Sleep loss, defined as sleep duration less than basal need (approximately 8 hours nightly), is common with survey data showing that 18% of adults report habitually sleeping 7 hours or less. The CDC reported statistics between 1985 and 2004 showing an increase in the number of men and women claiming that they regularly sleep less than 6 hours nightly.1 Similarly, there is evidence that many adolescents habitually sleep less than basal needs.2 In common medical conditions such as obesity, disorders of mood and anxiety, arterial hypertension, cardiovascular disease, and diabetes, there is a body of work supporting the notion that sleep loss and sleep disorders can act as disease enablers and/or modifiers. It follows that the societal effect of sleep loss and sleep disorders is widely distributed, impacting the young and aged, the healthy, public health, public safety, and chronic diseases. The Chronic Care Model (CCM), a health care system that relies on evidence-based practice guidelines, was designed to improve outcomes of chronic illnesses. Whether CCM applied to sleep medicine would improve outcomes remains speculative. However, it is plausible that the introduction of healthy sleep practices into educational elements of CCM and similar health care systems would, in fact, further improve health outcomes.
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I envision significant opportunity for sleep medicine to positively impact health and well-being by participation in the management of sleep loss and sleep disorders within the paradigm of care of other chronic health problems. As the professional society that represents sleep medicine and sets the standards of care for sleep disorders in America, the American Academy of Sleep Medicine (AASM) has been a leading force in the growth and recognition of sleep medicine as a medical specialty. As AASM president, it is my belief that the Academy should foster programs and encourage practices that extend our unique expertise into those areas and chronic conditions where proper management of sleep loss and sleep disorders is known to positively influence outcomes.
THE CHRONIC CARE MODEL
A chronic disease can be defined as any medical condition that requires ongoing adjustments and interactions with a health care system; 133 million Americans live with a chronic condition, and that number is projected to increase by more than 1% per year. It is estimated that by the year 2030 the chronically ill population will reach 171 million.3 Further, nearly half of all people with chronic illness have more than one chronic condition, and these numbers were derived without consideration of sleep disorders as chronic diseases.
The CCM identifies six fundamental elements that encourage high-quality care in chronic illnesses. A complete description of CCM is beyond the scope of this editorial, but interested parties can refer to the Institute for Healthcare Improvement Web site (www.IHI.org) for greater detail. Briefly, the elements of CCM include self-management, decision support, clinical information systems, delivery system design, and organization of health care and community. Investigations have shown that CCMs designed for diabetes, depression, heart failure, and asthma have improved specific health outcomes measures.4 The improvement in health outcomes was most robust when all six elements were used, but improved health outcomes can occur with adoption of less than all six elements. Importantly, the advantages derived from CCM programs endured beyond protocol completion.
Common sleep disorders, including sleep apnea, chronic insomnia, restless leg syndrome, and others, clearly fall under the rubric of a chronic disorder. CCM was designed primarily for primary care providers and uses systems to encourage consistent use of established practice guidelines. In this manner, CCM attempts to mimic health care utilization as delivered by the specialist. Hence, some CCM elements might prove less effective in improving health care outcome applied to specialty practices like sleep medicine. Nonetheless, CCM addresses several elements of chronic disease health care management such that one should still expect benefit by adopting CCM to suit specialty care practices.
Improving sleep health care is central to the vision and mission of the AASM. To this end, the Academy, through its standards of practice process, publishes evidence-based practice parameters and promotes their use through AASM center and laboratory accreditation. Under the stewardship of AASM Past President Lawrence Epstein, MD, the AASM will this year publish practice guidelines applicable to broad areas of clinical practice. These clinical guidelines incorporate AASM practice parameters when such exist and expert consensus in situations where evidence is lacking or limited. AASM clinical algorithms highlight the best practices for disorders of sleep and will serve as a valuable resource for sleep health care delivery. CCM relies on evidence-based guidelines to guide patient care, and indeed adherence to practice guidelines is fundamental for CCM success. Similarly, AASM accreditation of sleep centers and laboratories improves sleep health care in part by mandating adherence to AASM published standards. The purported benefit on health outcomes of CCM, coupled with AASM commitment to high-quality sleep health care, compels careful study of CCM strategies for use in sleep disorders medicine.
I have come to understand that it is not sensible for the AASM to mandate wholesale adoption of CCM to our member centers and laboratories. Nonetheless, since improved outcome can be achieved without simultaneous adoption of all six elements, it follows that substantial benefit can be reaped by successfully promoting those elements of CCM susceptible to the influence of a professional medical organization. CCM elements, such as the emphasis on patient centric care, use of evidence-based guidelines, and reporting and tracking specific outcome metrics, are selected areas where I believe that the AASM can exert influence. Additionally, the AASM can serve membership by providing CCM educational materials, references, and resources for interested parties and, once identified, by promoting successful CCM programs within sleep medicine.
As earlier stated, sleep loss and sleep disorders can have a profound effect on chronic medical conditions such as cardiovascular diseases, diabetes, and hypertension. Partnering with other specialists and introducing healthy sleep practices into the management of chronic medical conditions allow the sleep medicine specialist to positively influence health outside of the traditional sleep center boundaries. Within the primary care office setting, the systematic introduction of sleep elements to chronic disease management models can further benefit health by identifying common sleep disorders that might have otherwise gone unrecognized. Managing sleep loss and sleep disorders within the paradigm of care of chronic medical condition can only add value to these systems. The challenge for the AASM and the individual sleep medicine specialist remains to convince our colleagues, policymakers, and health insurers of the value that managing sleep loss and sleep disorders confers on general health.
Alejandro D. Chediak, MD, is president of the American Academy of Sleep Medicine and medical director at Miami Sleep Disorders Center. He is also chief of the Sleep Disorders Center, Mount Sinai Medical Center, and associate professor of medicine at University of Miami at Mount Sinai. He can be reached at [email protected]
- Percentage of adults who reported an average of < 6 hours of sleep per 24-hour period, by sex and age group—United States, 1985 and 2004. MMWR Morb Mortal Wkly Rep. 2005;54:933.
- Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in adolescents. Child Dev. 1998;69:875-887.
- Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care. Baltimore: Johns Hopkins University, for the Robert Wood Johnson Foundation; 2004.
- Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve chronic illness care. Am J Manag Care. 2005;11:478-488.