Sleep medicine practice across geopolitical boundaries.

Access to medical care for sleep disorders can vary greatly within and across geopolitical boundaries. Each local authority controls licensing and requirements to practice sleep medicine. Administrative and clinical practice can range from carte blanche (any physician can diagnose and treat any and all sleep disorders) to a very narrow restriction (specialist treating only specific disorders). In some countries, sleep medicine has attained recognized specialty status, while in others the specialty is self-designated. Finally, in some localities recognition is non-existent. Notwithstanding our general awareness of such diversity, very little systematic data exist. In this issue of Sleep Medicine, Dr. Fietze and colleagues examine data from a large multicenter group [1]. They document diagnostic and management practices for obstructive sleep apnea in 21 European countries and Israel. For those of us curious about how sleep medicine is practiced elsewhere, this article provides a panoramic vista stretching from the North Atlantic to the Straits of Gibraltar and from the Barents Sea to the Eastern Mediterranean. Reflexively we compare differences and similarities between our day-to-day routines and challenges and those facing colleagues on distant shores. So we read with personal interest. However, while interesting, these data provide a baseline against which we can measure change. Purists may wish to debate the nature of the sample and how well it represents the actual state of affairs, but the authors describe the process used and methods are transparent. Using a pair of questionnaires (accompanied by a sample for guidance), the authors show us a snapshot of our rapidly evolving field. This documented state-of-clinical-practice in 2010 supplies quantitative metrics that will enable future appreciation of how things evolved. For example, at present computerized automatic polysomnographic scoring is used in six of the 22 countries and in every such case visual scoring is also used. The Standardized Manual edited by Rechtschaffen and Kales [2] continues as the basis of sleep stage scoring in seven countries, and the American Academy of Sleep Medicine rules [3] are acknowledged as the basis for polysomnographic scoring of at least some sleep phenomena by all of the countries surveyed. Referral pathways, clinical approach, diagnostic methods, the use of positive airway pressure therapy, and clinical follow up appear to have coalesced fairly consistently across national borders. By contrast, clinical provider requirements, general approach for titrating positive airway pressure, and reimbursement were more varied. Like with a family picture album, we may look back with wonderment asking: did we really look like that back then? But perhaps even more important, this work provides a first model for seeing a broad spectrum of our field. These data, like most baseline measurements, are mainly descriptive. Nevertheless, this systematic, repeatable methodology, described in detail (with the evaluation instrument included) supplies a ready-made tool for further exploration. Many possible studies extending these data are easily envisioned. Future research in Europe can map practice changes with direct comparison to findings described here. The general model (and questionnaires) developed for this work focuses on obstructive sleep apnea. With appropriately adapted questionnaires, this approach can be applied to gather comparable information about other major sleep–wake disorders (e.g., insomnia). Most importantly, this model and identical (or as identical as translation allows) survey instruments can extend our peek at contemporary sleep medicine practice worldwide. South America, Asia, Oceania, and Africa are waiting.