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i don't agree with every point in this article, but i like it for its honest, fresh perspective on the sleep medicine industry. it's a perspective that's rare to come by in the US outside channels like SleepGuide:

Sleep disorders may be serious, but they are also a gravy train for some specialists

STEVEDORE Simon McKinnon snored like a train, but it took more than his wife's complaints or her recourse to earplugs to get him to do something about it.
Instead, the trigger was his wife's trip to her local GP surgery, where she saw a poster seeking participants for a trial at a sleep medicine clinic.

McKinnon attended the overnight clinic, run by the Woolcock Institute at the University of Sydney, where he spent the night wired up to machines that recorded his brainwaves, breathing, body position and an array of other data, including eye movements, heart rate and blood oxygen saturation.

The diagnosis: severe sleep apnoea, a condition that causes patients' throat tissues to fall inward during sleep, blocking the airway and causing them to choke and gasp before briefly waking.

The interruptions to sleep are so brief they are usually not remembered by morning. But they can happen so often -- up to 30 episodes an hour -- that they are very effective at preventing the brain from getting the restorative deep sleep it needs.

In McKinnon's case, he decided to try what doctors offer as the main treatment, a device called a continual positive airway pressure, or CPAP, machine, which prevents the airways from collapsing by pumping air through a mask or nozzle over the nose or mouth.

The devices are cumbersome to wear, and not cheap at about $1500. But after renting one for a month, McKinnon says he's so delighted he has just bought his own.

"The difference is out of sight. Previously, if I was on a morning shift, I would be driving to work and would already be feeling sleepy behind the wheel, whereas now I don't feel anything like that," the 36-year-old says.

Chalk up another satisfied customer for what is Australia's rapidly growing sleep medicine industry, which has come from nothing to represent a significant and growing sector of medicine.

Sleep studies were almost unheard of before the 1980s, yet the number performed in Australia has almost quadrupled in the past 11 years, rising from 33,700 in 1998-99 to nearly 117,000 in the last financial year.

The bill to Medicare -- which subsidises the tests -- has shot up from $12.5 million to nearly $48m a year in that time.

In many ways, it's an industry Australia can feel proud of, because the CPAP machine is an Australian invention that has been exported to the world in the 30 years since its discovery.

It's all a far cry from the traditional view of snoring and sleep problems as a harmless nuisance.

These days sleep is taken far more seriously, by doctors as well as the public, reflecting its status in today's more frenetic society as a commodity whose value has soared precisely because many people seem to feel they are getting less and less of it.

Doctors recognise nearly 70 different types of sleep disorder, but the most common are sleep apnoea, insomnia, narcolepsy, periodic limb movement disorder, sleep rhythm disruptions caused by jet lag or shift work, and sudden infant death syndrome.

Sleep expert Shantha Rajaratnam, an associate professor at Monash University, says obstructive sleep apnoea is frequently undiagnosed yet is associated with a "markedly elevated risk of cardiovascular disease, diabetes and a number of other adverse health outcomes".'

Stopping breathing while asleep, it seems, puts the heart under great strain, increasing blood pressure and the chance of heart attacks and strokes.

Services designed to detect and treat sleep apnoea have sprung up to service this new market, with CPAP heavily promoted as a successful treatment.

Australia has been a leader in this field thanks to the pioneering work of the University of Sydney's Colin Sullivan, whose investigations into the causes of cot death led to the realisation that adults could experience a similar phenomenon of interrupted breathing during sleep. His invention of the CPAP machine in 1980 -- when the only effective treatment was surgical widening of the throat -- sparked an explosion in sleep medicine services.

ResMed, the company Sullivan helped found to sell CPAP and related devices, is listed on the Australian and New York stock exchanges and reported net revenue of more than $US920m last year, and a five-year annual revenue growth rate of 20.75 per cent.

But as with most rapidly growing industries, particularly those part-funded by taxpayers, this growth has brought risks.

"There's no doubt that in the last 20 years sleep apnoea has gone from nothing to big business," says Drew Dawson, director of the Centre for Sleep Research at the University of South Australia.

"When [sleep labs] first started up, it was people at the egregious end of the scale who got treatment. But as they become more widespread, and the CPAP machines get smaller, there's more uptake.

"CPAP and sleep disorders are probably no different to any other disorder, in that there's a potential for over-servicing."

Next week, 500 sleep physicians from across the world will gather in Christchurch for the annual conference of the Australasian Sleep Association, where they will be presented with research showing, among other things, that one person in 20 suffers from severely disturbed sleep.

