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Adventures in Sleep

Why a Sleep Study?
December 12, 2013 10:01 AM by Amy Reavis

We need to encourage our patients. This is especially true this time of year when holidays are foremost in people's minds. So why do we need to treat sleep apnea? There are so many reasons, but most people do not realize they have symptoms -- they just think this is what normal is.

One of the men I work with is a typical example. He is a middle-age many who is overweight and has an 18+ inch neck. He looks tired and tells me he wakes up every two hours during the night but that is just because he has a stressful job. He does not need a sleep study because he does not have high blood pressure or any health issues.

So how do you convince someone like this to talk to his doctor about sleep apnea? Well if he is a truck driver or a pilot his work now requires that he have a study. If he does not have health issues then maybe you need to look at some of the reasons outside of blood pressure, MI and stroke because everyone believes it will happen to someone else. Then there is the vanity issue and the fact that people look healthier and have fewer wrinkles if they treat their sleep apnea. There is also the correlation between glaucoma, colon cancer and memory and sleep deprivation. 

There are issues specific to women and sleep as well. The fact that women have some protection from the effects of sleep apnea when they are young changes as they become premenopausal and menopausal. That protection not only goes away, but women actually become more symptomatic at lower apnea levels. Women also need to know that snoring and sleep apnea do not go hand-in-hand --with central apnea and hypopnea there is no snoring or very mild snoring. 

It is up to us to educate our patients when we are scheduling their appointments. It is essential that we educate the public because there are those out on the web who will tell people that sleep apnea is nothing but a money-making scheme. There are those who say that a 50% compliance rate proves that we do not have to treat sleep apnea. (I will talk about his fallacy of compliance rates and us being hung out to dry about it  in mynext blog.) What we need to do is share our knowledge and passion and I need more sleep geeks out there sharing the love. 

Have a great holiday and I hope you do not get snowed in.

Reasons PAP Devices Denied as ‘Not Medically Necessary'
December 5, 2013 11:23 AM by Penny Mehaffey

I want to comment on the following that I read online in SleepReview:

"The top two reasons for a positive airway pressure (PAP) device being denied as not medically necessary are as follows: 1) no face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea (OSA) or to document that the beneficiary continues to use the PAP device, and 2) no documentation that the beneficiary and/or caregiver has received instruction from the supplier of the proper use and care of the equipment. This is according to a complex review of 313 claims from July 1, 2013 to September 30, 2013 by the National Government Services' Medical Review Department. National Government Services is the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Of the 313 claims, 159 were denied, resulting in a claim error rate of 51%. A large portion of claims (51) were denied for failure of the supplier to respond in a timely manner to the request for additional documentation.Suppliers are reminded that failure to respond to requests for additional documentation is in violation of supplier standard #28, which states the following: ‘Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.')"

Whew that was a mouthful. I almost got bogged down reading it. Can you imagine trying to operate within these types of guidelines on a daily basis? Not only are they cumbersome but they seem to behave much like a virus ... we barely get caught up with new rules and standards than the guideline changes or mutates and we're caught scrambling to comply again.

And isn't that word "sanctions" terrifying? Or is that just me? I hear these laments from DMEs frequently and it's worrisome. After all, they are a link in the chain that patients, aka beneficiaries, must deal with.

For my part, I try to help the vendors obtain needed documentation as much as I can in a timely manner, but this has become more and more difficult. For instance much of what they need is not mine to give, and we've had to adjust our methods just as everyone else has in this changing scape. I imagine that in much of the country everything is done electronically.  That is not the case everywhere, though. I must refer all requests for information through the medical records department.  If a vendor does not follow the guidelines set forth by medical records, then delays will be inevitable. 

I am sure there are some really savvy people out there who have great success obtaining documentation. I would love to hear your methods or at least a tip or two on how to get what you need for billing. Any comments?
Blogging Blessings
November 21, 2013 11:23 AM by Penny Mehaffey

It's the week before Thanksgiving and earlier in the year I read on one of the web pages that being thankful was actually good for your heart -- and it certainly doesn't hurt your sleep either. This was not really news to me, but I think it's worth repeating. And so as we enter the holiday season, I would like to take this time to say how thankful I am for all  in the ADVANCE magazine and blog community. My fellow bloggers are a great bunch of people, dedicated professionals with a desire to help educate, inform and inspire others. We are fortunate to have them in our profession.

You, my readers, are tuned-in, savvy pros and you keep me sharp. I am lucky to be able to say that while I have been through several editors since I started blogging, they have all been wonderful. My first editor is now my editor for the second go-round. I could not ask for a more gracious and supportive person to work with. 

