© 2006 American Thoracic Society doi: 10.1164/rccm.200605-647ED
Rising to Meet An Unmet Public Health Need: Sleep Medicine and the Pulmonary CommunityCase School of Medicine, Cleveland, Ohio
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania The growing appreciation of the high prevalence of sleep apnea and the dramatic health benefits that may be derived by treating it with nasal CPAP has been accompanied by a marked increase in the number of pulmonologists seeking training in sleep medicine. In fact, pulmonologists constitute the largest proportion of specialists who have been recognized as diplomats of the American Academy of Sleep Medicine. Sleep medicine, however, is more than apnea and snoring, and to various degrees, pulmonologists have learned that it is a field that includes over 90 disorders of sleep and wakefulness, accepted as an independent medical discipline by both the Accreditation Council of Graduate Medical Education and the American Board of Medical Specialties. Specialists who include sleep medicine in their practice, however, may not all be fully committed to addressing the entire spectrum of sleep disorders. There are also too few specialists with any training in sleep medicine to begin to address the public health needs associated with sleep disorders and sleep deprivation. This impression is reinforced by a recent Institute of Medicine (IOM) report, "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem" (1), which, using evidence-based approaches, demonstrated an inadequacy of current resources to address sleep health issues. The Committee performed a critical review of the literature and concluded that 50 to 70 million Americans suffer from a chronic disorder of sleep and wakefulness. In comparison, approximately 20 million Americans are estimated to have active asthma and 10 to 15 million to suffer from chronic obstructive lung disease (COLD), conditions recognized for their public health burden. Somewhat similar to COLD, sleep disorders are associated with impaired quality of life and neurocognitive function, as well as with increased health care utilization and mortality. The Report also provides evidence that, unlike most conditions treated by pulmonologists, sleep disorders and chronic sleep loss contribute to the etiologies of a wide range of health effects that extend far beyond the respiratory system, including hypertension, diabetes, obesity, cardiovascular disease, and behavioral and mood disorders. The potential for sleep disorders to impact health at many levels presents both challenges and opportunities for the pulmonologist. The IOM report offers a compelling rationale for shifting emphasis from diagnosis to disease management. The myriad of health problems associated with sleep disorders mandates a new emphasis on chronic disease management, including commitments to addressing interactions of sleep with other organ systems and long-term treatment adherence. Although current reimbursement strategies favor in-laboratory intense diagnostic procedures, the large number of undiagnosed or inadequately treated patients mandates the development of more efficient systems for assessment and monitoring. The Report highlighted the large geographical disparities in access to sleep laboratories and estimated that the current number of polysomnograms performed per year may represent only 20 to 25% of the number required to address public health needs. Technological advances that enable miniaturization of sensors and enhanced efficiencies in data capture have not kept pace with clinical studies that have established the validity, reliability, and utility of such devices in clinical practice. The Committee identified a need for developing and validating simple devices for assessing sleep disorders. Industry, professional societies, and agencies, such as the Agency for Health Quality and Research, need to demand and facilitate collection of data necessary for defining the role of technology in expediting the diagnosis and management of sleep disorders. Third-party payers should assure that barriers to reimbursement do not impede the appropriate growth of the field; the pulmonary community needs to embrace technological advances, even if such changes alter revenue streams. Sleep disorders are frequently unrecognized; the Report estimated that less than 20% of patients with sleep apnea are appropriately diagnosed. The pulmonary community has a strong history in developing global approaches for screening and diagnosing airway diseases, as exemplified by the International Study of Asthma and Allergies in Childhood Asthma (2) and the Global Initiative for Obstructive Lung Disease (3). Pulmonologists may play useful roles in assisting with the development of screening tools for sleep disorders, and assure that these are implemented in routine pulmonary practice. There are also potential opportunities for the sleep medicine community to work more closely with public health agencies, including the Centers for Disease Control. The importance of broad public health campaigns aimed at promoting healthy sleep habits and for increasing the public's awareness of sleep as an essential component of health was noted. Efforts to increase public awareness of the health effects of tobacco and of asthma by the American Lung