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An interview with Professor Barbara Phillips
#1
"Not every patients needs to go to the sleep lab" presentation by Dr Barbara Phillips posted by Steven :
http://www.tnlc.com/Lara/laura/osa/Barba...t_0830.pdf

An interview with Professor Barbara Phillips [copied from old forum]
http://www.resmed.com/au/assets/document...dica14.pdf

Professor Barbara Phillips, MD, MSPH is a Professor of Pulmonary, Critical Care, and Sleep Medicine in the Department of Internal Medicine at the University of Kentucky College of Medicine. Prof. Phillips is former chair of the National Sleep Foundation and directs
the sleep medicine program at the University of Kentucky Good Samaritan Hospital in Lexington, Kentucky. She is board certified in internal medicine, pulmonary disease, critical care medicine, and sleep medicine. Prof. Phillips serves on the Board of Regents, and the Sleep Institute for the American College of Chest Physicians (ACCP). Prof. Phillips has been a medical consultant for the National Aeronautics and Space Administration, the RAND Corporation, the US Department of Health and Human Services, the National Institutes of Health, and other government agencies. She has served on the boards of the American Lung Association, the American Academy of Sleep Medicine, the American Board of Sleep Medicine, and the Medical Advisory Board of the National Center on Sleep Disorders Research. Prof. Phillips has led research studies and lectured and presented nationally and internationally on sleep disorders.

You must have an 'all-round view' of sleep disorders given that you have conducted research into obesity, the epidemiology of restless leg syndrome and sleepdisordered breathing (SDB), alternative treatments for obstructive sleep apnea (OSA), sleep disordered breathing in the elderly, attention deficit disorder and sleep, sleep loss among physicians in training, and the effect of CPAP on car crash rates for people with OSA (see page 10). Can you tell me how you became involved in SDB/OSA research?

As a young pulmonary fellow (almost three decades ago!), I was working with a junior faculty member who was learning about a new disorder called 'sleep apnea', and who was interested in the effects of sleep deprivation on breathing and respiratory control. That mentor, Dr Kevin Cooper, infected me with curiosity about sleep, sleep loss and breathing, because he was so practical and non-pretentious about doing research. From Kevin, I learnt that research doesn't have to be intimidating or complicated.

How was research into SDB/OSA viewed when you started out?
The field of sleep medicine has been multi-disciplinary from the outset, and thus has not been considered to be mainstream by pulmonary, neurology, psychiatry or any of its other constituent branches. Sleep research was neither fish nor fowl. Unfortunately, that is still partly true.

With increasing literature showing an association between OSA and other comorbidities such as cerebro- and cardiovascular disease and depression, do you think sleep medicine will become more mainstream?

Probably. And the recognition that sleep apnea has significant comorbidities may shift its management away from sleep specialists who haven't done a very good job of promptly, efficiently, inexpensively managing this very prevalent, deadly disease. For example cardiologists, who live in a culture of urgency, are among those who are getting involved in the diagnosis and management of sleep apnea.

Can you describe what the treatment for OSA was like when you started out?
Continuous positive airway pressure (CPAP) treatment was rarely used in the early '80s. We tried (with the same kind of success that is still the norm today) to get people to lose weight. But folks who were seriously afflicted with OSA were best treated with a tracheotomy.

How has the treatment for OSA evolved over the years?
Well, there is no question that CPAP is the treatment of choice. Much peer-reviewed literature demonstrates that it effectively treats most of the secondary consequences of sleep-disordered breathing. Oral appliances are clearly gaining in stature and popularity, because they are easier to use, and the dental community has done a good job of proving their efficacy. And I think that most clinicians now realize that upper airway surgery is not a good choice.

Do you think the treatment for OSA is going in the right direction?
No. Until or unless we figure out how to get people to lose weight and maintain weight loss, CPAP will simply be a bandaid on the much bigger problem.

Would you like to see the diagnosis/treatment of OSA alter in any way?
Get insurance rules and regulations out of the picture! Let clinicians manage patients. Stop requiring a sleep study in order to have CPAP paid for. Stop pretending that a CPAP titration (or an in-lab PSG, for that matter) is some kind of magical test.

Is the requirement that a sleep study must be carried out in order for CPAP to be paid for likely to change anytime soon?
Beats me. Probably not if those who profit by sleep apnea testing continue to loudly proclaim that it is necessary in every single case.

What would your ideal therapy device be like?
It would be a very simple blower with flawless, non-condensing humidity, and a pressure knob that patients could adjust between about 6 and 16 cm H20. It would come with a dozen different easy-to-use masks.

Would patients in the US healthcare system accept this or would they still want more?
Most of my patients want things to be simple and straightforward.

In a recent talk at ResMed, Sydney, one of the points that you made was that 'the prevalence and importance of sleep apnea are attracting attention'. Many researchers have been looking at sleep apnea for many years-why do you think it is receiving more attention now?
Because OSA harms not only the afflicted person, but also those on the road and in the car with them. And because we
now realize it is linked to very, very common medical problems such as diabetes and hypertension.

Is the prevalence of sleep apnea increasing? If so, why is that?
Yes. We are getting heavier and older.

Do you think there is any difference in the treatment of SDB/OSA in the US compared to other parts of the world?
Yes. I think it is more expensive here, partly because of insurance rules and partly because there is a financial incentive to test, rather than treat, the patient. We do way too many sleep studies and not nearly enough clinic visits in the management of sleep apnea patients in the US.

