Friend: "Doc refused to prescribe sleep study.."

[Dawnstar]

Agreed that doctors shouldn’t be using it for that purpose, but mine did for several years, and the end result is that he isn’t my doctor anymore. I wasn’t on a machine for several years, and my Epworth scores were his excuse for not ordering a followup sleep study.

[Gideon]

If your online friend feels he has sleep apnea I'd suggest he make an appointment with a sleep specialist

What we know, he gets excessively tired, one symptom.  Let me guess, he goes to sleep at 5 am and gets up at 6 am, well duhhhh, that would make anyone excessively tired.  Yes I know this is absurd but it points up a solid issue, the need to get properly evaluated.  I asked my GP to take over my sleep apnea treatments, she said no, that is not within her expertise.  Perhaps this is where his doctor is at.

[Hihowrya]

The obvious answer is to seek a second of opinion if a patient is concerned with their own well-being or has doubts about the medical advice they are receiving.

It has been my experience that some medical groups contracted with certain insurance companies are incentivized against providing extraordinary care or that the number of tests prescribed is measured and used as a metric in their compensation plan. Definitely an indicator of putting the group's interests above those of the patient.

IMHO, the suggestion to simply purchase and use their own xPAP device is not an optimal one as it can mask serious underlying cardiac, pulmonary, and endocrine systemic issues that are best detected sooner than later. Assuming a competent doctor, a full systemic workup is indicated.

^^^This answer

[srlevine1]

There are various opinions regarding the Epworth Sleepiness Scale, but many clinicians agree that any analysis that attempts to correlate scale values with diagnoses of OSA (especially in retrospective cohort studies) should be viewed with caution due to the generality of sleepiness symptoms. Many respondents are reluctant to indicate problems occurring during driving as they become a part of your medical record and can be used to demonstrate a degree of negligence after an accident. Here is an interesting piece from a noted journal.

J Clin Sleep Med. 2013 Oct 15; 9(10): 987.
Published online 2013 Oct 15. doi:  [10.5664/jcsm.3062]
PMCID: PMC3778187
PMID: 24127140

Abuse of the Epworth Sleepiness Scale - Stuart F. Quan, M.D., F.A.A.S.M.

Abuse can be defined as “Improper use or handling” or “An unjust or wrongful practice.”By either of these definitions, the Epworth Sleepiness Scale (ESS) is being abused. How and by whom you may ask? The answer, insurance companies and their surrogates, and we, sleep clinicians, are complicit in these activities.
  
One of the consequences of the prior authorization process implemented by many insurers for approval of diagnostic sleep testing is the requirement for completion of the ESS on the request form. How this information will be used is usually not documented on these forms, but one could surmise that the ESS is the metric by which the insurer assesses whether or not the patient is sleepy. If this is true, it is a prime example of using a tool for a purpose for which it was not intended. As originally described by Dr. Johns, the “questionnaire should be useful in elucidating the epidemiology of snoring and OSAS, and any associated cardiovascular or cerebrovascular risks." To my knowledge, it was never designed as a sole instrument to determine whether a patient is or is not sleepy for the purpose of approving diagnostic testing. For this purpose, it is actually a poor instrument.
  
Virtually all prior authorization requests to perform a sleep study are for the purpose of confirming a diagnosis of obstructive sleep apnea (OSA). Sleepiness is one of the common symptoms of OSA. However, there are several issues with including a request for the ESS to document sleepiness. First, the correlation of the ESS with physiologic sleepiness is inconsistent. Some studies fail to show an association, while others have found a relationship albeit imperfect. Second, only approximately 40% of persons with severe OSA will have an ESS greater than 10 (a commonly used cutoff to denote sleepiness). Importantly, some individuals with low ESS scores will give a positive response to a different question regarding sleepiness. Moreover, there are gender differences in the presentation of OSA. Although daytime sleepiness appears to occur with equal prevalence between men and women, women may emphasize fatigue and lack of energy in describing their symptoms This is reflected by a lower likelihood to have an ESS indicative of sleepiness. Hence, if the ESS is used to confirm sleepiness and sleepiness is a requirement for a sleep study, this might contribute to a greater gender disparity in the diagnosis of OSA. Finally, the ESS has much less value as a screening tool for OSA than other instruments such as the STOP-BANG questionnaire.

Certainly, there needs to be adequate clinical justification for requesting a sleep study of any type. Excessive daytime sleepiness is one of the cardinal symptoms of OSA. Documentation of its presence is important. However, using a tool such as the ESS with inadequate sensitivity and specificity as the sole evidence for sleepiness is inappropriate, especially if a low score results in denial of authorization to perform a sleep study. Sleep clinicians should stop facilitating this practice, and try to educate insurers about what information is useful for making such decisions.

[Big Guy]

Funny thing! My doc wanted me to take a sleep study test and I declined. He kept pestering me until I gave in. 

[Lolagirl]

My epworth score is like 0 and I was diagnosed with moderate osa w/ polysomnography. 
As far as a dr refusing to assess someone for sleep apnea that seems odd. It's becoming more and more considered a serious medical concern

[Fats Drywaller]

My epworth score is like 0 and I was diagnosed with moderate osa w/ polysomnography. 

Well, there ya go ... that's probably a good example of how useful the Epworth questionnaire is (not).

The thing about not admitting to being sleepy while driving is a good point. It occurred to me earlier that not only will some patients lie about that for obvious reasons (liability, commercial drivers, etc.), but with anyone, there could be subconscious denial of the condition and its potentially horrible side effects, so that the patient says to the doc "Oh, no, I would never fall asleep at the wheel and crash my car and kill a bunch of people!" even though the patient has almost done that several times but has repressed thinking about it because it is so disturbing.

As far as a dr refusing to assess someone for sleep apnea that seems odd. It's becoming more and more considered a serious medical concern

I agree. If my GP had that reaction, I would change GPs. There's no harm in going through a sleep study that turns out to have a negative diagnosis (AHI under 5); it merely costs the insurer some money.

[Lolagirl]

I've honestly never felt at risk of falling asleep while driving. And the other questions there is almost nil times I would fall asleep/near sleep in the other situations mentioned.

[Big Guy]

I have to assume that sleep apnea effects everyone differently to some degree. 

I was just diagnosed this past summer, in early July. I might have had it though for a few years, and just assumed that I was getting older and not quite as energetic as I used to be. 

In regards to falling asleep involuntarily, it never happened to me. Not behind the steering wheel, at dinner, or while watching tv, etc., etc. 

I've worked rotating shifts for over 30 yrs. Sleep apnea wasn't a problem for me while working. Not even sitting in a car overnight keeping watch, as in a stake-out. Did that countless times, and never a problem. 

If I was prone to falling asleep unexpectedly, there's no way I could have held my job. There's no way that I would have allowed myself to be behind the wheel of an auto. 

I'm sure that many individuals do have an issue with sleep apnea and falling asleep uncontrollably. But to imply or insinuate that all do, is incorrect.

[Fats Drywaller]

Just for fun, here's an interesting example of one result of a driver falling asleep at the wheel.  Chicago O'Hare Airport, March 24, 2014.  No deaths, 30-some injuries, $9 million in damage.

[Moderator note - attached images removed, please use off-site image hosting for images not directly relating to sleep apnea or CPAP]