Sleep Physicians Research Articles

Exploration of screening practices for obstructive sleep apnea in stroke medical community: A pilot study

BackgroundFrequency of sleep-disordered breathing (SDB) among stroke and transient ischemic attack (TIA) patients ranges from 30–80% and is associated with poor neurological outcomes. Per current stroke prevention guidelines from American Heart Association/American Stroke Association (AHA/ASA), SDB is included in the list of modifiable risk factors for stroke and TIA prevention. Goal of our study is to determine screening practices for SDB in stroke medical community. MethodsA web-based survey was sent to physicians taking care of stroke patients across North America and Europe. ResultsAmong 112 total responses, 91 (81%) were stroke physicians, nine (8%) were general neurologists, nine (8%) were from other specialties and three (3%) were sleep medicine physicians. Majority of physicians (72%, n=81) do not use SDB screening questionnaires in their stroke patients. Epworth sleepiness scale is the most used among SDB questionnaires (24%, n=25/105), followed by Berlin sleep questionnaire (10%) and STOP-BANG questionnaire (7%). Only 13% of physicians use screening questionnaires in both in-patients and outpatients, whereas 21% use only in outpatients and 5% use only in acute stroke setting. Only 50% (n=56/111) of physicians would refer their stroke patients to a sleep medicine specialist when patients screen positive for SDB on questionnaires. ConclusionDespite being an independent risk factor for stroke and TIA, majority of physicians in the pilot targeted cohort of medical professionals, who are involved in the management of stroke and TIA, do not screen these patients for SDB. Further work involving systematic, more detailed standardized surveys are needed to be developed to objectively evaluate and improve screening practices for SDB in national and international stroke medical communities.

Compliance With CPAP at 6 Weeks Following Initial Set Up at the Physician Office

SESSION TITLE: Sleep Disorders I SESSION TYPE: Original Investigation Poster PRESENTED ON: Saturday, April 16, 2016 at 11:45 AM - 12:45 PM PURPOSE: Untreated OSA is associated with hypertension and vascular disease, cognitive dysfunction, and increased motor vehicle accident as well as work related risk. Positive airway pressure (PAP) is considered the standard of care for moderate to severe OSA. However, treatment benefits may depend on the compliance with CPAP use. Many studies suggest that only a minority of patients use CPAP as recommended METHODS: Following CPAP titration study, patients are seen for follow up with in days to discuss findings and options to treat. Those who opted to be set up by us were carried out by the RN* certified in sleep education under the direct supervision of the sleep physician@. The mask was fitted as best as possible and was confirmed by physician for leaks, comfort with the CPAP set at the prescribed pressure. Any difficulty with usage was immediately attended to including changing the mask repeatedly till achieving desired comfort. Follow up appointment was made after 6 weeks. The computer data base was downloaded to obtain compliance data. RESULTS: 118 Patients with OSA were fitted with CPAP between Dec 2013 and July 2015. Computer generated data at 6 weeks were obtained at follow up on 108 patients. 9 patients were lost to follow up due to moving away and could not be contacted. 1 patient returned the machine due to unwillingness. Out of the patients seen at follow up the compliant data is as follows: Compliance at 6 weeks: 4 hrs. or more usage per night (Medicare criteria) 91 patients > 70 % usage 17 patients < 70 % usage. Overall, 6 weeks compliance per Medicare criteria was 77% with nearly half of the total reaching over 90% compliance. If we leave out those who could not be followed up, our compliance reaches 84% by Medicare criteria. CONCLUSIONS: Patterns of CPAP use develop as early as the first week of treatment and there is data to suggest early intervention and reinforcement is key to compliance. However, the compliance remains poor and much to be desired. Few studies have evaluated effect of initial set up in a familiar place by a team approach involving physician-nurse-RT as a one stop education and CPAP set up. We believe that making it a combined effort with involvement of patient at each step of decision making enabled us to achieve a high initial compliance. CLINICAL IMPLICATIONS: Direct physician-team involvement improve CPAP compliance DISCLOSURE: The following authors have nothing to disclose: Narayan Krishnamurthy No Product/Research Disclosure Information

Impact of Sleep Telemedicine Protocol in Management of Sleep Apnea: A 5-Year VA Experience.