A report by Access Economics released in 2005 -- funded by ResMed -- found sleep disorders were "a large and under-recognised problem in Australia", affecting more than 1.2 million people and costing the nation $10.3 billion in 2004.

The report found sleep apnoea and insomnia accounted for nearly 10 per cent of workplace injuries, 8 per cent of depression cases and 7.6 per cent of non-work-related car crashes.

The report also blamed poor sleep for 2.9 per cent of diabetes cases, nearly 1 per cent of kidney diseases and 0.6 per cent of heart disease cases.

Dawson says there are certainly "people for whom sleep is a real problem", leading to "quite high levels of dysfunction in their lives". But he questions whether CPAP is always the answer, as the devices do not cure sleep apnoea and can be difficult for patients to tolerate.

One Australian sleep physician's website warns many patients "want to pull the mask off at exactly the same time each night" after wearing it for just three hours.

By contrast, Dawson says weight loss -- the vast majority of sleep apnoea sufferers are overweight or obese -- is an incredibly effective treatment for the condition, but one that holds less appeal for patients. "If people have developed behavioural insomnia through bad sleeping habits, there are good cognitive behavioural programs that are extremely effective, but compliance is low because people can't be bothered," Dawson says.

"On the other hand, people love a tablet. [Sleeping tablets] have high compliance, but low long-term effectiveness.

"Telling fat blokes to wear a vacuum cleaner down their throat for the next 20 years, because they might have a heart attack 20 years from now, compliance is quite bad. If you don't get a short-term benefit, people go, 'What's the point?' "
In 1988, Ron Grunstein became Australia's first staff specialist sleep physician; Grunstein is professor of sleep medicine at the Woolcock Institute attended by patient McKinnon. He is adamant sleep apnoea is a dangerous condition that deserves the attention it gets. He says its increasing prevalence is unsurprising, given the increase in obesity with which it is strongly linked.

But at the same time, he says the difference between sleep apnoea and simple snoring can become blurred and clinics such as his "get a lot of patients who snore a bit and worry the hell that they're going to have a stroke".
"We spend a lot of time talking to these people, reassuring them that there's no data to support that," Grunstein says.

Further, he says there's "a generic issue of vertical integration" in the industry, in that some clinics conduct sleep studies to diagnose sleep apnoea and then also sell them the CPAP equipment.

"A section, and I think it's a small section, of the sleep medicine community have benefited directly from the sale of CPAP," Grunstein says.

"There are situations where the doctor is in one room [and] says, 'You need CPAP'; they go to the next room and family members are there providing and selling CPAP.

I don't know how you feel about it, but I don't think that's right. I'm not saying all those patients didn't have sleep apnoea, but you are going to be more enthusiastic about prescribing a treatment under those circumstances.

"My problem is that the people trying to create a CPAP factory line are in fact detracting from the true need in the Australian community, which is to properly diagnose the condition and decide who needs treatment and who doesn't, and actually spend the resources on ensuring that people use their machines as much as possible.

"That's a problem," Grunstein says, "because often the machine is sold and then it's 'see you later'. After-care is often very variable."

Fuelling some of this concern about potential overservicing and conflicts of interest is the rise of home sleep study providers, which offer to assess a patient for possible sleep apnoea without the need
for them to stay in a laboratory overnight.

Medicare began funding home sleep studies on an interim basis in October 2008, and in the two complete years they have been available uptake has more than doubled, from 12,745 in 2008-09 to 28,134 last year, when the cost rose to $7.5m.

The federal government's Medicare Services Advisory Committee completed a review of the safety and cost-effectiveness of these home-based studies earlier this year. As a result of this review, only home studies for adults aged 18 and over will continue to be covered by Medicare from November 1.

Sleep scientist Chris Bunney is the owner of Home Sleep Studies Australia, which charges a $220 gap on top of the $269 Medicare rebate for its service. This involves Bunney visiting the patient at home on the evening of the test, attaching the electrodes and monitoring devices, and showing them how to switch on the equipment when they go to bed.

The same array of data that would be collected and analysed live in a laboratory setting is then recorded on a flash drive type device and assessed by a sleep physician in the following days.

Patients have to be referred by their GP in order to qualify for the Medicare rebate, but Bunney says referrals for the tests are accepted if the patients tick just two out of a list of conditions on the order form, including "often tired", "wake unrefreshed", "depression" and "wake with headache".

Bunney admits that although he is not a doctor, he makes his own assessment of the patient's results and offers them a trial of CPAP before a contracted sleep physician has made his official treatment recommendations.

