Time for a unified federal sleep health care workforce?
INTRODUCTION
Service members (SMs) in the United States military are disproportionately impacted by sleep deprivation and disruption, particularly during deployments.1 Restricted sleep and circadian misalignment increase susceptibility to mood disorders and posttraumatic stress disorder, priming affected individuals for long-term challenges with mental health, metabolic, and immune health.2–10 In this issue of Journal of Clinical Sleep Medicine, Thomas et al provide an overview of the multitude of ways sleep disruption and sleep disorders impact military readiness and the importance of prioritizing healthy sleep in the SMs that serve and protect this nation.11 We would like to call attention to the relevance of their review to sleep practitioners everywhere given there is a critical shortage of sleep providers not only within the Department of Defense (DoD) but in the Veterans Health Administration (VA). Care beyond the capacity of both health care systems is frequently outsourced to community sleep practices. Awareness of how military service can trigger and promote the development of sleep disorders is thus relevant to all.
One striking point highlighted by the authors is the contrast between the large number of SMs presenting with sleep complaints and the exceedingly small number who are diagnosed with a sleep disorder. Chronic sleep deprivation, circadian misalignment of work schedules and biological clocks in younger SMs, and shift work lead to sleep-related complaints and are risk factors for long-term sleep challenges. Despite these risks, the number of SMs diagnosed with sleep disorders is a small percentage of those with sleep complaints. This is partly due to military culture, as the authors point out, and partly due to the small size of the sleep medicine workforce within the DoD.
We would also like to highlight the access and capacity challenges DoD faces, as VA similarly experiences greater demand for sleep care than can be provided within our health care system. In comparison to DoD’s 238,841 referrals and 6,280 SMs outsourced to the community in calendar year 2022, VA received 520,331 sleep referrals (exclusive of sleep testing) and sent 58,426 Veterans to the community for sleep care. While both health care systems are experiencing upward trends in demand for sleep care and continue to outsource care, the community does not necessarily offer sooner availability or greater capacity due to a critical shortage of sleep specialists.12 Sleep care sent to the community by VA has also been shown to lead to greater times to treatment for patients with sleep apnea compared to keeping care within VA.13 Thus, the goal for both systems which share the same patient population, albeit at different arcs in time, would be to retain as much care as possible within these health care systems where providers are most likely to understand the nuances of various sleep disorders impacting SMs throughout their lives.
How can this best be accomplished?
Limited resources foster innovation. Looking to new models of care delivery is necessary. In recent years shared care models have become increasingly common in VA, a federal health care system prime to distribute its workforce across facilities based on ebbs and flows in resources and an ever-increasing trajectory of demand. The pyramid of highly specialized providers (physician or advanced practice providers) supported by a strong base of sleep-trained respiratory therapists, sleep technologists, and sleep psychologists serves as the foundation of many current VA sleep programs. With the limited number of certified sleep medicine providers staffing 18 military sleep programs nationally, a partnership between VA and DoD seems optimal for further exploration. While the occasional joint forces initiative exists to share sleep resources in collocated regions, shared virtual care services could offer expanded options in the future. VA has evolved its model of sleep care delivery from partnerships between primarily two facilities, to hub-spoke models designed to reach rural Veterans, to newer regional hub-spoke models within integrated service networks.14 These models have greatly improved access to sleep providers and sleep testing in care deserts,15 but the impact on cost reduction and outsourcing to the community has not yet been achieved. To accomplish this latter goal, an infusion of sleep specialists is needed. Workforce augmentation within VA offers another novel option to augment services provided at both military sleep centers and VA health care systems alike as VA providers are not subject to the same occupational requirements of deployments and periodic relocations. Increasing capacity within the existing workforce by offering dual appointments across VA and DoD health care systems may offer yet another pioneering pathway to improving access to sleep care.
The solutions to the DoD’s sleep medicine issues will require that sleep itself be given higher priority in military operations. Discussions around growing a larger sleep medicine workforce vs greater reliance on community outsourcing need to take place. Another driving force for promoting a model of shared resources between DoD and VA is the Electronic Health Record Modernization program that will provide a single longitudinal record of care for SMs transitioning to veteran status. Finally, the ultimate state of resource sharing would be a joint federal health care workforce, particularly in specialty care areas such as sleep medicine.
DISCLOSURE STATEMENT
All authors have seen, contributed to, and approved the manuscript. Work was performed at San Francisco VA Health Care System and VA Pittsburgh Healthcare System. The opinions contained in this commentary are those of the authors and are not to be construed as official or as reflecting the views of the Department of Veterans Affairs. The authors report no conflicts of interest.
REFERENCES
1. . Physical sleeping environment is related to insomnia risk and measures of readiness in US army special operations soldiers. BMJ Mil Health. 2023;169(4):316–320.
2. . Neurocognitive consequences of sleep deprivation. Semin Neurol. 2005;25(1):117–129.
3. . The key role of insomnia and sleep loss in the dysregulation of multiple systems involved in mood disorders: a proposed model. J Sleep Res. 2019;28(6):e12841.
4. . Trauma associated sleep disorder: a parasomnia induced by trauma. Sleep Med Rev. 2018;37:94–104.
5. . Sleep deprivation disrupts recall of conditioned fear extinction. Biol Psychiatry Cogn Neurosci Neuroimaging. 2017;2(2):123–129.
6. . Does sleep disturbance predicts posttraumatic stress disorder and depression among college students during COVID-19 lockdown? A longitudinal survey. Front Public Health. 2022;10:986934.
7. . Prior sleep problems and adverse post-traumatic neuropsychiatric sequelae of motor vehicle collision in the AURORA study. Sleep. 2021;44(3):zsaa200.
8. . Good perceived sleep quality protects against the raised risk of respiratory infection during sleep restriction in young adults. Sleep. 2023;46(1):zsac222.
9. . Immune, inflammatory and cardiovascular consequences of sleep restriction and recovery. Sleep Med Rev. 2012;16(2):137–149.
10. . Sleep and antibody response to hepatitis B vaccination. Sleep. 2012;35(8):1063–1069.
11. . From trenches to technology: a narrative review of sleep medicine in the military. J Clin Sleep Med. 2024;20(6):973–981.
12. , Board of Directors of the American Academy of Sleep Medicine. The past is prologue: the future of sleep medicine. J Clin Sleep Med. 2017;13(1):127–135.
13. . Does community outsourcing improve timeliness of care for veterans with obstructive sleep apnea? Med Care. 2021; 59(2):111–117.
14. . Prevalence and management of sleep disorders in the Veterans Health Administration. Sleep Med Rev. 2020;54:101358.
15. . Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017–2020: bringing sleep care to our nation’s veterans. J Clin Sleep Med. 2023;19(5):913–923.