There is growing evidence that demonstrates an important role for telemedicine technologies in enhancing healthcare delivery. A comprehensive sleep telemedicine protocol was implemented at the Veterans Administration Medical Center (VAMC), Milwaukee, WI, in 2008 in an effort to improve access to sleep specialty care. The telemedicine protocol relied heavily on sleep specialist interventions based on chart review (electronic consult [e-consult]). This was done in response to long wait time for sleep clinic visits as well as delayed sleep study appointments. Since 2008 all consults are screened by sleep service to determine the next step in intervention. Based on chart review, the following steps are undertaken: (1) eligibility for portable versus in-lab sleep study is determined, and a sleep study order is placed accordingly, (2) positive airway pressure (PAP) therapy is prescribed for confirmed sleep apnea, and (3) need for in-person evaluation in the sleep clinic is determined, and the visit is scheduled. This study summarizes the 5-year trend in various aspects of access to sleep care after implementation of sleep telemedicine protocol at the Milwaukee VAMC. This is a retrospective system efficiency study. The electronic medical record was interrogated 5 years after starting the sleep telemedicine protocol to study annual trends in the following outcomes: (1) interval between sleep consult and prescription of PAP equipment, (2) total sleep consults, and (3) sleep clinic wait time. Two part-time sleep physicians provided sleep-related care at the Milwaukee VAMC between 2008 and 2012. During this period, the interval between sleep consult and PAP prescription decreased from ≥60 days to ≤7 days. This occurred in spite of an increase in total sleep consults and sleep studies. There was also a significant increase in data downloads, indicating overall improved follow-up. There was no change in clinic wait time of ≥60 days. Implementation of a sleep telemedicine protocol at the Milwaukee VAMC was associated with increased efficiency of sleep services. Timeliness of sleep management interventions for sleep apnea improved in spite of the increased volume of service.

Beyond Daytime Sleepiness: Medical, Behavioral, Psychiatric, and Sleep Co-morbid Conditions Associated with Pediatric Narcolepsy

Pediatric narcolepsy can be challenging to diagnose and manage given a broad range of co-morbidities only recently described in the literature. These co-morbidities are broad in scope and span medical, psychiatric, and sleep disorders. Such associated conditions highlight potential novel effects of hypocretin deficiency on metabolic and neural functioning. Clinically, medication treatments for narcolepsy have the potential to alter co-morbid symptoms for better or worse and may guide individual treatment plans. Furthermore, sleep physicians may need to ally with other health care providers in endocrinology and psychiatry to optimize the care of pediatric patients with narcolepsy.

Sleep-disordered breathing in heart failure.

Sleep-disordered breathing-comprising obstructive sleep apnoea (OSA), central sleep apnoea (CSA), or a combination of the two-is found in over half of heart failure (HF) patients and may have harmful effects on cardiac function, with swings in intrathoracic pressure (and therefore preload and afterload), blood pressure, sympathetic activity, and repetitive hypoxaemia. It is associated with reduced health-related quality of life, higher healthcare utilization, and a poor prognosis. Whilst continuous positive airway pressure (CPAP) is the treatment of choice for patients with daytime sleepiness due to OSA, the optimal management of CSA remains uncertain. There is much circumstantial evidence that the treatment of OSA in HF patients with CPAP can improve symptoms, cardiac function, biomarkers of cardiovascular disease, and quality of life, but the quality of evidence for an improvement in mortality is weak. For systolic HF patients with CSA, the CANPAP trial did not demonstrate an overall survival or hospitalization advantage for CPAP. A minute ventilation-targeted positive airway therapy, adaptive servoventilation (ASV), can control CSA and improves several surrogate markers of cardiovascular outcome, but in the recently published SERVE-HF randomized trial, ASV was associated with significantly increased mortality and no improvement in HF hospitalization or quality of life. Further research is needed to clarify the therapeutic rationale for the treatment of CSA in HF. Cardiologists should have a high index of suspicion for sleep-disordered breathing in those with HF, and work closely with sleep physicians to optimize patient management.

