Which older adults receive sleep medicine specialty care? Predictors of being seen by a board-certified sleep medicine provider.

STUDY OBJECTIVES: To characterize older adult Medicare beneficiaries seen by board-certified sleep medicine providers (BCSMPs) and identify predictors of being seen by a BCSMP.

METHODS: Our data source was a random 5% sample of Medicare administrative claims data (2006-2013). BCSMPs were identified using a cross-matching procedure based on national provider identifiers (NPIs) available within the Medicare database and assigned based on the first sleep disorder diagnosis received. Sleep disorders (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome) were operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. The number of sleep disorders per beneficiary was computed and compared between BCSMPs and non-specialists. Logistic regression was employed to identify medical and demographic predictors of being seen by a BCSMP.

RESULTS: A total of 57,209 beneficiaries received one or more sleep disorder diagnoses during the study period. Of these, 1,279 (2.2%) were initially diagnosed by a BCSMP. Relative to individuals seen by non-specialists, beneficiaries treated by a BCSMP were more likely to have ≥2 sleep disorders (9.0% vs 24.1%, p<0.001). The most common diagnosis assigned by BCSMPs was obstructive sleep apnea (OSA; 70.4% of patients seen by BCSMPs were diagnosed with OSA). The most common diagnosis assigned by non-specialists was insomnia (48.2% of patients seen by non-specialists were diagnosed with insomnia). In a fully adjusted regression model, male sex (odds ratio (OR) 1.53; 95% confidence interval (CI) 1.36, 1.72), asthma (OR 1.50; 95% CI 1.30, 1.73), and heart failure (OR 1.24; 95% CI 1.10, 1.41) were positively associated with being treated by a BCSMP. Conversely, depression (OR 0.85, 95% CI 0.73, 1.00), anxiety (OR 0.69, 95% CI 0.59, 0.82), Alzheimer's and related dementias (OR 0.80, 95% CI 0.65, 0.99), and anemia (OR 0.88, 95% CI 0.78, 0.99) were associated with reduced likelihood of being seen by a BCSMP.

CONCLUSIONS: Relative to older adults seen by non-specialists those seen by BCSMPs are more medically but less psychiatrically complex and diagnosed with a greater number of sleep disorders. These results suggest the possibility that medically complex patients are referred for specialty care, whereas psychiatrically complex patients might be seen at the non-specialist level. Further, these results demonstrate the value of board certification in sleep medicine in caring for complex sleep patients.