Improving Patient Adherence to Sleep Treatments

Written by
Aarogram Team
Published on
June 30, 2023

In the third installment of the The Efficient Care Podcast, Kashyap Purani, co-founder at Aarogram chats with. Dr. Audrey Wells, multi-specialty sleep medicine physician and CEO of Super Sleep MD. Certified in CBT-i and life coaching and a former Chief Medical Officer of OmniSleep Medicine Center, Dr. Wells brings a trove of unique skills, experiences and solutions that help sleep disorder patients find restful nights of sleep.

They discuss diagnosing and treating overlaps in Sleep Apnea and Insomnia, alternative treatments to CPAP, and treatment adherence tips that healthcare providers can leverage to improve patient outcomes.

Listen to the full episode here.

Transcript of the full episode:

Kashyap: Hi Dr. Wells, Welcome to our podcast The Efficient Care brought to you by Aarogram. So great to have you on our show.    

Dr. Wells: It's a pleasure to be here, Kash. Good to see you.  

Kashyap: Yeah, likewise. So, Dr. Wells, you know, why don't we start a little bit with a little bit of your background. So, could you just please share with our audience a bit about your background and what you have been up to lately?

Dr. Wells: I'd be happy too. I've been in medicine for about 20 years and for the past 15 years I've specifically been in sleep medicine which I've enjoyed thoroughly. I've worked in both private practice and in academics, and I also happen to be boarded in obesity, medicine, and pediatrics as well.

I like to joke that anybody who's sleepy, even if they're an adult, is reduced to the mentality of a toddler. Because sleep deprivation is definitely a challenge.  

Kashyap: Yeah. Right. That's a very interesting background with a unique combination that you have. So, you said, you were a CMO at a large medical group. Was it a sleep center?

Dr. Wells: Yes in New Mexico, I was Chief Medical Officer of a large group called Omnis Sleep Medicine Centers. It was a 10-bed sleep-lab and we provided comprehensive care for people with sleep problems.  

Kashyap: Yeah. So, in this leadership role, I'm sure you were witness to how things are done and how the care is delivered. So, did you observe some common challenges faced by the healthcare system of that size? If you can share your experience?  

Dr Wells: Definitely, there's challenges at every turn, and I think that because they're multi-dimensional one of the things that you have to have is a lot of agility and flexibility when you're in that type of setting, you know.  

Reimbursement is the first thing that pops to my mind and at the time when I held that position, reimbursements were better than they are today. Also, I think there's a market trend in more home sleep apnea testing, which is of course, associated with a lower reimbursement, even though it provides more access to care and in the face of an 80% undiagnosed sleep apnea burden.  

I think ultimately that's a good thing. Another challenge that I remember is just the idea that sleep is a 24-hour operation. So, during the day there were clinic visits and CPAP setups within our DME section. And then we were running sleep studies at night.  

And because the sleep lab and the clinic occupy two different spaces, there were periods of time when there was nobody there. So, at the sleep lab nobody was there in the daytime unless we were doing an occasional daytime study. And then in the clinic overnight there was nobody there. And I think, you know, at the time I was sort of wrapping up with that role, the vision was to move to a different building where the space could be utilized both during the day and at night. And so that would cut down overhead. And I think that's a really smart model.  

Kashyap: Yeah, that's great. So, looking back, how would you suggest you know, you would address those challenges based on your experience? Would you do something differently?

Dr Wells: That's an interesting question. If I had a magic lamp that I could rub and get my three wishes, I would say that there’s always staffing challenges when it comes to a sleep clinic or any medical clinic for that matter. But particularly in the realm of sleep there's challenges with finding sleep techs that are experienced. In my case, I would vet them for pediatric experience specifically because as a pediatric sleep specialist, it was in my interest to see a lot of children and conduct sleep studies, and it's a different kind of challenge compared to adults. I was also responsible for hiring mid-level providers or advanced care providers, nurse practitioners and physicians assistants, and training them on the job.