Unconstrained Sleep Stage Estimation Based on Respiratory Dynamics and Body Movement.

The aim of this study is to establish a sleep monitoring method that can classify sleep into four stages in an unconstrained manner using a polyvinylidene fluoride (PVDF) sensor for continuous and accurate estimation of sleep stages. The study participants consisted of 12 normal subjects and 13 obstructive sleep apnea (OSA) patients. The physiological signals of the subjects were unconstrainedly measured using the PVDF sensor during polysomnography. The respiration and body movement signals were extracted from the PVDF data. Rapid eye movement (REM) sleep was estimated based on the average rate and variability of the respiratory signal. Wakefulness was detected based on the body movement signal. Variability of the respiratory rate was chosen as an indicator for slow-wave sleep (SWS) detection. Sleep was divided into four stages (wake, light, SWS, and REM) based on the detection results. The performance of the method was assessed by comparing the results with a manual scoring by a sleep physician. In an epoch-by-epoch analysis, the method classified the sleep stages with an average accuracy of 70.9 % and kappa statistics of 0.48. No significant differences were observed in the detection performance between the normal and OSA groups. The developed system and methods can be applied to a home sleep monitoring system.

Sleep Disturbance, Obstructive Sleep Apnoea and Abnormal Periodic Leg Movements: Very Common Problems in Fabry Disease.

To assess the prevalence of sleep disorder(s) in males with Fabry disease and explore possible association with disease phenotype. Fabry disease, an X-linked lysosomal storage disease caused by deficiency in α-galactosidase, results in intracellular accumulation of globotriaosylceramide. It causes organ dysfunction, most significantly affecting renal, cerebrovascular and cardiovascular systems. Respiratory involvement may include obstructive lung disease, reduced diffusing capacity and thickened soft and hard palates. Patients commonly develop small-fibre sensory peripheral neuropathy manifested by acroparaesthesia and pain crises. Combined with self-reported sleep disturbance and snoring, these features suggest an increased risk of sleep disorders. In-laboratory polysomnography (PSG) studies and sleep inventory assessments, including Epworth Sleepiness Scale (ESS), were performed in a cohort of male Fabry patients. PSGs were reviewed by a sleep physician. Sleep-disordered breathing and periodic leg movements were targeted for analysis. Associations with renal, cardiovascular and cerebrovascular function were sought. Twenty males underwent overnight PSG. Patient baseline characteristics included age 43.9 ± 10.7 years, BMI 24.3 ± 3.8kg/m2, neck circumference 39.7 ± 3.3cm and ESS 9.8 ± 5.1 (7/20, abnormal ESS >10). Abnormal periodic leg movement index (PLMI) was present in 95% (mean frequency 42.4 ± 28.5/min) and sleep-disordered breathing in 50% patients. Periodic leg movements were associated with pain and depression but not with increased cortical arousal. Sleep-disordered breathing and abnormal PLMI are highly prevalent in patients with FD. The presence of abnormal PLMI alone appears to have minimal impact on sleep disturbance, but is associated with depression and analgesic requirement.

International Classification of Diseases, Tenth Revision, Clinical Modification for the Pulmonary, Critical Care, and Sleep Physician

After a patient encounter, the physician uses two coding systems to bill for the service rendered to the patient. The Current Procedural Terminology (CPT) code is used to describe the encounter or procedure. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code is used to describe the diagnosis(es) of the patient. On October 1, 2015, ICD-9-CM coding will end, and all physicians will be required to use a new diagnostic coding system, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). This article describes the new diagnostic coding system and how it differs from the old system. There are resources and costs involved for physicians and physician practices to prepare properly for ICD-10-CM. Similar to other important events, the more thorough the preparation, the more likely a positive outcome will occur. Resource use is very important in preparation for the transition from ICD-9-CM to ICD-10-CM. Greater familiarity with ICD-10-CM plus a thorough, effective preparation will lead to reduced costs and a smooth transition. Coding descriptor changes and additional codes occur in ICD-10-CM for chronic bronchitis and emphysema, asthma, and respiratory failure. These changes will affect the coding of these diseases and disorders by physicians. Because the number of codes will increase more than fivefold, the complexity of documentation to support ICD-10-CM will increase substantially. The documentation in the patient's chart to support the ICD-10-CM codes used will need to be enhanced. The requirement for accurate and comprehensive documentation cannot be emphasized enough. All of the coding and documentation changes will be a challenge to pulmonary, critical care, and sleep physicians. They must be prepared fully when ICD-10-CM coding begins and ICD-9-CM coding stops abruptly on October 1, 2015.