It's been a good year with you guys. I hope you all have something for which you are truly thankful in your lives. Think about it and take the time over the next week to be good to yourself and those around you.

Happy Thanksgiving.

Thankful for Many Things, Including a Sleep Career
November 14, 2013 11:02 AM by Amy Reavis

I always spend November being thankful. It is a busy month for me as I find that work is busy, my son's birthday is celebrated -- this year he is 21-- and the holidays gear up. This year I even get to deal with Hanukah in November. It has been a crazy year so I am grateful for so many things -- including the challenges.

I have learned how to be a caregiver as I deal with my husband's ongoing illnesses. It is something of a wonder that anyone survives and thrives when you spend all your free time caring for another. I admire those who do it so much more and I appreciate my own health as a gift while I watch him go through his troubles.

I had the opportunity to attend the BRPT conference and Sleep Educators Course. It has shown me how dynamic our field is and how many people want to move forward and grow our field. We are taking education much more seriously and we as a field are looking to move past the minimal education to a field that requires a degree.

I am grateful for my job and students. I have a fantastic EEG instructor who is teaching me more about my own chosen field as well as helping me to open up to areas I had no idea about. I have gotten to share my skills and knowledge with my students and have expanded my own skills in the areas of teaching, curriculum and test writing. There is so much to be learned.

I am grateful for all of you who respond to my blogs. Sometimes when you are a lone voice you wonder if anyone hears you. I know there are some people that I resonate with and some that I anger, but in the end my goal is to have people think more about the field and where it is going.

Finally, I am grateful for all the people who let me help them by teaching them more about sleep. Every person has a calling. I truly love sleep education and believe that if I can help just one person to sleep better then I have done a great thing and my life is worthwhile. So for those who give me that opportunity, thank you.
Embracing -- and Surviving -- Home Sleep Studies
November 7, 2013 9:21 AM by Penny Mehaffey

I concur! I read a blog by Matt Kaplan on the SLEEP SCHOLAR web site this week that I found gratifying. His lab has conducted over 5,000 home sleep tests recently and he has a seasoned insight into the dos and don'ts of home testing.  I have to say it was reassuring to hear I was having a similar experience with HSTs in my lab.  

I particularly dentified with the patient experience data that suggests: Patients do not return devices when they are supposed to. Amen and wow! We had one patient who kept the device for a month and then returned it blank. Really? If you keep a device for a month, you'd think you could at least use it --once! 

An interesting personal observation I've had, too, is that the people who seem to be the most digitally savvy and who I think won't have trouble with the device, are the ones who end up having to repeat the test. Meanwhile,  my Bubbas and grannies have no difficulty. It's comical really. I thought I knew better than to judge a book by it's cover. 

Matt's lab also has the patient use the device more than one night consecutively. We may or may not, depending on the lab schedule. Most of the time we wait to see the results of the first test and then repeat if needed. Matt, too, tapes the pulse ox to the hand and has tech support available to assist patients if needed. Great minds think alike. While we are nowhere near the 5,000 mark, I am confident we are on the right track.

I am encouraged to see someone embrace and not only survive, but thrive with HSTs. Keep up the good work Matt. You are an inspiration!!

Fun in the Sleep Field
October 31, 2013 12:29 PM by Amy Reavis

As an instructor I can tell you that there is a great passion for the field of sleep. I met the passionate at the BRPT conference, I met them at the Florida Association conference and I meet them every day as I interview people who are interested in coming to my school. Then they go online and on Facebook and they hear the sky is falling. They hear people complain about patients and physicians and they wonder what I am talking about.

Social media is a strong influence on our field. We can use it to communicate with our peers and to help educate the world about sleep. We have to watch that we do not destroy our own field with that same tool. If the physicians see desperation, bad attitudes and poor education, then they will believe we are not the professionals we claim we are. 

I do believe we should use it to ask questions and to look for support on bad days. We just cannot complain about the people we serve. If prospective patients see a post that is derogatory, they may not go have the sleep studies they so desperately need because of their fear the techs they have will see them the same way, as a burden. The physicians who keep fighting for the cheaper tech will not see our value if they see a bunch of complaining techs.

Remember we went into this field because of a desire to change lives. Remember we have fun in the field. I love watching someone understand the 10/20 system for the first time. I love when a tech learns the value and art of scoring their studies. I truly love a patient then next morning when they finally got their first good night of sleep in years. Our field is fun -- we just need to remember it.

