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New York State Society of Sleep Medicine

The New York State Society of Sleep Medicine

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To stay abreast of the workings of the New York State Respiratory Board, visit the official Agenda page of the Office of the Professions.

The date for the next NYS Respiratory Board Meeting can be found here

POSITION PAPER

 

The New York State Board for Respiratory Therapy recently recommended that the Respiratory Therapy Act of 1992 should be interpreted as mandating that only a licensed respiratory therapist would be permitted to undertake certain polysomnographic studies (sleep evaluations) performed in NYS sleep programs. This recommendation, if implemented, will diminish access to sleep medicine clinical services and increase costs with no discernible benefit to quality of care or patient safety. A careful consideration of the Board's recommendation by the State Education Department should consider the implications of this policy and should take into account the views and experience of the professionals-physicians, Ph.D.'s and polysomnographic technologists--who are the experts in this field.

The Role of Sleep Medicine:

Sleep disorders are extremely common and have a major impact on individuals with the disorders and on public health. Seventy-seven specific disorders are classified in the nosology of sleep medicine. Obstructive sleep apnea, for example, which affects 2-4% of the population, adversely affects quality of life, cardiovascular health and daytime alertness and increases the risk of heart attacks and motor vehicle accidents. Sleep medicine has developed as a separate medical specialty encompassing practitioners and disorders from the fields of neurology, psychiatry, psychology, otolaryngology, pediatrics, internal medicine and pulmonary medicine. It is now recognized as a distinct medical specialty with a seat in the American Medical Association's House of Delegates.

The Practice of Sleep Medicine:

The primary laboratory diagnostic tool in sleep medicine is polysomnography, which is designed to assess sleep quality. Sleep is evaluated through the simultaneous measurement of electroencephalography (brain waves), electro-oculography (eye movements), electromyography (muscle tone), body movement, electrocardiography (heart rate), nasal air flow, respiratory effort and oxygen saturation (oxygen level in the blood measured via a light beam.) Most of the diagnostic tools and equipment used in sleep studies bear no relationship to respiratory therapy. The one tool that overlaps with respiratory therapy practice, continuous positive airway pressure or CPAP, is used in sleep medicine in an entirely different setting with entirely different goals.

In the sleep therapy context, CPAP is not used, as it is in respiratory care, for ventilation or improvement of pulmonary function. Rather, it is applied as a pressure splint to prevent collapse of the nasopharynx, velopharynx, oropharynx and hypopharynx during sleep. Determination of the optimal level of CPAP during polysomnography testing requires evaluation of the quality of sleep as indicated by the electroencephalogram, electro-occulogram and electromyogram in addition to respiration. The treatment goal is not only to eliminate apneas but also to eliminate sleep fragmentation and arousals. This requires knowledge of sleep physiology not routinely taught outside the field of sleep medicine. Many sleep studies are also performed for neurologic, psychological and psychiatric-based sleep disorders such as narcolepsy, insomnia, somnambulism (sleep walking), restlessness disorders of sleep (periodic limb movements) and REM sleep behavior disorder, none of which have any relationship to respiratory therapy.

Sleep studies are routinely performed by polysomnographic technologists. The American Academy of Sleep Medicine's (AASM, formerly ASDA) position paper on the qualifications of technologists states that polysomnographic technology training qualifies these individuals to perform this testing, including the titration of CPAP for treatment of sleep apnea.

The Record of Sleep Medicine:

The practice of sleep medicine has had an extraordinary record of safety and efficacy. Sleep laboratories, staffed by polysomnographic technologists, have safely performed countless sleep studies for over 30 years. The performance of polysomnographic technologists is monitored by the sleep centers, by the parent or affiliated hospital, and by physicians and PhDs who are board certified experts in sleep medicine. In addition, evaluation of the competence of technologist is a significant part of the rigorous accreditation process of sleep centers by
the AASM.

Neither sleep laboratory diagnostic procedures, nor polysomnographic technologists, have ever been considered to relate to respiratory therapy. Historically, training of respiratory therapists rarely involves more than a minimal introduction to sleep disorders and no practical experience in a sleep laboratory. Sleep medicine has not been included within the national or state education syllabi for respiratory therapy and the job qualifications for respiratory therapists in our respective hospitals do not include knowledge of sleep medicine or the procedures used in the diagnosis and treatment of sleep disorders. In addition, the legislative history of the 1992 Respiratory Therapy Act includes hundreds of references to the broad and inclusive role of respiratory therapists, but makes no mention of involvement of respiratory therapists in sleep medicine or sleep laboratories.

Medicare regulations also recognize polysomnography as a separate classification bearing no relationship to respiratory therapy. The 1998 Medicare CPT codes classify all of the procedures encompassed by polysomnography under Neurologic and Neuromuscular Procedures and specifically recognize that the procedures are conducted by a technologist. CPAP, as used in sleep testing, is also coded under Neurologic and Neuromuscular Procedures (95811 - sleep staging with 4 or more additional parameters of sleep, with initiation of CPAP therapy or bilevel ventilation attended by a technologist). This is a totally separate CPT code from the code used in pulmonary medicine for the use of CPAP in treatment of respiratory failure (94660-CPAP ventilation, initiation and management).

Conclusion:

If the State Board of Respiratory Therapy's recommendation that respiratory therapists conduct all sleep studies were adopted, access to affordable and cost-effective sleep medicine services would be seriously compromised with no improvement in the quality of patient care. The requirement could actually reduce patient safety by mandating the involvement of persons who may not have any specific training in the appropriate field.

The existing personnel in the sleep laboratories across the State have a demonstrated record of protecting and promoting the public health. Respiratory therapists, who are extraordinarily well-qualified for the tasks they are educated and trained to perform, are inadequately trained to perform sleep studies, including polysomnographic titration of CPAP.

Given the extraordinary prevalence of sleep disorders, a significant shortage of sleep medicine services exists. To disenfranchise all the well trained polysomnography technologists, some of whom have been in the field for over fifteen years, will adversely affect the already limited availability of sleep medicine services. Current levels of reimbursement for sleep studies, particularly with recent reductions in the fee schedule announced by CMS, do not contemplate that sleep laboratories would be required to hire respiratory therapists to perform sleep studies and would not be sufficient to defray the additional cost. Respiratory therapists, who are already in short supply, should be devoted to those tasks and services for which they are uniquely trained and qualified, leaving the cadre of well-trained and highly capable polysomnographic technologists to perform their responsibilities without unnecessary regulatory intrusion.

This is also voiced by the American Association of Sleep Technologists http://www.aastweb.org/pdf/APTPositionExemption.pdf

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