CONFLICT OF INTEREST - Kansas Association of Sleep Professionals

Eldon Cook, BA, RPSGT, RPFT
Midwest Sleep Solutions, Clinical Director
JCCC Polysomnography Program, Adjunct Professor
CONFLICT OF INTEREST:
�
An individual involved in the planning of, or presentation of, an education
activity may have an interest in or affiliation with an organization, but the
audience must be informed of this relationship before the presentation of
the activity. For this purpose, a real or apparent conflict of interest is
defined as personal gain or benefit derived from involvement with any entity,
product or service. Vested Interest includes (but is not limited to)
employment, by owning stock, from inclusion in a speakers' bureau or a
relationship, personal or otherwise, with a company that could potentially
benefit from the relationship.
�
I declare that I do NOT have any affiliation with or financial
relationship/interest in a commercial organization that could pose a conflict
of interest with the educational content of this program.
DISCLOSURES
�
�
�
Started in Sleep in
1979
Employed as Clinical
Director Midwest Sleep
Solutions/ Assistant
Adjunct Professor at
JCCC
Have worked for Puritan
Bennett/ Nellcor /
BioLogic/SEFAM
Review of current AASM standards for
Respiratory scoring.
� Analyze Rules for hypopnea.
� Understand requirements for reporting of
scored data.
�
From: American Academy of Sleep Medicine [mailto:[email protected]]
Sent: Tuesday, May 28, 2013 4:15 PM
To: Sleep Lab
Subject: Special Update: CMS and Hypopnea Definitions for Scoring
If you are having trouble reading this e-mail, visit www.aasmnet.org to read the items from this update. This free update is delivered
as a benefit of your AASM membership. Please see the subscription information at the end of the publication to add or cancel
subscriptions.
Issue Date: 05/01/2013
Dear Members,
As you are aware, AASM accredited sleep centers will be required to use the new hypopnea definition characterized in The AASM
Manual for the Scoring of Sleep and Associated Events 2.0 starting October 1, 2013.
The AASM has contacted CMS to make them aware of this change in the preferred definition of hypopnea. The AASM has requested
CMS to institute this designation in their polysomnography criteria for diagnosing obstructive sleep apnea. However, until CMS
adopts this new definition, accredited centers will need to maintain two different apnea hypopnea indices (AHI) using the AASM's
revised definition of hypopnea and the current CMS definition.
In an attempt to provide guidance, the AASM suggests that centers report both values by using the following scoring guidelines:
Score "hypopneas" using the current CMS definition Score the additional "AASM Hypopneas" by a different marker using the revised
hypopnea definition. (a 30% reduction in airflow with 3% desaturations and/or associated respiratory related arousals.) Report the
CMS AHI as the sum of the apneas plus hypopneas (as defined by CMS ) divided by sleep time (hrs) Report the AASM AHI as the
sum of the apneas plus hypopneas (as defined by CMS ) plus the "AASM hypopneas" (using the new definition for AASM
hypopneas) divided by sleep time (hrs) The polysomnography report should note which hypopnea definition is being applied.
An example is provided below:
"This study was performed in standard fashion. The data acquired and the scoring of sleep and all associated events were performed
in accordance with the RECOMMENDED Standards and Specifications as outlined in The AASM Manual for the Scoring of Sleep
and Associated Events 2.0. Please note that the "AHI" in this report is consistent with the current hypopnea definition according to
Medicare Criteria and the "AASM AHI" is consistent with the current Hypopnea definition according to AASM criteria.
Sam Fleishman, MD
President
Issue Date: 09/23/2013
In August members were notified that the AASM has suspended indefinitely the requirement for accredited sleep centers to score
hypopneas in adult patients according to the 3 percent oxygen desaturation criterion in the new AASM scoring manual.
The AASM continues to recommend scoring hypopneas in adults when there is a greater than or equal to 3% oxygen desaturation
from pre-event baseline and/or the event is associated with an arousal. However, it is acceptable for accredited sleep centers to
score hypopneas in adults when there is a greater than or equal to 4% oxygen desaturation from pre-event baseline.
AASM sleep centers must specify in the PSG report whether hypopneas were scored using the recommended rule 1A or the
acceptable rule 1B:
Recommended
1A. Score a respiratory event as a hypopnea if ALL of the following criteria are met:
a. The peak signal excursions drop by greater than or equal to 30% of pre-event baseline using nasal pressure (diagnostic study),
PAP device flow (titration study), or an alternative hypopnea sensor (diagnostic study).
b. The duration of the greater than or equal to 30% drop in signal excursion is greater than or equal to 10 seconds.
c. There is a greater than or equal to 3% oxygen desaturation from pre-event baseline and/or the event is associated with an
arousal.
