By William C. Dement, MD, PhD, and Robert Koenigsberg

In order to advance patient care in the practice of medicine, change is necessary. Although for many reasons there is resistance to change, without it, the work that has been done to establish sleep medicine as a specialized medical practice would be endangered. Today, sleep medicine is adapting to shifts that we believe are taking our field to the next level of better patient care.


Ten years ago, the results of the first painstaking study of primary care medical practice revealed that 34% of males and 19% of females in the clinical population had flagrant symptoms of OSA.1 Responding to this need was strongly emphasized by the congressionally mandated National Commission on Sleep Disorders Research in its final report to Congress (Wake up America!). Shortly thereafter, the landmark study by Terry Young, PhD, firmly established the prevalence of OSA as afflicting 24% of adult males and 9% of adult females (approximately 30 million Americans).2 Today it is likely that, at the very most, only 15% of the 30 million victims have been diagnosed.

William C. Dement, MD, PhD, (left) and Robert Koenigsberg.

As sleep physicians know, there is a tremendous need in the sleep field for improving the overall very poor compliance of patients receiving PAP therapy. To underscore this issue, when an audience of more than 600 sleep professionals at the 2006 APSS meeting was asked, “Do you believe compliance with PAP therapy is a serious problem?” everyone raised their hand.

With the approval of in-home testing by CMS, a huge unmet demand has been created for professionals who are focused on portable testing, disease management, and wellness through compliance with PAP therapy. We are very pleased with CMS’s final determination on approving reimbursement for CPAP based on an in-home portable monitoring study. This decision by CMS was based on a thorough analysis of the available peer-reviewed literature. Adding in-home monitoring to the approved sleep medicine armamentarium can only have a positive impact on the continuing tremendous need to foster healthy sleep and to promote sleep awareness.

The CMS decision and the resulting paradigm shift in the diagnosis and treatment of sleep disorders should benefit both patients and clinicians: The diagnosis and successful treatment of OSA will be made easier and less costly, and clinical access by millions of OSA sufferers should increase dramatically. As a consequence, physicians and other health care professionals will deal with OSA patients similarly to how they deal with other very serious illnesses such as diabetes and cardiovascular disease.

Improved medical technologies are spurring innovations in sleep medicine as they have historically done in other specialties. For example, patients were once required to go to a pulmonary function laboratory within a hospital to have pulmonary function testing. This is now routinely carried out in a primary care physician’s office utilizing a device that provides immediate results. To give a second example, cardiac patients were required to spend an entire night and day in the hospital to have ECG monitoring for a 24-hour period. Thus, ECG in the hospital was the only approach available to identify and quantify arrhythmias until Norman J. Holter’s invention of his Holter Monitor in 1949.3 This led to the 1960s commercialization of his invention into what we now know as the portable Holter monitor. The original “portable” device weighed 75 pounds and used analog tape to record 24 hours of electrical activity from the heart. Today’s device, however, now records digitally and weighs less than a pound. Because of these spectacular technological improvements, the Holter monitor has achieved widespread use by primary care physicians as a cardiovascular diagnostic tool prior to treatment or referral to a cardiovascular specialist. These are two compelling examples of how advances in technology lead to changes in clinical practice that improve access, reduce costs, and ultimately provide an increased benefit to humanity. The same opportunity now clearly exists for technological advances to improve the practice of sleep medicine.

Although the CMS approval of in-home testing is great news for the sleep disorders industry, it is clear that a great deal of work still needs to be done to provide successful testing and treatment at a greatly reduced cost. For example, we need to advocate the use of and reimbursement for in-home PAP titrations to complete the pathway of testing and treatment in the home. PAP therapy compliance is an ever more complex challenge, and requires a more thorough understanding of the many types of PAP devices, interfaces, and related alternative treatments.


In California, we are developing a new sleep-related educational discipline. We have garnered support from a local community college to begin teaching and training individuals to become “Sleep Care Specialists.” The didactic focus of the program will be on basic knowledge on the nature of sleep, circadian rhythms, sleep deprivation and its deleterious effects, and finally, a good understanding of the full panoply of sleep disorders. The foregoing topics are thoroughly covered in Stanford University’s popular undergraduate course entitled “Sleep and Dreams.” This course will be replicated as a requirement in the above-mentioned program and initially taught by its creator, Dr William Dement. Separately, the students will be taught in the classroom, on the Web, and as on-site trainees learning to diagnose and treat patients with an emphasis on sleep-related breathing disorders.

The practice of sleep medicine is a relatively new field of study that is moving forward at a rapid pace. In order to achieve increased recognition as a medical specialty, the field will have to advance educationally and technologically. It is inevitable that change will be resisted by some, and though it may be difficult to accept, the time has come for sleep medicine professionals to adapt to the new educational endeavors and technological advancements that are taking sleep medicine to the next level of better patient care.

William C. Dement, MD, PhD, is professor of psychiatry and behavioral sciences at the Stanford University School of Medicine, Stanford, Calif, as well as chief of the newly established Division of Sleep Medicine. Robert Koenigsberg is president and CEO of SleepQuest Inc, San Carlos, Calif. Contact them at [email protected].


  1. Kushida CA, Nichols DA, Simon RD, et al. Symptom-based prevalence of sleep disorders in an adult primary care population. Sleep Breath. 2000;4:11-15.
  2. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-1235.
  3. Holter NJ, Generelli JA. Remote recording of physiologic data by radio. Rocky Mtn Med J. 1949;46:747-751.