Refer to Qualified Dentiststo Provide OAT DuringCPAP Shortage
In June of 2021, much of the obstructive sleep apnea (OSA) community was upended by the recall of continuous positive airway pressure (CPAP), bilevel positive airway pressure, and mechanical ventilator devices by Philips Respironics. This voluntary recall occurred in the sleep industry alongside the COVID-19 pandemic, which brought its own series of supply chain disruptions, creating a “perfect storm” for the CPAP industry. One year later, availability challenges persist for CPAP users, and this has been further exacerbated by safety issues with magnets that have a!ected medical devices in the recent CPAP Philips mask recall.
Oral appliance therapy (OAT) is a proven, e!ective treatment option for OSA that should be discussed with all patients. This is even more true during the CPAP shortage, as oral appliances are readily available and can be delivered in approximately three weeks. OAT can be used to treat all levels of OSA severity and has been proven to reduce apnea-hypopnea index and improve OSA comorbidities, such as blood pressure, fatigue and fatigue-related accidents, and cardiovascular mortality. OAT is covered by Medicare and most commercial insurances.
When sleep physicians refer patients for OAT, one of the most important aspects to consider is clear communication and collaboration with dentists who have the training necessary to o!er a continuity of optimal patient care.
WHAT IS A QUALIFIED DENTIST
Dentists are well-versed in oral biomaterials to manage dental occlusion and masticatory function. However, treating OSA requires additional education to understand sleep physiology and the pathophysiology of sleep-related breathing disorders. The dentist should be well versed in the mechanics of oral appliances to ensure the appropriate appliance is selected for each patient. Furthermore, the dentist must have demonstrated proficiency in clinical strategies to minimize and manage any potential side e!ects. When referring patients for OAT, sleep physicians should seek qualified dentists who have this appropriate training. The dentist should understand the role of collaborative care with other health care providers. The American Academy of Dental Sleep Medicine (AADSM) has defined qualified dentists as AADSM Qualified Dentists, American Board of Dental Sleep Medicine (ABDSM) Diplomates, and ABDSM International Certificants. These designations all require the successful completion of all or certain components of the AADSM Mastery Program. The AADSM Mastery Program is a comprehensive, unbiased, evidence-based training program o!ered by both the AADSM and ac credited dental schools. The AADSM Mastery Program is divided into two parts. Mastery 1 is approximately 50 hours of didactic and clinical education and provides a foundational overview of the practice of dental sleep medicine. Mastery 1 students are required to have a valid dental license, maintain professional liability insurance, and pass a standardized examination administered by the AADSM and are awarded the designation of “AADSM Qualified Dentist.” Dentists who seek additional training in dental sleep medicine continue with the AADSM Mastery Program and take Mastery 2. Mastery 2 is 60 hours of didactic and clinical education. As part of the program, dentists are required to complete a series of clinical competencies. Students who complete the entire program are eligible to sit for the certification examination o!ered by the ABDSM. Dentists who successfully complete the ABDSM examination are recognized as ABDSM Diplomates. The ABDSM takes many steps to ensure that ABDSM Diplomates have achieved the gold standard of excellence in dental sleep medicine. The ABDSM uses a testing model built on three principles: test standardization, criterion-based testing, and equitable di!iculty over time. The examination is developed in conjunction with a testing company to ensure the ABDSM is utilizing best practices and complying with recognized professional standards. The ABDSM tests on a standardized knowledge base organized into core content areas. All candidates are tested using the same proportion of questions from each content area, and the content focus does not vary from one applicant to another. The ABDSM’s examination is criterion-based, which is a proven model for delivering accurate, fair, and consistent results. The ABDSM compares each candidate’s test performance to a predetermined standard rather than using arbitrary standards that are not based on research (for example, 60%-70% correct answers) or normative standards (e.g., grading on a curve). This predetermined standard is set by the ABDSM to establish the foundational competencies an individual must have to provide excellent patient care. The ABDSM’s criterion-based testing approach means that all candidates are held to the same standard of competence. Examination content, by nature, consists of some material that is more di!icult than other materials. The ABDSM’s test development methodology includes a measure of the di!iculty of each question that could appear on the exam. The minimum passing test score may change from exam year to exam year based on the aggregate di!iculty of the questions included in the exam. Unlike normative pass/fail standards that alter the passing point based on the performance of di!erent groups of candidates, the model used by the ABDSM only adjusts the passing criteria based on the inherent di!iculty of the exam itself. This mitigates concerns about skewed test results over time due to “easier” or “harder” versions of the test. Finally, the ABDSM requires maintenance of certification to ensure that Diplomates remain current in their knowledge of dental sleep medicine. The ABDSM requires Diplomates to earn CE on an ongoing basis and verifies this through an annual CE audit process. As such, Diplomates need to earn 25 credit hours every two years.
