Point: Should Board Certification Be Required for Sleep Test Interpretation? Yes

Abstract

American Academy of Sleep Medicine American Board of Medical Specialties Accreditation Council for Graduate Medical Education board-certified sleep medicine physician out-of-center sleep test obstructive sleep apnea primary care physician polysomnogram Currently there is debate regarding the qualifications required of physicians interpreting diagnostic tests. In sleep medicine, the issue of who can interpret polysomnograms (PSGs) and other sleep tests for sleep disorders, such as obstructive sleep apnea (OSA), has been hotly debated. In the following paragraphs we present evidence that supports the assertion that board-certified sleep medicine physicians (BCSMPs) possess the training and demonstrated competence in this medical specialty, which uniquely qualifies them to provide the most reliable interpretation of diagnostic tests for sleep disorders and to establish an effective and longitudinal disease management plan for the patient. The evolution of medicine and medical science prompted the rise of specialization, which has allowed physicians to exclusively train in a focus of interest and to treat patients and manage disease across a continuum of care. The concept of specialized medicine has deep roots. Jean-Emmanuel Gilbert in the eighteenth century argued that the breadth of medical science cannot be mastered by a generalist, as it “depended on careful, methodical observations informed by a vast knowledge of the subject that permitted the physician to reflect, judge, make connections, and generalize.”1Weisz G The emergence of medical specialization in the nineteenth century.Bull Hist Med. 2003; 77: 536-575Crossref PubMed Scopus (90) Google Scholar With the continued evolution of medical science and technology, in addition to increased clinical practice burdens, it is challenging for a primary care physician (PCP) to maintain current continuing education in every area of medicine. Furthermore, primary care training includes specific requirements requiring completion in a defined period, thus allowing minimal time for exposure and training in many areas, to include sleep medicine. None of the current primary care specialties has any specific requirements for sleep medicine; therefore, it is highly unlikely that a PCP would at any time during their training learn how to effectively interpret the complex technical data reported on a PSG. The growth of pulmonary medicine as a specialty in the 1950s was in response to the treatment of TB and the emergence of lung cancer and COPD. Similarly, the need for BCSMPs highlights the accelerated identification of patients with sleep disorders to include sleep-related breathing disorders. In the 1980s, the development of CPAP as a therapeutic option for OSA revolutionized the clinical care of patients with sleep-related breathing disorders. Today, there is an acknowledgment of a vast number of discrete sleep disorders, to include complex sleep-disordered breathing. This has necessitated the development of more advanced treatment paradigms, such as bilevel PAP with intermittent ventilation, autotitrating PAP devices, and adaptive servoventilation. A thorough understanding of these treatment modalities should lead to improved outcomes for patients and are best administered by physicians with specific training in their application. Presently, the American Medical Association lists >200 specialty categories.2American Association of Medical Colleges Center for Workforce Studies Physician specialty data. American Association of Medical Colleges website.https://www.aamc.org/download/47352/data/specialtydata.pdfDate: 2008Google Scholar The specialty of sleep medicine has received designation as a medical specialty by the National Provider Identifier taxonomy codes from the Centers for Medicare & Medicaid Services, fellowship training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), and certification examinations offered by six sponsoring boards of the American Board of Medical Specialties, including the American Board of Anesthesiology, American Board of Family Medicine, American Board of Internal Medicine, American Board of Otolaryngology, American Board of Pediatrics, and American Board of Psychiatry and Neurology. The ACGME has accredited a 1-year sleep medicine fellowship since 2007. Completion of this rigorous fellowship is currently the only pathway to complete the certification examination. The rapid recognition of sleep medicine as a specialty is acknowledgment of the expertise required for our field, and the expanding list of ACGME training programs ensures that sleep medicine physicians will be highly trained in this specialized area of medicine. Comprehensive sleep care is guided by standards of practice as well as accreditation of facilities and providers who manage patient care. Standard health-care delivery for patients suspected of having OSA is initiated with a sleep evaluation that includes a sleep history and physical examination3Epstein LJ Kristo D Strollo Jr, PJ Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine et al.Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.J Clin Sleep Med. 2009; 5: 263-276Crossref PubMed Scopus (2091) Google Scholar followed by diagnostic testing via PSG conducted at an accredited sleep facility or an out-of-center sleep test (OCST) by an accredited provider. Currently, there are 2,600 full-service centers accredited by the American Academy of Sleep Medicine (AASM) and almost 1,000 accredited OCST providers. Provisions for clinical care and quality assurance serve as the foundation of the Standards for Accreditation, and the standards are evaluated regularly to ensure they reflect current practice standards. A primary tenet of the AASM's accreditation standards is a licensed BCSMP who coordinates patient care, including the interpretation of diagnostic testing, and initiates a treatment plan. Many local insurance carriers now require sleep care be provided by board-certified sleep medicine physicians in accredited sleep facilities to ensure optimal outcomes for the patient. This specialized expertise is critical as diagnostic testing shifts to include OCST and becomes increasingly complex with the proliferation of devices for OCST and variance among the devices. In 2005, Centers for Medicare & Medicaid Services issued National Coverage Determination 240.4, and an update was issued in March 2008.4Centers for Medicare & Medicaid Services National coverage determination policy. Centers for Medicare & Medicaid Services website.http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&DocID=240.4&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&Google Scholar Although OCST has been demonstrated to be as adequate compared directly to PSG for the diagnosis of OSA in highly selected patients with a high pretest probability in randomized trials, there is a paucity of data showing OCST is equivalent to PSG when used in broad clinical practice situations. In fact, there are few data to suggest that the use of OCST in practice will even be cost effective. Thus, it is the role of the specialist to use evaluation, testing, and interpretation as context for the long-term care that provides for meaningful outcomes and demonstrated improvement. In 2007, the AASM published clinical guidelines for the use of unattended portable monitors in the diagnosis of OSA in adults. Based on evidence and expert consensus, the guidelines recommend OCST should be performed only in conjunction with a comprehensive sleep evaluation in patients with a high pretest probability for OSA and without comorbid sleep disorders or medical diseases. Further, the guidelines recommend that OCST be managed under the auspices of an AASM-accredited provider and that the evaluation of data from the OCST must include a review of raw data by a BCSMP. The introduction of the national coverage determination created expanded opportunities in sleep medicine for diagnostic testing companies to provide OCSTs for the diagnosis of OSA. Many of the purveyors of diagnostic services provide no indication of state licensure and undiscerned training in sleep medicine. In addition, there is an absence of a clinical evaluation of the patient, and in many models it is unknown if the interpreting physician has access to raw data from the test to review. It is very realistic that patients with OSA, a chronic disease, are diagnosed without a sleep-related evaluation conducted by a specialized clinician. OCSTs present an additional challenge, as fewer channels for testing means limited data for the interpreting physician to review and make a sound clinical decision. The complexity of data interpretation for pulmonary function testing, chest radiographs, ECGs, and stress tests all involve specialized physicians, such as pulmonologists, cardiologists, and radiologists, in the diagnosis of the disease. Similarly, limited channels and fewer data for the diagnosis of OSA call for the clinical acumen and expertise of a BCSMP. There is a growing body of evidence that supports the BCSMP's role. The conclusion of a study conducted by Chung and colleagues5Chung SA Jairam S Hussain MR Shapiro CM Knowledge of sleep apnea in a sample grouping of primary care physicians.Sleep Breath. 2001; 5: 115-121Crossref PubMed Google Scholar suggests that PCPs are underinformed about the clinical features and medical and social ramifications associated with sleep apnea. Parthasarathy and colleagues,6Parthasarathy S Haynes PL Budhiraja R Habib MP Quan SF A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea.J Clin Sleep Med. 2006; 2: 133-142Crossref PubMed Scopus (69) Google Scholar however, reported that “accreditation or certification status of sleep centers and physicians were associated with better indexes of clinical management in patients with OSA.” In addition, a cohort study by Pamidi and colleagues7Pamidi S Knutson KL Ghods F Mokhlesi B The impact of sleep consultation prior to a diagnostic polysomnogram on continuous positive airway pressure adherence.Chest. 2012; 141: 51-57Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar found patients “who had a consultation with a sleep specialist used CPAP an average of 58 min/night more than patients who did not after adjusting for all covariates.” Increasingly it is demonstrated that the overall care management, including interpretation of the diagnostic test, by a BCSMP promotes improved patient outcomes. Similarly, the incidences of retesting on account of false-negative test results, as is the case in a high percentage of OCST, is better managed by a sleep medicine physician. According to the Institute of Medicine, an estimated 50 to 70 million Americans have a sleep disorder. Most of these disorders are chronic conditions that require long-term care. The importance of the specialization of sleep medicine will continue to accelerate as health epidemics, such as obesity and sleep deprivation, contribute to increasing incidences of sleep disturbances. As sleep medicine continues its evolutionary path in response to technology and policy, our patients will best be served by physicians uniquely qualified to manage sleep disorders long term. The partnership between the BCSMP and PCP, however, remains important, as regular interfacing is critical to the overall coordination of the patient's health care.8Strollo Jr, PJ Badr MS Coppola MP Fleishman SA Jacobowitz O Kushida CA American Academy of Sleep Medicine Task Force The future of sleep medicine.Sleep. 2011; 34: 1613-1619PubMed Google Scholar