Home Sleep Tests: Are they the future for OSA Diagnosis?

[SuperSleeper]

Apnea Board has a Linkedin.com discussion group and I thought this particular discussion was interesting enough to copy & paste over here. There were some commercial links included, and these have been removed to comply with our forum rules. Also, full names have been edited to just first names and last initials in order to preserve the privacy of the original posters.

Feel free to add to the discussion by replying in this thread. Here's the Linked thread, copied:

Home Sleep Tests: are they the future for OSA diagnosis?

Seems there's more options these days offered those who want to utilize a home sleep test for diagnosing OSA. With all the cost-cutting going on in the medical arena, are these viable solutions for patients? If you work for a sleep center or are a sleep professional, do you offer any home tests, or overnight stays at the sleep lab as the only option? I realize these home tests have nowhere near the data points and testing criteria as a PSG, but what do you all think of these home-based solutions? If you're a patient, have you used or considered a home test?

[SuperSleeper]

Most tests here in the UK are done at home, as we don't have that many sleep labs.

People in the insurance industry in the US are projecting that 70% of osa diagnositc studies will be done in the home. There are positive and negative ramifications. More osa will be diagnosed and treated. The nuances of sdb, uars and central apnea issues will tend to be overlooked to the detriment of the patient. Many patients may fall through the cracks as contact with sleep docs and more importantly support personell will shrink. The little support for patients needing pap therapy will become smaller. DME's will sell more masks and machines, insurance companies will save money, doctors will read and interpret hst studies and it will all appear fine. In my practice, every day, I meet people who feel through the old system. I fear that number will grow.

It is a good thing to fear. And further to this, only the really challenging patients will end up in the labs. This will cause tremendously more stress for the professional.

Kath, when you say most of the studies are done in the home. Is this an attended study where the tech comes in sets up equipment and runs it? This is not a bad model when the labs are in low quantity.

The guesswork involved in scoring a study without an EEG component is far inferior to an actual attended study. Further to this, if there is a more subtle sleep disordered breathing and upper airway restriction as Rick has already said, without being able to score arousals unless they have accompanying hyperpneaic breaths, I believe they will usually be overlooked without a 4% desaturation.

HST has a place, but patients vary greatly in regards to their sleep, I only see it as a first line screening tool. I think there always should be a lab component or if not in lab some form of attended study. The lab that I currently work in offers HST as an option, but we get so many more critical care patients, in lab is more feasible.

The one thing that I have never been able to understand is that there are a lot of patients are more ready to undergo some invasive surgeries than they are to sleep overnight in a lab. I think that for some reason, sleep testing is considered less important than other procedures.

[SuperSleeper]

No Rob, we are sent home with the equipment, eg [link removed]
with instructions on how to assemble it. It is used for one night, then taken back the following day to the clinic. We then get the results a week or so later and are put on APAP to titrate for the correct pressure. There are some hospitals who offer the overnight study, but these are few and far between.

The link that you posted did not work. However, that is depressing. There must not be a huge need for techs in the UK.

Do you happen to know what the compliance rate is? Do they have any education/support groups to enhance compliance? I am not familiar with the UK enough to understand the way the healthcare system works there. But I am very interested in hearing about how people on the other side of the world are diagnosing and treating sleep disorders. I assume that there is not a lot of diagnosis of PLMS or other disruptive sleep disorders if the only thing being done on a widespread basis is OSA screening.

Sorry Rob, am nor sure why the link doesn't work in here, but I just copied it pasted it into my browser and it works from there.You are correct in saying that other disorders will be missed, and I've heard of several people taking private home studies - they never see a medic at all just purchase a machine and masks. However, they later discover they have CSA, instead of or as well as, OSA and are on the wrong machine As for compliancy.... difficult to state, but I do know for a fact that 100's of people here in Europe have told me personally, that without finding my company [link removed] and the comfort products we supply, they would not be using their machines. My inbox is always full and the 'phone always ringing, of people needing extra help they don't get from the clinics, and it's for this reason I started the forum up [link removed] There are now local support groups popping up over the country (similar to your AWAKE meetings), but sleep apnoea is only just recently reaching the general public over here, so hopefully things will rapidly improve.

