Exploring Nurse Practitioner Students' Perceptions of a Sleep e-Learning Program.

AIM: The aim of this study was to explore nurse practitioner (NP) students' perceptions of a sleep e-learning program. BACKGROUND: Sleep assessment is uncommon as nursing curricula lack sleep education. By preparing NPs to conduct sleep assessment and screening and understand basic sleep diagnostics, sleep health is more likely to be part of the differential diagnosis. METHOD: The study is a qualitative descriptive study utilizing two focus groups. A directed content analysis, guided by the Kirkpatrick model, was used for analysis. RESULTS: Twenty-four students participated in focus groups. Two overarching themes emerged: perceptions of course design and content. Asynchronous, case-based scenarios and quizzes were favorable. Students spoke of content relevance to themselves and patients and intentions to adopt sleep assessment practices. CONCLUSION: NP students embraced sleep education and declared intention to apply learned skills in practice. This study highlights the feasibility of increasing curricular exposure to sleep education and ensuring NPs have skills to recognize implications of poor and disordered sleep in patients.

Mastery learning program to teach sleep study scoring.

STUDY OBJECTIVES: Scoring a polysomnogram is an essential skill for sleep medicine trainees to meet Accreditation Council for Graduate Medical Education Sleep Medicine Milestones. Appraisal is based on faculty evaluation rather than objective competency assessment. We developed a computer-based polysomnogram scoring curriculum, utilizing the mastery learning method, then compared achievement of competency using the new curriculum against standard institutional training. METHODS: The scoring program consisted of a pretest assessment, sequential acquisition of knowledge utilizing online modules, a posttest, and competency assessment. Fellows needed to demonstrate mastery of each module before moving ahead. Competency was demonstrating ≥ 90% on interscorer reliability assessment on 5 studies (out of up to 10 attempts). Participating fellows were assigned to Mastery Learning Participants (MLP) or Traditional Learning Participants (TLP) groups and completed the program within the first 1-3 months of training. RESULTS: Of 87 fellows enrolled in the program, 75 participants completed the program (40 MLP and 35 TLP). Among completers, there was no difference in the proportion that achieved competency (MLP 90.0% vs TLP 97.1%; P = .36) or studies needed to achieve competency (MLP 7.25 ± 1.3 vs TLP 7.41 ± 1.3; P = .60). Pretest scores were not significantly different between groups (MLP 61.2% ± 15.9 vs TLP 57.6% ± 16.6; P = .35), but MLP posttest scores were higher than TLP (MLP 80.9% ± 8.8 vs TLP 76.4% ± 9.8; P = .04). CONCLUSIONS: We demonstrated similar outcomes utilizing a novel, computer-based modular interactive course compared to traditional methods of teaching polysomnogram scoring. We used a mastery learning paradigm and set specific objective competency levels for this skill. CITATION: Epstein LJ, Plante DT, Rosen IM. Mastery learning program to teach sleep study scoring. J Clin Sleep Med. 2022;18(12):2745-2750.

A Blueprint for Increasing Ethnic and Racial Diversity in U.S. Residency Training Programs.

