Home Sleep Apnea Testing: A Positive Alternative for OSA Diagnosis and CPAP Compliance?

Home sleep apnea testing market continues to grow as more and more insurance companies decline reimbursement for in-lab diagnostic polysomnograms. This is not recent news and it doesn’t take much more than common sense to know that the average person that thinks they may have sleep apnea or  been told they have sleep apnea is looking for the most cost effective way of diagnosing and treating it. Does the average obstructive sleep apnea sufferer udergoing cosnultation understand they have options other than the traditional in-lab sleep study?

Home Sleep Study Testing Kit
As Shown: ApneaLink Home Sleep Apnea Test Kit

 

I was recently contacted by a sleep physician that made it a point to tell me he refers many customers to our site for CPAP supplies but will not be doing so in the future because of the wording we use to describe our home sleep testing program. Was this declaration driven by a fear that the growing market of home sleep testing programs is causing a financial threat to his practice? Was this physician really going to hold back information that can save his patients hundreds of dollars a year on their CPAP supplies?  Some, and let me stress the descriptive word SOME sleep professionals are in a defensive mode of what they believe is protecting their field (and their wallets) rather than embracing a program they can add to their current services and better all of sleep medicine.

Before I get into a rant about home sleep testing, I do want to point out something to the average customer looking to purchase a home sleep test. Do your home work on the company you are using for your home sleep apnea program. This is a growing business that many people are getting into (good and bad) and a disclaimer should be stated that the right personnel should be conducting these test for accuracy and reliability. Find out who the board certified sleep physician interpreting the results will be. Find out how the test is scored; is it scored manually by a certified technologist or auto scored by a computer. Auto scoring does not recognize artifact as well as a certified sleep technologist can and thus if not properly detected could lead to false negatives or false positives. Always find out how long a practice has been doing home sleep testing; a dentist that just added them to their practice last week may not be the best option for you.

 

I have been a sleep medicine professional for 12+ years and participated in many meetings where the primary emphasis was how we were going to thwart the efforts of home sleep testing programs because they posed a threat to our bottom line. As a registered polysomnographic technologist I have always been torn between two constant arguments I have seen in sleep medicine. The first is the accuracy and reliability of a home sleep apnea test versus an in-lab diagnostic test and the second being the fixed pressure CPAP machines versus auto adjusting CPAP machines. The best advice I can offer is have both programs as a service to your practice and advise your patients of the method that is most likely going to lead to better therapy, lower cost and long term compliance.

Yes, certain some patients NEED the in-labs study for the best possible diagnosis and treatment, especially those with co-morbid conditions but if they cannot afford the in-lab route, a home sleep test SHOULD be offered.  These patients are being treated clinically, not for research purposes, an AHI of 32 and AHI of 41 are clinically the same (severe OSA) and the recommendation of treatment will be the same (PAP). The average run-of-the-mill OSA sufferer can be diagnosed with an HST and treated with APAP (auto-adjusting positive airway pressure). I can already see the steam blowing out of every RPSGT ears as they read this, and trust me I have heard all the arguments but the truth of the matter is treatment and long term compliance are the common goals.

What’s the old saying, you can lead a horse to water but you can’t make him drink? You can consult a patient to have an in-lab sleep study and a titration but that doesn’t mean they are going to show up for the appointment. Do you know where you lose them at? You lose them when the billing staff contacts them regarding the costs of these tests or they contact their insurance company to find out what the coverage and billable rate is. Does your practice follow up with them and offer the home sleep testing route or does that patient go into that huge pile of charts that are labeled “People who have had consults but have not tested”?

Let’s face it, an in-lab sleep test can be a real pain in the butt for some patients; think about sleeping in a foreign environment with 22 wires/cables hooked up to you and people watching you sleep all night through a video camera. Now think about having only 3 wires/cables hooked up to you, sleeping in your own bed and doing your own routine. Which sound more appealing? How many people that go through the first night of diagnostic actually come back for a second night titration just to sleep like that all over again? Doesn’t a second night at home with an auto-adjusting CPAP machine in your own bed sound like an option the will result in better compliance?

In the lab I worked for we took great pride in our titration abilities and any sleep technologist worth their salt knows the goal is eliminate disordered breathing events through supine REM (the position and stage of sleep a person is prone to be most severe). We hit that mark like Bruce Willis drilling to 800feet in Armageddon and left the sleep lab every morning feeling like we had defeated sleep apnea one patient at a time. Unfortunatley a common scenerio is when they left that morning with their CPAP machine  and tried to sleep with it that nigh they found they could not tolerate it. What’s the next logical step if you are a patient with sleep apnea knowing you need to sleep with CPAP but cant because the pressure feels like it’s blowing you away? Call the sleep doctor.

The sleep doctor would get them back in for a follow up consult and reduce their pressure to lower level that the patient could tolerate and reschedule a follow up appointment to gradually raise them back up. Sleep techs sometimes just do not understand the fine line between clinically treated and compliant because they are too focused on accomplishing the mission at hand. It’s a career lesson to understand that person is still benefiting from lesser CPAP pressure than no CPAP pressure at all and even though you know that person needs 11cm/H2O to alleviate apneas, they are better off with a mild case of sleep apnea than a severe case. The best question is how would they have felt if they left that morning with an Auto Adjusting CPAP machine with a set range that encourages compliance and less follow up visits to the doctor?

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