And I think if I had another three months to develop a training program outside of the clinic, that would've gone a long way. I think people who are in that role of ACP are really critical to sleep medicine since there's only 7,000 sleep medicine physicians in the whole United States and so we really do need those physician extender roles to address the demand. But training them on the job was a challenge for both me and them. And, if I would've had time developing some materials for that training could have been really helpful.  

Kashyap: So, was it a challenge for clinical roles or nonclinical admin roles or both?

Dr Wells: I would say both, just different flavors. The admin roles are meant to support the operations of the clinic, and I felt that as a decision maker I could enhance that more than maybe a big academic practice. There's lots of layers of admin and red tape. And, then on the clinical side it was a matter of training people on the job accommodating patients and their different requests and needs in a way that still allowed us to keep the lights on and pay the bills.

Kashyap: Yeah, that's very true. So, in your years as a clinician as well as in practicing sleep medicine could you briefly explain the old app between sleep apnea and insomnia and its role in patient diagnosis? Like, what should sleep clinics look out for?

Dr Wells: Yeah, so in terms of what sort of disorders are most common in sleep medicine. The first is insufficient sleep. The second is insomnia, and the third is sleep apnea. And, perhaps more specifically, obstructive sleep apnea. And I think it's relatively common for people to have more than one sleep diagnosis.

So, the overlap between insomnia and sleep apnea is widespread. And recently, there’s a term for that condition which is COMISA- comorbid insomnia with sleep apnea. I think that one of the challenges with this disorder or combination of disorders is that for an individual patient, you need to figure out where to start with their treatment.

In other words, would they benefit most from addressing the insomnia first, or would they benefit from addressing the sleep apnea first and then work on the insomnia? And in some cases, especially for a really motivated and engaged patient, you can do both simultaneously. But if you add a diagnosis of sleep apnea to a person who already experiences insomnia, I think that really can complicate their treatment path. In other words, prescribing a treatment like CPAP can exacerbate their insomnia because now they have to deal with this appliance, the mass touching their face, and the routine changes that are necessary in order to use the equipment and maintain it. So, sometimes it's worth more frequent follow-up visits to address their concerns and to also make sure that you're giving them what they need to sleep better, which is the ultimate goal.

Kashyap: Yeah, I think that overlap between sleep apnea and insomnia is quite interesting and I don't think that is a holistic approach to treating both, right? When you go to sleep center, usually, you are getting treatment for one of the two like having the holistic approach in terms of getting the treatment.

Dr Wells: Right. It's really incompatible with our medical delivery system, right? So, a person who's struggling with two sleep conditions needs more high touch care. They need more access to the expert in sleep medicine. But I think, for me and for others who are in sleep medicine, the wait times to get an appointment are commonly two months, three months up to 4, 5, 6 months sometimes. And when a person does come to the appointment or show up on a telemedicine visit the time is limited, 20 minutes, 30 minutes maybe. And it’s simply not enough to make real and effective change. In fact, it's one reason why I took a pivot recently with my career and I developed an online support mechanism for people who are diagnosed with sleep apnea to get better treated, use their therapy throughout the night, whether that be CPAP or something else, and to also address problems with sleep that CPAP doesn't solve. So, I like to say CPAP treats sleep apnea, but it does not necessarily treat sleep. And so, I created Super Sleep MD as an online resource and a high-touch solution for people who are struggling with their sleep apnea treatment.

Kashyap: Yeah, I think that type of continuous care is definitely in need of the air especially in sleep medicine, whereas there's already overlap with a lot of other comorbidities and now you are mentioning another type of overlap which is the overlap between the sleep apnea and insomnia. Right?

Dr Wells: So true.

Kashyap: So, tell us a little bit more about your program, like you said, you are kind of designing the protocols and integrating with the coaching aspect and treating them as a holistically for sleep health, not just as one of the many conditions, right?  

Dr Wells: That's right. What it boils down to was, I realized, I was getting really good at diagnosing people with sleep apnea but because of the barriers that I mentioned, I couldn't have access to patient in a way that was really meaningful for their treatment.

 And so, I developed this online program, which involves education support and group coaching to allow people to have access to me and my knowledge so that they could apply that in their lives and get better treated in a way that I sort of envisioned when I went into sleep medicine in the first place.

