Doctors estimate that 18 million to 20 million Americans have moderate to severe sleep apnea, which is characterized as pauses in breathing during sleep. Of these, 80 percent are unaware that they have it. The condition can make you tired, raise your blood pressure, cause irregular heartbeats and increase the risk of heart attacks and stroke. The resulting sleepiness also can lead to motor vehicle accidents and injury.
The consequences of undiagnosed and untreated obstructive sleep apnea, or OSA, are responsible for higher insurance deductibles and an increased awareness of the costs and liability associated with OSA. Driven by cost-effectiveness, many insurance companies are pushing for the less expensive home sleep test, also called HST, which the sleep medicine industry has responded to by making this type of testing more accessible.
Advantages
HSTs have the advantage of reduced costs compared with facility-based attended sleep studies, often do not require pre-authorization, are more acceptable and accessible to patients, easier to schedule and are performed in the patients’ normal home and sleep environment.
Research to determine the effectiveness and cost of this treatment found that home testing is "functionally equivalent" to in-lab tests for OSA in those patients who do not have other medical conditions such as heart failure, lung disease or neurologic disease. Both tests track oxygen levels, heart rate and breathing — however, those done in clinics also monitor brain waves and other variables.
Disadvantages
HST cannot measure sleep time during the test, diagnose coexisting sleep disorders or determine sleep stage, which can therefore underestimate sleep-disordered breathing and be imprecise. Some patients who are negative for OSA on HST are proved to have mild OSA with in-lab testing. With inappropriate candidate selection, the result may be increased long-term costs and an increased number of false negative test results compared with those done at sleep clinics. The convenience of HST also could lead people who are unlikely to have sleep apnea to request home studies, resulting in overtesting and increased costs.
In-lab sleep studies have medical staff and technicians who provide constant monitoring of the lab test, which allows for equipment adjustments if sensor leads fall off during sleep. In contrast with HST, the patient needs to set up the device correctly, and technical failures require repeat testing.
Dr. Christine Fukui and Richard Suvanarat spearheaded the first HST program in Hawaii a year ago at Tripler Army Medical Center to much success. They also work with Niolopua Sleep Wellness Center at Manakai o Malama. Fukui said, "If properly selected, patients may begin auto-adjusting CPAP (continuous positive airway pressure) or oral appliance therapy after a positive HST without the need for a CPAP titration. These patients can bypass having to come to the lab altogether. Some patients do have to be retested, but if properly selected for high OSA risk, this number should be small."
Suvanarat, the lab supervisor, said, "At (Tripler) we are able to follow (American Academy of Sleep Medicine) guidelines, which lowers error rates and puts only the most appropriate patient in the HST program. On the mainland, insurers have been pushing HST as the only first-line test, which can result in increased error rates and repeat studies that increases overall costs. For patients with a positive HST who receive subsequent treatment, education is crucial since most may not encounter a sleep doctor or technician. Most insurers only will allow one HST or in-lab study every five years."
Objective parameters for accessing the risk of OSA include body weight, neck size, age, gender, craniofacial anatomy and upper airway evaluation. Other risk factors including symptoms and coexisting conditions can be documented using questionnaires. Patients should be excluded from HST when suspected coexisting disorders exist such as emphysema, heart failure and certain other medical problems.
The first step is to appropriately and professionally screen individuals for OSA risk. Then consistent protocols should be used for screening, analyzing and acting on the results of the HST. Protocols should include recommendations for prescribing and monitoring treatment.
Sleep testing is only one component of the overall care plan for patients with OSA, which collectively includes assessment, education, screening, testing, treatment, monitoring, outcome evaluation and follow-up. With the increased momentum for evidence-based cost-effectiveness in health care, HST is here to stay. It will reduce costs and improve access to proper evaluation of sleep apnea and help ensure effective treatment for those who suffer from this commonly undiagnosed silent sleep disorder.
———
Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
