Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Brown serves on the Polysomnography Practice Advisory Committee of the New Mexico Medical Board and on the New Mexico Respiratory Care Advisory Board. He currently receives no grant or commercial funding pertinent to the subject of this article. Dr Brown was a member of the American Academy of Sleep Medicine Board of Directors when “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients” was developed and approved. Correspondence to: Lee K. Brown, MD, FCCP, Department of Internal Medicine, School of Medicine, The University of New Mexico, 1101 Medical Arts Ave NE, Bldg # 2, Albuquerque, NM 87102; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1697

15. Southwell C, Moallem M, Auckley D. Cardiologist’s knowledge and attitudes about obstructive sleep apnea: a survey study. Sleep Breath. 2008;12(4):295-302. 16. Subramanian S, Desai A, Joshipura M, Surani S. Practice patterns of screening for sleep apnea in physicians treating PCOS patients. Sleep Breath. 2007;11(4):233-237. 17. Papp KK, Penrod CE, Strohl KP. Knowledge and attitudes of primary care physicians toward sleep and sleep disorders. Sleep Breath. 2002;6(3):103-109. 18. Schotland HM, Jeffe DB. Development of the obstructive sleep apnea knowledge and attitudes (OSAKA) questionnaire. Sleep Med. 2003;4(5):443-450. 19. Billiart I, Ingrand P, Paquereau J, Neau JP, Meurice JC. The sleep apnea syndrome: diagnosis and management in general practice. A descriptive survey of 579 French general practitioners [in French]. Rev Mal Respir. 2002;19(6):741-746.

References 1. Golden RL. William Osler at 150: an overview of a life. JAMA. 1999;282(23):2252-2258. 2. Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77(6):534-542. 3. Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75(12):1193-1198. 4. Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36(9):853-859. 5. Chen J, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction. J Gen Intern Med. 2006;21(3):238-244. 6. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002;96(5):1044-1052. 7. Reid RO, Friedberg MW, Adams JL, McGlynn EA, Mehrotra A. Associations between physician characteristics and quality of care. Arch Intern Med. 2010;170(16):1442-1449. 8. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102. 9. Parthasarathy 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(2):133-142. 10. Epstein LJ. Specialized sleep care benefits patients. J Clin Sleep Med. 2006;2(2):143-144. 11. Pamidi 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(1):51-57. 12. Kapur V, Strohl KP, Redline S, Iber C, O’Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath. 2002;6(2):49-54. 13. Rosen RC, Zozula R, Jahn EG, Carson JL. Low rates of recognition of sleep disorders in primary care: comparison of a community-based versus clinical academic setting. Sleep Med. 2001;2(1):47-55. 14. Silverberg DS, Oksenberg A, Iaina A. Sleep related breathing disorders are common contributing factors to the production of essential hypertension but are neglected, underdiagnosed, and undertreated. Am J Hypertens. 1997;10(12 pt 1): 1319-1325. 1754

Counterpoint: Should Board Certification in Sleep Be Required to Prescribe CPAP Therapy on the Basis of Home Sleep Testing? No effectiveness and least costly alternaComparative tive diagnostics and therapies have become pow-

erful mantras within Centers for Medicare & Medicaid Services (CMS) policies. These concepts played a role in the decisions by CMS to eventually provide reimbursement for home sleep testing (HST). This was based on supportive evidence proving that spending the higher cost of in-laboratory polysomnography (PSG) produced the same outcome; therefore, Medicare supported the least costly alternative of HST.1 Now, HST has become a mainstay in the diagnosis and management of patients with uncomplicated OSA. Most recently, the Agency for Healthcare Research and Quality published their report on the diagnosis and treatment of OSA in adults.2 They proposed that a future research-needs topic would be to examine the value of having a sleep medicine specialist involved in the diagnosis of OSA. A Web-based survey tool supported the role of a sleep specialist in delivering optimal education to patients with OSA but this only resulted in a better risk perception of untreated OSA.3 This would hopefully lead to less discontinuation of therapy but this was never surveyed. A more recent large retrospective cohort study evaluated the effect of a specialist consultation before in-house diagnostic PSG.4 The 403 patients with OSA had CPAP initiated at home after referral by either a sleep or nonsleep specialist and then objective adherence was assessed during the first 30 days of therapy. This was done without further consultation from the referring physician until final follow-up, which showed there was significantly more use per day (58.2 min; P , .002) in the cohort referred by a sleep Point/Counterpoint Editorials

