Written By: Jason Smith, RPSGT
Co-Written By: Jason Crowe
There has been an on-going debate in the field of sleep medicine about Auto CPAP machines being used to establish CPAP pressures versus a patient coming back in to the sleep lab for a CPAP titration. Which of these protocols are better? What is the cost analysis of these two processes? And most importantly, what has the better clinical outcome for establishing compliance.
Before we jump head first into this, let me give you a little back ground about my experience as a board registered polysomnographic technologist (RPSGT sleep tech) in the clinical setting. I spent 8 years working for a free standing sleep center that had locations in Ohio and Florida. I was the director of clinical operations responsible for a total of 48 beds in 6 different sleep centers with multiple board certified sleep physicians, so my experiences with in-lab titrations is quite extensive. So with that being said, let’s break down the factors of one versus the other.
Why Do I Need To Have So Many Sleep Tests Done? I Already Know I have Sleep Apnea.
Great question and in some cases individuals with complex and co-morbid conditions clinical and regimented consultations are absolutely warranted but in the majority of “run of the mill” obstructive sleep apnea diagnosis, consultations and sleep tests can be condensed, saving the patient hundreds to thousands of dollars. It’s sad to say but the patient’s healthcare coverage is evaluated just as much as the patient so the amount of visits and sleep studies may depend on how much or how little coverage you have as a patient. Listed below are some of the examples we have seen in patient flow for sleep studies once they have entered the sleep lab system.
A. Most common situation:
B. Split Night Sleep Study Scenario. (Occasional scenario, depending on how “BAD” your insurance is….)
C. Home Sleep Test Scenario. (Not very often as its less money in the doctor’s pocket and sleep lab’s pocket!)
D. Home Sleep Test and Auto CPAP Titration
E. 1800CPAP.com Self Pay Scenario
The cost of an in-lab diagnostic study (polysomnography or polysomnography with CPAP) can be upwards of $2500.00 EACH! These studies are billable to your insurance company, as long as you have good coverage. Adding a full set-up of a CPAP device can be another $2700.00-3500.00 additional and then all of the physician visits will add up accordingly. To break it down even further, scenario # 1 may cost you 8,000.00- 10,000.00 dollars billable to your insurance company by the time you are done, whereas scenario # 4 may cost you as little as $3,000.00 billable to your insurance company. It is no suppose to see with increasing deductible and co-insurance, why so many patients are opting for the 1800CPAP.com home sleep test service and Auto CPAP bundle, a package that can cost as little as $1,000.00 to you out of pocket.
So the big question is what is the best thing for me? At the end of the day, compliance and adherence to CPAP therapy is the goal we are all seeking. The commonly used definition of compliance is using your CPAP device at least 4 hours per night and at least 5 nights per week. However, a text book definition of what compliance is doesn’t accurately paint a picture of you as an individual and how your compliance is.
Everyone is different, some CPAP users notice the positive benefits the next day while others may take weeks to months before they notice a difference of how they feel or improved health conditions and symptom reduction. The obvious goal is to use CPAP whenever you sleep, as much as you sleep.
The sleep lab technician and physician face the daunting goal of optimal pressure needed versus patient use, meaning therapeutically you may need 16 cm/H2O to establish airway patency, keep your AHI (apnea hypopnea index below 5 per hour) and keep your oxygen level elevated above 90% but if that pressure setting is too high for you to tolerate, the likelihood of you using therapy as you should decreases and you become non complaint. This begs the questions of which is better, a patient that uses CPAP to a lesser degree of severity ( maybe a severe AHI decreases to a mild AHI) or a patient that doesn’t use the CPAP at all because of pressure tolerance. Follow up is key and Auto CPAP offers a better chance of compliance through pressure range settings, meaning the device would know you need 16cm/h20 as much as the person in the sleep lab will, however, a pressure threshold can be put in place that doesn’t allow the device to go above 12 cm/h2O or any pressure that you did tolerate well.
Auto CPAP (APAP) also decreases the need to continual follow up for pressure adjustments. What this means is, say you were on a fixed pressure CPAP for 2 years and dropped 30 lbs, chances are that you need less pressure than when you were first diagnosed and treated . This also can be said for those who have gained weight and need more pressure. Do you feel like you are not getting enough pressure from your CPAP machine? Odds are you probably do if you put on some weight. So what do you do? Go back to the sleep lab for a pressure increase? They will most likely want you to stay at the sleep lab again for a “CPAP Re-Evaluation”, which is another term for repeat CPAP titration. Open your check book again. However, with Auto CPAP, remember that algorithm, it’s still there and only delivers the CPAP pressure that you need without that need to go back to the sleep lab for another study.
Other professionals in the sleep community will look at this blog and deem it inaccurate or inappropriate; those people will most likely be the ones that benefit from you running the full spectrum of diagnosis and analysis at their sleep center. The majority of the people in the sleep medicine field will look at this and understand the importance of clinical pathway options and cost analysis for their patients. These sleep specialists are typically the ones that work well with us when it comes to providing therapy devices and supplies to their patients. We are not a perceived threat to these people but rather an option for their patients. So ask the questions. Am I a good candidate for home sleep testing? Should I be on an Auto CPAP? What will this all cost in the end? Am I better off self paying or using my healthcare insurance?
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