COMPETENCIES OF A QUALIFIED DENTIST
AADSM Qualified Dentists and ABDSM Diplomates have demonstrated competency in the following areas:
Clinical Knowledge
Basic sleep physiology, including the pathophysiology of SRBD
• Dentist and team member roles in managing SRBD
• Evidence-based therapeutic options and an awareness of emergent treatments and technologies for SRBD
• Comorbid nature of OSA and temporomandibular disorders and treatment e!ects from OAT on the temporomandibular joint (TMJ), dental occlusion, and related structures
• Patient Care
• Screening and risk assessment of SRBD
• Comprehensive, DSM-focused medical/dental examination and history, including relevant imaging
• Understanding objective sleep testing and other complementary assessments
• Gathering and synthesizing information from sleep medicine patients to appropriately screen patients and establish a treatment plan, including: OA selection, device fitting and calibration, long-term care, and management of potential side e!ects. These decisions should take into consideration patient values and preferences.
• Learning and Improvement
• Clinical practice and decision-making guided by evidence-based principles
• Continuing education
• Reflective practice and personal growth
• Identifying opportunities to standardize, simplify, and improve quality of care
• Professionalism
• Ethical principles, including billing and coding practices
• Accountability and team training with adherence to applicable state and federal laws and regulations
• Subjective, Objective, Assessment, and Plan (SOAP) note documentation, maintenance of treatment records, and protection of patient information
• Collaborative model of interdisciplinary care
• Informed consent
• Interpersonal and Communication Skills
• E!ective patient communication
• Barrier and bias mitigation
• Interprofessional and team communication
FINDING A QUALIFIED DENTIST
The AADSM maintains a list of AADSM Qualified Dentists, ABDSM Diplomates, and ABDSM International Certificants at www.aadsm.org/ oat_for_osa.php. This web page also provides additional resources about OAT including evidence briefs, template referral forms, and a free CME webinar providing more information about how OAT and working with a qualified dentist can help improve OSA outcomes. Mitchell Levine, DMD, MS, D.ABDSM is the president of the American Academy of Dental Sleep Medicine and a diplomate of the American Board of Dental Sleep Medicine. Dr. Levine is also an associate professor of orthodontics at St. Louis University. Jennifer Le, DMD, D.ABDSM is the president of the American Board of Dental Sleep Medicine. Dr. Le has a private practice in Raleigh, North Carolina dedicated to dental sleep medicine. But eight years after the A!ordable Care Act mandated “meaningful use” of EHRs in 2014; the American health system still struggles to realize the fulfillment of those promises. Why? In a word: “interoperability.” Interoperability became the buzzword capturing the zeitgeist of challenges in the post-paper era. Simply described, it is the idea that health record interchange between EHR systems should act as more than a glorified digital fax - one that is only accessible in the darkest corners of an EHR. Interoperability standards dictate that shared information (even between disparate systems) should not only be live, cloud-based, and easily accessible but be integrated at a deep level, to the point that imported data could enrich a patient’s health profile, predict risk categories, provide contextual information, etc.
ACHIEVING INTEROPERABILITY IN SLEEP MEDICINE The ache for well-applied EHR interoperability is perhaps felt most poignantly in the world of sleep medicine. Providers outside of the direct clinical sleep community, like PCPs, cardiologists, dentists, neurologists, and hospitalists, are all awakening to the reality that sleep disturbances like obstructive sleep apnea (OSA) have direct consequences on the diagnoses they specialize in.1,2,3,4,5 Consequently, testing for sleep disorders are growing in popularity and are ordered from this broadening base of clinical environments. The consequence of such a multi-layered system is that new complexities arise. Sleep centers struggle to keep up with the flow of information coming from all these sources, and workflows are largely manual and spread across five to six various healthcare record platforms to track patient screening, scoring, diagnosis, treatment, and compliance. Many sleep labs that are fed up with the di!iculties are turning to so-called “middleware” to address these challenges and achieve true interoperability.
WHAT IS MIDDLEWARE AND HOW DOES IT HELP?
At its core, middleware is software designed to communicate with other platforms. In sleep medicine, it is being used to connect EHRs, sleep devices, schedulers, scoring platforms, DME ordering, shipping logistics, etc. - all in one place, essentially “hacking” interoperability out of systems that weren’t designed for it. Doing this has several positive benefits.
