Download Academic and private medicine partnership to improve care for

Academic and private medicine partnership to improve care for
sleep disorders, particularly insomnia in metropolitan Houston
and surrounding areas.
Personnel:
Sudha Tallavajhula, M.D
Asst. Professor, Dept. of Neurology
University of Texas McGovern Medical School
Houston, TX-77030
Email: [email protected]
Mary Rose, PsyD
Licensed Clinical Psychologist, CBSM
Rehabilitation Psychology/Neuropsychology
TIRR Memorial Hermann Rehabilitation Network
Clinical Associate Professor, Department of Physical Medicine & Rehabilitation
Baylor College of Medicine
Email: [email protected]
Key words:
Sleep medicine
Academic – private partnership
Telehealth
Cognitive Behavioral Therapy
Introduction:
Telehealth, of which telemedicine is a component, has been a rapidly expanding technology in the past
decade. It has outpaced state legislation and clinical guidelines with regard to the legal and ethical
practice of health care. Law and guidelines vary significantly from state to state currently. However,
there is an increasing consensus that telehealth provides a valuable option for care to underserved
areas, [1] to patients for whom travel is a limiting factor, [2] and as consultation between clinicians.
Another little examined benefit telemedicine provides, is as a tool for fostering patient access to quality
care by a broader range of clinicians, and specific clinician choices. It is also likely that as telehealth
services expand it will be more palatable for clinicians to subspecialize in areas of health that even in a
large city, may be difficult to provide an adequate patient volume to support.
We present in this proposal, a mechanism to provide behavioral sleep medicine services in the Houston
metropolitan area through a centralized hub and spoke system, using a telehealth model. According to
national ambulatory medical care survey from 1999-2010, the number of office visits with insomnia as
the stated reason went up by 13% in the decade whereas the number with any sleep disturbance
increased by 29%. The number of prescriptions for any sleep medication rose up by 293%, a large
number for hypnotic medications. Insomnia symptoms occur in approximately 33-50% of the adult
population; insomnia symptoms with distress or impairment in 10-15%. According to the American
Academy of sleep medicine guidelines, psychological and behavioral interventions are effective and
recommended as a standard in the treatment of chronic primary and secondary insomnia. Short-term
pharmacological measures may be used to supplement behavioral and cognitive techniques. However
based on the above survey, hypnotic medications are often prescribed as long-term medications, mostly
because of lack of awareness of cognitive and behavioral therapy for insomnia [CBT-I], its principles,
indications and availability. This lack of awareness exists among both patients as well as prescribing
providers. There is a paucity of trained providers for this modality of treatment, even in large cities.
Several alternatives, including web-based and automated interventions are being evaluated and have
been found to be effective.
The Memorial Hermann network, one of the large healthcare providers in the Houston metropolitan
area, collaborates with the University of Texas McGovern medical school in several domains. One of
these is the sleep medicine services which contain sleep centers in a concentric pattern surrounding
downtown Houston. The Texas Medical Center, a well-known cluster of prominent medical facilities,
including the McGovern medical school is based in the center of the city. Access from distant areas of
the city as well as surrounding areas, particularly for recurrent visits as might be required for CBT-I, is
often cumbersome for patients.
Figure 1: Locations of sleep medicine centers affiliated with Memorial Hermann Health System in Houston area
Methods
The purpose of this project is to utilize collaborative expertise between the sleep medicine physician,
who is a faculty member in the Department of Neurology at the UT McGovern medical school and an
experienced behavioral sleep medicine psychologist employed within the Memorial Hermann network
to improve access via telehealth for sleep medicine services, primarily CBT in the city of Houston and
surrounding areas. For this purpose, Vidyo, an institutionally approved and patient data safety
compliant platform will be used. Educational material promoting awareness about sleep disorders,
psychological techniques for treatment of insomnia, availability and pathway for referrals will be
distributed among primary care physicians and other specialties particularly neurology, pulmonology
and psychiatry [most likely to encounter patients with sleep disorders].
The Behavioral Sleep Medicine Specialist [psychologist] with background and training in general Sleep
Medicine will provide services to patients referred for evaluation and treatment of insomnia,
hypersomnia, and circadian rhythm disorder. Patients will be given the option of telemedicine if they
live outside of the 15 mile radius of Texas Medical Center.
Patients will be consented and initial New Office Visit information electronically provided to facilitate
the initial assessment. Patients will be offered in person evaluation and treatment if they do not wish to
utilize telehealth. Patient materials such as a sleep journal, cognitive behavioral treatment information,
will additionally be provided during subsequent treatment visits. During the initial visit, questionnaires
to assess mood, and to identify personal goals related to sleep will be administered. Research has
suggested that some patients are more likely to reveal sensitive information when a veil of anonymity is
experienced (via technology such as automated reporting or possibly even telemedicine).
If insomnia alone is identified as the principal issue, the patient will continue to be provided cognitive
and behavioral therapy. However, if a primary sleep disorders [such as obstructive sleep apnea,
parasomnias, hypersomnia disorders] are identified, the patient will be referred to a local physician who
is a sleep medicine specialist for appropriate testing and management. If insomnia is identified as a
comorbid illness, CBT may still be provided simultaneously.
Data collected will include a gentle medical history including comorbidities, vital signs particularly blood
pressure, heart rate and blood glucose [abstracted from referring physician notes], sleep quality indices,
scales of anxiety and depression, specific outcome indicators for sleep [including wake time after sleep
onset, sleep onset latency, number of awakenings, sleep time or sleep efficiency, sleep-related
psychological distress]. Additional data will include metrics obtained from sleep specific testing for
example polysomnography [if conducted]. These data will be maintained on an institutionally available,
data protected server used for clinical care.
Figure 2: Proposed flow diagram for Sleep Disorders Telehealth Program.
Analysis
The variables mentioned above will be collected sequentially for each patient across successive
encounters. Constant communication will be maintained with the referring physician, particularly
regarding any unexpected changes in clinical status. Each patient is expected to be followed by the
psychologist for 5-6 sessions. Multivariate analysis will be conducted using standard statistical
techniques, specifically to compare changes from before and after intervention, impact of comorbidities,
patient and referring physician satisfaction as well as frequency of prescription of hypnotics.
Specific aims
1. To improve access to clinical care for sleep-related disorders within a large city using an academicprivate partnership and telehealth.
2. To study the effects of improving sleep health on physiological and psychological parameters at the
level of individual.
Hypotheses
1. The use of modern technology will help overcome barriers related to awareness of treatment options
and availability to appropriate providers.
2. Improving sleep health with result in an overall improvement in physiological and psychological
metrics.
Significance
Providing cost effective, yet comprehensive care has been a catch phrase in the recent medical
ecosystem. Using modern technology to improve access for treatment of a relatively common, yet
under treated set of disorders like sleep disorders is expected to have significant and sustainable impact
on health in general. It is well known that undiagnosed and untreated sleep disorders are associated
with several comorbidities including cardiac, neurological and psychological diseases. Collaboration
between expertise associated with academic medicine and resources embedded in private healthcare
systems is key to expand reach among under- served areas. The long-term goal of this project is to be
able to provide a Center of excellence for comprehensive treatment of sleep disorders, in a costeffective manner.