Obesity Hypoventilation Syndrome

As the prevalence of obesity continues to rise, morbidity associated with obesity becomes more and more endemic. Of particular interest to pulmonary and sleep medicine physicians is the entity of obesity hypoventilation syndrome (OHS), formerly known as Pickwickian syndrome. Most patients with OHS also will be found to present with obstructive sleep apnea (OSA), which appears to play a major role in the pathogenesis of OHS. With or without OSA, the etiology of OHS may also be related to the extreme mechanical limitations imposed by obesity on the ventilatory apparatus. Treatment of OHS has been profoundly changed by the advent of non-invasive positive pressure therapies, including continuous positive airway pressure, bilevel positive airway pressure, and average volume-assured pressure support. Despite these advances, morbidity and mortality remain elevated in these individuals unless substantial weight loss can be achieved.

High-resolution wrist-worn overnight oximetry has high positive predictive value for obstructive sleep apnea in a sleep study referral population.

Reducing the need for diagnostic sleep studies for obstructive sleep apnea (OSA) would reduce direct and opportunity costs while expediting time to treatment for this common and morbid disorder. We sought to determine if an established sleep apnea screening questionnaire (STOP-BANG) and wrist-worn overnight oximetry data could provide high positive predictive value for the presence of OSA. We conducted a prospective observational study of consecutive unattended sleep study patients at a single facility. Patients were referred for sleep testing after chart review by a sleep physician. We assessed area under the receiver-operating characteristic curve (ROC AUC) and positive predictive value (PPV) of STOP-BANG score and oxygen desaturation index (ODI) for a respiratory disturbance index (RDI) ≥15/h. Among 234 test patients, 65% had an RDI ≥15/h. STOP-BANG had poor ability to discriminate these patients (ROC AUC 0.62). ODI added significant diagnostic information to the STOP-BANG score, increasing the ROC AUC to 0.86. Having the ODI, the STOP-BANG score no longer contributed significant diagnostic information, and the ODI alone discriminated as well as the combination (ROC AUC 0.86). Forty nine percent had an ODI ≥7/h, which had PPV of 92% (95% confidence interval (CI), 86 to 96%). In the validation sample of 1,196 consecutive patients, ODI ≥ 7/h had a PPV of 97% (95% CI, 95 to 97%). Among patients with a high prevalence of OSA, high ODI is common and its presence has high PPV for OSA. These data suggest that overnight oximetry prior to sleep testing could significantly reduce the number of patients requiring sleep studies, thereby reducing costs and time to treatment.

Streamlining patient consultations for sleep disorders with a knowledge-based CDSS

ObjectivesThis paper examines the workflow of sleep physicians during a patient consultation and how an innovative clinical decision support system (CDSS) provides efficiency and effectiveness gains. MethodsThe CDSS tools consisted of two input applications for patient data, with a knowledge based decision support system developed participatively with physicians and an international panel. An argument tree approach was used to produce diagnostic explanations and an evidence-based report for the physician using medically correct and shared terminology. A usability evaluation using a qualitative approach was carried out to ensure that the CDSS met the physicians׳ information needs, as well as the wider needs of a Sleep Investigation Unit. ResultsThe physicians found the CDSS both useful and usable with clear applications in triage and diagnostic decision-making, and in patient education. ConclusionThe CDSS both reduces the time and number of visits needed for consultations, and helps focus consultation on better individual patient care through informed explanation of diagnostic and treatment decisions.

Identifying Obstructive Sleep Apnea in Administrative Data: A Study of Diagnostic Accuracy.

