The Medicare
Evidence Development and Coverage Advisory Committee
currently is in the process of examining the question of whether to pay
for in-home testing for the diagnosis of
href="http://www.sleepapnea.org/" rel="tag">sleep
apnea. If approved, this could lead to a
significant loss of income for sleep specialists.
Pulmonologists can't get a break, can they? In the 1980's
many lung specialists faced declining income, because of the reduction
in the number of cases of tuberculosis. Then the number of
smokers began to decline, leading to reduction in smoking-related
illness. Many pulmonologists became sleep specialists, in
part to make up for the lost revenue. (Donald Dimcheff, personal
communication) ...
Sleep studies are complex tests, done in purpose-built labs,
and they are pretty costly. Typically, a person with
obstructive sleep apnea needs two sleep studies: one to
establish the diagnosis, another to initiate and assess the
effectiveness of treatment. A reliable in-home test would
greatly reduce the number of diagnostic tests that would need to be
done in a lab.
, writing on his blog, Sleep
Doctor, has a couple of posts on the subject (
href="http://sleepdoctor.blogspot.com/2007/09/home-testing-for-obstructive-sleep.html">1,
href="http://sleepdoctor.blogspot.com/2007/09/update-on-home-testing-for-osa.html">2).
His opinion is that MEDCAC is unlikely to approve payment for
the in-home testing.
Using current technology, the test in the lab is more informative than
any proposed in-home test would be.
If patient routinely got the in-home test first, some of them would end
up getting equivocal or uninformative tests, and would need to get the
regular test anyway. There are a lot of issues for MEDCAC to
mull over.
Personally, I like the idea of the in-home test.
Technological advances, such as
href="http://www.news-medical.net/?id=31383">infrared imaging,
seem promising. But given the current technical limitations,
I have to agree that in-home testing is not yet appropriate for routine
diagnostic use.
I do wonder, though, whether in-home testing could be useful and
appropriate for ongoing monitoring of treatment. I sometimes
see people who are already using
href="http://en.wikipedia.org/wiki/Positive_airway_pressure">CPAP
or BiPAP, who develop worsening of somnolence. This
always raises the question of whether the existing treatment is
working, or is sufficient, or if something else is gong on.
It would be nice to have a simple, quick, and relatively
inexpensive way to find out.
It might even make sense to do this routinely, say once per year, for
patients on established PAP therapy.
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I tried going to a sleep lab once for an assessment of my snoring and RLS. I didn't get a wink of sleep. The unfamiliar surroundings in the room, snoring fellow subjects down the hall, electrodes/glue/wire in my hair and omnipresent video surveillance above my head are definitely off-putting. I can't be bothered going back, but I would be willing to try an at-home test.
The pulmonologists were actually latecomers to the party.
Sleep studies got their impetus from Drs. Dement and Guillemenault in California, both psychiatrists, who developed the techniques and began pointing out the high prevalence of sleep disorders, and in particular demonstrated the medical risks of sleep apnea, including not only sudden death, but also exacerbations of cardiac and pulmonary disease.
As a variety of medical treatments developed (about all there was at first in severe cases was soft palate surgery or tracheostomy), in particular noninvasive things like BiPAP, that's when the pulmonologists got involved, since they were the ones knowledgeable and willing to deal with the equipment.
My guess is that home sleep studies are likely to be done with the aid of someone to come to your home and set it up, so will be related to home health. Quality will likely be a big issue.
I am concerned about the quality issue, because anytime a new source of revenue opens up, there is a torrent of folks who are only in it for the money. Having said that, I suspect that there valid clinical roles for this, but not as a replacement for the definitive first diagnostic test.
I long have suspected that there are people who simply will not go to sleep labs. It is hard to get a handle on this, but my impression is that there are, in particular, persons with PTSD or a PTSD-like condition who simply will not do it. Other anxiety problems may be involved. And, like the first commenter, some people just can't sleep in a sleep lab, at least not on the first night.
Of course, there are people who subjectively think they did not sleep, but by EEG you can see that they did. Even a fitful night can sometimes give enough information to establish the diagnosis.
There are two kinds of problem patients we see:
Those who are either in denial about their sleep disorder or acknowledge they may have one, yet refuse to be evaluated.
Those who have the studies done, which show a severe problem, yet either refuse BiPAP/CPAP, or cannot tolerate the equipment.
Frankly, I'd miss having the polysomnographic data in the hospital, since I use it for research purposes.
It depends on the tests. If it's just a measure of airway pressure during sleep, or just O2 saturation levels, it might miss important things, like co-existing sleep disorders (PLMD, etc). And the lack of the second titration visit isn't really practical until the self-adjusting CPAP machines have the problems ironed out.
But I just finished my undergrad, so my opinion isn't particularly valuable.