By Dr. Michael Wilkes
Celeste can tell you it is no fun to sleep with, or near, someone who snores. She told her husband's doctor that he has snored for over a decade. Finally she felt she had no choice but to move to another bedroom. For the first time in very long time she now sleeps through the night. Her doctor suggested her husband might have sleep apnea and suggested an overnight sleep study.
Sleep apnea is defined by bouts of snoring, daytime fatigue and periods during sleep when breathing stops. It is much more common in older, heavier men and much more common in those with diabetes. It can result in a person being chronically tired, and it has been associated with an increase in the rate of motor vehicle accidents and other health conditions.
The problem is that a huge number of people snore but only a few actually have sleep apnea. Some experts have called for wider testing of all snorers – but herein lies the problem.
Sleep studies are all the rage these days. They are expensive tests and require an overnight stay and close monitoring. But are they any more accurate than the doctor taking a good history and performing a careful physical exam?
In one study, four simple questions asked by the doctor and a home monitor were just as accurate as a fancy sleep study.
The number of sleep labs has quadrupled in the past decade, perhaps because the test can generate $1,900 per study – even more if the person spends two nights in the lab. A quick Web search turns up companies that offer to help doctors set up money-making sleep labs – most suggest that a small up-front investment can quickly turn into large profits. Some of these companies even suggest that doctors work with a local hotel that has unfilled rooms.
This is another example of technology driving the practice of medicine. Owning a sleep lab creates a lucrative incentive for doctors to use more of the test than is necessary. I suspect doctors who own sleep labs are far more likely to order sleep studies than are doctors that have no ownership stake.
Yes, we have an obesity epidemic, a diabetes epidemic, an aging population and perhaps a snoring epidemic. But the answer is not to offer an expensive test to everyone who has even the slightest chance of being at risk. The answer going forward is to move away from reimbursement systems that provide doctors a profit if they order tests.
Celeste's husband has lost 15 pounds and uses a mouthpiece to help with snoring. She's not ready to move back into the bedroom yet, but she hopes to after the next 10 pounds.
Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality.
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