Accreditation of sleep medicine in the Kingdom of Saudi Arabia: A critical step toward quality outcomes.

Over the last 30 years or so, there has been an extraordinary expansion in the number of sleep laboratories and sleep centers in the US and around the world to meet with the increasing demand for evaluating and treating sleep disorders. However, the rapid and uncoordinated expansion of such facilities has been fraught with the obvious consequence of tremendous variability in the quality of sleep studies, and more importantly perhaps, with a wide spectrum in the quality of clinical performance as far as accurate diagnosis and treatment are concerned, thereby leading to substantially discrepant outcomes from one sleep center to another, and from one country to another.

Not surprisingly, in-depth analysis of these problems revealed that the huge variance in quality of services and outcomes was dependent on the lack of standardization of both medical and technical personnel, and in the application of guidelines toward implementation of technical diagnostic and management procedures. In a pioneering effort to address these serious issues and to promote the recognition of Sleep Medicine as a legitimate and distinctly singular medical specialty, the American Academy of Sleep Medicine (AASM) undertook a series of initial processes and steps to provide benchmark standards for each of the areas involved in the clinical practice of the discipline. Such efforts have ultimately paid off by not only abutting in the formal recognition of Sleep Medicine as a distinct specialty board by the American College of Graduate Medical Education (ACGME), but also by the now stringent requirement by medical insurers of formal AASM accreditation of a sleep center as a condition for payment and reimbursement for delivery of sleep clinical services.

A third level of complexity in this rapidly evolving process of accreditation and professional guidelines in Sleep Medicine has entailed the more recent and progressive transition of many diagnostic services from full-fledged overnight polysomnographic evaluations in a sleep laboratory to home-based restricted polygraphic recordings. The jury is still out as to decide whether such process, now inexorable and irreversible, will lead to more widespread recognition and diagnosis of frequent and relatively unrecognized sleep disorders such as obstructive sleep apnea, and as such improve overall outcomes of this condition. There is evidence from research conducted at academic centers that this indeed could be the case, and thus allow us to assume that implementation of ambulatory-based home multichannel studies will finally achieve the goal of identifying and treating the whole iceberg of patients, rather than being restricted to the tip of such massive sector of our population.[1] However, portable testing and interpretation protocols are more likely to suffer from the absence of sleep specialist oversight, and occasionally minimal physician oversight and involvement, a challenging situation when quantity and quality are simultaneous goals of our discipline.

The results from the accreditation steps taken by the AASM, and since then emulated by others, have provided robust assurances that this is a meritorious process, and have yielded consistent evidence to show that accreditation programs improve the process of care provided by healthcare services.[2-4] Well-implemented accreditation programs are likely to improve clinical outcomes of a wide spectrum of clinical conditions, and therefore, such programs should be supported by policy makers as an essential tool aiming to improve the quality of healthcare services. A recent pro-con debate on the need for more stringent accreditation procedures involving the evaluation and treatment of children within existing sleep centers in North America further illustrates the unique benefits and potential dangers of the accreditation process.[56] One important consideration is that the accreditation guidelines need to be specifically tailored to the environment and resources in which they are planned to be implemented, and that such guidelines must therefore continuously monitor their impact on the quality of the practitioner, serve as an educational vehicle for self-assessment and updated knowledge, assess clinical practice through well-established outcome measures, and be flexible enough to enable radical changes in the system, when such changes are needed.[7] Most importantly, the emphasis and priority of the accreditation process should be patient-centric, and not serve the interests created by the economic or professional forces centered around the accrediting organizations or their individual practitioners.[8]

In this issue of the Journal, an important and fundamental step will take place in the Kingdom of Saudi Arabia, and will forever change, undoubtedly for the better, the way that Sleep Medicine is practiced in this country.[9] This critically important initial step not only reveals the maturity of the sleep professionals in the Kingdom, who have come together to self-regulate their professional activities and those of the technical staff involved in the evaluation and care of patients with sleep disorders, but further illustrates the delineation of a careful process that will ultimately lead to a more homogenous and up-to-date standardization in the evaluation and treatment of their patients. I therefore applaud such initiative, and wish you all the best of success as far as the efficient implementation of some of the important policies embedded in the text of this important document. I am hopeful that this initial set of guidelines will ultimately serve as a vehicle for the establishment of a vibrant and informed organization of sleep professionals whose self-supervising mandate will be to educate, to serve, and more importantly to heal.