All Night, Every Night: California dental specialist takes on obstructive sleep apnea

This article prviously appeared in the AARCTimes January 2015 written by Debbie Bunch

 

all night every night Dr Bradley Eli San Diego Sleep Dentist and Team

(Left to right) Robyn Forbes, CMA; Majel Carnell, CRT;

Bradley Eli, DMD, MS; George Lannon, RRT; and Gensis Lugo, RN

 

Bob is like a lot of patients with obstructive sleep apnea (OSA). He never suspected he had it and only went to the doctor after his wife saw a news report about the signs and symptomsCPAP mask fitting

on TV and said, “Honey, that’s you.” He reluctantly agreed to an overnight polysomnogram and even more reluctantly agreed to give the positive airway pressure (PAP) device the doctor prescribed for him a try. A durable medical equipment (DME) provider came out to the house and set him up on the equipment. He went ahead and put it on that night, only to ditch it two

hours later, telling his now frustrated spouse, “I’m not wearing that dang thing.” Respiratory therapists who treat OSA patients are all too familiar with that scenario; but at a specialty sleep treatment practice with offices in San Diego, CA, they’re finding some better solutions to the problem of treating this potentially life-threatening condition. Bradley Eli, DMD, MS,

and his colleagues, Majel Carnell, CRT, and George Lannon, RRT, treat OSA as the lifelong condition it is for most people, offering them a full range of treatment options and theongoing care and support they need to achieve good sleep all night, every night.
With the help of two respiratory therapists on staff, Dr. Bradley Eli is making a difference in the lives of people with OSA.

Bradley Eli and Majel Carnel

Dr Eli with Majel Carnell CRT

 

Multidisciplinary approach
Dr. Eli says his interest in treating patients with OSA grew out of his expertise as an orofacial pain specialist. “Orofacial pain specialists have extensive experience and insight in

treating OSA and other sleep breathing disorders, in part because the patients we see with chronic orofacial pain conditions often struggle with compromised sleep,” he explains. “We

help patients find the treatment strategies to manage their pain condition over time, and sleep treatment options are a key component to overall health and quality of life.” He and others

in his specialty have also learned that what works for one patient may not work for another, and they are equipped to work with patients over time to find the right solution for them.

Sometimes that means combining treatments into a customized and individualized strategy. “For treating patients diagnosed with OSA, our offices use a multidisciplinary, patient-

centered, disease-management model of care,” says Dr. Eli. In addition to the two respiratory therapists, the practice includes a medical assistant, certified sleep coordinator, integrative

health care provider, and health psychologist. “This was modeled after the training I received in the pain field and is used in the treatment of other lifelong conditions.” He believes a big

team is necessary because OSA simply requires more than an initial sleep test followed by a prescription for a PAP device or dental appliance. There’s a wide range of treatment options

available today, and patients have the right to know what they are and use more than one if that’s what it takes to achieve a good night’s sleep. “Our group provides all of the currentlyGeorge patient consult

available non-surgical treatment options that are in the marketplace — this means all forms of PAP therapy, several options for oral appliances, nasal dilators, pillows, sleep and stress

management coaching, weight management, and medication. I’m sure I missed a few, but suffice it to say if it’s out there, we do it.” For OSA patients who opt for surgical procedures, the

practice coordinates pre-surgical treatment planning, post-surgical pain control when needed, and ongoing post-surgery management. “Most surgical procedures are not

curative;therefore, improved apnea is still monitored and treated as needed, also as a lifetime illness,” says Dr. Eli. His practice also keeps tabs on factors like increased BMI, age, and

additional diseases that may require updated testing. He credits this comprehensive approach, coupled with ongoing one-on-one care, for the high compliance rates achieved by patients

— currently 96% for those on PAP and 97% for those with oral devices (self-report).

 

PAP equals RTs
Despite the complete range of OSA treatments offered by his practice, however, Dr. Eli is quick to point  out that PAP therapy is still the gold standard for the condition; and he tries to get

his patients to begin with it whenever possible. That’s why he decided to bring respiratory therapists into his office. “I needed dedicated RTs who would work with our patients

immediately, in the first few weeks of delivery, to troubleshoot and coach,” he says. “I believe that the patient’s health is paramount; and in terms of OSA treatment, we try to get it right

as soon as possible, before a patient stops caring or trying.” Majel Carnell was the first to come on board. “I became aware of this opportunity through a friend,” she explains.

“I love a challenge, and Dr. Eli is a challenge-driven type of provider — constantly pushing forward with the ‘what would be best for the patient’ mentality.” After discussing ways to best

serve their patients, she says Dr. Eli realized the value of opening and maintaining a DME company focused solely on sleep and put her in charge of the effort. It proved to be a bigger job

than she ever imagined — Carnell says she was amazed at the paperwork associated with becoming an accredited DME provider — but was well worth the investment in time,

energy, and money. She says, “I was astounded by what Dr. Eli has been willing to go through to get this done but am very proud to have been a part of the beginning and

“They want and need more than to continue on as part of the ongoing business to deliver the finest, most specific treatment available to our patients and partners.”

