" (2006) Smith reports that the laboratories experiencing the most dramatic growth are two which are located the "farthest from the Hillsboro flagship" as they are located in two areas that were "formerly underserved." (2006) Smith additionally reports that the demand is stronger in the areas where the two fastest growing centers are located which supplies "plenty of fuel for expansion."

Smith states that the Sleep Health & Wellness NW is attempting to "fill a gap so that patients who previously were overlooked or not being reached or who fell through the cracks no longer are," she says. "We have no plans to open centers in areas where there are already quality sleep services programs. We only want to go into areas where needs are not being met." (Smith, 2006) Smith reports that some of the laboratory locations were chosen on the basis of "community demographics" but others "were selected for their potential to support a provider partner." (2006) Since the first of the centers was to be one that was unknown it was located in a community "...where the only access to sleep services of any kind was at a hospital..." (Smith, 2006) the second laboratory is reported to have been set up "in a similarly hospital-dominated market, but this time the choice of location was at the behest of an otolaryngologist...a community where he wanted to make inroads..." (Smith, 2006)

According to Smith "as awareness of the Sleep Health & Wellness NW model of multispecialty integration spread, other medical providers stepped forward with offers to participate. "These board-certified physician specialists sought us out because they wanted more say in how their customers were handled, more say in the delivery of the outcomes. They understood that it was harder to be community- and service-based at this level when the laboratory you are involved with is owned by and operated from a hospital. Our third, fourth, and fifth centers all came about in response to overtures from doctors."(Smith, 2006)

Each of the centers is stated to feature "six beds (save for one laboratory which operates with three) and while the "look and feel of the laboratories are not cookie-cuttered, all are meant to be uniformly comfortable and home-like so as to make them as conducive to sleep as possible." (Smith, 2006) the centers make provision of "attended overnight and unattended home diagnostic studies." (Smith, 2006) Furthermore, the centers deliver "...fully analyzed summaries, which usually are available the first business day after the study is completed." (Smith, 2006)

After diagnosis the centers further attempt to meet the needs of treatment "...with CPAP/bi-level equipment and help with treatment compliance. It offers a CPAP support clinic that delivers patient education and durable medical equipment services at no extra cost." (Smith, 2006) Smith states that the laboratories are: "...semiautonomous entities, with only limited oversight from a core management team...Certain functions -- such as contracting, accounting, and purchasing -- are handled centrally. Consequently... locations can reflect the character of the neighborhoods they serve while, at the same time, the company can lay claim to a consistent, smooth-running operation that benefits from economies of scale." (2006)

It is stated that promotion of quality is through use of "...one common set of clinical systems and protocols from laboratory to laboratory..." And the centers put its sleep studies "...puts its sleep studies through a stringent review process." (Smith, 2006) the sleep lab also pays its employees above-the-average wages and states that the team it has assembled is "creative, progressive and very entrepreneurial-minded.

The centers are also reported to desire the role of "leading resource of community education" intended for consumption by patients, providers, payors and employers" which includes such as "sponsorship of numerous health fairs." (Smith, 2006) Other initiatives includes visiting the offices of "medical referral sources, which are conducted by individual Sleep Health & Wellness NW providers who also meet with large employers to acquaint them with sleep-related conditions that can affect employees and cause unnecessary absenteeism, hobbled productivity, higher corporate health care costs, and reduced marketplace competitiveness -- all detrimental to the bottom line. These efforts are supplemented with comprehensive advertising campaigns that take in print and broadcast media, plus the Internet." (Smith, 2006)

Smith reports that many individuals are not aware of the link between existing health problems and sleep and just as well are not away of the outcomes of those problems. Others, however, possess a good "basic understanding of that already, but are unaware of Sleep Health & Wellness NW being the best equipped to help address those problems."...

(Sleep Doctor Blog, 2008)
The third type of structure comprises merely 5% of all sleep labs and it is stated that the differences existing between the three types of sleep labs are complex in nature. This article states that the reduction in the number of sleep labs identified in the third structure or the extension of the physician practice sleep lab is worrisome and states that the Sleep Review Magazine reports that a "...new interpretation of an old Florida law has led to a severe restriction on this type of lab..." (Rack, 2007; Sleep Doctor Blog, 2008)

Apparently the State of Florida Board of Medicine finds that a physician of physician-owned labs must directly supervise sleep studies." (Sleep Doctor Blog, 2008) the article relates that the State of Florida Board of Medicine stated "If the Sleep Center does provide services under the direct supervision of Jax Heart, the Petitioner's proposed arrangement does not constitute a 'referral' that is precluded by Section 458.053(5), Florida Statutes. We found that the law dictated that patients needing a sleep study would be supervised differently depending upon whether the lab was owned by a physician group rather than an IDTF/Hospital." (Rack, 2007; Sleep Doctor Blog, 2008)

Case Study - Review

James MacFarlene (2009) in the work entitled: "The Painful Pursuit of Sleep" reports a case study of an individual he refers to as R.T. who is 38 years of age and a mechanic who reportedly "felt a snapping sensation in his lower back and fell to the floor, unable to move. The work-related accident left R.T. with two ruptured lumbar discs (L4, L5), nerve root injury, and intermittent episodes of severe lower back pain.

When his pain was most severe, R.T. woke up nearly every time he changed positions during sleep. His pain and the resulting insomnia came under some control with medication, but soon afterward, the insomnia resumed, leaving pain clinic physicians in a quandry. Why would an otherwise healthy individual suddenly develop intractable insomnia after the successful management of a chronic pain condition? In the case of R.T., he had no previous personal or family history of insomnia. Sleep disruption due to chronic pain had been an issue, but sleep had initially improved after assessment in a pain clinic and the initiation of methadone treatment. What changed? The case of R.T. highlights the clinical value in evaluating for sleep-related central apneas compounded by narcotic medications." (MacFarlane, 2009)

MacFarlene reports that opioid and narcotic medications have been "...the mainstay of chronic pain therapy for hundreds of years. The term opioid refers to those medications chemically related to opium. The term narcotic refers to a broader variety of substances, often denoting a high potential for dependency. Since morphine was the first pure alkaloid to be isolated from opium in 1806, numerous morphine-like synthetic compounds have been produced. They all bind at the m-receptor subtype of the endogenous opioid receptors." (2009) in 1981 the symptoms of insomnia were first noted by Kay, Pickworth, and Neider in the work entitled: "Morphine-like Insomnia From Heroin in Nondependent Human Addicts" which was published in the British Journal of Clinical Pharmacology.

Insomnia symptoms associated with opioid use were first noted as early as 1981.1 in more recent years, increased risk for sleep-related central apnea has been demonstrated in patients taking narcotics, including stabilized methadone program patients.2,3 This effect is compounded by midazolam and possibly other sedative hypnotics.4 the pathogenesis of these apneas is nonspecific, and may include disturbances in regulatory activity related to medullary centers and brain stem structures, afferent influx to CNS, sleep stages, upper airways, lungs, and respiratory muscles. It is now becoming clear that these narcotic induced central apneas can lead to sleep onset insomnia and significant sleep disruption. The patient is usually unaware of any breathing problems during sleep. Also, it is difficult for the bed partner to add a corollary history, as snoring patterns may not have changed." (MacFarlene, 2009)

Following R.T.'s accident, he was off of work for approximately six months. R.T. is stated to have suffered since them from "...periodic episodes of severe lower back pain. He was told he was not a surgical candidate because his injury was not causing functional limitations. He had several series of epidural steroid injections that provided only moderate relief. He was…