It's more equitable, accessible, and cost effective.
Obstructive sleep apnea affects an estimated 3 million American adults. It causes significant morbidity and mortality. Effective treatment options exist. All of this makes the current long delays in diagnosis via polysomnography (PSG) performed in the sleep laboratory simply unacceptable.
PSG in the sleep lab is the preferred method for diagnosis of sleep apnea. But it's expensive, inconvenient for patients, and generally not available in a timely fashion. Studies indicate that the average waiting time in the United States from a referral to a sleep specialist to a diagnosis in a sleep lab is 2-10 months, although in a few urban areas the wait is a few weeks.
The problem is that demand outstrips supply. An estimated 600 dedicated hospital beds per 100,000 population per year are needed to meet the demand for diagnosis of sleep apnea via PSG. In the United States, we have only 427 earmarked beds per 100,000.
Portable monitoring (PM) has fewer data channels, is easier to use and interpret, and costs at least 35% less per sleep study than does PSG. The use of PM to evaluate patients at home rather than by split-night PSG in a sleep lab would save our nation's health care system $4.5 billion.
PM is not as accurate as PSG, but the positive predictive value of PSG in patients with moderate to severe obstructive sleep apnea is 99%, compared with 95% for PM. The modest reduction in diagnostic power that PM monitoring cedes to PSG is more than counterbalanced by its timeliness, the greater patient access afforded, and the substantially lower cost.
The relative merits of PM and PSG are often debated. A practice guideline jointly developed several years ago by the American College of Chest Physicians, the American Thoracic Society, and the American Academy of Sleep Medicine concluded that PM isn't appropriate for nonattended home monitoring (Sleep 2003;26:907-13). The Centers for Medicare and Medicaid Services concluded that sufficient evidence does not yet exist to support a coverage decision regarding home PM.
What is needed to settle this debate once and for all is a large clinical trial in which the two diagnostic methods are applied head-to-head to a target population, with the end points being the number of cases detected and patient outcomes. Such a trial is now being planned under the sponsorship of the American Sleep Medicine Foundation.
DR. MORGENTHALER of the Mayo Clinic, Rochester, Minn., chairs the standards of practice committee of the American Academy of Sleep Medicine.
TIMOTHY L. MORGENTHALER, M.D.
It could reduce access to diagnostic expertise.
Many issues need to be explored further before a national portable sleep monitoring policy can be implemented. Paramount among these is determining the validity, reliability, and accuracy of data collection using portable sleep monitoring. We don't yet know the sensitivity and specificity of portable sleep studies in the diagnosis of obstructive sleep apnea compared with in-laboratory sleep studies.
How many patients with obstructive sleep apnea will be misdiagnosed if portable sleep studies are used? How likely will the diagnosis of concurrent sleep disorders be delayed or missed altogether? What will be the legal implications for sleep physicians for these misdiagnoses? These are questions that demand answers before wholesale adoption of the portable technology.
Studies on the cost-effectiveness of in-laboratory versus portable sleep monitoring will need to be more extensive; they should involve not merely the relative cost per sleep study, but the economic impact of such programs on Medicare, Medicaid, private insurers, sleep medicine physicians, and laboratories (i.e., capital expenditure, loss or damage of portable equipment, and failure of data collection with the need to repeat sleep studies), and providers of durable medical equipment.
Economic analyses should also include comparison of portable sleep monitoring with newer cost-saving models of sleep medicine services, including outsourcing of sleep study components and the use of auto-titrating positive airway pressure devices for therapy. There should also be a comparison between the two systems in terms of their bearing on patient preference, access, safety, and satisfaction as well as their influence on specific outcome measures (e.g., positive airway pressure adherence and follow-up care.) This might be particularly important for patients with comorbid medical disorders.
Finally, portable sleep monitoring should be assessed for its applicability in special patient groups, such as institutionalized, hospitalized, or homebound individuals. Portable sleep monitoring also ought to be evaluated in drug trials and population based studies.
To achieve significant national cost savings with the use of portable sleep monitoring, reimbursement for sleep services will need to be cut sharply. A likely unintended consequence of this would be the closure of many sleep laboratories. This would, in turn, further limit patient access to services for sleep-related complaints.
Now, my question to this is, "Have you been stuck in a Timewarp"?
Our road to treatment is as follows:
1. Doctor (Local Clinic)
2. Local hospital with Home Study (Sent home with Equipment attached)
3. Given equipment.
Now number 3, Given equipment is sometimes exchanged for full sleep study depending if the home study has shown anything. What I find hard to believe is you dont have a home study? Over in the UK we go to our local clinic get wired up and then sent home with attachments and recording equipment. Some people dont even need a full study. I did think that America was way in front of the rest of us yet still we all have different issues, seems if the hospitals around the world put all their heads together we may get the treatment we deserve