So, on Supersleep MD.com there are four online courses that people can take at their own leisure. I also do group coaching experiences and I host a private Facebook group for people diagnosed with sleep apnea so that they know they're not alone and they can get encouragement and support from other people who are in their same shoes.

Kashyap: Yeah, that's very important work that you're doing in this space. So in your experience, what are some of the most common barriers that you would come across to getting proper treatment for all these conditions? What are the barriers to adherence in sleep disorder treatments?

Dr Wells: I think one of the things that people talk about the most when they struggle with CPAP is the mask. The CPAP mask is arguably the most important piece according to the patient because it's the part of the therapy that touches them, and that's an intimate relationship with the treatment. So, finding the mask that's going to work best is instrumental in their treatment success.

In fact, if you can reduce the number of mask refits, there is a direct relationship with having a successful outcome with CPAP. So, I have a course on CPAP masks that educates people in a way to empower them to choose a mask that would be helpful. Now there are also artificial intelligence and, sort of face mapping software available but I like to also pull the curtain behind how these programs or apps work so that patients can understand it's not terribly complicated once you can know what factors play into the mask that you choose, and then you can tailor that and personalize it for yourself. I think another issue that I've run up against a lot, and it was a little bit surprising for me when I started interacting in the field with people with sleep apnea was that the education about the condition of sleep apnea, about sleep and how sleep affects not only mental health, but physical health, all of that was very fuzzy for most people.

And part of what I do is just to really crystallize for people who are interested in improving their sleep, how sleep benefits health. Again, I'm talking about mental health, emotional health, and physical health, and it's a way to proactively take charge of your well-being. This is what medicine is meant to do. It's not meant to be reactive to disease, and especially where sleep is concerned, you can harness the power of your sleep to give yourself vitality and well-being for the long term and not just react to disease. So, I think that's part of the challenge that I'm trying to solve as well.

Kashyap: And what can the sleep centers do about this within their current setup? Is there anything that would help with communicating the importance of these practices to the patient or something they could employ to encourage patient’s adherence in the treatment plans. Do you have any advice for sleep centers?

Dr Wells: I think this is a big challenge, truly, because there is a dearth of professionals. CBT programs, for example, I think there's challenge of having a one-on-one interaction. With a patient who needs help and to set that up to recur with the frequency that's necessary for real change may be something that's not economically feasible.

And I wish that it weren't the case, but it's part of why I created the platform that I did. It allows me to scale my expertise. To be honest, there was a massive amount of work that I put into my online courses, and I'm drawing from my years of experience when I coach. If sleep centers would like to have access to that kind of care for their patients, they can certainly refer to my program. I think the alternative is to create something of their own in order to help the patients that need that extra high touch support.  

Kashyap: Yeah, that's excellent advice. Do you, like you mentioned, about that a lot of patients have issues with mask and the adherence. So, are there other types of alternative therapies or treatment that are emerging or maybe complimentary approaches to sleep disorder treatments that the sleep center should be aware of?  

Dr Wells: That’s a fantastic question and I actually created a course called 21 plus CPAP Alternatives to answer the question. Oh my gosh, what else is out there? That's something that people are asking for all the time because they perceive that CPAP is the only treatment for sleep apnea, and while it is the gold standard, it simply does not work for everyone. From a sleep center perspective, the challenge is the patient who comes in to have that discussion in their 20- or 30-minute time slot. It's really a difficult thing to lay out all of the options and then answer questions about those choices in the time.

So, what my course does is highlight the most effective and best available alternatives to CPAP therapy for the patient to consume. And within this recording, I've sort of laid out what the criteria for the different alternatives are.

I've highlighted the main decision point, which is a surgical versus non-surgical CPAP alternative. And then I've gone into some detail about how to access these alternative treatments, who they should speak to, what insurance pays for or doesn't, and the time to benefit. And finally, I put a little thing in there that I hope is useful, which is what I call the family test.

So, for each CPAP alternative, I speak to what type of family member it would be appropriate to. Just kind of putting myself in that position of advising someone related to me, which, I think helps to underscore. Would I really recommend this treatment to someone that I love. Who is a qualified candidate?