Health administrative (HA) databases are increasingly used to identify surgical patients with obstructive sleep apnea (OSA) for research purposes, primarily using diagnostic codes. Such means to identify patients with OSA are not validated. The authors determined the accuracy of case-ascertainment algorithms for identifying patients with OSA with the use of HA data. Clinical data derived from an academic health sciences network within a universal health insurance plan were used as the reference standard. The authors linked patients to HA data and retrieved all claims in the 2 yr before surgery to determine the presence of any diagnostic codes, diagnostic procedures, or therapeutic interventions consistent with OSA. The authors identified 4,965 patients (2003 to 2012) who underwent preoperative polysomnogram. Of these, 4,353 patients were linked to HA data; 2,427 of these (56%) had OSA based on diagnosis by a sleep physician or the apnea hypopnea index. A claim for a polysomnogram and receipt of a positive airway pressure device had a sensitivity, specificity, and positive likelihood ratio (+LR) for OSA of 19, 98, and 10.9%, respectively. An International Classification of Diseases, Tenth Revision, code for sleep apnea in hospitalization abstracts was 9% sensitive and 98% specific (+LR, 4.5). A physician billing claim for OSA (International Classification of Diseases, Ninth Revision, 780.5) was 58% sensitive and 38% specific (+LR, 0.9). A polysomnogram and a positive airway pressure device or any code for OSA was 70% sensitive and 36% specific (+LR, 1.1). No code or combination of codes provided a +LR high enough to adequately identify patients with OSA. Existing studies using administrative codes to identify OSA should be interpreted with caution.

Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015.

Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. The purpose of this new guideline is to replace the previous and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring. The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) commissioned a seven-member task force. A systematic review of the literature was performed and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the quality of evidence. The task force developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations. 1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD) 2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE) 3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD) 4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE) 5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE) 6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE). The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs. This guideline reflects the state of knowledge at the time of publication and will require updates if new evidence warrants significant changes to the current recommendations.

Effects of obstructive sleep apnea on hemodynamic parameters in patients entering cardiac rehabilitation.

Obstructive sleep apnea (OSA) is a prevalent form of sleep-disordered breathing. Evidence suggests that OSA may lead to cardiac remodeling, although the literature is equivocal. Previous literature suggests a high percentage of individuals entering a cardiac rehabilitation (CR) program also have OSA. The objective of this study was to determine whether resting hemodynamic variables were altered in OSA subjects entering CR compared with those without OSA, as determined by impedance cardiography. Subjects entering an early outpatient CR program were screened for OSA using an at-home screening device and verified by a sleep physician. Subjects were divided into an OSA group (n = 48) or a control group (n = 25) on the basis of the screening results. Hemodynamic variables were measured during supine rest using impedance cardiography. A 6-minute walk test was performed to assess functional capacity. The proportion of cardiac diagnoses was similar between groups. Overall, 66% of the subjects were positive for OSA. Subject groups did not differ by age, body mass index, heart rate, diastolic blood pressure, or functional capacity. Cardiac output, cardiac index, stroke volume, contractility index, and left cardiac work index were all significantly decreased in the OSA group compared with the control group (P < .05). Findings suggest that OSA results in decreased cardiac function in patients entering CR, likely because of pressure and volume changes associated with apneic events. This may place those individuals at a disadvantage in recovering from their cardiac event, and place them at increased risk for secondary complications.

Being mindful of later-life sleep quality and its potential role in prevention.

