Outcomes for patients with suspected obstructive sleep apnea (OSA) were not inferior when managed with data from limited-channel sleep testing versus full laboratory-based polysomnography (PSG). The findings, published in Annals of Internal Medicine, suggest that data for informing OSA patient management can be obtained at home.
Demand for diagnostic sleep services has grown substantially due to the prevalence of OSA. Considered the gold standard for OSA evaluation, PSG can be labor-intensive, time-consuming, and costly. In response, there has been a push for the adoption of limited-channel sleep studies, which record fewer physiologic signals than during PSG and are increasingly conducted at home, to diagnose suspected OSA. While previous studies have found that there are similar patient outcomes with limited-channel testing versus PSG, it is unclear whether they should be adopted in routine practice for a broad range of patients being evaluated for OSA.
In a randomized controlled trial, researchers separated patients into one of three groups, which determined the level of sleep study information to be disclosed to treating physicians: full polysomnographic data, cardiorespiratory data only, or oximetry and heart rate data only. Sleep study reports and data corresponding to the randomized groups were distributed to treating physicians to guide diagnosis and management. After review, a similar proportion of patients were diagnosed with moderate to severe OSA and received similar treatment recommendations in all groups.
Authors of an accompanying editorial say that these results are welcome news to health providers and other stakeholders interested in delivering cost-effective care options, like home sleep testing (HST). The lack of infrastructure required for HST allows for reduced wait times for testing, and the ability to expand access to underserved groups, such as rural populations. Professional medical societies will need to work with payers and other stakeholders to ensure an economically-sustainable strategy of replacing in-laboratory polysomnography with HST in order to provide high-value-care for patients with this common disease.
HST is rapidly becoming the first choice of the majority of my providers and patients, in southern California Not the gold standard, but great diagnostic tool for OSA.
Numerous studies have clearly shown the validity of HST vs. PSG, however, NO ONE is addressing the most important issue we face when it comes to sleep apnea… and that’s cost-effective treatment! Diagnosing OSA is no big deal; that is NOT where the focus should be! Once you’ve saved a few hundred dollars on an HST, what then? Throw them on APAP 4-20cm with inadequate training or coaching from a DME provider that knows very little (at best) on how to instruct a new pt? What type mask is best? What pressure range settings? That’s what we see happening over & over again throughout the industry… and the outcomes are abysmal!
If the insurance industry were really concerned about curbing costs & treating pts most effectively, they would do 3 things:
1. Stop approving 2 full-night PSG’s and only approve for 1 splitnight study. Any good sleep lab can diagnose & treat with CPAP all in 1 night. Only on rare occasions is a 2nd night necessary, which can be authorized. Better diagnosis, and pt benefits from proper instruction & time to adapt to Tx. Proper pressure levels are obtained & MD has a clear understanding of how to prescribe therapy.
2. Understand that placing pts on APAP/CPAP without in-lab titration & instruction is a recipe for failure! Without proper instruction & coaching, long-term compliance to APAP/CPAP is almost impossible. At best, long-term compliance has never been over 50-60% industry wide, which is pathetic! And the ins industry wants DME’s to achieve this compliance within 90days! or else!…while cutting reimbursement to levels that are almost unsustainable now!
3.(most important)With CMS leading the way, the ins industry should allow ALL sleep practices to provide DME to their pts & population. It is THE BEST, most efficient, cost-effective way to manage & treat the sleep apnea pt! When pts can be seen by sleep specialists, tested & treated properly all within 1 location it streamlines the process & removes unnecessary procedures & delays and allows for successful treatment. Sleep apnea in most cases is never cured… it’s properly managed! And who do you think will manage it better, the sleep physician or some 3rd party DME? Our long-term compliance has ALWAYS remained above 92-95%. Not hard to achieve when it’s done properly. There is NO better model for this incredibly growing & under-diagnosed pt population!
Conclusion: HST should have a limited role to play in sleep medicine and not be used as a means for replacing the all-critical in-lab titration part of a study. In most cases when we have to comply with HST first (Cigna mainly!), we then request a titration study to be done, which is approved! This makes no sense!…Why not just do it all in 1 night?… and save the cost of an HST?
Let’s streamline the process with splitnight studies and get these pts treated much more efficiently & effectively. That’s the goal we should all be striving for… long-term compliance to therapy.
Kevin Justice
Director, Sleep Services
Cumberland Lung & Sleep Specialists, PC
Registry #87 (yes, I’ve seen it all)
(Side Note) One of the biggest mistakes being made by the vast majority of labs & DME providers is placing pts on APAP with an inadequate starting press. Most, I would argue, need at least 7-8cm to start, otherwise, they struggle to fall asleep due to air hunger. You cannot just send a pt home with APAP 4-20cm and expect a good result! It almost never happens.
