Citation:
Chirakalwasan N, Preutthipan A, Maranetra KN, Yongchaiyudh P, Kotchabhakdi N. Sleep medicine in Thailand. J Clin Sleep Med. 2020;16(3):451–453.
INTRODUCTION
Thailand is located geographically in South East Asia. The country is considered as gateway to Asia, which connects many countries in the continent.1 Furthermore, Thailand’s health system is in need of expansion to support and enhance cooperation with the Association of Southeast Asian Nations Economic Community.2 Strengthening competency of national human resources for health will increase competitiveness of the national economy in global market. The ten-year strategic plan aims to invest in medical staff production, research, and development of medical technology and medical devices in order to become the medical hub of Asia.
According to physician licensing, the Medical Council of Thailand estimated population-national human resources for health ratio physician at 1:1546 in 2019.3 Although, there will be mild shortage of physicians, taken into account the current production rate, the government declares no need to increase physician production at the moment. The strategic plan aims to address this problem by improvement in quality of productivity and utilization of technological application.
Thailand is considered an aging society. It is predicted that by 2030, over 15% of the population will be > 65 years of age.4 Hence, aging related diseases are major health concern. Noncommunicable diseases including diabetes, stroke, ischemic heart disease, liver and lung cancer are now leading causes of death.5
Obstructive sleep apnea (OSA) is one of the most common sleep disorders studied in Thailand. The first epidemiological study was conducted in 4,680 participants in Bangkok by a face-to-face interview using 49-question sleep inventory. The study reported 4% of the total sampled population complained of habitual snoring (> 3 nights/week) and excessive daytime sleepiness (> 3 days/week) for at least 3 months (5.3% of men and 3.5% of women).6 Subsequently, prevalence of OSA in Thais was reported in 2011 using the data from office-based workers and people who came to contact with one of the university hospitals.7 Prevalence of OSA utilized criteria of apnea-hypopnea index (AHI) ≥ 5 events/h were 15.4% and 6.3% in men and women; respectively. Incorporating excessive daytime sleepiness symptoms into AHI, the prevalence of OSA in men and women were 4.8% and 1.9%; respectively. According to the recent reported global OSA prevalence, OSA prevalence in Thailand is comparable to that found in other countries.8
SLEEP MEDICINE TRAINING AND CERTIFICATION
The Sleep Society of Thailand (SST) was established in 2009 by the group of Thai physicians who trained or studied in sleep medicine abroad. During the commencement of SST, the American Academy of Sleep Medicine provided SST with examination material for a sleep medicine specialist certification examination. Total of 10 physicians passed the examination and were certified as sleep medicine specialists for the first time in Thailand. Subsequently, SST developed its own examination material and had been holding sleep medicine certification examination annually. Physicians who met the prerequisite criteria in terms of number of polysomnography interpretation, number of encountered sleep disorder consultation, or demonstrable completion of training in accredited sleep medicine fellowship internationally are eligible for the examination. To date, total of 41 physicians were certified by SST as sleep medicine specialist (26 internists, 8 otolaryngologists, 6 pediatricians, and 1 psychiatrist).
Chulalongkorn University established the first international sleep medicine fellowship in 2011. To date, total of 10 international sleep medicine specialists were trained in this program. In addition, a 1-year sleep medicine fellowship also has been offered at Siriraj hospital. Furthermore, a master of science degree in sleep medicine has also been available at Ramathibodi hospital and Siriraj hospital.9 However, sleep medicine was not recognized under the Medical Council of Thailand as a separate medical subspecialty. There is no national medical practice regulation at the moment for sleep medicine related procedures such as interpretation of polysomnography, Multiple Sleep Latency Tests, or prescribing sleep medicine related medical devices such as continuous positive airway pressure (CPAP). Practically, any physicians holding active medical practice license in Thailand can conduct aforementioned sleep related procedures.
A major turn in sleep medicine education in Thailand occurred in 2018, when SST approached the Medical Council of Thailand to establish sleep medicine specialty as a unique entity and to propose formal sleep medicine fellowship training. Ultimately, the Medical Council of Thailand declared sleep medicine as a formal medical specialty. Furthermore, 2-year fellowship training in sleep medicine for Diplomate of the Thai Subspecialty Board of Sleep Medicine was granted under Royal Colleges of Medicine, Psychiatry, Pediatrics, and Otolaryngology. To date, a total of 26, 8, 12, and 32 qualified physicians received Thai subspecialty board of sleep medicine under Royal Colleges of Medicine, Psychiatry, Pediatrics, and Otolaryngology; respectively based on their demonstrable ongoing engagement in sleep medicine or completion of formal sleep medicine training abroad.
Curriculum of this 2-year fellowship training in sleep medicine integrates multispecialty knowledge during the first 6 months. During this period, core content in sleep medicine is required despite different medical background of the trainees (internal medicine, psychiatry, pediatrics and otolaryngology). For the subsequent 1.5 years, the rotation is tailor-made according to the trainees’ medical specialty background. In July 2019, for the first time, the 2-year sleep medicine fellowship enrolled the first fellow at Chulalongkorn University. The first sleep medicine board examination endorsed by the Medical Council of Thailand will be held in June 2021 when this first sleep fellow completed the 2-year fellowship training. In response to the inaugural 2-year sleep medicine fellowship program, SST terminated its sleep medicine certification examination in 2019. Concurrently, in 2019, the Thoracic Society of Thailand has started a 1-year certified program in sleep-related breathing disordered medicine for individuals who have already completed the fellowship training in pulmonary medicine.
