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Quality Measures for the Care of Patients with Narcolepsy Lois E SPECIAL SECTION pii: jc-00029-15 http://dx.doi.org/10.5664/jcsm.4554 Quality Measures for the Care of Patients with Narcolepsy Lois E. Krahn, MD1; Shelley Hershner, MD2; Lauren D. Loeding, MPH3; Kiran P. Maski, MD4; Daniel I. Rifkin, MD5; Bernardo Selim, MD6; Nathaniel F. Watson, MD, MSc7 1Mayo Clinic, Scottsdale, AZ; 2University of Michigan, Ann Arbor, MI; 3American Academy of Sleep Medicine, Darien, IL; 4Boston Children’s Hospital, Boston, MA; 5University at Buffalo, Buffalo, NY; 6Mayo Clinic, Rochester, MN; 7University of Washington, Seattle, WA The American Academy of Sleep Medicine (AASM) commis- assessment. The third outcome was to reduce adverse events sioned a Workgroup to develop quality measures for the through three steps: ensuring treatment follow-up, documenting care of patients with narcolepsy. Following a comprehensive medical comorbidities, and documenting safety measures literature search, 306 publications were found addressing counseling. All narcolepsy measures described in this report quality care or measures. Strength of association was graded were developed by the Narcolepsy Quality Measures Work- between proposed process measures and desired outcomes. group and approved by the AASM Quality Measures Task Following the AASM process for quality measure development, Force and the AASM Board of Directors. The AASM recom- we identifi ed three outcomes (including one outcome measure) mends the use of these measures as part of quality improve- and seven process measures. The fi rst desired outcome was ment programs that will enhance the ability to improve care for to reduce excessive daytime sleepiness by employing two patients with narcolepsy. process measures: quantifying sleepiness and initiating treat- Citation: Krahn LE, Hershner S, Loeding LD, Maski KP, Rifkin ment. The second outcome was to improve the accuracy of DI, Selim B, Watson NF. Quality measures for the care of diagnosis by employing the two process measures: completing patients with narcolepsy. J Clin Sleep Med 2015;11(3):335– both a comprehensive sleep history and an objective sleep 355. arcolepsy is one of the most intriguing causes of excessive REM sleep on polysomnography/multiple sleep latency test Ndaytime sleepiness. Narcolepsy (with cataplexy) affects (MSLT) (see Table 1).4 approximately 25–50 per 100,000 people in the US.1 The preva- The AASM commissioned Workgroups to develop quality lence of narcolepsy without cataplexy is higher still, yet the dis- care measures aimed at optimizing care for patients suffering order remains under-recognized and under-diagnosed. Presently, from sleep-related disorders, including narcolepsy.5 These qual- narcolepsy treatment varies due to a heterogeneous presentation ity care measures focus on both outcomes and processes since of symptoms and severity of disease among patients. Although both infl uence the care of the patient. Outcomes are often patient narcolepsy is uncommon compared to other sleep disorders, the oriented, whereas processes are typically more controlled by an American Academy of Sleep Medicine (AASM) included it in individual provider. The outcomes and processes detailed in the quality measure process because it is a disorder that generally this report were developed by the Narcolepsy Quality Measures results in signifi cant daily dysfunction when not appropriately Workgroup and received fi nal approval from the AASM Quality treated. The quality measures described in this position paper Measures Task Force and the AASM Board of Directors. include children and adolescents in the targeted patient popula- tion, as 40% to 50% of adult patients report onset of symptoms before age 15 years.2,3 However, the Workgroup notes limitations METHODS in diagnostic testing and lack of level 1 evidence-based treatment studies in the pediatric population. Because of the paucity of clin- Literature Review ical trials and FDA-approved treatments for narcolepsy for both As described in the parent paper5, a comprehensive search pediatric and adult patients, the Workgroup believed that it was identifi ed publications addressing quality improvement, safety imperative to include off-label options in treatment plans. issues, and evidence-based treatment for narcolepsy. All The International Classifi cation of Sleep Disorders, Third searches were limited to articles published between 2002– Edition (ICSD-3) was used as the narcolepsy diagnostic ref- 2013, pertaining to humans, and in English. Publication types erence. The ICSD-3 subdivides narcolepsy into type 1 and 2, such as newsletters, editorials, and case reports were excluded. with type 1 characterized by excessive daytime sleepiness, A total of 306 articles were retrieved for review. hypocretin defi ciency