#1: Automating Evaluation to Treatment
When a patient is being evaluated for sleep apnea, sometimes even what is thought to be a routine diagnosis can be complex, with a pathway that involves, at minimum, first clinical screening, home or in-laboratory sleep test orders, scoring, results communication, insurance authorization, and obtaining durable medical equipment such as positive airway devices. This workflow often involves many routine, manual tasks that take time and human capital to get through, placing additional stress on technologists and other sta! and thus limiting the volume a lab can support. Middleware can centralize all this information and put many of these tasks on autopilot. Unfortunately, it isn’t until implementing a solution like this that lab operators realize how much time these rote duties used to take. With the current sleep technologist shortage, the value of freed time goes a long way in improving operations and making space for revenue-generating procedures.
#2: CPAP Adherence and Reimbursement
Evaluating a patient’s success with therapy remains an enormous challenge for sleep labs. E!ective follow-up programs require human capital and interruptions in the course of a patient’s daily life. When most sleep clinicians think about digitizing the EHR, PAP follow-up is the main benefit they hope to achieve. And for a good reason - a 2018 2-million-participant study showed the incredible impact of remote PAP monitoring: 75% adherence to CMS utilization criteria (at least 4 hours of use in > 70% of nights during 30 consecutive days in a 90-day period).6 Thankfully, the last few years have seen the rise of cloud-based telemonitoring to make follow-up more e!ective and improve reimbursement. Care Orchestrator from Philips is an example of this, but third-party companies like Somnoware are paving the way for integration with all of the devices or software a lab could possibly use. These platforms not only automate initial patient evaluation but can also track device usage, compile utilization dashboards for entire patient populations, and monitor the e!ectiveness of various follow-up strategies. Dennis Hwang, MD, is the medical director at the Kaiser Permanente San Bernardino County Sleep Disorders Center and co-chair of sleep medicine for the Southern California Permanente Medical Group, with a particular practice interest in realizing the promises of interoperability not just in the future but now. After positioning themselves to capture an enormous amount of sleep diagnostics, PAP devices, and patient-reported data, Dr. Hwang encountered a familiar dilemma: “The problem with data is if you don’t have the tools to do something with it, the data becomes overwhelming.” In response to this, the network of ten sleep centers and 600k patients adopted Somnoware to unify and centralize all the disparate information while simultaneously automating certain adherence follow-up tasks to trigger based on a specific set of live patient behaviors. In doing so, they realized an 83% e!iciency improvement in risk identification and proactivity in patient care.
#3: The Great Leveraging of Data
Telemonitoring with good EHR integration and rule-based automation only scratches the surface of what’s possible in truly interoperable environments. Artificial Intelligence (AI) and Machine Learning (ML) o!er us a glimpse into an even more exciting future where meaningful conclusions can be drawn from across the entire patient journey. In a conversation with Somnoware’s CEO, Subath Kamalasan expressed excitement over the operational outcomes they’ve been able to achieve but noted that the future of applying AI to sleep is much more compelling. He notes that, since patient behaviors are one of the most critical components to successful sleep apnea treatment, AI’s highest value proposition for patients and clinicians will be in its ability to predict those behaviors and make contextual whole-person treatment recommendations. Somnoware is building towards a future where software-generated recommendations can be made and then automated based on the specific follow-up or PAP habits of each patient. Is a text 21 days after beginning therapy more e!ective than an email to engage your patients and increase adherence? How are a patient’s comorbidities a!ecting their sleep? These are the types of questions that AI applied to aggregated, anonymized patient data could answer in an automated fashion. But going even further, the term “whole-person” here matters - Subath’s team wants to see interconnected data touching each specialty in a two-way flow of information: CPAP adherence data used to continually update cardiovascular health scores, neurological stroke events used to predict apnea risk, etc. These elements represent the most promising ideals of the interoperability dream put into practice.
INTEROPERABILITY IS COMING SOONER THAN WE EXPECTED
Interoperability is needed to realize the promises o!ered by EHRs, but sweeping change across an entire healthcare system is complex. A 2019 paper by Lehne describes the challenge: “Most of today’s medical data lack interoperability: hidden in isolated databases, incompatible systems and proprietary software, the data are di!icult to exchange, analyze, and interpret. This slows down medical progress, as technologies that rely on these data – artificial intelligence, big data or mobile applications – cannot be used to their full potential.”7 The most notable organization looking to make a di!erence is Health Level Seven (HL7). This international non-profit has created the most widely agreed-upon set of interoperability standards known as FHIR (Fast Healthcare Interoperability Resources). But while getting everyone in American healthcare on board is a challenge, industry giants like Kaiser Permanente, the VA, and Wellstar Health have leveraged companies like Somnoware to unify their experience, save time, enhance diagnostics, and, most importantly, improve patient outcomes. It’s encouraging that broad interoperability in healthcare is coming, but it is even more exciting to think about the doors it may open for tomorrow.