Older adults commonly report disturbed sleep, and an expanding literature suggests that poor sleep increases the risk of adverse health outcomes.1 In this issue of JAMA Internal Medicine, Black et al2 present a randomized clinical trial (RCT) among adults 55 years and older with moderately disturbed sleep, comparing a sleep hygiene intervention with a community-based mindfulness meditation intervention. They assess the outcomes of global sleepquality, insomnia symptoms, fatigue, and depressive symptoms. As the authorsexplain, effectivenonpharmacological interventions that are both “scalable” and “community accessible” are needed to improve disturbed sleep and prevent clinical levels of insomnia. This is imperative given links between insomnia and poor health outcomes, risks of sleepmedication use, and the limited availability of health care professionals trained in effectivenondrug treatments suchasbehavior therapyandcognitivebehavioral therapy for insomnia.This contextmakes the positive results of this RCT compelling. Behavior therapy and cognitive behavioral therapy for insomnia arenonpharmacological interventions for clinical levels of insomnia, with known efficacy across age groups, including inolder adults.However, awarenessof these therapies is lowamongphysicians and the general public, and the availability of trainedhealth careprofessionals to administer these treatments is below what is required to address the clinical need.Fortunately, initiatives tomorewidelydisseminate these interventions have begun. The Department of Veterans Affairs has been training non–sleep specialist physicians, psychologists, nurses, and socialworkers to deliver cognitive behavioral therapy for insomniawithin its primary care,mental health, and other clinics.3 Outside of the Department of Veterans Affairs, a nurse-administered brief behavioral treatment for insomniahasbeendevelopedforuse inprimarycare.4 Althoughthesearepositivedevelopments, suchtreatmentsare notyetwidely available inprimary care settings, rendering the outside-of-the-clinic approachofBlacket al2 to treatment (and perhaps prevention) of disturbed sleep all themore relevant. There are some important methodological aspects of the study by Black et al2 thatwarrant discussion. The authors did not require participants in their RCT tomeet criteria for a particular common sleep disorder such as insomnia, sleepdisorderedbreathing, or restless legs syndrome. Instead, they excluded individuals reporting sleep-disordered breathing or restless legs syndrome and recruited individuals with a selfreported Pittsburgh Sleep Quality Index (PSQI) exceeding 5, whichsuggestspoor sleepquality.5 Sleepquality is abroadconstruct that has been defined in various ways. It encompasses and is affectedbyseveral aspectsof sleep, including sleep fragmentation, extended latency to sleep onset, perceived restfulness of sleep, and (according to some definitions) sleep duration.5 The cutoff value of greater than 5 on the PSQI was originally selected for its ability to differentiate poor sleepers (definedas individualswithproblems fallingor stayingasleep, excessivedaytime sleepiness, or depression) fromgood sleepers with no sleep complaints.5 Some may question the decision to recruit study participants on the basis of a PSQI score rather than, for example, an insomniadiagnosis.However, the selection of the PSQI makes sense given the epidemiological evidence that among older adults a PSQI exceeding 5 is associated with adverse health outcomes, including frailty and lowercognitive function.6,7Therefore, thePSQIcutoffofgreater than 5 should identify individuals at risk for poor sleeprelated health outcomes and would likely capture a greater number of them than would be identified by more stringent diagnostic criteria for insomnia. These are important qualities for a community-based intervention inwhich prevention of clinical insomnia and its outcomes may eventually be the goal. In line with this, while Black et al2 describe their study participants as having moderate sleep problems, a PSQI exceeding5 canalso reflect severedisturbances. Therefore, their sample likely included older adults with subclinical insomnia and others with clinical levels of insomnia. In addition, there may well have been cases of sleep-disordered breathingand restless legs syndrome in the samplegiven that thehistory of these disturbances was screened for only via selfreport. The likelihood that their sample contained individuals with sleep disturbances other than insomnia and that their sleepmay have beenmore thanmoderately disturbedmakes the authors’ positive findings all the more impressive. This excellent study raises somequestions that need tobe answered in future research.Forexample,whichaspectsof the broad construct of sleep quality does the mindfulness meditation intervention improve?While the global PSQI scorewas the primary outcome of this trial, how does the intervention affect the different PSQI components,5 including sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, sleepmedications, anddaytimedysfunction? Inaddition, the mechanisms by which mindfulness meditation affects sleep remain unclear. Indeed, depression and fatigue were classifiedbyBlack et al2 as secondary “sleep-relateddaytime impairment” outcomes andwere improvedby themindfulness intervention. However, rather than being consequences of improvements in insomnia, it is possible that improvements in depression and fatigue mediated the effect of mindfulness on sleep quality. Future studies with repeatedassessmentof theseputativemediators throughout the intervention would help determine whether this is the case. Finally, theauthors indicated that theirRCTwas the first study Related article page 494 Research Original Investigation Mindfulness Meditation in Sleep-Disturbed Adults

Polysomnography for the diagnosis of sleep disordered breathing in children under 2 years of age.

