Taking cues from home testing implementation in Veterans Affairs health programs.

Henry L. Johns, BS, RPSGT, CRT, CPFT

The Q309 Sleep Review/Wells Fargo Securities, LLC Sleep Center Survey found that a mere 16% of sleep labs currently use home sleep testing (HST). Within that small percentage are programs within the Veterans Affairs Health System. Sleep Review spoke with Henry L. Johns, BS, RPSGT, CRT, CPFT, about how the VA is using HST. Johns is program manager of sleep, respiratory therapy, EEG, and cardio-diagnostics for the VA Eastern Kansas Health Care System.

Sleep Review: Is the VA Eastern Kansas Health Care System using home sleep testing? If so, what approach is being taken to implementing this form of testing?

Johns: We are currently in the process of developing a plan and considering the use of HST in our area. One key consideration is which patients to use HST on. Not all patients are good candidates for HST. Patients with comorbid conditions such as severe hypertension, congestive heart failure, COPD, morbid obesity with hypoventilation, physical or mental limitations, or low Spo2 should not be considered for HST.

SR: Can you briefly explain the treatment pathway when home testing is used by the VA?

Johns: The Department of Veterans Affairs has used HST as an addition to facility-based sleep labs for nearly a decade in some areas of the country. It is used to serve high demand areas and more rural, remote areas. Programs are run a bit differently in each Veterans Integrated Service Network (VISN). Generally, providers use a screening questionnaire, which includes all the exclusion criteria for testing. If a patient meets all the requirements for HST, with a 75% probability of OSA, equipment is set up, and the patient is instructed by the sleep clinic or lab. The patient is required to return the equipment the next morning. Some programs allow the equipment to be returned by mail for the patient’s convenience. Following review of the data, the patient is either brought into the sleep lab for further testing or sent home with AutoPAP for a trial period. If the patient does not tolerate APAP, they are returned to the lab for desensitization and in-lab titration. Once a therapeutic PAP level is determined, the patient is issued a machine and supplies by physician order.

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SR: What has been the result of implementing the testing method, particularly in terms of cost?

Johns: In discussing HST with Max Hirshkowitz, PhD, of the Houston VA sleep lab (one of the largest programs), he reports that of the 2,500 patients receiving HST each year, only about 35% of patients need to be seen in the lab. Max also commented that he felt the lab was busier because of the use of HST, due to increased referrals and demand. Max feels that OSA is a chronic condition that lasts a lifetime; close follow-up is the key to success.

In discussions with VA sleep program managers around the country, programs with the most success had two to five full-time employees dedicated to HST and CPAP follow-up. It is imperative to have adequate staffing to run a successful program.

SR: What can other sleep labs learn from the approach that the VA is using?

Johns: Home sleep testing, when properly applied, can be a strong adjunct to a sleep program as long as an aggressive follow-up program exists within the sleep lab and CPAP clinic.


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