So, there's more than 21 CPAP alternatives in my course. I've highlighted 10 treatments and I've included PAP alternative treatments, moving from APAP to CPAP, who's a good candidate for BI-PAP and what are the effects or expectations around weight loss as a sleep apnea alternative or sleep apnea treatment alternative?

Kashyap: So, you mentioned that not the same type of therapy or treatment would work for all types of patients. So how do you find that match with the patients? I'm curious about, in your program and your protocol, like what are different types of patients you come across and how do you find a match with the type of treatment they would be most comfortable with, or most effective results they would get from?

Dr Wells: People enter my world at all different stages of sleep apnea and insomnia treatment. In other words, some people are looking for support and help from someone like me right after they're diagnosed or soon after they receive their CPAP therapy or other type of therapy. Others seem to come out of frustration that something's not working, and they've been trying for a while, or perhaps they've had a medical condition that kind of prompts them to improve their sleep.

So, it's really all stages of the sleep apnea treatment life cycle where people enter my world. And I think that one of the challenges that I try to highlight quickly is the effect that a person's mindset has on their choices. So, if you are trying to use CPAP treatment, for example, with a very negative outlook on the therapy and you’re lying in bed with the mask on, just hating every minute of the experience, that all by itself is incompatible with sleep. And so, bringing that to the surface to allow for the fact that you could make a different choice. Helps people to feel empowered, not only in taking control of their sleep, but also to say, I can make a different choice.

I can be curious about whether this new mask is going to work for me. And changing that perspective, changing that emotion as you're lying there at night in the quiet, in the dark, can really start to make some headway in improving sleep, which is again, the whole point. I think for people who want to explore the world of CPAP alternatives, I encourage them to do that.

It is not my mission to get everybody in the world adapted to CPAP but you can do that simultaneously. While you're still acclimating to CPAP or you can do so with the mindset that you would alternate between two treatments or even use two treatments simultaneously for the optimal effect. So, there's lots of ways to get creative with your sleep apnea treatment.

Kashyap: That's very interesting point that you mentioned about the negative outlook itself can influence the effectiveness of the treatment. And that's very interesting and it makes sense because that's how the sleep works and you know that your outlook here, perspective, your mind state, all affects your quality of your sleep. Right? And that's why you have programs like cognitive behavioral therapy to treat insomnia.

So, are there any other recent trends or advancements in the field of sleep medicine that sleep center owners and staff should be aware of?  

Dr Wells: There are, and I keep my finger on the pulse of what's new because, my first introduction to CPAP was seeing treatment in the neonatal intensive care unit, little, tiny CPAPs on babies in their little isolates. It made an impression on me. It's not the sexiest medical treatment in the world. And I think there's a big drive both in the scientific world and in the world of commercialism to come up with alternatives. I like to caution people to be really critical of something that sounds too good to be true because the truth is there's no magic bullet.  

But that I would keep my eye on in the future are surgical procedures that are more and more adept at addressing the multi-level nature of sleep apnea. So, for example, right now we have the inspire treatment, very popular as hypoglossal nerve stimulation addressing the airway obstruction at the level of the tongue.

In my experience, it has not been as successful as reported on the website. And their marketing claims don't address things like how long it takes to get to the surgery itself, the candidacy, the qualifying conditions, and such. But there is good treatment for many people. And there's two others, Hypoglossal nerve stimulation procedures in the pipeline for release very soon.  

And, we have diaphragmatic pacing remedy out there as treatment for central sleep apnea. So, for example, can we use a sonar technique to better predict somebody's response to a surgical procedure? Or can we use a type two home sleep apnea device that would more appropriately diagnose people since you have that brainwave component defining sleep and possibly even sleep stages. Now, this is near and dear to my heart because one of the things I feel passionate about is how women are treated with sleep apnea diagnosis and insomnia. They tend to present differently than men. And our current state of home sleep apnea testing with type three devices. Likely under diagnosis or creates false negative results for women because you're missing that one type of hypopnea scored with arousal.  

