Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697636584155.pdf (Australia)
Parliamentary Inquiry into Sleep Health Awareness – Aspects related to Obstructive Sleep Apnoea, the commonest medical sleep disorder Summary of key challenges 1.

Obstructive sleep apnoea (OSA) is highly prevalent on a public health scale.

There is compelling evidence of benefit to support the identification and treatment for those with significant OSA related symptoms.

The evidence of benefit for milder or minimally symptomatic forms is limited.
This poses challenges for clinical decision making by health care providers to ensure their clinical determinations maximise healthcare benefits and minimise over and under diagnosis/treatment.

It highlights the importance of further research and training into the clinical impacts of this disease – both in terms of clinical effectiveness and healthcare service delivery.

2.

The prevalence of OSA in the community is sufficiently large that speciality services are unable to adequately address the problem.
This is particularly acute in peripheral city centres, regional, rural and remote centres, for children and minority groups – where access to services is difficult.

3.

There is inadequate training in sleep medicine for General Practitioners and no co- ordinated GP-led model of care currently in place.

As a consequence, there is an over- reliance on commercial, industry-led treatment pathways which means commercial and healthcare priorities do not always align.

4.
4.

The evidence of benefit for treatment of OSA on cardiovascular health remains unclear and represents the most significant knowledge limitation necessary to inform wholistic treatment approaches.

5.

There is no co-ordinated national sleep disorder registry/database to monitor healthcare outcomes 6.
There is no nationally co-ordinated mechanism for the prescription and reimbursement of CPAP treatment, a highly cost-effective treatment for OSA which adds healthy life years and provides society with a net cost saving.

Recommendations 1.

National consumer survey Evaluation and treatment delivery pathways for OSA vary significantly.

Patient experience and perceived outcomes from these disparate models is currently unknown, however is essential to informing optimal clinical care pathways.
A national survey would evaluate the patient’s experience with the clinical pathway they accessed, their understanding of their diagnosis and treatment choice and Inquiry into Sleep Health Awareness in AustraliaSubmission 50 adherence and overall level of satisfaction.

This information critical for informing the design of optimal care delivery pathways moving forward.

2.
2.

Development of evidence based clinical care pathways involving the co-ordination of sleep specialists, primary care general practitioners, technical staff and nursing practitioners.

“Hub and Spoke” models are envisaged to provide specialist care pathways for more complex cases and to provide back up support and ongoing professional development for primary care practitioners, while enabling greater involvement of primary care for more simple cases.

3.
3.

Primary care practitioner upskilling It is proposed that with adequate training and specialty support, primary care practitioners could manage a large component of the burden of OSA evaluation and management.

Underpinned by a national guideline, an online training curriculum would be established for primary care practitioners, endorsed by the Australasian Sleep Association.
Primary care practitioners completing the training would be incentivised to manage OSA and potentially other sleep disorders with specific item numbers that generate a small amount of additional remuneration.

This model is considered to be especially important to improving access to care in regional and rural areas, and for minority groups.

4.

Affordable access to OSA treatments Australia has some of the highest purchase prices in the world for CPAP devices.
These devices are not subsidised for lower income earners and their prescription is unregulated.

Lack of regulation for prescription of CPAP is believed to contribute to clinical pathways geared toward treatment sales that risk a duality of interest between health outcomes and commercial goals.
Currently there is no formal requirement for medical devices to be prescribed by medical practitioners, and a process to establish such a system is likely to be onerous and risks un-intended consequences around access and affordability.

However, a federally based government subsidised CPAP program for low to middle income earners would significantly improve affordability.

Health economic evidence shows this would have a net positive economic and health benefit for society.
Modelling is recommended to predict the extent of cost savings from better training clinicians applying appropriately targeted diagnosis and treatment pathways that would offset costs of this medically managed, subsidy scheme.

Access to such a program would require prescription by medical and nursing practitioners who have received accredited sleep medicine training (as discussed in point 3) to ensure clinical decision making was in-line with established guidelines.
Furthermore, a tendering process with CPAP manufacturers and distributors who would supply to this scheme, would see wholesale costs reduced.

5.