PROBLEM: People who identify as African Americans, Latinos, or from indigenous backgrounds, are dramatically underrepresented in the U.S. physician workforce. It is critical for academic health centers to recognize racial and ethnic diversity at the residency level and implement changes to enhance diversity among trainees. APPROACH: The Office of Graduate Medical Education (GME) at the University of Pennsylvania Health System (UPHS) developed a multipronged approach to enhance diversity and inclusion (D&I) among residency trainees. The approach included the development of an underrepresented in medicine (UIM) professional network; UIM-focused visiting clerkship programs; holistic review implementation by selection committees; and targeted outreach to UIM candidates, overseen by an associate designated institutional official for UIM Affairs. The authors reported demographic data on residency applicants invited for interviews and matching for all programs at UPHS from 2014-2015 (baseline) to 2020-2021. They also reported data on maximum ranking number programs reached to fill their positions and the average United States Medical License Examination (USMLE) Step 1 scores of matched candidates. Finally, they discussed the implications for leaders who wish to enhance D&I at academic health centers. OUTCOMES: During the baseline year (2014-2015), UIMs represented 12.1% of interviewees and 8.7% of all matched candidates into UPHS residency programs. Over the successive 6 years after incremental implementation of the approach, UIM representation steadily increased. In 2020-2021, UIMs represented 23.2% of interviewees and 26.4% of matched candidates. Programs' maximum rank number to fill and USMLE Step 1 scores of matched candidates remained relatively unchanged. NEXT STEPS: The UPHS Office of GME incorporated a purposeful approach to enhance the D&I of its residents. Across 6 years of implementation, UIM representation among resident matches tripled while quantitative program and candidate metrics remained unchanged. Similar efforts should be given further consideration for implementation and evaluation nationwide.

Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students.

STUDY OBJECTIVES: Primary care nurse practitioners (NPs) receive little sleep education in graduate programs but are often first-line providers for patients presenting with sleep-related symptoms. A pre-/postevaluation study was conducted using asynchronous, case-based sleep education modules in a cohort of primary care NP students enrolled in a single academic institution's nursing master's degree program. METHODS: Six virtual, case-based modules addressed adult sleep health and disorders, prioritized based on prevalence and primary care presentation. Kirkpatrick Training Evaluation Model guided outcome selection. Descriptive and paired comparative analyses were conducted. RESULTS: Participants were first-year NP students (n = 149; 88% female; 82% ≤ 35 years of age) in an adult primary care program that included psychiatric/mental health track. Participants reacted positively to course delivery methods and content. Insomnia was endorsed by 87% as most relevant to practice with healthy sleep (88%) and obstructive sleep apnea (50%) also frequently endorsed as practice relevant. Posttest knowledge scores significantly improved for all modules (P < .001). Self-rated confidence for future practice application was high. CONCLUSIONS: This novel asynchronous, virtual curriculum met Kirkpatrick levels 1 and 2 (positive reaction and knowledge transfer) in NP students who predicted an impact on their practice (Kirkpatrick level 3). Studies are needed to assess the benefits of increasing primary care NP knowledge in sleep medicine on quality of care and access to care (Kirkpatrick level 4). Future use of this novel sleep curriculum in other professional curricula, new-to-sleep clinical researchers, and practicing primary care providers may further potentiate care quality and sleep care access. CITATION: Sawyer AM, Saconi B, Lyons MM, et al. Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students. J Clin Sleep Med. 2022;18(10):2367-2376.

Strategies to improve patient care for obstructive sleep apnea: a report from the American Academy of Sleep Medicine Sleep-Disordered Breathing Collaboration Summit.

NONE: In Chicago, Illinois, on Saturday, November 10, 2018, the American Academy of Sleep Medicine hosted 35 representatives from 14 medical societies, nurse practitioner associations and patient advocacy groups for a one-day Sleep-Disordered Breathing Collaboration Summit to discuss strategies to improve the diagnosis and treatment of obstructive sleep apnea. This report provides a brief synopsis of the meeting, identifies current challenges, and highlights potential opportunities for ongoing collaboration.

Competency-based sleep medicine fellowships: addressing workforce needs and enhancing educational quality.

None: The path for physicians to become credentialed sleep medicine specialists has changed in many ways in the last few decades. Currently, sleep medicine is recognized as an independent subspecialty with appropriately rigorous and comprehensive training required to become a board-certified sleep medicine physician. However, added time for requisite fellowship training, coupled with an aging sleep medicine physician workforce, have had the unintended consequence of decreasing the number of sleep medicine physicians at a time when the demands for sleep medicine care continue to rise. Thus, new training pathways that provide flexibility to trainees, while ensuring high-quality, comprehensive, and multidisciplinary sleep medicine training are needed to maintain a workforce that can meet the sleep health needs of the present and future. Here, we describe two pilot programs that apply principles of competency-based medical education to sleep medicine fellowship training. These novel models are likely to attract additional well-qualified physicians to the field who might otherwise not pursue a career in sleep medicine.