specialist. Details of how the follow-up was conducted, however, were not provided or standardized, likely again emphasizing the importance of comprehensive management and not who makes the diagnosis. Other studies have shown that optimization of adherence occurs most importantly when tied to a complete management program especially focused on the follow-up not just the diagnosis.5,6 The evidence review by the American Academy of Sleep Medicine (AASM) put heavy emphasis on a comprehensive management program for optimal outcomes as well.7 The evidence review also pointed out that given the expected large number of patients with undiagnosed OSA, programs should be developed to improve recognition of the signs and symptoms of OSA that might lead to earlier and more frequent diagnosis of untreated OSA. The Institute of Medicine further reported on the high incidence of undiagnosed OSA and urged that primary care providers play a greater role in the diagnosis and management of these patients.8,9 Another study, however, demonstrated that primary care physicians (PCPs) from many clinics had little documentation or efforts in place to identify OSA.10 Information was obtained from five regional practicebased research networks using 44 randomly selected primary care clinics. It was noted that on any specific practice day, more than one-third of patients were at high risk of having sleep apnea based on the wellverified Berlin Questionnaire results. Less than onethird of PCPs document sleep-related symptoms and even fewer routinely screen for OSA. The more enlightened would not chastise the PCPs for these findings but rather urge them to develop skills and comprehensive management programs. Many medical organizations such as the American College of Chest Physicians and AASM have made an active effort to get the message out with focus on a broad population of primary care givers through lecture circuits and other communications. I have participated in such programs with the American College of Chest Physicians and find that PCPs are eager to become involved with diagnosis and management of OSA. Virtually all studies that have looked at the efficacy of HST or portable monitoring vs laboratory-based PSG were done within very structured sleep-specialist-driven protocols.11 The AASM guidelines on the long-term care of patients with OSA concluded with a blatantly self-serving statement that “PM [portable monitoring] should be performed under the auspices of an AASM accredited comprehensive sleep medicine program,” but offer no data directly supporting this contention.12 After another Agency for Healthcare Research and Quality report, even CMS concluded that there is little harm to be done in prescribing CPAP after misdiagnosing a patient who does not have OSA, but the opposite is not true.13 The endocrinologic, cardiovascular, menjournal.publications.chestnet.org

tal health, and potential accident consequences of undiagnosed OSA are well known by clinicians, and any obstacles to diagnosis, such as restricted HST coverage, are unreasonable.7 In a retrospective study of 57 patients with newly diagnosed OSA, only 25 of those who failed to follow-up after CPAP titration in an accredited sleep laboratory environment were successfully contacted and agreed to an interview; only seven of these patients (28%) were regular users of CPAP while the remaining 18 patients (72%) were noncompliant.14 Sleep laboratory-based diagnosis of OSA is not a guarantee of treatment success. There is but one randomized controlled trial that actually evaluated a simplified model of care for OSA in a primary care setting from Australia.15 Although as-yet only presented in abstract form, both my debater and I had a chance to view the poster presentation at the American Thoracic Society 2012 International Conference in San Francisco, California. The sleep-specialist primary investigators introduced a screening program to a group of PCPs using the Epworth sleepiness scale (ESS), reviewed symptoms suggestive of OSA with them, and then instructed them with regard to use of an HST to confirm OSA. Qualifying patients with OSA were randomized to compare management with either usual care with their management guided by a sleep physician in a specialty sleep center with laboratory-based testing or management led by their PCP with a community-based nurse and autotitrating CPAP done in the home after positive HST. The outcome measures included symptom reevaluation with the ESS (primary outcome) as well as change in functional outcomes of the sleep questionnaire, and the objective CPAP compliance was recorded after 6 months. After 155 patients were randomized and 137 participants were reevaluated at 6 months, the mean improvement in ESS score was near 5 and not different for the two groups. The mean change in functional outcomes of the sleep questionnaire score was near 2 and similarly not different for both groups. The authors also noted that the CPAP compliance in the specialist group was not significantly better at 5.4 (⫾ 1.8) hours vs 4.8 (⫾ 2.1) hours in the primary care-based group (P 5 .1). The within-study costs for primary care management were significantly lower with a savings of $2,157 per patient (in Australian dollars). The investigators concluded that “a simplified, ambulatory approach which utilizes the skills of appropriately trained PCPs and community-based nurses are not clinically inferior to usual management in a specialist sleep center.”15 This study might seem to support an equally efficacious and cheaper PCP model, but this seems plausible only when done within a highly structured program; the savings primarily came from not doing HST in both groups, not because of a sleep specialty-based diagnosis. CHEST / 144 / 6 / DECEMBER 2013