If these concur with his assessment, he will then offer to sell CPAP to the patient if the trial period shows the patient likes the device.

Bunney says the problem of sleep apnoea is huge but adds there is definitely a scandal in the provision of CPAP services, claiming other home sleep study providers take fewer measurements than his laboratory-equivalent service.
They often also give the equipment to the patient during the day, with instructions on how to put it on, instead of attaching it themselves at the patient's home.

He also rejects criticisms from sleep specialists, who he says have "made millions" from the industry and are seeking to retain their market share.
"It's a gravy train they don't want to end," Bunney says.

"Of course they are highly protective . . . I'm talking about [sleep physicians making] probably half a million dollars a year for basically doing five to 10 hours' worth of work a week. "It's extraordinary, and it's probably what people outside the industry don't see."

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It is unfortunate but there are many who see polysomnography as a gravy train. In our small twin cities we now have 10 Sleep Labs. It is hurting the patients. A few of the labs use untrained non-registered Technicians. The reason is the almighty $$$. Physicians who have briefly been exposed to sleep training currently can read a sleep study receiving a reader fee and dare I say it... and under the table referral bonus from a few back ally DME companies. There needs to be more regulation.
Sleep Apnea related complication are killing people world wide. Apnea has been linked to Sudden Cardiac death, CAD, Stroke, Type 2 diabetes.
I agree with everything you said, Wayne with the exception of one sentence: "there needs to be more regulation." With all due respect, all the excesses you summarize so well here bring me to the exact opposite conclusion: there needs to be less regulation. what would happen if you could get screened for OSA using over-the-counter home tests -- think pregnancy tests analogy -- and then buy an auto-adjusting, auto-titrating PAP machine in WalMart or CostCo? i think these back alley deals and shady physician incentives would lessen, and that high-caliber, highly trained and experienced professionals like yourself would compete on a more level playing field for the more complex cases. it's a little bit like the rationale to decriminalize marijuana -- take away the big money available through criminal marijuana trafficking, and you'd have less criminality.

D. W. Conn said:
It is unfortunate but there are many who see polysomnography as a gravy train. In our small twin cities we now have 10 Sleep Labs. It is hurting the patients. A few of the labs use untrained non-registered Technicians. The reason is the almighty $$$. Physicians who have briefly been exposed to sleep training currently can read a sleep study receiving a reader fee and dare I say it... and under the table referral bonus from a few back ally DME companies. There needs to be more regulation.
Sleep Apnea related complication are killing people world wide. Apnea has been linked to Sudden Cardiac death, CAD, Stroke, Type 2 diabetes.
I was offered a trial period of CPAP though my sleep apnea was mild. My symptoms were such that I jumped at the chance being somehat familiar with CPAP. Even though I still struggle with getting correctly titrated and have some daytime sleepiness, my life has much improved. But I appreciated that it was offered as an option and continues only because data shows it's necessary.
I am 100% compliant.
With every set of initials added to end of the name, the physician become one more step removed from the patient. It has gotten to the point where a patient never talks to a doctor, he talks to every trained monkey along the way and is billed as if the doctor spoke to him.

If you can't prescribe it, then I don't need to pay for you in the process.



Mike said:
I agree with everything you said, Wayne with the exception of one sentence: "there needs to be more regulation." With all due respect, all the excesses you summarize so well here bring me to the exact opposite conclusion: there needs to be less regulation. what would happen if you could get screened for OSA using over-the-counter home tests -- think pregnancy tests analogy -- and then buy an auto-adjusting, auto-titrating PAP machine in WalMart or CostCo? i think these back alley deals and shady physician incentives would lessen, and that high-caliber, highly trained and experienced professionals like yourself would compete on a more level playing field for the more complex cases. it's a little bit like the rationale to decriminalize marijuana -- take away the big money available through criminal marijuana trafficking, and you'd have less criminality.

D. W. Conn said:
It is unfortunate but there are many who see polysomnography as a gravy train. In our small twin cities we now have 10 Sleep Labs. It is hurting the patients. A few of the labs use untrained non-registered Technicians. The reason is the almighty $$$. Physicians who have briefly been exposed to sleep training currently can read a sleep study receiving a reader fee and dare I say it... and under the table referral bonus from a few back ally DME companies. There needs to be more regulation.
Sleep Apnea related complication are killing people world wide. Apnea has been linked to Sudden Cardiac death, CAD, Stroke, Type 2 diabetes.

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