New AASM Quality Measures for Common Sleep Disorders

Pauline Anderson

March 31, 2015

As quality of care becomes increasingly important across the entire healthcare system, the American Academy of Sleep Medicine (AASM) has taken the first steps to develop measures to help evaluate the quality of care for five common sleep disorders: restless legs syndrome (RLS), insomnia, narcolepsy, obstructive sleep apnea (OSA) in adults, and OSA in children.

"The model in health care for many years was fee-for-service, and the more services you provided the better, but health care is changing and there's an increased focus on quality with physicians being increasingly reimbursed for quality of care rather than volume of care," said Ronald Chervin, MD, director, Sleep Disorder Center, and professor, neurology, University of Michigan, Ann Arbor.

Dr Ronald Chervin

"In order to improve quality, you have to measure it, you have to assess it, and this is the first organized attempt to provide measures."

Dr Chervin was one of the authors of a paper published in the current issue of the Journal of Clinical Sleep Medicine that explains the process used to develop the new quality measures and the factors related to their appropriate application and implementation. He was also a member of one of the five task forces on RLS that were charged with developing the measures.

Papers pertaining to quality measures for the individual sleep disorders are published in the same issue.

The new quality measures have the potential to significantly change patient care, the authors said. Dr Chervin outlined examples in the field of RLS where the recommended quality measures could have an impact.

Impulse Control

High-quality care, for instance, should include assessment for an impulse control disorder, which can be an adverse effect of dopamine agonists used to treat restless leg. Clinicians may think impulse control disorders are rare, or they aren't aware of the devastating impact they can have on patients' lives, said Dr Chervin. "Some of these patients spend uncontrollably; they spend every last cent they have or they borrow, usually on gambling."

No patient with RLS should go through the system "without having an alert up for this" adverse effect, said Dr Chervin.

Another example is checking iron stores. "There's reasonable evidence out there that if you fix iron depletion, RLS symptoms will improve or resolve and patients don't have to take more complicated medication; they just have to keep iron levels normal."

These and other quality measures are included in an appendix to the summary paper. This section includes a guide for clinicians on how to implement the sleep quality measures in their practices, and it outlines what they need to do at the initial evaluation, when they should do follow-ups, and what should be included in these visits.

The quality measures are designed to be applied by any doctor who treats a patient with a sleep disorder, said Dr Chervin. "They were very much created with the thought that they would benefit anyone with a sleep disorder whether they are being seen by a sleep specialist or by someone who is not a sleep specialist," such as a family doctor.

Standardized Care

The AASM sees the new measures as helping to standardize care. "Patients who receive care for OSA, for example, should not experience one standard of care in one setting and a different one in another," the authors write in the overview.

How would physicians be tested on whether they're incorporating these quality measures? According to Dr Chervin, individual assessments could be through chart review where, for example, samples of a physician's charts in the past year would be randomly selected and scored.

In recent years, physicians have been under increasing pressure to decrease costs. In sleep medicine, this has been particularly evident as incentives promote expanded use of home sleep apnea testing, reduced reimbursement of technical and cognitive services, and restricted patient access to sleep specialists, the authors write.

"However, exclusive focus on cost reduction to the exclusion of quality of care in sleep medicine is myopic and may decrease quality of care," they write. "There is growing evidence of the influence of healthy sleep in adequate quality of other medical conditions and overall improvement in quality of life."

The AASM chartered five workgroups to develop quality measures for assessment and management of the sleep disorders. The process had multiple steps: Each group first reviewed the literature to identify published evidence regarding the measurement of quality, care processes, or validated outcome tools and selected specific outcomes and process measures to consider.

The groups determined the strength of the evidence related to each measure, then evaluated the validity and reliability of the data.

The groups developed both "process" measures and "outcome" measures. Most of the measures are "processes" or strategies that lead to outcomes and are directly measurable, said Dr Chervin.

Stakeholder Feedback

The AASM requested review and feedback on the measures from a variety of stakeholders, including sleep specialists, primary care providers, other medical specialists, professional organizations and patient advocacy groups.

The authors see this as a "first exercise" in developing quality measures but "certainly not an end" in improving quality of sleep medicine, he said.

"With the exception of management of adult OSA, little prior experience existed upon which to draw in sleep medicine quality measures development," they write. "Absent are mature literature and long experience in quality improvement in sleep medicine, this effort is a first and early step, with many opportunities for improvement in the future."

According to Dr Chervin, the process of developing quality measures is evolving. "I would be very surprised if they're still the same in 10 years from now, but we had to start somewhere and this is where we started."

Under the Gun

As health systems are increasingly "under the gun to document quality care," these new recommended quality measures provide strategies on how to do that, said Dr Chervin.

To physicians who might gripe about the added burden these measures might place on their practice, he warned that reimbursement will increasingly be linked to quality whether they like it or not. "Physicians may ask how they're going to pay for the extra office staff that may be needed and the answer unfortunately is that there won't be extra money for it, but there might be less money if you don't do it."

Additional quality measures for some of the other sleep disorders — there are some 80 in total — will likely also be developed, he noted.

Medical Model

When asked for her reaction to the new measures, sleep expert Judy Willis, MD, a neurologist in Santa Barbara, California, and member of the American Academy of Neurology, said she was impressed with how those who developed them "clearly demonstrated" how they used the "medical model" to evaluate validity and value of data regarding management of these five common sleep disorders.

"They attest to the need for clinical research to be supported by adequate supporting data, measurements, and size of control and variable groups. They also demonstrate the need for appropriate statistical analysis to confirm that the data does indeed support claims of correlation between the research results and the desired patient outcomes to specific interventions."

Dr Willis noted that once an intervention is applied in a variety of "real world" situations, many factors can affect outcomes that are beyond the healthcare provider's influence, such as socioeconomic status, heredity, cultural variations, and comorbidities. "These can significantly alter the touted 'outcomes' based on highly controlled, preselected test groups," she said.

Dr Willis also agreed with the authors about the value of an extended network, from specialized consultants to caregivers. Using data acquired from a variety of stakeholders can be used as feedback to help further improve patient care, she said.

"This information will be a powerful resource to guide future research and ongoing improvement in health care efficiency and equity for the larger pool of patients."

This was not an industry-supported study. Dr Chervin has consulted for MC3 and Zansors and has received royalties from UpToDate and Cambridge University Press.

J Clin Sleep Med. 2015;11:279-291. Abstract

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