I agree with the majority of your statements but would add insurance support for patient education and patient support to increase compliance.
Very good article. I question why the author still thinks that an in-lab titration is still necessary.
The new machine have built-in modems, many times I will up the starting the pressure for the patient based on their morning after feedback while they’re testing with APAP; we do multiple nights APAP testing for patient compliance
They seem to fail to mention that HSTs are an “at risk” study. We’ve seen patients commit disability fraud by simply handing over the unit to “uncle joe” so that they can recieved benefits. Furthermore, the mass majority of non compliant patients who do not wish to be monitored or use CPAP that are drivers or pilots of any kind we’ve seen them put these units on their children so they don’t have to comply with DOT regulations. The trend is HST with APAP…what if the patient has CSA and it’s worsens the condition?
I have had severe OSA diagnosed since 2000. I needed a new CPAP(BIPAP) machine a little over a year ago but a new insurance benefits manager did not have a copy of my last PSG on file. I was sent to a sleep lab that worked inside a hospital. Hospital bed mattresses are usually covered with a thick plastic cover for easier sterilization between patients, and this bed also had memory foam of the non gel-cooled variety. On top of my normal intractable insomnia I have had since at least age 7 (I was 50 at the time of this test) I was requested to sleep considerably earlier than I usually am able to fall asleep (about 2am, AFTER taking a plethora of medications that my psychiatrist has prescribed to try to help me fall asleep each night. I tried everything I normally do to fall asleep, but nothing worked as the room and bed were causing me to sweat. I tried music I use regularly to help me relax & sleep. I tried self-hypnosis/guided meditation, I added a heavy-duty pain pill, hoping it would help the muscle the hospital pillow caused to cramp up. I finally was able to fall asleep about 7am for 86 minutes. Medicare and the reviewing sleep doctor determined from that 86 minutes that I no longer had OSA. Yeah, sure. That would explain why, when I fall asleep without my CPAP, I snore like a freight train & wake up a few hours later with a soaking wet bed from having urinated in my sleep. My previous CPAP machine was never covered by insurance because the person reading the SD card had been taught that everyone’s compliance must be 100% for 4 weeks for 8 hours between 9 pm and 9 am. I don’t sleep during those specific times. Also, when my insomnia acts up (often under pressure) I may go 2-3 days (or more) without any sleep at all. However, when I know I am going to be sleepy or tired, I am 100% compliant with using my CPAP, if for no other reason than to keep my bed dry! Sometimes, I will sleep all through the day, take a break for a meal, and then go back to sleep a few hours later and sleep through the night. This happens on the days every three weeks when I get my gamma globulin infusion (IVIG). I tend to sleep for most of the three days & nights starting the day I receive the IVIG. Despite the unyielding nausea during that time, I still wear my CPAP mask because I know it will help my sleep.
Now, a new sleep doctor, knowing I failed the previous hospital-based PSG wants me to use a HST to determine for himself that I even have OSA. For some reason, previous testing (before the 86 minute fiasco) was not acceptable to Medicare as well as being among the missing! He wants me to use an HST, where I have to sleep the night before and have the machine and card back to them by 11 am. If I have to have it back so early, with no knowledge of whether I’m likely to fall asleep the day before from what I have called “the sleepies” – a situation where I feel so sleepy that even if I’m talking to someone on the phone, I will start dreaming and incorporate the person I’m talking to into my dream, becoming completely incoherent. When this happens I try to grab my CPAP mask before I fall completely asleep. Sometimes I miss. But after sleeping 6 hours that way (assuming I haven’t wet the bed), it is incredibly difficult to sleep afterward for several hours. Not the thing to have happen during the day preceding a NSPG. I thought the whole idea behind the HST was to allow you to have a normal home sleeping experience. With no CPAP and this thing on me all night (not a split night) or anything not delivering PAP, I’m going to wet the bed. I really don’t want that to happen in MY OWN BED, better the sleep study bed or the hospital where someone else is going to have to clean it up! The HST also has a high risk of being moved or laid upon by my 16-20 lb cat. If she decides to sleep on me while I am on my back or side, it’s definitely going to alter the breathing effort measurement based on a belt around my chest. The ONLY good thing I can see about the HST is that I can adjust the room temperature to the 67-68 degrees I like for sleeping. How do I ever get to find out what my true sleep cycle is, if the tech can’t measure when/if I go into REM sleep, and when the cycle ends? I would really like to awaken feeling like I have actually slept a refreshing sleep. (Without having been knocked out to sleep by a drug that feels like a sledgehammer.) Do I get rid of the sleep Dr of 1 year that only sees me every 6-12 months, in favor of my PCP of 23 years? Or try to find another sleep dr who deals w/Medicare? At the moment I can’t even get replacement parts for my mask or CPAP machine.