[SuperSleeper]

Robb/Kath - the link provided does NOT work if you try it from Linked-In, but, oddly, DOES work if you copy it an paste it into the url bar of your browser... Go figure...

Is there perhaps a "third way"? Might there be a "tiered" approach? MD has you do a home study with a recording device; then, based on those results, the MD can determine if further study is needed... Maybe people can be eliminated? Or prescribed mouthpieces?

Or maybe an MD can assess the patient and make a judgement call: This person is in such bad shape they should do a full-out sleep study; or that person presents milder symptoms (or is younger or has fewer health complications) and thus perhaps a home study would be efficient...?

Just asking...

Their is some logic and has been some effort to approach diagnosis that way. However, unfortunately the only thing that the HST will screen for is apnea. There are other considerations in home studies that I feel also contribute to the inaccuracy. These include environmental factors such as a bed partner with untreated sleep disordered breathing, or sleep related movement disorders, allergies, pets, etc. All of these are control factors that in a lab can be isolated to just the patient related issues. These factors can be addressed if there is still no physiological evidence. But since most patients never tell the whole story to their physicians(or even know that they are leaving anything out), the only way to observe any aberrations require a more objective approach.

Let's take Obstructive Sleep Apnea out of the equation altogether because we know that the HST will catch that. There are 80 different sleep disorders that HSTs won't even touch. A monitored in lab study still maintains a broader spectrum of possible diagnoses.

I am not even going into mouthpieces or surgeries. I have seen far too many failures in that line of treatment.

[SuperSleeper]

I agree with your Robb, but after all my campaigning, and that of the British Lung Foundation's OSA Campaign which is currently underway supported financially by Philips Respironics [link removed] , I'm just thankful that at least people are getting tested and diagnosed now. However, hoping for great strides in improvement here in the UK.

It's obvious that money is a huge force behind the changes in diagnostic and treatment practices. And while none of us is so naive as to think it should not have a place in the process, it's a shame that it drives so much of the decision making. Perhaps the upside is that osa is a relatively small piece of the cost that insufficient sleep creates for business and for insurance companies. The latest changes surrounding HST have also influenced and dramatically limited the behavioral treatment of insomnia and parasomnias. Insurance companies still reimburse inadequately for these treatments and now with the damage done to sleep labs by HST behavioral departments are suffering. As we educate the public, business and the non-sleep professionals our message will finally begin to register. They may begin to understand that if we only diagnose and treat osa, and if there is little support for long term patient adherance, the results will ultimately be dismal. And the cost of sleep disorders will remain almost untouched. Good discussion folks.

[SuperSleeper]

Since we are on the topic of HSTs and what they can and cannot diagnose; I have an interesting case story to share to drive home the issue.

In a discussion of HSTs today I was told that a male in his early 20s was diagnosed with PLMS from an HST! Okay, given that some breathing patterns in a best guess no desaturation scenario may lead to the possibility that what is being seen is the lead in to a leg movement. Still with me, it gets better..or worse...depending on what your view is. The physician prescribes a sedative as is generally the case with PLMS, no confirming study was necessary, the physician diagnosed it and a prescription was written...for a pt that turned out to have severe NARCOLEPSY! After the situation did not improve he had an MSLT and went into REM within three minutes on the first three naps. So a sedative was being prescribed to a patient with an already hypersomnolent disorder based on a hunch based on a method of diagnosis that was not designed to diagnose anything but OSA.

Now, given this...I think it satisfies the need for in lab studies and/or more effective monitoring and education of what can and cannot be diagnosed with a HST. I am in favor of HSTs if they are used for what they are designed to do. But any other indications should have triggered the need for an in lab study without question.

Your thoughts?

Scary stuff Rob To tell you the truth, there are very few places people can go to here for checks on sleep disorders, but hopefully as people as becoming more aware of OSA, the other disorders will get the attention they deserve. Meanwhile, at least the HST's are catching plenty of folk. My own Dad's having one this Wednesday.

Amazing Rob and well stated. I had a client last week who has been complaining to his pcp for the past 18 years of very poor sleep. He's fallen asleep at the wheel and has his wife drive him to work, and has excessive daytime sleepiness. He has had some observed apneas and occasionally snores. He's also overweight. His pcp has responded by prescribing benzodiazopines and sedatives. While working on improving on his sleep, I strongly suggested that he ask his pcp for a sleep study, and not take no for an answer. This is a story I have heard time and time again with minor changes in details.