George Lannon says his interest in joining the practice stemmed in part from a family member who suffers from OSA. “I was familiar with PAP treatment, but after

looking and listening to the approach that Dr. Eli took to patient care, it was a real expansion in my view of the disorder,” he says. “I did not realize that there were so many different and

successful ways to address this difficult problem.”

Carnell says her primary patient care responsibilities center around the review of sleep testing, discussing information with the patient, participating in case conferences,

assembling and noting data downloads, and managing all phases of her patient’s care. “Since all of our treatment plans are focused on confirming compliance before they are measured

for effects, I am also responsible for noting when alterations are needed to provide the maximum treatment success.” Lannon is involved in all phases of PAP therapy, from initiation and

modification through adaptation and confirmation. He also oversees home sleep testing set up and download, PAP set up and download, and like Carnell, participates in case

conferencing, reporting, and compliance monitoring. He says Dr. Eli’s strategy of listening to his patients and taking their opinions into account is one of the main reasons he took the

job. “This treatment approach, paired with a forward-thinking doctor who made the patient-centered mentality a priority, allowed me to see that matching patients with their desired

treatment would result in better compliance and ultimately better results.” Dr. Eli says that Carnell and Lannon are an integralpart of the practice’s comprehensive and unbiased

treatment planning group. “They make recommendations, and they develop positive patient relationships. The input of the RTs in treatment meetings and case planning is critical to the

success that we enjoy.” If he didn’t have these therapists to meet with patients, coordinate care with other providers, and encourage adherence to treatment, he doesn’t believe he would

be able to offer the comprehensive care he knows is vital for OSA patients. “I give our RT staff credit for improved patient experience — quality and satisfaction — and high levels of

compliance resulting in reduced overall costs of care for the patients.”

Dr Bradley Eli San Diego Sleep Apnea Dentist

Wide range of referrals
Dr. Eli says patients are referred to his practice from medical specialty and primary care groups. They often also receive referrals from DMEs that, out of frustration, will provide

information about his practice to patients who have failed their initial treatment. Other patients locate the practice through their own search for a solution. “We should talk more about

the highly motivated patients seeking to get treatment that really works for them,” he says. “In general, most are very motivated to get the sleep they desire and will do whatever it takes to

make that goal.” In other cases, patients arrive seeking help on a diagnosis made years ago. Dr. Eli notes that it is not unusual for patients to come into the office with 10-year-old

continuous positive airway pressure (CPAP) machines. “Before we reorder a similar device, we re-test them and acquaint them with today’s machines and masks,” he explains. “They

want and need more than just bags of tubes and filters sent in the mail.” Majel Carnell says part of this problem has to do with recent insurance changes that have resulted in an

extremely impersonal treatment process for people with OSA. “Patients are often tested and then simply told to get a PAP, without their results or what is actually wrong with the patient

ever being discussed directly with them. As you can imagine, this can be very frustrating and confusing.” By contrast, in their practice, they provide patients with personalized care

throughout the process. “Many of the current care providers do everything by phone, and patients really value the face-to-face interaction that we provide,” Carnell says. How

does the practice get around the insurance obstacles plaguing others in the field? Dr. Eli says that unlike a DME that is only reimbursed for equipment delivery, he assumes full

responsibility for the treatment of his patients’ chronic and life-threatening condition and thus can bill for his services.“When we deliver combination therapy, it is treated

as a medical necessity — not for us to make money,” he emphasizes. Often, the practice also ends up saving money for the insurer by working more closely with the patient to

accept PAP therapy in lieu of more costly treatments. “If they are predisposed against CPAP, we can get the equipment returned quickly.” He also notes patients can get

everything they need for their OSA treatment right in his office instead of having to go from place to place to obtain

referrals and evaluations.

 

Additional training needed

 

Dr. Eli believes that involving more members of the dental community in the treatment of OSA patients could greatly improve the treatment these patients receive. “The dental community

is keenly interested in participation in treating OSA and can add tremendous value if they are integrated into a sleep treatment team that is able to provide comprehensive services,” he

states. On the plus side, dentists have and maintain ongoing relationships with their patients over the course of routine visits, they are comfortable working with appliances and

equipment, and they understand the importance of comfort and fit. To get more dentists on board with this type of care, however, Dr. Eli believes most will require additional

training. Right now, that training appears to be lacking. According to Dr. Eli, too many DMEs and medical groups are simply contracting with dentists to fabricate oral appliances

for their patients, with no education or follow up provided. He notes, “So who bears the responsibility for the patient, we ask?” Dentists who do nothing more than take a course on

making an oral appliance leave patients without the crucial information they need to effectively use the device. “They lack the medical training to adequately inform the patient,

encourage the patient to consider PAP therapy, and to even know if the patient is compliant — yet in these instances, the patient and dentist consider the patient to be ‘treated,’” explains

Dr. Eli. That goes back to his strong belief that PAP therapy deserves at least a try. “In our offices, if a patient strongly prefers an oral appliance for initial treatment, I am interested

in why that is their position. Do they have experience with PAP treatment already; and if so, when?”

