Physician Dentist Collaboration Ronald S. Prehn, ThM, DDS Legal Perspective MD CAN LEGALLY MAKE PROPER DIAGNOSIS DDS CAN LEGALLY FABRICATE DENTAL SLEEP APPLIANCES Legal Perspective TWO PROFESSIONS WORK TOGETHER IMPACT PATIENT CARE MEDICAL LIABILITY 1
LEGAL (BASIS OF LICENSURE) STANDARD OF CARE (BASIS OF MEDICAL LIABILITY) Collaboration with a Sleep Physician Besides the law and liability... WHY COLLABORATE? PREVALENCE OF SLEEP APNEA IN COMORBIDITIES Resumed 2014 I 2
PREVALENCE AND CHALLENGES OF TREATMENT More than 40 million US adults suffer from sleep-disordered breathing (SDB) More than 85% remain undiagnosed Resumed 2014 I PREVALENCE AND CHALLENGES OF TREATMENT 820,000 patients are non-compliant or refuse CPAP every year for various reasons 51% compliance to CPAP therapy The dental option provides alternative pathways for patients to achieve better sleep. Resumed 2014 I Economic cost of unmanaged mod severe OSA in the US estimated between ~$65B and $165B Public Health Costs 1. Diagnosis and treatment 2 10B 2. Hidden healthcare costs 45 80B MD visits, testing, treatment Co morbidities, traffic/workplace accidents Public Safety Costs. Traffic accidents 10 40B 4. Workplace accidents 5 20B 5. Loss of productivity 5 15+B 6. Other Unknown costs Source: Price of Fatigue Report 2011, p16 Resumed 2014 I McKinsey & Company analysis; Harvard Medical School 3
IMPORTANCE OF COORDINATED CARE CAN BE COMPLICATED Resumed 2014 I General Algorithm for Dentists and Physicians Methods of Screening Each contribute towards a full assessment Several Sleep Questions on Routine Dental Intake Questionnaire Focused, Detailed Sleep Questionnaire Physical Exam in conjunction with Sleep history Screening for Sleep Apnea Syndrome Positive responses from screening assessments Refer patient to a physician, preferably a sleep specialist. The dentist MUST provide a history and exam findings to the physician. The Physician sends the report of the evaluation and testing to the dentist to collaborate on a treatment plan Telemedicine Consult done remotely Medical Evaluation Sleep Testing NPSG or HSAT Testing type depends on many factors Traditional Office Visit The Dentist The Physician makes final determination of resolution of OSAS The Physician Diagram developed by Jerald H. Simmons, MD 2017 www.csma.clinic Any questions should be directed to Dr. Simmons Patient NO Previous Sleep Evaluation 4
Patient Previous Sleep Evaluation Who the Dentist chooses to work with. 100% Factors in Choosing Which Sleep Doctor to Refer to for Diagnosis 80% 60% 56% 40% 38% 37% 20% 0% Refer to Several Local Sleep Doctors/Labs 15% Partner with a Patient Chooses Use AASM Doctor to Help Accredited Labs Manage Only Patients 12% Use the Sleep Doctor(s) Contracted to Read HSTs 6% Other Base: 98 Sleep Dentists who refer at least one suspected OSA patient for a sleep test Q6. How do you determine which sleep doctor you refer to for diagnosis? Select all that apply. ResMed 2014 I THE FIVE ASPECTS WHERE THE DENTIST PLAYS A VITAL ROLE 1. Screening 2. Dental Appliance as Mono Therapy 3. Dental Appliance as a Hybrid Therapy 4. Dental Appliance as an Augmentation of treatment in patients requiring positive Pressure Therapy 5. Dental Appliance in conjunction with Surgery. 5
Working with a Sleep Physician 1. Physician responsibility: Diagnosis by Boarded Physician Final determination of treatment efficacy 2. Dentist responsibility: Determine if OAT is effective for airway patency (obj & sub) Communicate with MD Establish a written SOP (standard operating procedure) SOP Standard Operating Procedure 6
The Dentist should put this SOP in writing for them both to sign. 4. It would be ideal if the Sleep Physician would see every patient to review the study and to talk about options including OAT. No local Sleep Physician? Establish a relationship with any Licensed Physician for a diagnosis and resolution of OSA Consider using a Telemedicine Option to link in with a physician sleep specialist But all PSG or HST studies should be interpreted by a Boarded Sleep Physician SLEEP REFERRAL FORM Patient Name: DOB ORDERS PLEASE EVALUATE FOR THE FOLLOWING TENTATIVE DIAGNOSIS: Possible OSA INSOMNIA RLS OSA w CPAP difficulties Excessive Daytime Sleepiness Unusual Behaviors during sleep Sleep Bruxism PROTOCOL/ORDERS: NEED CONSULT BEFORE TESTING - HSAT or PSG Good OAT patient or IF OSA PROCEED WITH CPAP Tx History CURRENT HISTORY/NOTES : HEAVY/MOD/LIGHT SNORING Onset DAYTIME SLEEPINESS/NAPS Onset WITNESSED APNEA Frequency PERIODIC LEG MOVEMENTS METABOLIC SYNDROME PREVIOUSLY DX WITH APNEA When? IMAGING - shows very small airway REFERRAL TYPE: NIGHT TIME CLENCHING GERD CVD/HBP TMJ ESS: MORNING HEADACHE FREQUENT AROUSALS Type Complex sleep patient. (Needs consultation first before PSG is ordered) TMJ patient that I need to have airway stable with CPAP before I go into OAT later. Simple OSA patient that needs a MAS if mild/mod OSA. Return here for consult. CPAP titration study only. Calibrate CPAP to proper pressure. Original PSG att. Unresolved OAT patient. Need to go into Combination Therapy with CPAP. Confirm OAT success with final PSG or HSAT. Surgical candidate who needs evidence of SDB with a PSG. Surgeon name: PROVIDER SIGNATURE: DATE: Print Provider Name: NPI #: 7