[SuperSleeper]

I have lost count, Rick, of the amount of people who've contacted me wondering if they have OSA when all their GP's keep doing is prescribing more and more sleeping pills, thus making their condition worse

I believe it Kath. We have so much work to do educating the general public and the medical community. So far I've much better outcomes teaching my clients and the general public. When pressed many of the pcps acquiesce, though they think it's foolish and unnecessary.

I'm with you on that Rick - the challenge is HUGE, but just 'hope' our small voices are heard! On our website we sell the Sleep Strip [link removed] (which isn't allowed to be sold in the US) and many people buy this over here to convince their GP's they need referring for a full sleep study (our health system is very different here). The Sleep Strips are very accurate too! Shame the US won't allow them to be sold without a prescription, as they're only the same thing an off-the-shelf pregnancy test is

Ha Ha Rick and Rob.... I've been looking at your profiles and it seems we're all musician too. It's not on my profile, but I teach the piano and keyboard in my spare time - not that I have much of that these days

[SuperSleeper]

Wait a minute... How would a "civilian" - me, say - get my hands on an "HST" (the jargon is absolutely killing me... "pt" for patient, I presume? Nice and dehumanizing, thanks..)? Would not a physician of some kind have to prescribe one? Would it then not follow that the physician would have to be able to interpret the data within the context of the actual patient?

I mean, doesn't the same thing apply for the results of a full sleep study? If the physician is worth their salt, wouldn't they recommend a full study if there were any doubt? And if they're NOT worth their salt, what makes us think that they'd interpret the sleep study results effectively?

The people on this thread who are professionals are obviously concerned about doing the right thing by the "pt". They sound like the kind of people who, if they did the study, might go out of their way to make sure the physician took note of notable things. All that is good and commends getting the full study done.

But since when do physicians listen to people like you all? Some MDs care about their patients, get involved, make judgements and explain them to their patients. They'd say, "well, a home sleep test is more convenient and less costly to the entire system, but in your case, I don't think it will give us all the data we need, so, despite the inconvenience, I'm afraid you should get a full study."

They also might say, "I suspect you have a sleep issue, but I doubt it's major, so a home sleep test should give us what we need to know."

But there are some MDs who are not so involved, not so forthcoming. So, as usual (and I'm not griping!) it's up to the patient to get informed and take charge of their own care.

[SuperSleeper]

Nice site Kath. You have a lot of good products that I often recommend to clients about to begin or strugling with pap therapy. I'd have to see more background to comment on the strips.
I just saw your comment. We're fellow musicians. That's pretty neat. I have a gig with my new 3 piece band on Wednesday night. Music keeps us sane.

I think our efforts are best spent on informing people so that they can advocate for themselves. Pcps can prescribe a home sleep test but it must be read and interpreted by a sleep doctor. A sleep doctor would approacg the choice between in lab and hst as you described. But the difference here in the US is that the insurance company also has a great deal of authority in the final decision. One of the big drawbacks in the use of hst and the strips that you described is that they don't measure sleep. And so we don't know if breathing episodes are occuring in sleep or wake.

[SuperSleeper]

People here in the UK and in fact all of Europe tell me that they wouldn't be CPAP-compliant without the products we stock. I agree, as I wouldn't either! However, I was determined to be compliant due to my own mother's untimely death at the age of 49 of a heart attack (most probably caused through her undiagnosed OSA). This is where my passion comes from.

Yes, music keeps us sane and if I were nearer I'd come to your gig

Bed now, as it's 12.25 am here. Good Night and thankfully none of this now...Zzzzzzz

Sleep well and have good dreams.

Sad to hear those comments.
Yes, there are physicians, sleep techs, respiratory therapists, and individuals in every category of the medical industry that are better off "pumping gas" than working in the medical field. The truth about HST is that it is only to test for OSA, period. Unfortunately from what I see in most forums people are more interested in protecting their rice bowl then going with change that saves costs on an already taxed system & provides better care for the pt. Again, HST are testing for OSA only, all other suspected disorders should be tested in a Sleep Center.