When patients note they have tried positive airway pressure before with no success, he advocates for a do-over, saying that they will still work with them over time to try CPAP for a week

and coach them if necessary to reconsider PAP therapy. Dr. Eli believes more of his colleagues in the dental profession could do the same. “What I am saying is that I do see dentists

becoming active members of the sleep treatment community. Plus, I believe that they can provide a level of specialty that is beyond the levels that are currently generallavailable — a

treatment specialist able to deliver positive airway pressure and oral appliances, but only with more training or better integration into a comprehensive practice like our model.”Body position training

He has been offering consulting services to RTs and dentists in this regard. A goal worth pursuing Study after study has shown PAP therapy is effective in treating OSA, but statistics

continue to paint a fairly dismal picture of its acceptance by patients as a treatment method. By some accounts, half of the people referred for the therapy will be noncompliant one year later.

Many other treatments are now available to help patients with OSA, and practices like the one run by Dr. Eli in California may bode well for those patients. As the case of

Majel Carnell and George Lannon illustrates, RTs have a key role to play in those practices. “Respiratory therapists are experts in the treatment of OSA,” says Dr. Eli. “What I would

suggest to RTs is to consider any opportunity they can identify to work in a center that provides comprehensive treatment and understands the disease management model.”

Both Carnell and Lannon say it’s a goal worth pursuing for respiratory therapists interested in sleep. “In a model like this, you have more options and more tools to help the patient be

successful with a good night of sleep,” says Lannon. “It’s a personal relationship that is

formed and followed — we care about the patient’s progress, and we let them know their success is important to us.” Says Carnell, “Having the opportunity to match the appropriate treatment for each patient to achieve a compliance goal of 100% all night, every night, is a good feeling and very rewarding.”

 

Dr Brad Eli San Diego Sleep Apnea DentistDr. Brad Eli is a nationally-recognized leader in sleep disorders treatment and pain management.

His expertise in sleep led him to develop a patient-centered method that offers a variety of sleep treatment options and matches each patient with the best treatment for their symptoms and lifestyle. Patients diagnosed and treated by Dr. Eli consistently achieve better compliance rates and improved outcomes. Dr. Eli is the first Medicare and Tricare approved provider for multi therapy sleep treatment in Southern California. Dr. Eli earned a post doctoral Master’s Degree at UCLA where he received advanced training in sleep disorders. He remains the only expert with this unique skill set in the San Diego region.

Dr. Eli is on the hospital staff at Scripps Memorial Hospital La Jolla and UCSD. He is a member of numerous professional associations including the American Academy of Sleep Medicine, American Sleep and Breathing Academy and the American Academy of Dental Sleep Medicine. Dr Eli holds multiple patents in the fields of both sleep and pain. Dr Eli can be reached at http://bit.ly/19l6GBu

Photos by Bradford Tennyson, San Diego, CA (www.bradfordtennyson.com)

Bradley Eli DMD, MS

Bradley Eli DMD, MS

Dr. Brad Eli is a nationally recognized leader in pain management and sleep disorders treatment. He has developed a multi-disciplinary approach to treat acute and chronic orofacial pain including migraines, stress and tension headaches, myofascial pain, neuralgia, temporomandibular disorders (TMD), Sleep Bruxism, and head and neck injuries. Refined techniques include behavior modification, psychology, physical medicine, and anesthesiology. His expertise in sleep led him to develop a patient centered method that offers a variety of sleep treatment options and matches each patient with the best treatment for their symptoms and life style. Dr. Eli understands how much chronic/acute pain can limit and negatively impact a person’s life, so he is tenacious about finding whatever is the right method is to help a patient so they can not only live a better life, but they can wake up knowing their day isn’t going to be defined by their pain.

Dr Eli earned a post-doctoral master’s Degree at UCLA where he received advanced training in the field of orofacial pain and the treatment of sleep disordered breathing. He remains the only specialist with this unique skill set in the San Diego region. He is a member of and teaches for numerous professional associations including the American Headache Society, American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine. He maintains offices in San Diego county, where he is on the staff at both Scripps Memorial Hospital, La Jolla and Encinitas, Tri-City Medical Center, and Palomar Medical Center. Dr. Eli is the first specialist of this type in San Diego and works with multiple insurance plans, including Medicare and Tricare. www.sleeptreatmentspecialists.com

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