SummaryObjectivesTo describe clinical polysomnography (PSG) results, sleep physicians' diagnosis, and treatment of sleep disorder breathing in children less than 2 years of age.Study DesignRetrospective clinical chart review at a pediatric tertiary care center, pediatric sleep laboratory.Subject SelectionChildren less than 2 years of age who underwent clinical PSG over a 3‐year period.MethodologyPSG results and physician interpretations were identified for inclusions. Children were excluded if either PSG results or physician interpretations were unavailable for review. Infants were classified in three age groups for comparison: <6 months, 6–12 months, and >12 months.ResultsMatched records were available for 233 PSGs undertaken at a mean age 11.1 ± 7.0 months; 31% were <6 months, 23% were 6–12 months, and 46% were 12–24 months of age. Infants <6 months showed significant differences on sleep parameters and respiratory indicators compared to other groups. Compared to physician sleep disordered breathing (SDB) classification, current pediatric apnea–hypopnea index (AHI)‐based SDB severity classification overestimated SDB severity. Age and obstructive‐mixed AHI (OMAHI) were most closely associated with physician identification of SDB.ConclusionChildren <6 months of age appear to represent a distinct group with respect to PSG. Experienced sleep physicians appear to incorporate age and respiratory event frequently when determining the presence of SDB. Further information about clinical significance of apnea in infancy is required, assisted by identification of factors that sleep physicians use to identify SDB in children <6 months of age. Pediatr Pulmonol. 2015; 50:1346–1353. © 2015 The Authors. Pediatric Pulmonology published by Wiley Periodicals, Inc.

Evolution in Reimbursement for Sleep Studies and Sleep Centers

Because of the rapid increase in the volume and costs of polysomnography and other sleep medicine diagnostic services, the Centers for Medicare & Medicaid Services (CMS) recently commissioned the Office of Inspector General (OIG) to review claims submitted for these services. The OIG found numerous cases of inappropriate payment for submitted claims and recommended significant changes in the CMS auditing process for polysomnography claims review. Additionally, a local Medicare Administrative Contractor released the most specific rules and regulations to date regarding billing and payment for sleep medicine services. These regulations specify covered diagnoses for submitted claims for both facility-based polysomnograms and unattended home sleep tests (HSTs) and list noncovered diagnoses that cannot be used to document medical necessity for such studies. The proposed rules specify minimum credentials for technologists performing polysomnograms and HSTs, mandate education prior to application of HST devices, demand a follow-up visit to discuss results after studies, and elaborate new requirements for physicians interpreting these studies. Providers of sleep medicine services must be prepared to provide documentation of diagnoses and indications when submitting claims for sleep services, and they can expect to be required to produce evidence of accreditation of the physicians and technologists providing services and the credentials of the sleep center. These changes will dramatically affect sleep medicine practitioners who order sleep studies and positive airway pressure therapies. Successful sleep medicine centers and sleep physicians alike will need to develop strategies to meet these new challenges.

Abstract T P263: Screening Practices for Sleep-Disordered Breathing in Stroke Medical Community

Background: Frequency of sleep-disordered breathing (SDB) among stroke and TIA patients ranges from 50% to 94%, and is associated with poor neurological outcomes. Per current stroke prevention guidelines from American Stroke Association, SDB is included in the list of modifiable risk factors for stroke and TIA prevention. The goal of our study was to determine screening practices for SDB in stroke medical community. Methods: A web-based survey was conducted between 12/2013 to 7/2014 among practitioners taking care of stroke patients across United States and Europe. Results: Among 112 total responses (18%), 91 were stroke physicians (81.25%), 9 were general neurologist (8.04%), 3 were sleep medicine physicians (2.68%) and 9 were other specialty (8.04%). Majority of practitioners (72%, n= 81) do not use SDB screening questionnaires in their stroke patients. Epworth sleepiness scale is the most used among SDB questionnaires (24%), followed by Berlin sleep questionnaire (9.5%) and STOP-BANG questionnaire (7%). Only 12% of practitioners use screening questionnaires in both in-patients and out- patients, where as 20% use only in out- patients and 5% use only in acute stroke setting. Only 50% of practitioners would refer their stroke patients to a sleep medicine specialist when patients were screened positive for SDB on questionnaires. Conclusion: Despite being an independent risk factor for stroke and TIA, majority of practitioners do not screen stroke and TIA patients for SDB. Further work is needed to improve screening practices for SDB in stroke medical community.