Role of the Dentist in Sleep Apnea
October 24, 2013 9:21 AM by Penny Mehaffey

I confess I missed a webinar this week on the topic, much to my dismay.  I was atop the beautiful North Carolina mountains visiting my husband's kinfolk.  A girl has to keep her priorities straight after all. 

But, you will recall that earlier in the month said girl hosted a sleep seminar and one of the speakers so happened to be a dentist whose topic was about this very thing.  I found it very interesting, the dentist's role.  It's another tactic to come at sleep apnea.  After all, there are many ways to skin a cat.

For one thing, I would think a dentist would see kids just as frequently as a pediatrician perhaps. And therefore may have more opportunity to diagnose OSA.  As pertains to adults who have been diagnosed but are not convinced they want CPAP, it seems many would  rather do anything  than try it.  I think sometimes just having an oral appliance as an option would be beneficial.  

I know CPAP is the gold standard for treatment but we have to be realistic and know that it's not going to work a 100% of the time.  Our speaker, Dr. David Carter has a large practice and is very passionate about helping people with sleep apnea.  He is dedicated to the process of diagnosis and treatment with whatever therapy works.  He is a CPAP wearer himself!  I think this is what speaks volumes in the industry: A professional who has been there and done that and can tell you from personal experience what  worked and what did not and why.  

I will take in the webinar as soon as it hits the archives ... but isn't this a role for all of us? We must empower our patients with all the options and help them make the best decision for their circumstance.

A Call to Arms
October 17, 2013 10:58 AM by Amy Reavis

The AAST has called us to arms. Our future is banging on the door and we do need to embrace it.  Many of us saw the handwriting on the wall and have attended the sleep educators coarse with the desire to earn a new credential. Why do we want this new credential? Who told us this would be the next step and the best idea? The AAST hopes to step up and support the move to degree programs.  Advanced education -- embracing the skills of the educator as well as the statistician who can prove outcomes -- is what is needed. We have an idea what the balance of the degree should be, but I believe that many would miss the classes that specifically would help the technologists the more.

We always need to be on top of the new technology; including HST, dental sleep therapy and the new surgical options. But there is so much more. We need to understand age-related competencies. We need to understand education and educational styles. We need to understand learning styles. We need to know some cognitive behavioral therapy. 

We need to understand how to create outcome reports and run studies that prove the improvement in quality of life. This is what reimbursement will be based on. 

This is the time for our field to change and the only way we can do it is if we work together. With this in mind we should move past old animosities and angers and come together. We need to become a group that can draw from each other. In the case of outcome-based medicine we need to be working to create studies that justify our care. We are about to grow and we need to come together as a group through the AAST and the BRPT or one of the other national associations such as ASET or AARC. Just remember it is important to be involved and informed.
Thankful for Our Sleep Techs
October 10, 2013 10:07 AM by Penny Mehaffey

It's official, Sleep Tech Appreciation Week 2013 is here! Yay!

I really do enjoy this particular time of the year. I appreciate the opportunity to take some time out to recognize my co-workers for the wonderful job they do. I think it's important that they know they are valued -- not just this week, but all year long. If your lab has survived the changes in healthcare and made it through the competitive bidding war then you are doing well. If you have a handful of dedicated techs, you are doing even better. 

I am proud to say that my lab has some of the best sleep techs you will find anywhere. They are not only competent but caring. They take pride in their profession and are invested in learning and training to become better at what they do. They are engaging and warm and our clients frequently call back to comment on how well they were treated by this one or the other. I am proud of them. They care about each other and the lab. They come in early and stay late when needed. Are they perfect? No, of course not. But I would not trade them for any others. 

This week to celebrate them, we tried to sprinkle each day with a few surprises. Last night we had an excellent Chinese buffet brought in. Tonight we are having a potluck dinner in the lab with the presentation of a few small gifts. The week culminates with our second annual sleep seminar, during which they are doing a case presentation. They are great and we would not be the same without them. Thank you for all you do, Beverly, Brittany, Chandra, Joanna, Jordan, Lisa, Sana, Tiffany and Warren.  You are the best!

Sleep Educators Course
October 3, 2013 8:54 AM by Amy Reavis

I have to admit that the BRPT has really stepped up to create the next step of growth in our field. It is an impressive sight, when a conference room is overfilled and there are 300 eager people learning about the extended role of the educator. This was a motivated group of people open to learning new skills, the role of education in our field and how we can obtain the advanced credential. 

