Raghu Upender, MD Assistant Professor in Neurology Medical Director Vanderbilt Sleep Disorders Center

 Referrals for sleep services have increased 12-fold in the last 10 years.  Obesity epidemic and aging population are driving demand for sleep services.  1/5 Americans has mild sleep apnea.  1/15 has moderate or severe sleep apnea.  70% of men and 56% of women over 50 have moderate to severe sleep apnea. Obesity in Tennessee %63%

 AASM accredited labs  337 in 1996  2,461 in 2012  Medicare expenditure on sleep testing  $62 million in 2001  $235 million in 2009

“We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value.” -Dr. Fred Holt Medical Director BCBS, NC NPR news-Jan 2012

"This is a good example of something where we have technology, we have financial incentives to use more of it... You have enough problems, including a growing obesity epidemic, and you sort of put together the so- called perfect storm for driving up overuse and health care costs.” - Helen Darling President National Business Group on Health

 " I believe lab tests, as opposed to the home tests, are being wildly overprescribed…it should be 70 percent at home and 30 percent in the lab.” Michael Backus VP of American Imaging Management WellPoint

Treat wide range of sleep disorders with an aim to:  Improve sleep quality and daytime functioning  Prevent fatigue related accidents/errors  Prevent or reduce risk of chronic medical conditions (hypertension, heart disease, diabetes, stroke, headaches)  Improve overall quality of life

 Review interconnection between  Sleep and health  Sleep and chronic illnesses  Review sleep apnea treatment outcomes  Review the cost of untreated sleep apnea  The future of sleep medicine  Vanderbilt strategy

 Daytime sleepiness  Fatigue related accidents  Medical errors  Depressed Mood  Decreased Productivity  Increased absenteeism

Sleep (hours) 0% 5% 10% 15% 20% 25% 30% 35% Obesity Prevalence Sleep Obesity Sleep & obesity in the U.S. Fred Turek

 Obesity is the strongest risk factor for obstructive sleep apnea (OSA)  Each increase of 10 kg in weight doubles the risk of OSA  OSA contributes to weight gain causing a vicious cycle ObesityOSA

 Diabetes  Hypertension  Heart disease  Stroke  Cancer

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 Attention and Vigilance  Memory function  Frontal lobe executive functions  Motor function

Reaction Times Principles and Practices of Sleep Medicine 2011

 Motor function  Attention and Vigilance  Memory function  Frontal lobe executive functions

 Short-Term  Patient satisfaction  Quality of life measures  Productivity measures  Health measures ▪ Weight & BP ▪ Glucose control (HgA1c) ▪ Lipid control ▪ CRP

 Long-Term  Hospitalization rates  Cardiovascular events  Cancer incidence  Dementia Incidence  Mortality rates

 Patient engagement  Care coordination  Outcomes measurements  Cost-benefit analysis  Iterative Process

 Care Coordinator  Patient Education  Patient Engagement  Partnership with Primary Care Physicians  Medical Home  Medical neighbor  Partnership with Vanderbilt Health Plan  Cost-sharing  Cost-benefit analysis  Web-app to Coordinate activity of Program

 The future of our field will be dictated by our ability to show how our services add value to the healthcare enterprise.  We must focus on short and long-term outcomes and design our practices to maximize best outcomes.  We must see the evolving changes as an opportunity to fulfill the promise of better sleep.