programs.
Greater technology adoption	Leverage validated digital therapy tools to improve access to evidence-based care. Use telemedicine to provide care from a distance, especially for underserved and rural areas. Use new wearable and bedside devices to monitor patients over time.
Recognized value of insomnia care	Use health policy strategies to foster changes to payer policies (eg, standardized insomnia billing codes). Advocate for policies that empower all providers to be compensated at an appropriate rate for insomnia care.
Increased awareness	Emphasize sleep as a vital sign in public awareness campaigns and public health initiatives. Provide health curricula focusing on the importance of sleep at all levels of the education system.

SESSION 3: ACHIEVING A BRIGHTER FUTURE

The third and final segment of the day focused on the future, and presenters highlighted how science and policy changes might improve care. The following topics were presented.

Influencing payer policies

Fariha Abbasi-Feinberg, MD, provided an overview of strategies used by the AASM to impact payer policies regarding obstructive sleep apnea to demonstrate possible approaches that could be used for improving the alignment of payer policies with clinical practice guidelines related to insomnia. She also noted several important differences, including the absence of insomnia-specific payer policies and the fact that many providers of CBT-I do not accept insurance payment directly.

Applying public health principles

Natasha Williams, EdD, MPH, shared thoughts on health equity and insomnia care. She first discussed the role of social determinants that impact access to health care. She highlighted the importance of educating communities about sleep, collaborating to identify strengths in those communities, promoting inclusivity in developing programs, and using implementation frameworks to inform where and how to deliver care.

Ensuring successful implementation

This session concluded with a presentation from Sairam Parthasarathy, MD, who highlighted the need for accelerated implementation of evidence into practice. He noted that CBT-I has a strong evidence base to support its use, but there are limited data on how best to implement CBT-I. He discussed how the use of implementation science frameworks such as RE-AIM (reach, effectiveness, adoption, implementation, maintenance) may facilitate advancement of evidence-based insomnia care. Finally, Dr. Parthasarathy summarized the need for research that addresses implementation barriers, such as cost, screening tools for widespread use, and understanding how to incorporate insomnia care into existing clinical and wellness programs.

Breakout groups

At the conclusion of these presentations, participants broke into 7 breakout groups to discuss future directions and innovations. Breakout group participants were asked the following:

1. What ideas from the presentations were most intriguing or surprising?

2. Are there any new perspectives or future directions that did not come up in the previous discussions?

3. What are the “action items” that you can take back to your organization or your practice now?

4. What can the field of sleep medicine (and the AASM) do to advance high-quality care for insomnia disorder?

Breakout group participants then identified high-priority next steps and shared their ideas with the larger summit group (see Table 4).

Table 4.

Summary of Session 3: Achieving a Brighter Future.

Domain/Theme	Description of Future Priority
Collaboration	The AASM, other clinical and scientific societies, and organizations in other disciplines (eg, human resources) need to collaborate to develop a tiered framework for insomnia care.
Advocacy	An advocacy coalition comprising health care professionals, patients, and other stakeholders (ideally including a celebrity spokesperson) needs to lobby for appropriate reimbursement of high-value, evidence-based care.
Screening	More resources need to be invested in age-appropriate prevention and screening strategies within primary care (using diabetes and depression prevention programs as a model) for both pediatric and adult patient populations.
Training	Widespread deployment of behavioral sleep medicine training is needed through graduate/professional schools, online programs, professional associations, academic institutions, and health care systems.
Research	Increased funding from government institutions and private foundations is needed for junior faculty and senior scientists to conduct targeted research examining insomnia mechanisms and treatments.

AASM = American Academy of Sleep Medicine.

SUMMARY AND NEXT STEPS

Insomnia disorder is associated with substantial burden that impacts patients, providers, payers, health systems, and society at large. As a foundational step toward improving access to high-quality insomnia care, the AASM convened key stakeholders and thought leaders for the AASM Insomnia Summit. Participants described key barriers to, and facilitators of, high-quality insomnia care, and they identified notable opportunities to improve access to care in the future. In terms of next steps, the most important principles discussed were influencing payer policies, applying public health principles, and ensuring successful implementation of best practices. To advance these efforts, the AASM and other summit participants are developing an online “Insomnia Toolkit” with the intention to make these resources freely available. Given the scope of the problem and burden of insomnia, improving outcomes will require sustained engagement from diverse stakeholders and a patient-centered approach. The AASM Insomnia Summit collaboration represents an important step in this right direction.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. Work for this article was performed at the American Academy of Sleep Medicine (AASM). E.W.’s institution has received research support from the AASM Foundation, Department of Defense, Merck, National Institutes of Health/National Institute on Aging (NIH/NIA), ResMed, and the ResMed Foundation. E.W. has served as a scientific consultant to DayZz, Eisai, EnsoData, Idorsia, Merck, Purdue, Primasun, and ResMed, and is an equity shareholder in WellTap. J.L.M. is an employee of the Veterans Health Administration. This work does not represent the opinions of the Department of Veterans Affairs or the US government. J.L.M. is supported by a VA Health Services Research & Development Research Career Scientist Award RCS 20-191 and the NIH/National Heart, Lung, and Blood Institute K24 HL143055. J.L.M. has no other relevant interests to disclose. J.C.O. receives salary from Nox Health, Inc, which owns Somryst, a digital platform for cognitive behavioral therapy for insomnia (CBT-I). The other authors report no conflicts of interest.

ABBREVIATIONS

AASM

American Academy of Sleep Medicine

CBT-I

cognitive behavioral therapy for insomnia