The program was designed to look at the role of an educator and what the necessary tasks would be and how to perform them. With that in mind there was a great deal of scientific information that backs up how we approach this role. The issue that really struck me is that we as a field do not know how to create the information to support our role. We do not know how to create the research to prove the critical outcomes, to prove that we contribute to the successful outcomes of the patient. 

This then demonstrates what we need to work together on: the creation of some studies to help prove our input and education increases the compliance of the patient. This will take a great deal of extra work on our part, but we are on the ground floor of healthcare change. If we can prove our worth we will have secure jobs for years to come. 

As a respiratory therapist I have lived through this once before. I heard over and over that the field was going to die, that nursing and physical therapy were going to take our jobs. Now I hear we are going to lose our jobs, we will be replaced by machines, that we have no future. I do not believe this. I believe we need to show how much better a patient, who has a sleep study in a lab and who has a technologist properly fit the mask and titrate a study, does with CPAP. We need to prove that Autopap is not right for everyone, or even most patients. We need to become researchers, we need to prove our worth. We need to show that we are part of the preventive care movement. 

Can a Mere David Take on the Goliath of Medicare?
September 26, 2013 9:17 AM by Penny Mehaffey

An recent article in Medpage Today expressed concern that the general public does not understand how Medicare works and that in general we are clueless as to it how it is paid out and funded. The author, David Pitman, said that our policymakers need to create an educational campaign to help us understand the system.

That sounds like a monumental task to me. I am of two minds on this subject. On the one hand, I agree, but I tend to think the reason the public does not understand is two-fold. One, apathy; they just don't care enough to get involved -- until they don't get something they need. Only then does it become an emergency to them. 

Two, I think the government is unreliable and maybe (?) dishonest in conveying how Medicare is handled. The reason I say this is because Medicare is a big machine and if you have to offend someone, would you chose the Davids or Goliath? I am considered "general public," so I am sure my view is naïve. But if you read your Medicare statements they tell you what percentage they paid, what percentage you owe and what the doctor may bill you for. Read your paycheck and it will tell you how much taxes you paid to Medicare. That is no small amount either. 

I think we all operate with some degree of apathy. As consumers we should be more concerned and involved in all areas of government and healthcare and safety. And it is a merry-go-round at every juncture, from the cradle to the grave. What we should do is not always what we actually do, even though what we should do is in our best interest. Get involved.  We are like the little frog that lives in my backyard. He has his head stuck in the grass and his hind side sticking out... 

How to Educate about Studying
September 19, 2013 9:16 AM by Amy Reavis

At the beginning of the school year the one thing that everyone is looking for is new study skills. Students want to know the latest trick to get better grades. So I did a little research and have figured out how to add value and encourage sleep at the same time. It works with my students who are aged 17+ years and they have taken it home to share it with their children of multiple ages.

Step one: Know how to retain more knowledge.               

  • If you read it you retain 20%
  • If you read it and write it you retain 60%
  • If you read it, write it and say it out loud you retain 80%

Students love this and it encourages them to do their vocabulary and spelling because they understand that if they say it out load while writing the words out they will retain most of it.

Step two: Identify the best time to study.

  • For memorizing fact study, before dinner. 3-5 p.m. is usually the best time for your brain to retain this type of knowledge.
  • For learning skills, it is best to study between dinner and bedtime. Your brain is designed to learn these and recall them better if you practice or learn the steps during that time of the day

Step three: Recognize that cramming is evil. This is where being a sleep tech comes in handy.  This is where I explain slow wave sleep, memory consolidation, sleep deprivation and the frontal lobes' involvement in decision-making and judgment. Yes, being a sleep tech makes you an expert in the student's eyes and they will listen to you before they will listen to parent or teachers.

Step four: Teach the importance of a sleep routine to get to sleep. So many people do not know how long it takes to fall asleep, what you need to do to help you go to sleep and the importance of darkness, porper temperature and quiet in the role of preparing for bed. Use your own sleep routine as an example. Again, it makes you an expert in their eyes since you live your talk.

Step five: Summarize rules one through four. 

Go out and talk at colleges, talk to high school students, talk to mother's groups -- you would be amazed what people will ask you during these times, since you are teaching study skills and not talking about sleep. Usually it turns to sleep hygiene and someone inevitably has a sleep disorder. 

September 5, 2013 9:17 AM by Amy Reavis

The AASM announced what the techs have been saying all along: It is too time consuming to score a study twice, once for the AASM and once for CMS. The AASM changed the hypopnea scoring rules from 4% to 3% desaturation when they came out with the new scoring manual. When they changed the rule they did not take this small issue into account. 

