Leadership of the American Academy of Sleep Medicine (AASM) should be an easy gig. Together, the AASM and the affiliated organizations it helps manage from its Westchester, Ill, headquarters make up the largest sleep-medicine-only group in the world. Its coffers are full. Its membership continues to increase. It occupies a key niche in a field nearly every expert predicts will grow by double digits for the next several years. So why is new AASM president Michael Silber, MBChB, jumping into the home testing debate—possibly the most controversial and emotional issue currently facing sleep medicine—instead of simply sitting back and enjoying the attention and respect that comes with his 1-year position? Because being a leader is about doing the right thing, even when that thing may be unpopular.
Silber has announced that the AASM will be examining the validity of using portable monitoring devices in sleep medicine diagnostics. At present, its policy is that there is not enough evidence to support the use of these devices (ie, home testing) to diagnose sleep disorders. However, because this is an area where the number of new and improved devices is exploding, the old objections to using portable devices to diagnose may fall away as technology improves.
Having the AASM become involved in studying these devices and issuing opinions on if, when, and how portable monitoring may be appropriate is a courageous move. Any results it comes up with will certainly be criticized by some as too biased toward the commercial interests of the device manufacturers, as well as the sleep professionals who have already begun using portable monitoring instead of laboratory studies. Meanwhile, the other side will likely complain that the AASM was too cautious and too deferent to its nearly 1,000 accredited sleep centers that use the laboratory-study model for all sleep tests. It can’t win, but it is doing the right thing, and, for that, it and Silber should be applauded.
Human beings are biased and imperfect, and it will certainly be a challenge for the AASM members who look into the portable monitoring issue to not be swayed by one side or the other of the debate. However, if they stay true to what is best for the patient, they just may be able to provide unbiased scientific information upon which to base practice guidelines.
By all estimates, the number of people diagnosed with sleep disordered breathing—the most common sleep disorder seen in sleep laboratories and the one that lends itself most easily toward diagnosis by portable monitoring devices—is just the tip of the iceberg. As many as 90% of people with sleep disordered breathing (SDB) may not even know they have it. Increasingly, researchers are finding that the consequences of undiagnosed SDB could indeed be quite serious. Everything from hypertension to erectile dysfunction to cognitive-behavioral problems in children have been linked to the disorder. It is therefore becoming increasingly clear that medicine needs to find a way to get more people diagnosed and treated easier and faster.
Is the risk of a new diagnostic modality falsely labeling someone as either having or not having SDB worth the risk of a person not being tested at all and possibly developing one of the more serious comorbidities associated with the disorder? What if easier diagnosis drives up utilization of CPAP and there is a backlash by insurers not yet fully convinced of the effectiveness of SDB treatment? The AASM will have to wrestle with these and many other hard questions when it takes up this debate.
No, doing the right thing is certainly not easy, and we must congratulate them for trying. In short, the AASM is being true to its vision and goals as the national sleep medicine representative, and, as Silber told the Academy’s members, “We will not aggregate this role to any other group.”