Funding for the establishment and maintenance of a national sleep disorder database and registry, beginning with OSA and expanding to include other sleep disorders in subsequent iterations.

This will enable outcomes to be adequately monitored and will inform improvements in models of care, clinical guidelines and health practitioner training programs.
Inquiry into Sleep Health Awareness in AustraliaSubmission 50 6.

Funding priority for research into the important ongoing clinical uncertainties in sleep medicine.

This includes research into: the impact and outcomes of OSA (particularly cardiovascular and cognitive), better understanding of the clinical expression of OSA (e.g.
why some patients experience sleepiness, some tiredness and fatigue, some become depressed, while others are minimally symptomatic), better prediction of treatment success for CPAP alternative treatments and research into novel treatment approaches for those who are unable to use or benefit from currently available therapies).

It is proposed that Sleep be regarded as a National Health Priority area of research and dedicated funding provided from the Medical Research Future Fund (MRFF).

7.
7.

Avoid and remove barriers to the appropriate investigation and management of sleep disorders.

Foster access to clinical review and sleep disorder testing, both in-home and sleep laboratory.

This includes making sleep studies available to bronze and silver categories of private health insurance, noting the recent MBS review and restructuring of MBS item numbers have put in place the appropriate triage mechanism for different types of testing.

Issues in relation to Terms of Reference: 1.


The potential and known causes, impacts and costs (economic and social) of inadequate sleep and sleep disorders on the community; • Sleep disorders are among the most common of all medical problems in the community • Obstructive sleep apnoea (OSA) is a disorder characterised by recurrent episodes of upper airway collapse during sleep.

These episodes trigger arousals from sleep and expose individuals to sleep disruption.
In addition, breathing efforts against a blocked airway lead to recurrent falls in blood oxygen levels and increases in the adrenaline based stress response system • Prevalence of the major medical sleep disorders (which includes obstructive sleep apnoea) is 22.4% in the general Australian population(1) • 8.3% of the Australian population have moderate or severe obstructive sleep apnoea (OSA), a much higher percentage have mild OSA (over 25%)(1) • 19.1% of the Australian population report excessive daytime sleepiness, either due to medical sleep disorders, mental health disorders or chronic insufficient sleep(1) • The major risk factor for OSA is obesity Inquiry into Sleep Health Awareness in AustraliaSubmission 50 • OSA is associated with an increased risk for: depression, workplace and motor vehicle accidents (2), work absenteeism, workplace productivity, high blood pressure (3), cardiovascular disease & stroke (4), dementia, and early death (4) • The financial cost to the Australian community of medical sleep disorders and inadequate sleep is $26.2 billion per annum.
There is also $40.1 billon in loss of well- being, for a total of $66.3 billon per annum(5) • Sleep disorders remain underdiagnosed but are highly treatable.

There is compelling evidence that treating symptomatic forms of OSA improves sleepiness and has a beneficial impact on performance, safety, productivity, quality of life and mood.

It remains unclear whether treating OSA reduces cardiovascular risk and if so, by how much.
This is an area requiring urgent ongoing research • The primary treatment for OSA is continuous positive airway pressure (CPAP).

It is safe, effective and highly cost effective.

Treating OSA with CPAP leads to a net cost saving in society of $857 per person treated(6).

Treating OSA with CPAP saves money and adds healthy life years.

Despite this, there is no nationally co-ordinated reimbursement mechanism for CPAP treatment.
• The limitation of CPAP treatment for OSA is that up to 50% of patients recommended to use CPAP cannot tolerate it in the long term.

Alternative treatments include mouthguard devices, surgery, body positioning and weight loss.

These are all less effective overall compared to CPAP.

Some benefit and others don’t.

Predicting who will benefit from these treatments is difficult and requires further research.

2.
2.