syndrome, and signs of REM-sleep An additional search was conducted to identify clinical prac- dissociation (e.g., cataplexy, hypnagogic and hypnopompic tice guidelines, measures, systematic reviews, meta-analyses, hallucinations, sleep paralysis) and type 2 characterized by and consensus recommendations published by the AASM excessive daytime sleepiness and abnormal manifestations of or other organizations or groups in the National Guidelines 335 Journal of Clinical Sleep Medicine, Vol. 11, No. 3, 2015 LE Krahn, S Hershner, LD Loeding et al. Table 1—ICSD-3 diagnostic criteria for narcolepsy type 1 and 2. Narcolepsy Type 1 Narcolepsy Type 2 ICD-9-CM code: 347.01; ICD-10-CM code: G47.411 ICD-9-CM code: 347.00; ICD-10-CM code: G47.419 Alternate Names Alternate Names Hypocretin deficiency syndrome, narcolepsy-cataplexy, narcolepsy with Narcolepsy without cataplexy. cataplexy. Diagnostic Criteria Diagnostic Criteria Criteria A-E must be met Criteria A and B must be met A. The patient has daily periods of irrepressible need to sleep or daytime A. The patient has daily periods of irrepressible need to sleep or daytime lapses into sleep occurring for at least three months. lapses into sleep occurring for at least three months.1 B. A mean sleep latency of ≤ 8 minutes and two or more sleep onset B. The presence of one or both of the following: REM periods (SOREMPs) are found on a MSLT performed according 1. Cataplexy (as defined under Essential Features) and a mean to standard techniques. A SOREMP (within 15 minutes of sleep onset) sleep latency of ≤ 8 minutes and two or more sleep onset REM on the preceding nocturnal polysomnogram may replace one of the periods (SOREMPs) on an MSLT performed according to standard SOREMPs on the MSLT. techniques. A SOREMP (within 15 minutes of sleep onset) on C. Cataplexy is absent.1 the preceding nocturnal polysomnogram may replace one of the D. Either CSF hypocretin-1 concentration has not been measured or CSF SOREMPs on the MSLT.2 hypocretin-1 concentration measured by immunoreactivity is either > 2. CSF hypocretin-1 concentration, measured by immunoreactivity, 110 pg/mL or > 1/3 of mean values obtained in normal subjects with the is either ≤ 110 pg/mL or <1/3 of mean values obtained in normal same standardized assay.2 subjects with the same standardized assay. E. The hypersomnolence and/or MSLT findings are not better explained Notes by other causes such as insufficient sleep, obstructive sleep apnea, 1. In young children, narcolepsy may sometimes present as excessively delayed sleep phase disorder, or the effect of medication or substances long night sleep or as resumption of previously discontinued daytime or their withdrawal. napping. Notes 2. If narcolepsy type 1 is strongly suspected clinically but the MSLT criteria 1. If cataplexy develops later, then the disorder should be reclassified as of B1 are not met, a possible strategy is to repeat the MSLT. narcolepsy type 1. 2. If the CSF Hcrt-1 concentration is tested at a later stage and found to be either ≤ 110 pg/mL or < 1/3 of mean values obtained in normal subjects with the same assay, then the disorder should be reclassified as narcolepsy type 1. Clearinghouse, the National Quality Measures Clearinghouse, or improving quality of life, but the Workgroup decided that PubMed, EMBASE, PsycInfo, and the Cochrane Library per- they were not applicable to all patients with narcolepsy in clini- taining to narcolepsy (and all associated MeSH terms). Searches cal practice. The AASM Quality Measures Task Force deter- were limited to articles published between 2002–2013, pertain- mined that outcomes that could be tracked through a review of ing to humans with no age restriction, and in English. Other the medical records (reduce excessive daytime sleepiness) were publication types noted above were excluded. Twelve additional designated “outcome measures,” while those that were goals but articles were identified from this search. Workgroup members could not be quantified (improve the diagnosis of narcolepsy and performed “pearling,” where references from full articles found reduce adverse effects) were listed simply as “outcomes.” Pro- through the literature search were examined to identify any ad- cess measures were selected for each of the three outcomes. The ditional relevant evidence, adding 9 articles. technical specifications associated with each of these quality The titles and abstracts of all articles were reviewed by two measures can be found in the Appendix. These specifications members of the Workgroup to identify papers relevant to qual- outline how to calculate an individual provider’s performance in ity improvement, safety and evidence-based treatment. Any meeting these measures using a combination of diagnostic and disagreements were resolved by a third Workgroup
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