Auto CPAP Machines versus Fixed Pressure for Sleep Apnea

Are Auto CPAP Machines Better Than Fixed Pressure CPAP?

Written By: Jason Smith, RPSGT
Co-Written By: Jason Crowe

Date: 2/29/12

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:

  1. Initial consultation visit with sleep specialist to discuss sleep apnea or sleep disorders. ($30-$50 avg. co-pay)
  2. In-lab diagnostic sleep study (polysomnography).  ($800-$1,200 depending on your region)
  3. Follow up visit to discuss the results of the in-lab diagnostics sleep study. ($30-$50 avg. co-pay)
  4. If sleep study revealed pathological breathing disorder, patient returns for in-lab CPAP titration to establish pressure and therapy device setting.  ($800-$1,200 depending on your region)
  5. Follow up visit with physician to discuss results of the in-lab CPAP titration.  ($30-$50 avg. co-pay)
  6. CPAP/ Bi-Level or ASV Purchase or Rental and associated supplies.  ($1,200- $6,000 depending on machine, supplies and again, region)
  7. 6-8 week follow up visit to evaluate compliance and adherence to CPAP therapy.  ($30-$50 avg. co-pay)
  8. Whew, can you imagine having to go through all of that just to get a CPAP machine. Sounds expensive, doesn’t it?  In most situations this will run from $2,920 to $8,600!

 

In Lab Sleep Test Polysomnography

1999 Called, They Want Thier Sleep Testing Process Back

B. Split Night Sleep Study Scenario.  (Occasional scenario, depending on how “BAD” your insurance is….)

  1. Initial consultation visit with sleep specialist to discuss sleep apnea or sleep disorders.
  2. In-lab diagnostic sleep study split night (polysomnography PLUS CPAP titration all in one night). Yep, that’s right, read that sentence again. The sleep lab can do BOTH the diagnostics and CPAP titration ALL IN ONE NIGHT.
  3. A follow up consultation and subsequent consultation to establish compliance and adherence.
  4. CPAP, Bi-Level or ASV Rental or Purchase and associated supplies
  5. Initial (3-4 weeks) follow up to see how you are doing with the machine and pressure.
  6. Another follow up to make sure you are compliant for insurance purposes and sometimes to get that additional co-pay!

C. Home Sleep Test Scenario. (Not very often as its less money in the doctor’s pocket and sleep lab’s pocket!)

  1. Initial consultation visit with sleep specialist to discuss sleep apnea.
  2. An At Home Sleep study. Yes, sleep studies can be performed in your own home, your own bed and without the need of 22 leads and sensors. However this applies to candidates that have obvious suspected sleep disordered breathing without co-morbid conditions. (Psst, some insurance companies are insisting this be performed first, prior to any in-lab sleep studies).
  3. Follow up consultation to discuss Home Sleep Test
  4. In-lab CPAP titration to be performed accordingly.
  5. Follow up consultation to discuss initiation of therapy
  6. CPAP/ Bi-Level or ASV Rental or purchase and associated supplies
  7. Initial Follow up (3-4 weeks) to discuss how the first couple of weeks are going.
  8. Another follow up to make sure you are compliant for insurance purposes and sometimes to get that additional co-pay!

D. Home Sleep Test and Auto CPAP Titration

  1. Initial consultation visit with sleep specialist to discuss sleep apnea.
  2. An At Home Sleep study.
  3. Follow up visit and instruction for use of an Auto CPAP device.   Auto CPAP machines have algorithms that detect airway patency and increase and decrease CPAP pressures as needed. In certain positions and stages of sleep, patients are more prone to apneaic events and thus need more pressure versus others.  In many cases, this eliminates the need for an in-lab diagnostic sleep study. Cases studies have shown comparisons of therapy outcomes between in-lab diagnostic titrations versus auto adjusting CPAP devices, please visit the American Academy of Sleep Medicine to view published papers www.aasmnet.org. Dr. Richard Berry has some wonderful insight on this subject; I encourage you to check out his research for The Use of Auto Titrating Continuous Positive Airway Pressure for Treatment of Adult Obstructive Sleep Apnea.
  4. CPAP Rental or Purchase and associated supplies
  5. Initial (3-4 weeks) follow up to see how the first couple of weeks have gone with the CPAP.
  6. Another follow up to make sure you are compliant for insurance purposes and sometimes to get that additional co-pay!

    At Home Sleep Apnea Test Kit

    The New Road of Sleep Apnea Testing Has Been Paved by Home Sleep Testing Devices

 

E. 1800CPAP.com Self Pay Scenario

  1. Phone call or order placed on-line for Home Sleep Test ($349)
  2. Interpretation by Board Certified Sleep Physician ($0, no additional cost to patient)
  3. The sleep study results are reviewed with the patient in detail by a Registered Polysomnographic Technologist.  ($0, no additional cost to patient)
  4. Auto CPAP or Auto Bi-Level is provided with associated supplies ($500- $2,200 depending on if you get an Auto CPAP or Bi-Level)

 

Cost

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.

Compliance

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.

 

Closing Thoughts

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?

Disclaimer: The disclaimer provides that such medical information is merely information – not advice. If users need medical advice, they should consult a doctor or other appropriate medical professional. The disclaimer also provides that no warranties are give in relation to the medical information supplied on the website, and that no liability will accrue to the website owner in the event that a user suffers loss as a result of reliance upon the information.

 

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