I am in Seattle this week, attending the annual meeting of the Associated Professional Sleep Societies. I was at a presentation by Dr. Lisa Meltzer of the Children's Hospital of Philadelphia yesterday afternoon which I found very interesting, and have reflected upon several times since hearing it. In her study, Dr. Meltzer reviewed the charts of over 150, 000 children in the greater Philadelphia area, to assess how many of them had been diagnosed with any form of sleep disorder. She found that in fewer than 4% of the charts was mention made of any form of sleep disturbance or disorder, despite the findings of multiple studies which have demonstrated a prevalence of sleep disorders in between 25-37% in children under the age of 18. She found that the frequency of diagnosis varied, depending upon who saw the children. Physicians in training (residents and fellows) made the diagnosis most often, followed by attending physicians (those who have completed their training), and then by nurse practitioners. This pattern of apparent under-diagnosis was not present for other illness looked at in the same charts, whose prevalence rates were compared to their known prevalence rates in the general population, and which were found to be similar, indicating that it was not a problem of sloppy record keeping.
Dr. Meltzer's explanation for her findings was that there is likely not enough awareness amongst general pediatricians to ask about sleep as part of the routine well child office visit. She felt that the higher diagnosis rate made by more junior physicians reflected growing awareness about the very high prevalence of sleep disorders in children, and that this should encourage sleep specialists to redouble efforts to further educate fellow practitioners and the general public about the importance of sleep for children.
Dr. Meltzer's conclusion may be correct, but I cannot help wondering if her findings reflect not a lack of awareness of this issue on the part of health care professionals, but instead a simple, cold economic reality. As the economy undergoes the worst recession in more than 70 years and expenses are being slashed everywhere they can be and then some, people are starting to really notice just how much treasure our health care system consumes. As a result of efforts to reduce costs, re-imbursements to physicians for services are being reduced, and denials by insurance companies to pay for many services, procedures and tests are increasing. At the same time, however, the expenses borne by physicians continue to rise. This means that more patients need to be seen, and more work done by the providers just so they can keep their heads above the water financially.
In my own state of Massachusetts, an additional factor has come in to play since universal health care legislation was enacted in 2006. While this gave hundreds of thousands of uninsured citizens of the commonwealth access to health care, the number of primary care providers did not increase in proportion to the sudden jump in demand, which meant that it became very difficult to find a new primary care provider, or to book an appointment with one for a well-visit less than several months in advance. This outcome was not anticipated when the legislation was passed, and it is something well worth considering especially as major healthcare reform looms close on the horizon.
The end result of all of this is that physicians need to work longer hours and see more patients, leaving them less time to devote to each one. This leads to frustration and bitterness for patients and their families, as well as for the doctors and nurse practitioners who feel that they are not able to provide the full and comprehensive care they believe their patients deserve. Quality becomes compromised, as there is simply not enough time in a 15 minute appointment to discuss healthy eating habits, drug and tobacco avoidance, immunizations, seatbelts, exercise, bicycle helmets, sleep, and many other important topics.
This, I believe, is the true implication of Dr. Meltzer's findings: our health system isn't functioning as it should, and the under-diagnosis of sleep disorders in Philadelphia is only one symptom of a much larger problem. All of us need to remember this, and consider how we can improve the quality of care we deliver to our children even as we go about trying to reduce costs and make the health care system more efficient.