Kashyap: It's very fascinating to learn about all these advancements going on in the sleep medicine world but I think we need those advancements especially the care quality. Care is still not prevalent as much as we would like. And one of the things you mentioned about the pediatric sleep care, and I was recently talking to somebody providing the pediatric sleep care and I was really surprised, shocked to know that 40 to 50% pediatric population would have some kind of sleep issues to comorbidities or even outside of that. So, and there's a lot of awareness to be done as well.  So those are very important clinical aspects and the advancement that are happening in that we need in sleep medicine. But then there are also admin and non-clinical aspect to it as well.

Earlier you mentioned that patients must wait for like two months for a 20-minute appointment. So, is it because of the lack of capacity in the system or is it because of the long insurance processes? Could you share what you have found? Why do patients have to go through this such long wait time?

Dr Wells: It's multifactorial for sure. I think there's definitely a shortage of expertise in sleep medicine to accommodate the demand. But there's probably some component of patient motivation that plays into this too. One of the things that I remember really being on top of with was the rate of no-show appointments. So, people just not coming to their sleep appointment because in our society sleep is undervalued. There's this common saying, I'll sleep when I'm dead, or I'm burning the candle at both ends or it's a little bit romanticized, this idea that you can cut your sleep short and it's some sort of evidence that you are overperforming when in fact the opposite is true.

So, it kind of takes me back to what I was saying before about how it can affect sleep problems and can affect your mental health, your physical health, and your emotional health. And that message has not fully penetrated the general public yet. I think if there were people who really valued their sleep and felt better, felt refreshing, felt like it was doing something for them then there would be much more attendance at sleep appointments even seeking out to anticipate sleep problems and address them before they became chronic. So that's something I would like to see in the future for sure.

Kashyap: That's great. You are already doing important work in that regard. That's really great. So, you've been a healthcare provider for all these many years and to provide good quality patient care, you would also know it's not this clinical side to it but also admin side to it and financial side to it, right?  

So, at Aarogram you will believe that being efficient in your business or your practice as a healthcare provider, also means providing more patient centered care and innovating on the go. So, we ask this question and it's a fun one to every guest on our podcast that can you tell us any example of an interesting or even a ridiculous way that you have ever solved a workflow problem in your care setting?

Dr Wells: I think what I'm doing now is significantly different. I don't know of any other sleep physician who has stepped outside of the clinic to make themselves available. For people, to access my expertise, and I do that proudly and with care because I want to make a bigger difference in people's lives beyond what I was able to do behind the doors of my clinic, repeating the same things over and over.

I think there's a really great role for sleep coaching. The Behavioral Sleep Medicine Society has opened that training experience to people and using this type of job role in the clinic I think will be helpful. But the truth is there's also a role for addressing this as a group.

I think that people in my Facebook group or my group classes really enjoy a lot of reciprocity among the members. Just knowing that there are other people out there like me, they've done. They've dealt with this challenge and so can I. They really enjoy that community feeling and where sleep is concerned because everybody sleeps to some degree or another, it's a thing that can unite us and kind of bring us together.

Kashyap: That’s excellent. I never thought of bringing the community aspect to providing patient care. That's very innovative and fantastic. So, thanks Dr. Wells for sharing all this knowledge and your perspective on it. And you are doing very interesting important work and we wish you all the best for that.

And tell us a little where can our audience find you, if they want to get in touch with you?  

Dr Wells: The best place to start is at Supersleepmd.com there they can see what I have available in terms of my course offerings and group coaching experiences. And I do host a private Facebook group for those diagnosed with sleep apnea to ask questions and have that community support.

So doing a simple Facebook search called Super Sleep MD, a Facebook community about sleep apnea with Dr. Wells. It's got a very long name, but the website is probably the best place to start. And I also have some free materials and resources for folks who are interested.

Kashyap: So, I really enjoyed this conversation with you, Dr. Wells. Thank you so much again for coming to our podcast and sharing your knowledge with us. All the Best.  

Dr Wells: Thank you so much Kash. I hope you have a great day.

This podcast series is brought to you by Aarogram.