When was the last time someone described what you had done as brilliant.

I have just returned from a brief trip to London where I participated in the Sleep Apnoea Trust Association's annual meeting, held John Radcliffe Hospital in Oxford (pictured here on the left).

I managed an invitation to speak at their annual meeting after a long correspondence with one of their trustees (Rob Holt) and their Chairman (Frank Govan). The ASAA has been on the mailing list of their newsletter for many years and I saw this visit an opportunity establish a personal connection with their leadership.

I had a wonderful time. Frank and his wife Wilma hosted me on the day I arrived. We had a number of long talks about operating a non-profit (read getting money) and about areas where we have mutual interests. Another guest at their home was Jean Gall who is the Chair of the Sleep Apnoea Scottish Association.

The next day was onto Oxford and SATAday (I love the name). The meeting drew about 300 people from all over England. It is similar to an A.W.A.K.E. meeting... with medical speakers (in this case Prof. John Stradling) and others from the hospital. There was an equipment fair and since there is no DME/HME arrangement in England - the manufacturers can sell direct to the patient (with proper documentation, ie prescription). Lunch was also served and there were "chatshops" or break-out sessions in the afternoon on specific topics.

I spoke in the morning session, following a presentation by Professor Stradling. My topic was OSA in the USA.

My title slide had two pictures of Jimmy Stewart. One from the Alfred Hitchcock film "Rear Window" and the second from the Frank Capra film "It's A Wonderful Life." I told the audience that many times in my capacity as executive director of the ASAA that I felt alternately like the Jimmy Stewart character in "Rear Window"; he was stuck watching a murder being committed and was somewhat powerless to do anything, I am stuck watching apnea patients not get the care they need at the hands of unethical sleep testing facilities or uncaring homecare companies (though unlike him, I don't have Grace Kelly to keep me company). On the other hand, sometimes I feel like Jimmy's character George Bailey in "It's a Wonderful Life" because despite all the bad stuff and my despair, the association has a positive influence and the apnea patient would be worse off if we weren't there.
My presentation had two objectives: providing some insight into healthcare in the United States in general and to provide some specific insights about the treatment of OSA for the American patient.

My brief discussion of the healthcare reform debate began by saying there are a number of challenges to reforming the system. The first is captured by a quote attributed to Princeton economist Uwe Reinhardt, Ph.D: Americans are the only people who think death is a failure of the healthcare system. The second has to do with the attitude towards the problem of obesity. Here I trotted out a slide that has become iconic on obesity. The audience had a good laugh on both comments.

The second part of my talk compared the way sleep apnea diagnosis and treatment are provided in the United States versus England. And while there maybe some shortcomings with the National Health Service, though less now that the National Institute for Health and Clinical Excellence has weighed in on the subject of treating sleep apnea; at least there is less chance of a patient falling through the cracks because in the U.S. in some cases the diagnosis is delivered by one medical professional and treatment is delivered/"monitored" by another possibly leading to what I called a bad Alfonse and Gaston routine.

The second point I made was concerning the technology to treat sleep apnea. The audience might feel a bit jealous that the devices available to treat sleep apnea in the United States is latest and greatest available compared to what is provided to them. But in actuality, the technology is like the bullet train passing Mt Fuji in Japan and getting ahead of the physician who prescribe them. The patients who consult the Internet learn about these devices and demand prescriptions specifying these machines, without the physician fully understanding if this is the

appropriate therapy for the patient.

My final point in this part of the talk was on adherence or compliance to therapy. For a number of different reasons adherence to therapy particularly with CPAP is not great averaging around 50%. Though this rate of adherence is comparable to adherence to therapy of other chronic diseases. That said, people are always looking for additional reason to use the CPAP... beyond that fact that it improves the quality and quantity of your life. I pointed out to the

audience the result of a recent study conducted in the U.S. showing that using the CPAP takes a stroke off your golf score and that an improved golf score was motivation enough to improve compliance with therapy... everyone wants to be Tiger Woods.

The audience was very appreciative and many made a point of coming up to me afterwords to express thanks for coming all that way to speak. They said the talk was "brilliant" and they usually had a story to share about a relative in the States.

I was happy to receive the invitation and would be happy to return at some point in the future to talk about sleep apnea diagnosis and treatment when healthcare reform is done.

Comparative Effective Study on sleep apnea

In the beginning (prior to 1978), there were two treatment options for obstructive sleep apnea: radical weight loss program and a tracheotomy. Then there was the UPPP. This was up until the introduction of Continuous Positive Airway Pressure, which according to the inventor was intended to be a stopgap treatment.


CPAP was so effective that it replaced surgery as the first line ( it became the "gold standard") treatment for OSA. Since its invention, there have been variations on UPPP using laser and ablation, which have had varying levels of success. Also introduced were other types of surgical interventions that are intended to manage the tongue.


Also developed with the intent of managing the tongue and enlarging the opening to the upper airway through moving the jaw forward are oral appliances - tongue retaining devices and mandibular advancement devices.


There are also more radical surgical procedures... breaking and moving the jaw forward and bariatric surgery.


Finally there are new therapies now the horizon such as Provent and Aura6000.

How do we establish the relative merits of these various therapies? What does it mean that they "work"? Is it the elimination of snoring and/or reduction of Apnea-Hypopnea Index and/or lowering blood pressure and/or reduced insulin resistance and/or improved psychomotor vigilance and/or improved cognitive functioning? Are we missing something if we stop at saying - four hours per night for 70% of the nights over a 30 day period.

It is difficult to measure quality in healthcare with respect to OSA if the benchmarks themselves vary from person to person.

It may be that the science of treating sleep apnea is still too young to have a specific number similar to diabetes, where if your HA1C is above or below a certain point there is a problem.

Today, I don't offer any answers. Today I only ponder.