Polysomnography: To a Hammer, Does Everything Look Like a Nail?

[Sheepish]

Great to read the well-thought out and well-referenced contributions here.

As a corollary to this question, my wife was recently referred for a polysomnagraphy by her GP, but her GP said to preferably get it done in a hospital rather than at one of those private sleep clinics where they also sell CPAP equipment or where doctors or other health professionals have a financial interest. Her GP told my wife those places tend to over-diagnose apnea and there is a conflict of interest at play.

Under those circumstances, that made me think of my original question in this thread. Is her doctor overstating things, or is there empirical evidence to support her plausible statements?

[HalfAsleep]

There are heavily-marketed companies, too, now, that do everything online, soup to nuts, testing, consultations, machine... No doubt raking in $$$$. Unclear if these operations are licensed. Unclear if they're licensed in your state. Unclear if their "respiratory therapists" are licensed or simply salespeople. These shops would have 0 incentive even to be "accurate" in any of their testing since they are selling product along with the testing, no incentive to provide a machine that matches the apnea disorder ($$$$ being a serious consideration here, perhaps with several thousand downside to the online company for the correct machine), mask issuance but no mask fitting. Yes, all online.

[srlevine1]

"Respiratory therapists must be licensed in ALL states EXCEPT Alaska." "However, Alaska’s respiratory therapists are still expected to complete a degree in respiratory therapy to become proficient in the field, and are encouraged to earn nationally recognized RT credentials as a way to remain competitive in the field."  <Source>

The easiest way to distinguish between salespeople and licensed RTs is simply to ask about their license number and training. Most are proud of the hard work required to achieve certification and will tell you about their schools. 

Another way is to ask for their contact information for your physician and most salespeople will hesitate and give to the name of a licensed RT. Unfortunately, with many DME sales companies, you may have no way of knowing if your RT is moonlighting from a medical facility on a "per diem" basis or is a permanent employee.

[HalfAsleep]

Respiratory therapists (or lack thereof) at DMEs don’t really concern me, since compliance and follow up occur in the context of a licensed physician/nurse practitioner. My concern is about online for-profit companies that have evidently unlicensed salespeople masquerading as “respiratory therapists”. How the heck is a customer getting “respiratory therapy” delivered online anyway?

[Timur]

How does it work in Quebec? Do you have any provincial program that covers the costs for XPAPs? I'm guessing probably not if there are private clinics set up to do these tests and they are unregulated ....

In Ontario there is a specific program that covers the cost of machine, hose, mask.

Because the Ontario government foots the bill we are quite well regulated in terms of who gets to test, how often one can have an in-hospital PSG,  and who gets to prescribe. 

As far as I'm aware, there is only one private sleep clinic here in Ottawa and it is very highly regulated, other than that all PSGs are overnight, in hospital. 

Here, the wait time for an in hospital sleep study is significant, sometimes up to 9 months or more ..., but there is a triage system in place. 

I think your wife's GP is probably right. Sadly, too many vultures in this business.

[phrogpilot73]

I've been under the umbrella of military medicine my entire life. I was born in an Army hospital in California (Navy brat), then spent 23 1/2 years in uniform myself - so still doing the military medicine thing. The problem with military medicine is that you get the whole spectrum of doctors in the LOGAF category. Everything from "It's not my money - I'm referring you to X" to "I must be a good steward of the taxpayer's money" and everything in between.

My first sleep study was in March, and it was a take home. Results came back and said "no evidence of OSA, treat for primary snoring." I went to my doc afterwards and he starting going down the medical definition of OSA... My response was "I don't give a F*CK what the definition is, I just want to sleep." He referred me to an ENT, because my mallampati is smaller than average.

The ENT didn't even sit me on the exam table - just said "I'd like to say you're the first guy that has come here with a negative result from a home sleep study, but then I'd be lying. The home sleep study is only designed to detect severe sleep apnea. I'm going to refer you back to sleep medicine for an in-house, which is what your PCM should have done."