OR
Acceptable
1B. Score a respiratory event as a hypopnea if ALL of the following criteria are met:
a. The peak signal excursions drop by greater than or equal to 30% of pre-event baseline using nasal pressure (diagnostic study),
PAP device flow (titration study), or an alternative hypopnea sensor (diagnostic study).
b. The duration of the greater than or equal to 30% drop in signal excursion is greater than or equal to 10 seconds.
c. There is a greater than or equal to 4% oxygen desaturation from pre-event baseline.
Please note that the criterion involving arousals is included in 1A and excluded from 1B.
The AASM also reminds members that this clarification is applicable only to the adult scoring criteria for hypopneas. Criteria for
scoring hypopneas in children, which are provided in a separate section of the scoring manual, remain unaffected.
This revised rule is in effect immediately and is included in the current version of the AASM Manual for the Scoring of Sleep and
Associated Events, Version 2.0.2.
Comments about the hypopnea scoring criteria can be submitted to the AASM at [email protected]. Questions or
comments about requirements for accredited sleep centers can be submitted to [email protected].
This is not going to end well……..
�
Medicare Vs Non Medicare
� Some
insurances follow medicare guidelines.
Central vs. Obstructive Hypopnea vs RERA
-what “buckets” do these go into?
RESPIRATORY SUMMARY TABLES
CPAP
Level
Time
(min)
REM
(min)
NREM
(min)
Wake
(min)
Apnea
Index
Hypop
Index
AHI
Obs
Apnea
Central
Apnea
Mixed
Apnea
Hypop
REM
AHI
RERA
Index
Sleep
Eff%
Off
139.0
0.0
112.0
27.0
27.9
30.5
58.4
2
50
-
57
-
2.7
80.6
Min OSat
73.3
%
5.0
5.5
0.0
5.5
0.0
-
87.3
87.3
-
-
-
8
-
-
100.0
88.1
%
7.0
16.5
0.0
16.5
0.0
-
32.7
32.7
-
-
-
9
-
-
100.0
84.2
%
9.0
26.0
0.0
22.0
4.0
62.7
19.1
81.8
-
23
-
7
-
-
84.6
76.3
%
8.0
4.0
70.0
9.0
4.0
73.5
11.0
4.0
170.0
0.5
69.0
0.5
19.9
3.5
23.3
-
23
-
4
-
4.3
99.3
73.3
%
47.0
25.0
1.5
-
2.5
2.5
-
-
-
3
-
-
98.0
89.1
%
42.5
118.0
9.5
-
0.4
0.4
-
-
-
1
-
0.7
94.4
990.1
%
SUPINE
SUPINE
Time
(min)
TST
(min)
REM
(min)
AH
REM
AH
REM
AHI
NREM
AH
NREM
AHI
Apnea
Index
Hypop
Index
AHI
RERA
Index
RDI
Index
Off
62.0
44.5
0.0
109
-
-
109
147.0
70.1
76.9
147.0
2.7
149.7
5.0
5.5
5.5
0.0
8
-
-
8
87.3
-
87.3
87.3
-
87.3
7.0
16.5
16.5
0.0
9
-
-
9
32.7
-
32.7
32.7
-
32.7
8.0
4.0
4.0
4.0
0.0
5
-
-
5
75.0
75.0
-
75.0
-
75.0
9.0
26.0
22.0
0.0
30
-
-
30
81.8
62.7
19.1
81.8
-
81.8
9.0
4.0
4.0
3.5
0.0
3
-
-
3
51.4
-
51.4
51.4
-
51.4
11.0
4.0
120.5
114.5
12.5
1
-
-
1
0.6
-
0.5
0.5
1.0
1.6
Time
(min)
TST
(min)
REM
(min)
AH
REM
AH
REM
AHI
NREM
AH
NREM
AHI
Apnea
Index
Hypop
Index
AHI
RERA
Index
RDI
Index
Off
65.5
63.5
0.0
-
-
-
-
-
-
-
-
1.9
1.9
8.0
4.0
66.0
65.5
0.5
22
-
-
22
20.3
16.5
3.7
20.2
4.6
24.7
9.0
4.0
69.5
68.5
47.0
-
-
-
-
-
-
-
-
-
-
11.0
4.0
49.5
46.0
30.0
-
-
-
-
-
-
-
-
-
-
Time
(min)
TST
(min)
REM
(mi
n)
AH
REM
AH
REM
AHI
NREM
AH
NREM AHI
Hypop
Index
AHI
RERA
Index
RDI
Index
11.5
4.0
0.0
-
-
-
-
-
-
-
15.0
15.0
CPAP
Level
LATERAL
CPAP
Level
PRONE
CPAP
Level
Off
Apn
ea
Ind
ex
-
Questions?