C l i n i c a l A s s i s t a n t C o m m e n t s : C l i n i c a l A s s i s t a n t I n i t i a l s : _ 8/28/2018 Subjective Oral Appliance Titration Evaluation Patient Name: DOB: Main Sleep Complaint: Patients Global Impression of Changes Scale (PGIC) Since beginning treatment at this practice, how would you describe the change (if any) in ACTIVITY LIMITATIONS, SYMPTOMS, EMOTIONS and OVERALL QUALITY OF LIFE, related to your condition? (check ONE box) No change (or condition has worsened) 1 Almost the same, hardly any change at all 2 A little better, but no noticeable change 3 Somewhat better, but the change has made no real difference 4 Moderately better, and a slight but noticeable change 5 Better, a definite improvement that has made a real difference 6 Much better, huge improvement that has made a big difference 7 Epworth Sleepiness Scale (ESS) Rank how likely it would be for you to become drowsy during the day in the following situations: 0= Would never doze 1= Slight chance of dozing 2= Moderate chance of dozing 3= High chance of dozing Situation Chance of dozing Sitting & Reading Watching TV Sitting inactive in a public place (i.e. theater) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch without alcohol Objective OAT Titration Worksheet Patient name Weight DOB Age BMI Type of MAS: Date of insertion: Pulse OX unit # Date Dispensed Initial Date Returned Original sleep MD/facility: HST type on this report: Pulse Ox HST Type 3 Other Original PSG date HST date HST date PSO2 RDI AHI ODI Percent time under 90% Pes ESS PGIC Original Sleep Complaints: fatigue OSA snoring Check one: patient satisfied symptoms not resolved Current disposition: All symptoms resolved Titration study to see if advancement needed MAS out as far as possible what is next? Final to determine if MAS is effective Dr. Comments: In a car, stopped for a few minutes in traffic What is your Patient Signature: Ht: Wt: Total score: Date: Dr. Recommendations: Adv MAS redo HST Adv MAS then send for final HST/PSG with Sleep MD Send for final HST with Sleep MD now Send for PSG w/ PES to see why symptoms remain Send for PSG with Sleep MD to consider Combination Therapy Other: Ever wonder what the average sleep physicians thinks about Oral Appliance Therapy? { Helpful Hint: Address these concerns when establishing a relationship with a Sleep Physician} ROLE OF ORAL APPLIANCES IN THE TREATMENT OF OSA Q14.What role do Oral Appliances play in the treatment of OSA? Second line treatment after CPAP Helpful for mild to moderate OSA 19% Effective/symptom relief 19% Advantageous for mild OSA 17% Oral appliance are not very useful 11% Useful in conjunction with CPAP or surgery 8% Well-tolerated/comfortable 7% Beneficial for non-obese patients 4% Useful for pateints with good teeth 3% Helpful for snoring 3% Useful if surgery failed or is not an option 1% Helpful where ease of oxygenation needed 1% Possibly useful in cases of severe OSA Other 7% Percentage of sleep physicians 44% Oral Appliance Attitudes & Behaviors, April 2013 N=63 ResMed 2015 I 24 8
CONCERNS OVER ORAL APPLIANCE TREATMENT FOR OSA Q21. What are your concerns, if any, when using an oral appliance to treat patients with OSA? (Select all that apply) Percentage of sleep physicians Concern about efficacy of treatment Lack of insurance coverage Concern about long-term effects to the patient's bite and/or jaw Patient discomfort with oral appliance 0 Other No concerns 9 67 59 59 57 Oral Appliance Attitudes & Behaviors, April 2013 N=101 ResMed 2015 I 25 DDS Collaboration MD Ideas Sleeping Doctor Locate Boarded MD that practices Sleep Medicine 9
Improved Outcome of Full Face Mask CPAP Treatment with Mandibular Stabilization using a Dental Appliance Dental appliance Stabilize Mandible Offer to take the CPAP intolerant and the difficult full mask patients (combination therapy) Oral Appliances OA vs CPAP Oral Appliance Therapy Combination Therapy AASM and AADSM Clinical Guidelines highlighted Orthognathic surgery information Any personal articles/testimonies Suggested protocol for collaboration 10
Set up a meeting, visit sleep lab. Bring snack for lab technicians. Spend time talking to them after talking to MD. Become a Board Certified Sleep Dentist 11
Other ideas to enhance collaboration? ORAL APPLIANCE MARKET TRENDS The oral appliance market is projected to grow exponentially as patient education on product use as well as increased clinician training continues to advance 1 ResMed 2014 I Summary Why Collaborate? 1. Legal/liability/standard of care 2. Unmet need for screening 3. Unmet need for initiating treatment 4. Need for effective treatment 5. Need for excellence in patient care 6. New technologies allow collaboration from remote locations. Consider Telemedicine methods. 12
Believe me I know about DDS MD collaboration!!! MD Collaboration DDS SUCCESS 13