I believe that there is a lack of forethought when the AASM makes an announcement. Their endorsement of HST not only affected technicians but also the physicians they represent. Their suggestion for a new sleep credential fractured the field of sleep within the technologist community, hurting the profession and making the outside world wonder what the point of a sleep study is. The role they play in the AAST has caused distrust throughout our community as well.

When is the AASM going to take its role as a representative for the field of sleep past its immediate gratification and think long term? I have not seen anything they have done in the last three years benefit the field. 

This is just another instance of causing difficulty. If they change the scoring manual it changes the rules and that affects education and testing for credentials. This change went up on the website and I would not have known about it if a fellow technologist had not told me. Where was the email from the AAST letting all the techs know about the change?  Why didn't the AASM make sure everyone -- not just their members -- knew they changed the rule? It affects us all. We are a profession and as such we should be working together to show our professionalism, not our self-interest. I am annoyed to say the least. 

I now have to go into my curriculum and my tests for my program and change the information. This is no small task. I will then have to go through a curriculum change form and get approval from the company. I do not know when the BRPT will be changing the test to reflect the rule change so I will not know when to teach the rule change and how to instruct my students about how to answer the questions on the boards. Did the AASM not think about how this affects everyone? Did they think about it when the originally changed the rules?

How Much Are You Affected by the Digital Invasion?
August 29, 2013 10:31 AM by Penny Mehaffey

I am reading a good book right now called The Digital Invasion by Dr. Sylvia Hart Frejd. I really like this book -- it's well worth the read. The author is a psychologist who is studying the effects our digital lifestyles are having -- not only on our health,  but our families and teens particularly. 

We all know the effects hormones have on us. But I don't think we really give a lot of thought to it in our day-to-day lives. I mean, we all know that we should stop all electronic stimulation 30 minutes before bedtime. That's sleep hygiene 101. Digital exposure, including cell phone, ipads, computers and especially gaming, causes a release of chemicals in our brain that directly effects our ability to relax and feel joy. 

Oxytocin, which the doctor calls our "love" hormone, is inhibited and so we - and especially teens -- experience a disconnect and have difficulty making intimate connections emotionally. We'd rather be in touch with our devices than people.

The flip side of that is the over stimulation we get from being constantly plugged in is causing an over-production of the stress hormone cortisol. This is not good for any of us but particularly harmful to our teens. If current statistics are right, one in four teens has some level of depression and they are also being stressed out by the very devices they can't live without. What are we to do? 

The answer would seem simple, limit the time spent playing or texting, etc. Good luck with that one.  It's probably going to be a battle royale.  Dr. Hart-Frejd does give hope and some good insights for coping and making a plan to deal with digital invasions. There are some good self quizzes included in the book as well. I found it good food for thought.

Are You an Apnea Tech or a Sleep Tech?
August 22, 2013 8:48 AM by Amy Reavis

Our job is to work with people with multiple disorders and to help educate them about the need for sleep and how sleep apnea affects the body. But are we really only teaching about apnea?  I would tend to say no. Our audience in the lab may be limited but I have learned when teaching about sleep that hygiene, parasomnias and basic sleep physiology always come up. 

We have stopped having extended families. We have also stopped teaching our children the importance of sleep routines. We as a society have rebelled against rule and structure and in the process are robbing ourselves of sleep. However, I have found that when I teach about sleep routines (I use my routine as an example) I have at least two of the students ask more questions. Sometimes it is what they can do for themselves, but more importantly, sometimes it is what they can do for a family member. If one of my students was never taught how to prepare for bed and that they need to turn down the lights and noise and unwind, then they cannot teach it to their children. I have found that these short educational sessions have helped families deal with sleep in a more constructive way. 

So that is why I ask what you are. Are you just teaching your patients about sleep apnea or are you teaching them about healthy sleep? 

People are looking for answers. It might not be just the patient you are treating -- it could be a family member who is having other sleep issues and you happen to say something that helps them.  It could be that your education encourages a woman who is going through menopause thought it was normal to have insomnia to talk to her doctor about her sleep. We have the ability to change whole families. 

You might even be able to team up with a wellness provider (we have some chiropractors' offices in our area who focus on wellness) and speak at their monthly meetings about good sleep as a way to promote wellness. That might encourage someone to talk to their primary care provider about their sleep. It may not be a direct referral but it is still a patient whose life is changed. 



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    Adventures in Sleep
    Occupation: Sleep technicians
    Setting: Various sleep facilities
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