Reply to Letter to the Editor - Guidance Needed in Patient-Centered Medical Home Concept for Management of Obstructive Sleep Apnea by David Kuhlmann, MD

The authors thank Dr Kuhlmann¹ for his thoughtful comments. The two concerns that he raises are important ones and merit further explanation.

With regard to the concern that the case that illustrated co-management of an insomnia minimized the role of the sleep specialist, we believe that Dr. Kuhlman may have misunderstood the vignette. We state that the sleep specialist has provided cognitive therapy in addition to a hypnotic that the patient uses less than five times per month. What is implicit in this brief case presentation is that in order for the sleep physician to provide cognitive behavioral therapy, a consult with the sleep physician must occur and in the context of this evaluation, other comorbid sleep disorders would be explored and additional diagnostic testing such as a home cardiopulmonary sleep study, an attended polysomnogram and/or a multiple sleep latency test, if deemed to be appropriate, would be pursued. Such an approach highlights the value of the sleep physician in developing a personalized care plan as opposed to a generic unfocused work-up involving unnecessary sleep testing that would drive up the cost of care. In addition, the case highlights the need for the sleep physician to maintain a collaborative partnership with the primary care physician with at least yearly follow-up.

The other concern voiced by Dr. Kuhlman relates to the lack of clear guidelines for co-management of obstructive sleep apnea. Dr. Kuhlman also points out that sleep physicians “do better” in improving adherence than primary care physicians (PCP).² This is a point well taken; however, the data he refers to is process and not outcomes data. While encouraging, these data would not be considered definitive evidence to convince many third party payers. What is needed, is to show that this modest increase in adherence related to a sleep physician consultation and continued management, as opposed to a “direct referral” and the associated “gaps in care” that are created, result in lower healthcare costs and improved overall health (i.e., cardiovascular, metabolic, and neurocognitive). The leadership of AASM and the coauthors of our paper understand that there is an urgent need to transform our care models away from a focus on diagnostic testing to longitudinal personalized care that is coordinated with the PCP. This is being addressed by the AASM. The Academy has recently submitted a competitive proposal to the Center for Medicare and Medicaid Innovation team. The project is titled “Innovation Care Delivery and Management Program for Patients with OSA.” This project was in part an outgrowth of the Future of Sleep Medicine initiative.³ If funded, data generated from the evidence based pathways tested, will serve to demonstrate the value of care by a sleep specialist in the longitudinal management of OSA. The complete proposal can be viewed on the AASM website.

DISCLOSURE STATEMENT

Dr. Strollo has received research support from ResMed. Dr. Kushida has received research support from Philips-Respironics, ResMed, Pacific Medico Co., Merck, Cephalon, Ventus Medical, Jazz Pharmaceuticals, GlaxoSmithKline, and XenoPort via grants to Stanford University. He has consulted for Seven Dreamers, Apnex, Noven Pharmaceuticals, and UCB Neuropro. Dr. Badr has received research support from Inspire Medical. The other authors have indicated no financial conflicts of interest.

CITATION

Strollo PJ; Badr MS; Coppola MP; Fleishman SA; Jacobowitz O; Kushida CA. Reply to letter to the editor - guidance needed in patient-centered medical home concept for management of obstructive sleep apnea by David Kuhlmann, MD. SLEEP 2012;35(6):753.