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Behind The Times?
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Dreamcatcher Offline

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Post: #1
Question Behind The Times?
I came across an article from CBS Life and Health Library and I read it with my mouth open. heres the article in question:

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.


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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 Oh-jeez
04-04-2012 03:34 AM
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iSnooze Offline
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Post: #2
RE: Behind The Times?
I believe the medical field is sometimes slow at change when its used to doing something one way. Case in point is the discovery that most peptic ulcers are caused by bacteria. Even after the 2 doctors that discovered this won Nobel Prizes in Medicine, many doctors still refused to treat ulcers with antibiotics because they either didn't believe that bacteria was the cause or their tried-and-true treatments worked for them so why switch. I know it took several years before most doctors in my area accepted that bacteria is the cause of most peptic ulcers.

When my doctor approved the sleep studies, the soonest I could get scheduled was 4 weeks later. The time frame from my first doctor's visit complaining about extreme fatigue to receiving my cpap machine was 4 months. It doesn't seem that the US medical field treats OSA as such a serious disease or else we would be able to get therapy sooner. It is good that the UK people get their machine the same day as the sleep study.
04-04-2012 07:14 AM
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Dreamcatcher Offline

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Post: #3
RE: Behind The Times?
(04-04-2012 07:14 AM)iSnooze Wrote:  I believe the medical field is sometimes slow at change when its used to doing something one way. Case in point is the discovery that most peptic ulcers are caused by bacteria. Even after the 2 doctors that discovered this won Nobel Prizes in Medicine, many doctors still refused to treat ulcers with antibiotics because they either didn't believe that bacteria was the cause or their tried-and-true treatments worked for them so why switch. I know it took several years before most doctors in my area accepted that bacteria is the cause of most peptic ulcers.

When my doctor approved the sleep studies, the soonest I could get scheduled was 4 weeks later. The time frame from my first doctor's visit complaining about extreme fatigue to receiving my cpap machine was 4 months. It doesn't seem that the US medical field treats OSA as such a serious disease or else we would be able to get therapy sooner. It is good that the UK people get their machine the same day as the sleep study.

Its not that good we can wait upto a year to get our equipment but it all depends on what county (State) you live in for me I had a home study then sent to the hospital for a full study then they gave me my machine. In all it took about 4 months but I dont understand why you dont have a home study first?
04-04-2012 07:20 AM
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iSnooze Offline
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Post: #4
RE: Behind The Times?
(04-04-2012 07:20 AM)Dreamcatcher Wrote:  .... I dont understand why you dont have a home study first?

I had an at-home oximeter test first to determine if my 02 levels dropped during sleep. They did and then that's when he doc gave the OK for me to schedule a sleep study at the hospital.

I often wondered what would have happened if my oxygen didn't drop low enough to warrant the sleep study. I'll never know.
04-04-2012 07:47 AM
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PaulaO2 Offline
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Post: #5
RE: Behind The Times?
I like the idea of an oximeter as the initial study. For example, my partner snores. After gaining some weight, the snoring got worse and I strongly urged visiting the doc. The doc referred for a sleep test. The test did not show sleep apnea.

If an oximeter had been used first, we'd have seen the O2 did not drop and we would have been saved the expense (and hassle) of the sleep test.
04-04-2012 10:54 AM
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Post: #6
RE: Behind The Times?
My timeline, from not knowing any of my problems had anything to do with sleep apnea to having a CPAP, was about two months:

Referral from primary doc to cardiologist appt- one week

Referral from cardiologist to sleep doc appt - one week

Sleep doc appt. to initial sleep study - one day (they had an opening literally the next day, which was great)

Initial sleep study to titration study - two weeks (included waiting for results of 1st study)

Titration study to having a CPAP in my hands - three weeks (included waiting for results, getting prescription, and sorting through the DME process)

Had a followup with the sleep doc after six weeks, next one was scheduled for a year later after he saw I was doing well on the CPAP.
(This post was last modified: 04-04-2012 12:42 PM by shanzlik.)
04-04-2012 12:39 PM
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