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More sleep labs, more unneeded tests - ApneaNews - 01-08-2013
Inside Medicine: More sleep labs, more unneeded tests
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.
fair use from:
http://www.sacbee.com/2012/09/13/4813411/more-sleep-labs-more-unneeded.html
RE: More sleep labs, more unneeded tests - zimlich - 01-08-2013
This is very interesting. In the study she referred to- four simple questions and a home monitor that were just as accurate as a fancy sleep study. More information would have helped. What were the four simple questions? In our desire to help the undiagnosed knowing these questions would be helpful. And what did she mean by a home monitor. If it's just a pulse ox- I have moderate sleep apnea and never in six sleep studies and two at home pulse oximetry tests have I desaturated. A pulse ox would miss me. I went to my GP because of quite excessive daytime sleepiness that seriously impacted my life- he suggested the sleep study and the Pulmonologist Sleep Specialist concurred (2008). In people who are otherwise in good health perhaps the simple way of diagnosing would work, but this leaves the job of titration sort of up in the air. I'm sure sometimes this would be accomplished with little effort. We are so individual in our pressure needs for some folks this might be time consuming and difficult. I believe home testing when done to gather as much information as possible and graded by an accredited person overseen by a sleep specialist would fit the bill for some of us. Others with high blood pressure, COPD, heart problems, etc. should probably be supervised in the lab, even if only for titration. Thanks for posting the article.
Sure would like to know those four questions. I'll Google them.
Mary
RE: More sleep labs, more unneeded tests - aehjr - 01-08-2013
(01-08-2013, 01:19 PM)zimlich Wrote: (snip) What were the four simple questions? In our desire to help the undiagnosed knowing these questions would be helpful. And what did she mean by a home monitor. If it's just a pulse ox- I have moderate sleep apnea and never in six sleep studies and two at home pulse oximetry tests have I desaturated. A pulse ox would miss me. I went to my GP because of quite excessive daytime sleepiness that seriously impacted my life- he suggested the sleep study and the Pulmonologist Sleep Specialist concurred (2008). (snip)
Sure would like to know those four questions. I'll Google them.
Agree on all counts. During my first sleep study (2008) I desaturated a lot (down to 70% during events). Been using a fixed pressure CPAP ever since. I went back to my GP early in 2012 due to excessive fatigue. He ordered two home pulse oximetry tests; neither of which indicated a desaturation issue. I got off my butt and went to a pulmonologist after this site showed me how to change the settings on my CPAP so I could see the efficacy data. When I saw my seven day average AHI between 7 and 14 on a regular basis (and never lower than 7), I called a pulmonologist. Still waiting for the appointment to discuss the sleep study but the tech told me "your pressures were all over the place."
Would love to know what four questions would have provided the doctor the needed info...
RE: More sleep labs, more unneeded tests - Shastzi - 01-08-2013
aehjr:
Perhaps you may need to snag a wearable pulse oximeter and run the monitoring for a week.
#1. It is possible that your two night snapshot missed any real desaturation events but other issues with the environment kept you awake so you never got the chance to get any real de-sats going.
I say that because a friend of mine had a single night oximetry run but the equipment cables and bulky device he was issue kept him awake all night. He went off thinking he is ok, but truth is, no one knows for sure since no one did any cross checking. The device results were accepted as gospel and this is the real travesty.
#2. I have seen a few scary demonstrations of pulse oximeters turning in *false negative* results!
The patent, under controlled conditions was purposefully put into known desaturation conditions and
some oximeters *missed the event*..!
Keynote here is trust...but verify!
#3. I think you are doing the right thing in checking with the pulmo specialist. You might need to lean on them a bit harder though.
Best of luck!