Sat down with my newly assigned sleep doc, and found out very quickly that I had ended up with one that has a high LOGAF. Said that he didn't evaluate my home sleep study, but he would have brought me back in for an in-house based on the fact that my spO2 was 85. Did the sleep study, and he walked through and explained ALL the data/results before giving me my diagnosis. Even explained why he was prescribing me a specific machine.

At my DME, when I told them that my doc wanted it so he could more easily monitor my progress/make changes to the scrip - they said "Oh, you must have Dr. D, he's the only one in the area that really cares that much, and wants to see you sleeping well."

After my wife (on active duty in the Navy) saw how he was (she sat in on one appointment with him), she asked him to be her sleep doc. It's unusual to get that good of a doc in the military medicine world...

[SarcasticDave94]

..."Oh, you must have Dr. D, he's the only one in the area that really cares that much, and wants to see you sleeping well."  

After my wife (on active duty in the Navy) saw how he was (she sat in on one appointment with him), she asked him to be her sleep doc.  It's unusual to get that good of a doc in the military medicine world...

First, fortunate for you to find the doc that cares about his patients like this. Unfortunately, we hear lots of stories that are quite the opposite. Even my own original pulmonary doc wasn't as good as he could have been. Granted, it could have been even worse.

Now, for the sake of being realistic, most times people post on how things went at the doc office, or anything else for that matter, tending to readily vent or complain on how BAD things were, but are LESS likely to praise the good experiences. The bad experience more easily embeds itself into the memory than does the positive ones. Human nature I suppose.

As is, I remember the worst parts from my pulmonary doc were when he chose from my titration for BiPAP that which was my worst combo of pressure settings and stating I was treated with that setting. Secondly, was his contrary responses to weight loss and inability to work a job on my part, stating my weight was well-controlled at 300 pounds and needs work a year later at 205 pounds. He pretty much said that CPAP and only CPAP would fix my apneas in 2015.

I get to see how the new doc at the same facility will be next month, as doc 1 retired a month ago. If it goes well, then all is OK. If it doesn't go well, I have previously opened a door via a 2nd opinion earlier this year.

Bottom line IMO is that it SEEMS there's more Ducks (no typo duck in this context means doc that equals Quack) than doctors that really care about treatment to the patient. It seems so easy to cookie cutter treatment to any with symptoms of SA...get a PSG...yep you have apnea...here's brick CPAP and mask...I'll set it to x pressure and you need to use it or else you will get worse...

Just remember, it only takes a few bad docs and bad reports to cause patients to be biased against all docs. Think bad car salesmen I suppose.

good day y'all,
Dave

[dracus]

My sleep doc was pretty hands off. He prescribed the sleep study.. Verified the Osa (25 AHI), sent me in for a tritation.

The sleep clinic tested about 4 different pressures and suggested one.

Luckily in my area all Dmes deal exclusively with resmed and dispense a10 auto.

The sleep doctor follow up was "what did you think about the tritation" I said I'm not thrilled but I'd rather not die in my sleep.

I told him what I wanted as far as machines he said that's what he normally prescribes. I mentioned auto and he said, we can certainly try that if you want but the tritation showed treatment at 11.

I had thought the Dme would do "more" with respect to mask fitting etc.

The entire appointment was 15 minutes and consisted of a verbal version of the quick start manual. Along with her asking "do you understand how to use the machine" I reached over hit the clinical menu and checked hours. She looked at me and went I guess you do. Then she said which mask do you want. She had hundreds in the office.

Thank God I had already read reviews. I picked the dreamwear which I returned for the p10 (love it).

I tried the prescribed pressure for one night then changed it based on advice in the group. Turns out that my pressure is pretty much averaging just a tad below the prescription but it has gone up 2 above the prescription in few spots.

I have my follow up in a couple weeks. Not sure what the follow up will look like.

[Kryogen]

my DME deals exclusively with philips, but I'll try a resmed machine next time. insurance pays one every 4 years.