Integrating EEG provides clinical, technical, staffing, and financial advantages.
The market need for neurodiagnostic testing is increasing. Its long-term growth is driven by an aging population that needs treatment of neurodegenerative disorders, management of strokes, intervention with spinal cord injuries, and therapeutic devices for psychiatric disorders—all diseases that impact sleep. There is a synergy between the sciences of neurodiagnostics and sleep diagnostics, including much overlap in expertise and equipment. Sleep centers can thereby benefit themselves and their patients by integrating neurodiagnostic services into their offerings.
Recognizing the interdisciplinary understanding of medical disorders secondary to dysfunctional sleep highlights the value for considering the integration of neurodiagnostic services. This is supported by the prevalence of sleep-disordered breathing (SDB) in adults who have comorbid medical conditions such as cardiovascular complications, increased risk for stroke, and increased risk for seizures. Patients evaluated for seizures complete a routine electroencephalogram (EEG) with recorded spontaneous sleep, which can help to differentiate a SDB pattern on the EEG. Patients with witnessed SDB during the EEGs are referred to the sleep center to record nocturnal sleep to diagnose the SDB and differentiate among obstructive, central, and mixed events, correlate changes in oxygen, and measure the impact on sleep continuity through interdisciplinary expertise.1
Overlap in Expertise and Equipment
Neurodiagnostic and sleep technologists alike complete the same specialized training to learn application of EEG, electrocardiogram (ECG), and eye leads for monitoring clinical parameters. Both techs study cardiovascular, respiratory, psychiatric, and neurologic disorders. There is a technical overlap of the electrical parameters required to perform both EEG and polysomnography (PSG), including adjustment and documentation of gain, filters, calibrations, and impedances. Some recording devices on the market even have the capability of recording both EEG and PSG on the same device, which makes such equipment a cost-effective investment for sleep labs that offer both neurodiagnostic and sleep services.
The process for completing credentialing to perform both EEG and PSG is comparable, with some techs electing to complete credentialing in both. Techs with dual credentials provide a staffing bridge between the neurodiagnostic and sleep centers. EEG techs who work days can also be trained to perform daytime multiple sleep latency tests and maintenance of wakefulness tests, which are in the domain of the sleep center. Also, since the same techs with expertise in neurodiagnostic and sleep studies are observing the EEG for symptoms of SDB, it follows that more studies will be referred to the sleep center for testing.
Therefore, the cross-training between neurodiagnostic testing and the sleep center provides clinical, technical, staffing, and financial advantages. Hence, integration of the technical and clinical staff to assess and diagnose neurologic disorders such as epilepsy is a profitable addition to consider.
Neuroimaging advances including magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT), EEG, and magnetoencephalography (MEG) improve diagnosis of neurologic disorders. New biomarkers and imaging protocols contribute to earlier diagnosis and monitoring of disease. Neuroinformatics provide multidimensional databases and software systems that store and analyze data ranging from genetic to behavioral scopes.
Key clinical directions add to the benefits of sleep center diversification. The aging market impacts the demand for more research and sustainable treatment options of neurodegenerative disorders, Parkinson’s disease, and other movement disorders. Novel stimulation devices are available for the treatment of asthma, migraine, and epilepsy. There is a demand to use diagnostics to change the treatment landscape of anxiety, depression, and attention deficit hyperactivity disorder.
Neurodiagnostics and assessment of sleep disorders both impact the management of psychiatric disorders, mood and anxiety disorders, as well as neuromuscular disorders.
The career outlook for staffing the hybrid integration of neurodiagnostic and sleep testing provides increased employment opportunities in hospitals, clinics, and independent testing facilities. The increase in the job market necessitates the need for well-educated techs. The challenge for adequate training resources is significant in the current market, which is a potential barrier for integration of the two services. Yet solutions for increasing educational programs may be another financial investment that provides a viable platform for success—such as collaborating with a community college to create a program leading to an associate degree, thereby also creating a niche for the sleep center.
Questions to Ask
Embarking on expanding the sleep center through integration of EEG does merit answering some questions before proceeding.
First, create a business plan to identify realistic revenue and expenses compiled from an honest evaluation of the market for referrals, as well as actual contracting and credentialing requirements for receiving payments from third-party payors.
Second, assess staffing availability or possibility of staff restructuring to improve the clinical, technical, and fiscal processes.
Third, study the market for the effective implementation of technology to improve productivity. Reach out to other providers, business leaders, and strategic planners to obtain tools to define measurable outcomes and realistic timetables for implementation.
Lastly, identify the accessibility of board-certified medical direction to interpret diagnostic studies.
The clinical community is responding with interest to expanding services in the sleep center through adding monitoring for epilepsy and other neurologic disorders.
In September 2017, the University of South Florida Health will host a continuing education program entitled “Current Concepts in Sleep and Epilepsy.”
The Epilepsy Foundation posted a clinical opinion by Carl W. Bazil, MD, PhD, stating: “Attention to sleep in patients with epilepsy has important implications for diagnosis, seizure control, and quality of life. Recent advances have helped clarify the value of recording sleep EEG in diagnosing and localizing partial epilepsy. Syndromes of sleep and epilepsy, particularly nocturnal frontal lobe epilepsy, are better understood. Finally, it is becoming clearer that independent sleep disorders frequently coexist with epilepsy, and that seizures themselves cause sleep disturbance.”2
Evidence supports a viable benefit to integrating neurodiagnostic testing into the sleep center, as demonstrated by the benefit of cross-training to provide clinical, technical, staffing, and financial advantages. Due to the prevalence of undiagnosed SDB, detection of SDB during a routine EEG will increase referrals to the sleep center. Epilepsy and sleep disorders coexist and require clinical and technical expertise to effectively assess, treat, and manage the disease. Hence, integration of the technical and clinical staff to assess and diagnose neurologic disorders such as epilepsy is a profitable addition to consider.
Kathryn Hansen, BS, REEGT, CPC, is executive director of the Kentucky Sleep Society and the Society of Behavioral Sleep Medicine, and a member of Sleep Review’s editorial advisory board.
1. Poothrikovil R, et al. Prevalence of sleep-disordered breathing during routine electroencephalogram (EEG): a hospital-based descriptive study. Neurodiagn J. 2017;57(2):153-64.
2. Bazil CW. Current Opinion: Sleep and Epilepsy. Epilepsy Foundation. Available at: www.epilepsy.com/article/2014/3/current-opinion-sleep-and-epilepsy