Association and American Thoracic Society may provide useful models for addressing similar needs in sleep medicine. The pulmonary community could assist with such efforts by considering all appropriate opportunities for including assessments of sleep disorders in other pulmonary-oriented public health and research initiatives. Adding sleep assessments to large-scale initiatives that were originally designed to address other pulmonary conditions may provide efficiencies in data collection, and the sleep data so collected are likely to enrich the other data. Many of the barriers identified may be addressed by strengthening the national infrastructure for sleep research. Although there has been a doubling in the number of R01s in sleep research over the last decade, there is evidence that the pipeline of physician scientists is shriveling. In 2004, there were only 19 K Awards in sleep research across the 17 NIH Institutes who support sleep research. Of these K awards, 46% were from only three academic medical centers. The Report recommends a major emphasis on training for careers in sleep research, including increased investment by both the NIH and professional societies. This calls for novel mechanisms for training, such as adding individual supplemental positions for sleep research to relevant training grants, such as in pulmonary medicine and neuroscience. Leaders in these fields should recognize the importance of training individuals in sleep medicine, the potential for cross-fertilization across disciplines, and redirecting resources to support such training. Remote mentorship is encouraged where there may be a methodologic mentor in the home institution of the trainee with a sleep mentor in another institution. There is clearly a need to improve the pipeline, particularly of physician-scientists, and creative strategies need to be implemented and encouraged by the pulmonary community. The Report identified sleep research as a prototypical interdisciplinary endeavor with the strong potential to be included in NIH Roadmap initiatives that highlight translational and transdisciplinary medicine. The science of sleep medicine, or "somnology," requires involvement of individuals from many different backgrounds. As with any interdisciplinary program, departmental or divisional "silos" represent barriers to progress (4). The Report calls for interdisciplinary sleep centers to be established in all of the nation's 125 academic centers. It proposes that three types of centers to meet the varying goals of different institutions (Table 1). The proposed regional comprehensive centers (type 3) are based on the Cancer Center model, and it is envisaged that they will form the basis for a national network for sleep medicine research. These regional comprehensive sleep centers will be involved in: research training for both basic and clinical research; providing cores for basic, translational, and clinical research; being the anchors for multicenter clinical research, such as clinical trials and genetics; and creating a data coordinating center. The sleep medicine field has not yet benefited from support for clinical research networks similar to those that have stimulated asthma, chronic obstructive pulmonary disease, and acute lung injury research. Thus, the proposed network will accelerate progress in sleep research where there is a dire need for the rigorous clinical trials and genetic epidemiologic research that have effectively advanced other areas in pulmonary medicine.
The IOM recommendations represent a major opportunity for pulmonary medicine and other disciplines which have a stake in this emerging, exciting interdisciplinary field. As interdisciplinary centers evolve in our academic centers, there will be a need to create career paths for individuals trained in sleep medicine, some of whom will also be pulmonologists. The research opportunities in this area are major. The growing recognition of the importance of sleep disorders outlined in the IOM Report will spur additional clinical activity. The vision laid out can, however, only be accomplished if existing models, whereby sleep medicine is simply a "cash cow" to support other areas in pulmonary medicine or other disciplines who have taken control of the sleep center, becomes a thing of the past. There is a larger, bolder, less parochial vision laid out in this report that leads to addressing the unmet public health need of undiagnosed, unrecognized sleep disorders and sleep deprivation. FOOTNOTES Conflict of Interest Statement: S.R. serves as a co-investigator on a NIH SBIR grant awarded to Cleveland Medical Devices in Phase I study of a new diagnostic test for sleep apnea. The total subcontract (2005–2006) was $40,000, all of which was applied to technical cost and none to support S.R. She is also is a co-investigator in a pending SBIR application from Advanced Bruin Imaging. No salary support has been requested. She has acted as a consultant to Cypress Bioscience and Organon Pharmaceuticals. A.I.P. receives royalties from Marcel Dekker Publishers for a book he edited entitled "Sleep Apnea: Pathogenesis, Diagnosis and Treatment." He has acted as a consultant to Cypress Bioscience and has given a paid lecture to Merck Pharmaceuticals. REFERENCES
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