Use of electronic data and existing screening tools to identify clinically significant obstructive sleep apnea.

To assess the ability of electronic health data and existing screening tools to identify clinically significant obstructive sleep apnea (OSA), as defined by symptomatic or severe OSA. The present retrospective cohort study of 1041 patients referred for sleep diagnostic testing was undertaken at a tertiary sleep centre in Calgary, Alberta. A diagnosis of clinically significant OSA or an alternative sleep diagnosis was assigned to each patient through blinded independent chart review by two sleep physicians. Predictive variables were identified from online questionnaire data, and diagnostic algorithms were developed. The performance of electronically derived algorithms for identifying patients with clinically significant OSA was determined. Diagnostic performance of these algorithms was compared with versions of the STOP-Bang questionnaire and adjusted neck circumference score (ANC) derived from electronic data. Electronic questionnaire data were highly sensitive (>95%) at identifying clinically significant OSA, but not specific. Sleep diagnostic testing-determined respiratory disturbance index was very specific (specificity ≥95%) for clinically relevant disease, but not sensitive (<35%). Derived algorithms had similar accuracy to the STOP-Bang or ANC, but required fewer questions and calculations. These data suggest that a two-step process using a small number of clinical variables (maximizing sensitivity) and objective diagnostic testing (maximizing specificity) is required to identify clinically significant OSA. When used in an online setting, simple algorithms can identify clinically relevant OSA with similar performance to existing decision rules such as the STOP-Bang or ANC.

Automatic Sleep Stage Detection and Classification: Distinguishing Between Patients with Periodic Limb Movements, Sleep Apnea Hypopnea Syndrome, and Healthy Controls Using Electrooculography (EOG) Signals

Background: To improve the diagnostic and clinical treatment of sleep disorders, the first important step is to identify or detect the sleep stages. Utilizing the conventional method-known as visual sleep stage scoring-is tedious and time-consuming. Therefore, there is a significant need to create or develop a new automatic sleep stage detection system to assist the sleep physician in evaluating the sleep stages of patients or non-patient subjects. The first aim of this study is to develop an algorithm for automatic sleep stage detection based on Electrooculography (EOG) signals. The second aim is to utilize sleep quality parameters to classify and screen Periodic Limb Movements of Sleep (PLMS) patients and Sleep Apnea Hypopnea Syndrome (SAHS) patients, as distinct from healthy control subjects. Methods: 10 patients with Periodic Limb Movements of Sleep (PLMS), 10 patients with Sleep Apnoea Hypopnea Syndrome (SAHS), and 10 healthy control subjects were utilised in this study. Several features were extracted from EOG signals such as cross-correlation, energy entropy, Shannon entropy and maximal amplitude value. K-Nearest Neighbour was used for the classification of sleep stages. Several polysomnographical (PSG) features were measured for screening and classification of the sleep disorders, such as the percentage of the sleep stages over the total time of sleep, the duration of the sleep stages, Sleep Latency (SL), and sleep efficacy. A decision tree analysis was utilised for identifying the three groups of subjects. Results: The overall accuracy, sensitivity and specificity of automatic sleep stage detection were 80.5%, 81.3% and 88.8%, respectively. The Cohen’s Kappa was 0.73. The performance of the classified sleep disorders showed an overall accuracy of 90%. The sensitivity and specificity were 90% and 95%. The Cohen’s Kappa was 0.85. Conclusion: One advantage of the automatic sleep stage detection method based on Electrooculography (EOG) signals is that it can be utilized with portable sleep stage recording instead of using a multichannel signal. Classification of sleep disorders based on the automatic system is an improvement, in that it can make the screening or diagnostic processes much faster and easier than with other methods.