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As we return to the primary point of this debate, it is clear that optimal management of the patient with OSA is more critically dependent on recognition and comprehensive therapeutic programs that result in long-term good adherence to treatment. There is no guarantee right now that the sleep-specialist performance of the HST is the key to this door, so restricting CMS coverage of HST to this much smaller group of clinicians merely provides another barrier to capturing vastly undertreated patients with as-yet undiagnosed OSA. The American Board of Medical Specialists has approved a Certificate of Added Qualifications in Sleep Medicine for PCPs that would likely foster more comprehensive management programs (as was done in Australia), and we should support this.7 This special certification makes good sense as the PCP has surely quicker and more vast access to the many patients in need of OSA treatment, and a PCP certainly is more likely to see return patients more frequently to ensure their progress than the sleep specialist. Peter C. Gay, MD, FCCP Rochester, MN Affiliations: From Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Mayo Foundation for Medical Education and Research. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Peter C. Gay, MD, FCCP, Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Mayo Foundation for Medical Education and Research, E18B, Rochester, MN 55905; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1699

References 1. Centers for Medicare & Medicaid Services. National coverage determination (NCD) for continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) (240.4). Centers for Medicare & Medicaid Services website. http:// www. cms . gov / medicare - coverage - database / details / ncd details.aspx? Accessed August 24, 2012. 2. Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative effectiveness review No. 32 (prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-100551). AHRQ Publication No. 11-EHC052-EF. Rockville, MD: Agency for Healthcare Research and Quality. http://www.effectivehealth care.ahrq.gov/ehc/products/117/731/OSA_ExecSumm.pdf. Published 2011. Accessed August 24, 2012. 3. Parthasarathy 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(2):133-142. 4. Pamidi 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(1):51-57. 1756

5. Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep. 2007; 30(5):635-640. 6. Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;65(12):1061-1066. 7. Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29(3):381-401. 8. Colten HR, Altevogt BM, eds. Sleep disorders and sleep deprivation: an unmet public health problem. The National Academies Press website. http://www.nap.edu/catalog.php?record_ id511617#toc. Accessed August 24, 2012. 9. Kapur V, Strohl KP, Redline S, Iber C, O’Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in US communities. Sleep Breath. 2002;6(2):49-54. 10. Mold JW, Quattlebaum C, Schinnerer E, Boeckman L, Orr W, Hollabaugh K. Identification by primary care clinicians of patients with obstructive sleep apnea: a practice-based research network (PBRN) study. J Am Board Fam Med. 2011;24(2): 138-145. 11. Collop NA, Anderson WM, Boehlecke B, et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3(7):737-747. 12. Epstein LJ, Kristo D, Strollo PJ Jr, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276. 13. Trikalinos TA, Ip S, Raman G, et al. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Agency for Healthcare Research and Quality (AHRQ) Technology Assessment Program. Centers for Medicare & Medicaid Services website. http://www.cms.hhs.gov/determinationprocess/downloads/ id48TA.pdf. Accessed August 24, 2012. 14. Lin HS, Zuliani G, Amjad EH, et al. Treatment compliance in patients lost to follow-up after polysomnography. Otolaryngol Head Neck Surg. 2007;136(2):236-240. 15. Chai-Coetzer CL, Antic NA, Rowland LS, et al. A randomised controlled trial to evaluate a simplified model of care for obstructive sleep apnea in primary care [abstract]. Am J Respir Crit Care Med. 2012;185:A3853.

Rebuttal From Dr Brown Price is what you pay. Value is what you get. Warren Buffett

Gay’s first and foremost argument in favor of Drallowing physicians without board certification in 1

sleep medicine to prescribe CPAP on the basis of the home sleep testing (HST) is the potential cost savings. That would be a cogent argument if the cost-benefit ratio of HST with interpretation and clinical decisionmaking by a non-board-certified physician was sufficiently superior to laboratory polysomnography (PSG) Point/Counterpoint Editorials