However, sleep medicine practice is not limited to physicians as ancillary professions are as important. Sleep technology is one of the major drivers of the field. An inadequate number of sleep technologists are the major obstacle of advancing sleep medicine in Thailand and globally. Starting in 2010, SST has been conducting 5-day basic level sleep technology course annually. In addition, 4-day advance level sleep technology course has also been conducted every other year. In order to maintain the standard of sleep technologists in Thailand, SST conducts examination for sleep technologist certification for basic level and advance level since 2010. To date, total of 140 and 56 were certified as basic level sleep technologists and advance level sleep technologists; respectively. However, this certification is not required to practice as sleep technologist as there is no national regulation at the moment.
PRACTICE AND STRUCTURE OF SLEEP MEDICINE
For sleep medicine practice in Thailand, total of 64 level I sleep laboratories operate currently. Approximately half are located in Bangkok. There are 8 sleep laboratories in university hospitals and 28 sleep laboratories in government hospital. Only 19 provinces have at least one level I sleep laboratory. The remaining provinces rely on level 3 or pulse oximetry in the case of children. In order to standardize sleep laboratories in Thailand, SST uses standard international accreditation criteria to accredit sleep laboratories. To date, total of 7 sleep laboratories are accredited by SST (6 in government hospitals and 1 in private hospital). However, there are no national law or regulations at the moment that mandate sleep laboratories to be accredited in order to operate.
The most common referral reason is clinical suspicion for OSA. According to recent publication from Thailand, majority of the patients were diagnosed with severe OSA (≈71.4%).10 The cost of polysomnography ranges from 7,000–48,000 baht (≈230–1,600 USD) with the mean cost of approximately 10,000 baht (≈330 USD). Polysomnography conducted at government hospital is free for patients referred from civil service welfare system (civil servants and their families), social security for private employees, and universal coverage scheme. Limited private health insurance covers the cost of polysomnography that can be done at government or private hospitals. The coverage for CPAP cost is currently limited. Civil service welfare system and some limited private health insurance cover the cost of CPAP. For civil service welfare system, CPAP can be reimbursed up to 20,000 baht (≈660 USD) if there is the presence of OSA using criteria of AHI ≥ 5 events/h. This reimbursable value approximates the lowest cost of available CPAP in Thailand. The CPAP device can be replaced and reimbursed up to 20,000 baht (≈660 USD) every 5 years if the device is dysfunctional and unable to be restored. CPAP mask cost can also be reimbursed annually up to 4,000 baht (≈130 USD). Given the limited coverage of CPAP cost in Thailand primarily only by civil service welfare system, the country is in the process of defining the cost effectiveness of CPAP treatment in reducing the overall medical expenses with the aim to broader the cost coverage of CPAP for patients with OSA in Thailand. Oral appliance as the alternative treatment option for OSA is generally not covered by any system or health insurance in Thailand. The cost of treatment strategy to manage other sleep disorders such as cognitive behavior therapy for insomnia is also not covered in Thailand.
BARRIERS TO THE PRACTICE OF SLEEP MEDICINE
Thailand uses tremendous effort to advance the field of sleep medicine in order to meet the international standard. Thai Guideline for Childhood Obstructive Sleep Apnea was published in 2016.11 Subsequently, Clinical Recommendation for Diagnosis and Management of Obstructive Sleep Apnea in Thailand for Adults was published in 2018.12 These clinical practice guidelines were developed using rigorous evidence-based methodology with the strength of evidence for each recommendation explicitly stated.
Thailand is honored to host many international sleep congresses including the 3rd Asian Sleep Research Society Congress in December 2000, the 22nd International Physiology-Pathophysiology Symposia and Workshops in March 2004, the 2nd World Association of Sleep Medicine Congress in February 2007, and the 2nd Association of Southeast Asian Nations Sleep Congress in August 2013. Thailand is honored to be recently approved to host the 4th Asian Society of Sleep Medicine meeting in 2022.
Furthermore, Thailand also received Distinguished Activity Award for World Sleep Day from the World Sleep Society for 3 consecutive years from 2017–2019.13 These activities aim to raise the public awareness of the importance of sleep and sleep disorders in Thai community.
Given sleep medicine is in an early stage in Thailand, some barriers are commonly observed. In terms of practice, there is no regulation in terms of board requirement for physicians to practice sleep medicine in Thailand. These will potentially discourage the trainees to pursue this specialty compared to the others. Currently, there is no sleep medicine in the undergraduate curriculum in medical schools in Thailand. Early implementation of sleep medicine education is crucial to disseminate the knowledge among the future general practitioners and to grow the interest in sleep medicine. In terms of research, sleep medicine research in Thailand is evolving. Most of the research grants in sleep medicine are supported by university or professional society. However, multicenter, multidisciplinary, longitudinal studies are lacking at the moment and essential in order to compete for large federal grants.
CONCLUSIONS
Sleep medicine in Thailand is in rapid growth in the past 10 years. Sleep disorders are among the diseases linked to the development of noncommunicable diseases; the leading cause of death among Thais. OSA is among the most common sleep disorders studied in Thailand. Sleep medicine was recently recognized as a medical specialty under the Medical Council of Thailand in 2018. The 2-year fellowship training in sleep medicine was recently started in 2019. Currently, there is no national regulation for license to practice sleep medicine for physicians, sleep technologists, or dentists. There are limited sleep laboratories in the country and few centers are accredited at society level. Polysomnography is reimbursable for most of the health insurance system when conducted in government hospital. However, reimbursement of CPAP is limited only in civil welfare system and certain private insurance. Research in sleep disorders gained more interest but multicenter/mutidisciplinary studies are essential. Sleep medicine needs collaboration among various disciplines in order to advance the field forward.
DISCLOSURE STATEMENT
The authors report no conflicts of interest.
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