A Guide to Management of Sleepiness in ESKD.

Daytime sleepiness, also known as hypersomnolence, is common among patients receiving maintenance dialysis and following successful kidney transplantation. Sleepiness may be secondary to medical comorbid conditions, medication side effect, insufficient sleep syndrome, and sleep-disordered breathing or the result of a primary central disorder of hypersomnolence, such as narcolepsy. Unrecognized and untreated sleep disorders are associated with substantial morbidity and mortality among patients with end-stage kidney disease. Effective management of hypersomnolence can improve quality of life in patients with kidney disease. This review focuses on the principal causes of sleepiness in patients with end-stage kidney disease. Awareness of these disorders by treating nephrologists is crucial. This review provides a systematic approach to guide providers through the recognition, early diagnosis, and treatment of hypersomnolence, which is commonly encountered in this patient population. Areas of future research are also suggested.

Study design considerations for sleep-disordered breathing devices.

None: In recent years, sleep-disordered breathing (SDB) has been recognized as a prevalent but under-diagnosed condition in adults and has prompted the need for new and better diagnostic and therapeutic options. To facilitate the development and availability of innovative, safe and effective SDB medical device technologies for patients in the United States, the US Food and Drug Administration collaborated with six SDB-related professional societies and a consumer advocacy organization to convene a public workshop focused on clinical investigations of SDB devices. Sleep medicine experts discussed appropriate definitions of terms used in the diagnosis and treatment of SDB, the use of home sleep testing versus polysomnography, clinical trial design issues in studying SDB devices, and current and future trends in digital health technologies for diagnosis and monitoring SDB. The panel's breadth of clinical expertise and experience across medical specialties provided useful and important insights regarding clinical trial designs for SDB devices.

Chronic Opioid Therapy and Sleep: An American Academy of Sleep Medicine Position Statement.

None: There is a complex relationship among opioids, sleep and daytime function. Patients and medical providers should be aware that chronic opioid therapy can alter sleep architecture and sleep quality as well as contribute to daytime sleepiness. It is also important for medical providers to be cognizant of other adverse effects of chronic opioid use including the impact on respiratory function during sleep. Opioids are associated with several types of sleep-disordered breathing, including sleep-related hypoventilation, central sleep apnea (CSA), and obstructive sleep apnea (OSA). Appropriate screening, diagnostic testing, and treatment of opioid-associated sleep-disordered breathing can improve patients' health and quality of life. Collaboration among medical providers is encouraged to provide high quality, patient-centered care for people who are treated with chronic opioid therapy.

Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing.

OBJECTIVES: To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model. DESIGN: Prospective observational study. SETTING: Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing. PATIENTS: Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS: As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS: Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS: Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

Clinical Use of a Home Sleep Apnea Test: An Updated American Academy of Sleep Medicine Position Statement.

ABSTRACT: The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. It is the position of the American Academy of Sleep Medicine (AASM) that only a medical provider can diagnose medical conditions such as OSA and primary snoring. Throughout this statement, the term "medical provider" refers to a licensed physician and any other health care professional who is licensed to practice medicine in accordance with state licensing laws and regulations. A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of OSA in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. It is also the position of the AASM that: the need for, and appropriateness of, an HSAT must be based on the patient's medical history and a face-to-face examination by a medical provider, either in person or via telemedicine; an HSAT is a medical assessment that must be ordered by a medical provider to diagnose OSA or evaluate treatment efficacy; an HSAT should not be used for general screening of asymptomatic populations; diagnosis, assessment of treatment efficacy, and treatment decisions must not be based solely on automatically scored HSAT data, which could lead to sub-optimal care that jeopardizes patient health and safety; and the raw data from the HSAT device must be reviewed and interpreted by a physician who is either board-certified in sleep medicine or overseen by a board-certified sleep medicine physician.