Access to, support and treatment available for individuals experiencing inadequate sleep and sleep disorders, including those who are: children and adolescents, from culturally and linguistically diverse backgrounds, living in rural, regional and remote areas, Aboriginal and Torres Strait Islander; • Approaches to managing OSA in Australia have evolved over time in non-systematic fashion as resources have struggled to keep up with the high burden of disease.
The field now comprises various diagnostic and treatment models, including specialist physician, general practitioner and industry led pathways • The heterogeneity of this system makes it difficult to strategically adjust or focus management practices to align appropriately with contemporary scientific evidence and healthcare needs • The rate of increase of diagnostic services in Australia for ambulatory sleep studies approximates 17% per year and in-laboratory testing at 8% per year.
Given the burden of disease identified by population studies, this high level of activity is not unexpected or unwarranted.
However, the clinical care pathways that support these services have inconsistently evolved and can be adversely affected by high rates of insufficient training among healthcare providers and distortions driven by commercial incentives • Furthermore, there is no co-ordinated mechanism to systematically monitor the healthcare outcomes from the current forms of clinical activity in the assessment and management of OSA.
National registries or databases would serve to inform Inquiry into Sleep Health Awareness in AustraliaSubmission 50 clinical practice and policy makers to assist the design of clinical pathways and funding priorities for this large-scale public health burden • Although people living in major city centres benefit from better access to adult sleep medicine specialists, sleep clinics and hospital sleep services than their regional counterparts, significant access constraints remain.
Public hospital clinics have long waiting lists both for clinic appointments and sleep testing, and patients will not uncommonly wait many months to more than 1 year to progress through the service.
Hospital clinics in particular are focused on OSA and other breathing related sleep disorders, and they are not well set up to manage the “non-respiratory” sleep disorders such as insomnia • Those living in the peripheral suburbs of major cities, regional, rural and remote areas are severely underserviced and find it difficult to access sleep medical care.

There are fewer sleep specialists in these areas, regional and rural hospitals provide limited sleep medicine services compared to major city hospitals.
This lack of access to specialist sleep medicine care is particularly extreme for children and adolescents, and Aboriginal and Torres Strait Islanders.

• This poor access to sleep medical services has meant that the void has been filled by the sleep apnoea device industry.

Companies selling CPAP perform a large volume of treatment in these peripheral areas.
This is a major problem because these patients are: 1) not able to easily access independent medical device, removed from the desire to sell equipment to the patient (commercial and healthcare priorities may not always be aligned); and 2) have their other sleep problems (e.g.

insomnia) ignored and untreated 3.


Education, training and professional development available to healthcare workers in the diagnosis, treatment and management of individuals experiencing inadequate sleep and sleep disorders; • Given the prevalence of sleep disorders, there is a severe shortage of sleep medicine specialists, but more particularly, a paucity of knowledge and training in sleep disorders among general practitioners (GPs) and other health care workers.
• There is minimal teaching in sleep disorders and sleep health in medical schools and post graduate doctor training programs • Currently, management of sleep disorders is primarily by sleep specialists.

This is not sustainable moving forward in order to provide access to all those in the Australian community with sleep disorders.
• Barriers to general practitioners becoming more involved in the sleep medical care include: lack of knowledge and training, lack of time given the short consultations in primary care, lack of reimbursement mechanisms (this disincentivises GPs to spend the time required to upskill and to provide the complex consultations), lack of nurse practitioner pathways (who could undertake a lot of the work involved).

4.
4.

Workplace awareness, practices and assistance available to those who may be impacted by inadequate sleep or sleep disorders, with a focus on: rostering practices for shift workers, heavy-work requirements, and the transport industry as compared to international best practice; and Inquiry into Sleep Health Awareness in AustraliaSubmission 50 • See other submissions specifically addressing this topic 5.

Current national research and investment into sleep health and sleeping disorders.
• Australian researchers are recognised world leaders in sleep medicine research.

Many of the major developments in sleep medicine (e.g.

the invention of CPAP) have been from Australia.

This is despite very low comparative levels of research funding.

Australian researchers are well placed to address the major gaps in sleep medicine knowledge and medical care delivery, if they have adequate funding to do so.
Australian researchers have a strong history of commercialising this success to the ongoing economic benefit to the community.

Examples of successful biotech companies include Resmed and Compumedics • Current research funding from the NHMRC biases against sleep medicine.

It shares a funding panel with respiratory medicine and pharmacology.

It is the smallest of these 3 fields in terms of research grant applications and hence only a small number of research ideas are funded, regardless of overall quality.
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