Do you have a particular area of SDB/OSA research that you are currently involved in? Could you tell us a little about that, and how you came to be involved in it?
I am interested in sleep-disordered breathing in older patients. It 'looks' different to sleep-disordered breathing in younger patients, and appears to be much more prevalent. How should it be defined? How should it be treated? Is there a benefit to treatment of OSA in older people? Stuff like that. Why am I interested? Well, someday, if I'm lucky, I'll be old too
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#2
Bump2
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#3
Great interview. I found her "heavier and older" comment interesting. It isn't all due to that. My pulmonologist and my general practitioner have both said to me, "you're the last guy I'd look at and think you have sleep apnea." I know a number of folks like myself who exercise regularly, have BMI in the good range and light use of alcohol who I am sure have sleep apnea. I'm on a bit of a mission to convince them to get checked.

I do have to say, though, that the risks from "inappropriate CPAP" are pretty scary. Bigwink
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#4
Great-info
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#5
I would agree with her on almost every point but one (or better said, I would add to her point) - while I agree that you shouldn't need a titration test to get insurance to pay for a device, I think that establishing the correct airway pressure through sleep study is necessary - too high or too low a pressure can be just as bad as not using the device at all, and it is not advisable to set the levels without first knowing what the patient's physical situation is. Beyond that, one needs to establish what sort of apnoea it is, as different types need different therapy and devices, and well, not something you can do at home, exactly, so a sleep study and/or titration exam is still the best way to get at that. Thankfully, these days you don't need to go to a sleep lab for that - they can give you a portable device that you wear at home and the data from that can usually give sufficient information to make the correct diagnosis and treatment recommendations, and that brings costs considerably down.

Also, in some countries, her desire to see a more interdisciplinary approach to diagnosis and treatment is already coming true - in Switzerland, for instance, there are many avenues to getting put on a CPAP (Although they all pass through the pneumology department at some point), and almost always, it starts at the GP's office, sometimes at the Cardiologist's. And that is a good thing, IMHO.
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#6
I am very very blessed to say THAT SHE IS MY SLEEP M.D. I cannot you how wonderful it is to have a sleep M.D. That Truly knows what she is doing. It's thinks to her my Neuromuscular progression has decreased and my pulmonary function tests are VERY VERY SLIGHTLY BETTER! My FEV1 has come up from 35% to 37% and I'm doing better with almost 24/7 use of my VPAP
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#7
(02-05-2013, 09:40 PM)DocWils Wrote: I would agree with her on almost every point but one (or better said, I would add to her point) - while I agree that you shouldn't need a titration test to get insurance to pay for a device, I think that establishing the correct airway pressure through sleep study is necessary ...
I agree with DocWils, 100%.

I was a little alarmed when the headline here seemed to question the veracity of a sleep study. Certainly they are not perfect, but what better way to get to the bottom of what is going on?

But then the headline is a little misleading; what she seems to be irked about is not the veracity of the study as much as it is the fact that it is the knee-jerk reaction for insurance (who ironically pays for it).

Another part is that it is a lucrative profit center for "sleep institutes"; if I were 25 years old and starting a practice in medicine I would be tempted to start a sleep center myself, both to help people, but also to help put my kids through college and pay for rent on that villa in Italy every summer.

So there is a tendency for sleep docs to push it, whether its a good idea or not for any particular patient candidate. The overhead for a $3700 sleep study is use of the facility for a night and sharing the cost of one technician's shift among multiple studies for that night. Schedule 5 PSGs on a Wednesday and the profit is in the $18,000 range for that single 7-hour time frame. And that was just on Wednesday.

But maybe there is a better way.

I think they started with a better way for me, because they started with a home study to get a general view of what my issues were. That alone was enough to get insurance to fork over for an APAP. But they also forked over for a full PSG later on; also probably a good choice.

Maybe another way is to send someone home with an APAP for a couple of weeks, and then use that info rather than a PSG study to get a starting point on a patient's therapy. That would certainly be less expensive; you could use that same APAP on hundreds of candidates, with basically the cost of a mask and DME instruction being the bottom line costs.

Then a sleep doc could parse that data and decide how important further study is, and the insurance co. could either opt for a PSG or opt to just allow a prescription for an APAP. The best interests of all parties are probably served by that.
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#8
That is great information...too bad the second link does not work, is that the whole text??

Storywizard
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#9
Do you think the treatment for OSA is going in the right direction?
No. Until or unless we figure out how to get people to lose weight and maintain weight loss, CPAP will simply be a bandaid on the much bigger problem.

SO, how would this help those that are thin/not overweight, that have OSA? Not everyone that has been diagnosed with OSA are fat. Those that are fat, if they lose weight and not the bulk or whatever you want to call it that is in their throat and neck area, they will still have OSA.

THIS is NOT to discourage weight loss! Even if a person still has OSA after weight loss, their heart and other organs and body parts will thank them for losing weight
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#10
(04-28-2015, 09:02 PM)storywizard Wrote: That is great information...too bad the second link does not work, is that the whole text??

Storywizard

This link should work ... (pages 9 and 10)
http://www.resmed.com/ch/assets/document...dica14.pdf
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