Polysomnography for Obstructive Sleep Apnea Should Include Arousal-Based Scoring: An American Academy of Sleep Medicine Position Statement.

ABSTRACT: The diagnostic criteria for obstructive sleep apnea (OSA) in adults, as defined in the International Classification of Sleep Disorders, Third Edition, requires an increased frequency of obstructive respiratory events demonstrated by in-laboratory, attended polysomnography (PSG) or a home sleep apnea test (HSAT). However, there are currently two hypopnea scoring criteria in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (AASM Scoring Manual). This dichotomy results in differences among laboratory reports, patient treatments and payer policies. Confusion occurs regarding recognizing and scoring "arousal-based respiratory events" during OSA testing. "Arousal-based scoring" recognizes hypopneas associated with electroencephalography-based arousals, with or without significant oxygen desaturation, when calculating an apnea-hypopnea index (AHI), or it includes respiratory effort-related arousals (RERAs), in addition to hypopneas and apneas, when calculating a respiratory disturbance index (RDI). Respiratory events associated with arousals, even without oxygen desaturation, cause significant, and potentially dangerous, sleep apnea symptoms. During PSG, arousal-based respiratory scoring should be performed in the clinical evaluation of patients with suspected OSA, especially in those patients with symptoms of excessive daytime sleepiness, fatigue, insomnia, or other neurocognitive symptoms. Therefore, it is the position of the AASM that the RECOMMENDED AASM Scoring Manual scoring criteria for hypopneas, which includes diminished airflow accompanied by either an arousal or ≥ 3% oxygen desaturation, should be used to calculate the AHI. If the ACCEPTABLE AASM Scoring Manual criteria for scoring hypopneas, which includes only diminished airflow plus ≥ 4% oxygen desaturation (and does not allow for arousal-based scoring alone), must be utilized due to payer policy requirements, then hypopneas as defined by the RECOMMENDED AASM Scoring Manual criteria should also be scored. Alternatively, the AASM Scoring Manual includes an option to report an RDI which also provides an assessment of the sleep-disordered breathing that results in arousal from sleep. Furthermore, given the inability of most HSAT devices to capture arousals, a PSG should be performed in any patient with an increased risk for OSA whose HSAT is negative. If the PSG yields an AHI of 5 or more events/h, or if the RDI is greater than or equal to 5 events/h, then treatment of symptomatic patients is recommended to improve quality of life, limit neurocognitive symptoms, and reduce accident risk.

Change is the Only Constant in Life (and in Sleep Medicine).

ABSTRACT: Heraclitus, a philosopher who lived nearly 500 years before the common era, made the assertion that "Life is Flux," meaning that change is the only constant in life. Modern medicine, inclusive of the field of sleep medicine, has undergone dramatic changes over the last 10 years. For the American Academy of Sleep Medicine (AASM) specifically, the last year has been one of great change. Yes, change happens, but with great change comes even greater opportunity. As AASM president, I have been focused on staying abreast of the changes in our health care system while anticipating and preparing to adapt to challenges in our field. In June 2017, given all the changes in our health care delivery system, I challenged the AASM membership and our field to adapt our models of care to reduce the number of patients with undiagnosed and untreated obstructive sleep apnea (OSA) by 10% over 5 years. This article will provide a brief update describing how the AASM board of directors has responded to my challenge and capitalized on change in the areas of the physician pipeline, patient access, advocacy, new technology and strategic research. Change is inevitable and often beyond our control, but how we anticipate and respond to change is entirely within our power. As sleep specialists, it is our responsibility not only to respond to change so that we can deliver the best possible care for our patients, but also to be the leading voice for change so that we all achieve better health through optimal sleep.