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Value Added Polysomnography

By Thomas Mayer posted 04-15-2015 01:31

  

In 1976, I first heard the term “value added.” I was looking for a college and found one in a small Midwestern town. This University’s educators claimed they would add value to my education if I gave them the chance. I did, and I have thought about the value added concept ever since.

Value added philosophers throw around their ideas in several disciplines--education, economy, and marketing to name a few. Education took top spot in my readings on the subject, but I soon discovered that economics and marketing lead the way in value added thinking. Here is a basic definition from a marketing perspective:

The enhancement a company gives its product or service before offering the product to customers. Value added is used to describe instances where a firm takes a product that may be considered a homogeneous product, with few differences (if any) from that of a competitor, and provides potential customers with a feature or add-on that gives it a greater sense of value (http://www.investopedia.com/terms/v/valueadded.asp).

I soured on the exact terminology about fifteen years ago when I discovered that Marxists had commandeered value added, or perhaps claimed its genesis as their own; but that is a tough discussion and one left to much more intelligent people than me. As such, I think I will just change the terms slightly and ask, “How can technologists add value to the basic product called polysomnography?”

Adding Value to Billed Services

Diagnostic testing is often mysterious to the typical consumer of those services. Polysomnography, in particular, can be daunting with its 25 or more connections--leads, electrodes, belts, sensors, etc. Almost all of our patients ask a version of the dreaded sleep question at some point in the set-up: “How am I supposed to sleep with all these things on me?” or “I thought this was a sleep study—are you trying to keep me awake on purpose?”

An educated patient is more likely to appreciate the value of such an intricate study, but the silent tech misses many opportunities for education. The technologist who takes time to explain lead placement around the eyes or in the hairline gives valuable information and creates hope that solutions to their problems may actually end up in the physician’s hands because of this test. When a patient believes that the test—positive or negative outcome—is valuable, they are more apt to remit payment when the bill or co-pay comes due.

Adding Value to Physician Contact

I have worked around physicians for thirty years and worked in collaborative disease management settings with them for over nine of those years. I have seen them deftly juggle questions from all sorts of patients. However, when physicians get very good questions from well-informed patients they can really shine. The intersection of knowledge on the part of practitioner and patient prompts a download of information that enhances care. Related to the previous point, a patient who leaves the sleep lab with a thorough understanding of what the test may reveal is more likely to look forward to the physician visit afterward. That can reduce no-shows in the doctor’s office, adding value to the whole experience from office visit, to diagnostic testing, and back to the office.

Of course, we technologist must practice this valuable art with a few caveats. Stay within the boundaries of explaining the purpose of the testing tools, and relegate our explanations to pre-test operations. Zipped lips are the rule of the morning. Diagnosis is the doctor’s venue, and a good test explanation will promote the doctor’s visit.

Adding Value to Ongoing Care

The mask. What else need we say? That interface is a conundrum and the most common reason for failure with CPAP. Acclimation to CPAP and the right mask choice is paramount. The technologist who pays attention to the mask fitting just might play a part in keeping that patient on CPAP for the first several weeks—the most important weeks—of CPAP use.

Finding Value in the Mundane

We sleep techs spend our nights concerned about sleep positions. We observe the degree to which the various positions of sleep produce sleep disordered breathing, snores, cardiac arrhythmias, or limb movements. Certain positions quite often produce more sleep disruptions than do others. However, we focus most intently on supine sleep because obtaining REM in supine position is the gold standard, especially when we claim that we have found optimal CPAP pressures.

This question of supine sleep stirs up a lot of controversy. Do some technologists go overboard with their insistence on supine sleep? Does that insistence on supine sleep over estimate the degree to which a patient suffers sleep disordered breathing? Can we claim optimal CPAP pressures based on supine sleep when some patients simply never sleep in that position at night? These are legitimate questions. Perhaps the sleep physician is the only one who can answer the questions. Sometimes the physician bases his or her decision on the sleep technologist’s note, for instance: “The patient achieved supine REM sleep for twenty minutes on a CPAP pressure of 12 cmH2O with no events.” There is nothing wrong with this note, but does it pack the value added punch?

A few questions come to mind with regard to the aforementioned statement. Did the patient only achieve REM sleep while supine? Did the patient display positional changes during sleep? Did the patient turn spontaneously supine during CPAP treatment time? Did REM in other positions require significantly less pressure than those required while supine? These are small observations, but the question of spontaneous movement during sleep can play a role in how the sleep physician makes a decision on behalf of the patient. That decision is often collaborative in nature, and the physician might trust a patient to utilize positional therapy along with a lesser pressure setting if that patient really showed no inclination to turn supine during testing. Such decision-making processes are never perfect, but the technologist can lend a helping hand by going a step beyond stock observations, adding value with peripheral information such as “The patient turned supine spontaneously during treatment time.”

A Value Added Article

Technologists everywhere probably add value to sleep testing in ways that employers simply never see and rarely ever market. A sleep technologist’s commitment to applying his or her knowledge of even simple things can result in a product that is not run-of-the-mill, and technologists everywhere add value to sleep study results in diverse ways. Sleep techs are welcome to add value by making this an interactive article through the following comments section.

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