If you want to get sleep specialists fired up, simply ask about home testing. The issue may be one of the most hotly debated in the field, and the intensity of the debate only increased this summer as the field awaited the September 12 meeting of the Medicare Coverage Advisory Committee. As this issue went to press, we had yet to hear the outcome of the meeting.
At the heart of the debate is what the future of sleep medicine will look like. Some see a future where a simple and accurate test can be prescribed by any physician to diagnose sleep apnea at which point more energy and health care resources can be put into treatment and compliance monitoring. Others see a future where a too early switch to home testing without proper guidelines leads to any patient with a hint of snoring being prescribed CPAP and the focus becoming how more CPAP devices can be sold rather than how more patients can be helped.
MOST COMMENTATORS OPPOSED
In 2004, the Centers for Medicare and Medicaid Services (CMS) had decided against paying for treatment for CPAP prescribed on the basis of any other test than in-laboratory PSG. However, a request by the American Academy of Otolaryngology—Head and Neck Surgery (AAO—HNS) to reconsider the decision reopened the issue. CMS subsequently invited the public to comment on the proposed coverage change and received 138 written comments, the majority of which expressed a clear opinion. There were 72 letters opposed to allowing home testing at present and 58 letters in favor of adopting home testing, albeit with proper guidelines. (An additional eight offered more information without taking a stand for or against home testing, or weighed in on an additional proposed change to allow some flex in the amount of recorded sleep time necessary to prescribe a Medicare-covered CPAP device.)
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Among those counseling a wait-and-see approach was the American Academy of Sleep Medicine (AASM), the American Thoracic Society (ATS), and the American College of Chest Physicians (ACCP). All three organizations took issue with the AAO—HNS’s contention that wait times for sleep studies were excessively long and disagreed with its evidence that home testing devices were as good as in-laboratory polysomnography on the key respiratory measures that are used to diagnose sleep apnea. In particular, they pointed out that little objective research has been done on home testing in people old enough to be Medicare recipients.
ACCP President Mark J. Rosen, MD, FCCP, summarized the position well in his comments. He wrote: “Unfortunately, few studies of adequate quality allow clinicians to know precisely those patients with suspected OSA for whom non-facility based sleep apnea diagnostic testing works best, or not at all. This is especially true of the age group of most Medicare beneficiaries.”
Furthermore, while the price of a home test is lower than the price of an in-laboratory attended polysomnogram, there may be hidden costs, such as those generated by a greater need for retesting, that could make home testing as expensive or more expensive in the end, the AASM pointed out. Citing a 2006 meta-analysis of portable monitoring studies, AASM outgoing president Michael Silber, MBChB, wrote: “The investigators showed that the lower costs of portable monitoring compared to in-laboratory studies are at least partially offset by the increased number of poor recordings during portable monitoring that would require repeat testing.”
WILL COST SAVINGS SWAY CMS?
However, strong voices were raised in favor of home testing. One of the more powerful letters came from Lisa Getson, executive vice president of Apria Healthcare, Lake Forest, Calif, whose company says it provides CPAP and bilevel PAP therapy to approximately 25% of all patients diagnosed with some form of OSA in the United States. According to Getson, there is no need for additional study before accepting home diagnostic testing because such testing is already widely accepted by managed care organizations. In a sense, by not accepting a diagnostic modality that other insurers are, CMS is missing out on savings that the private companies are realizing. According to Getson, the 10-year savings to Medicare would exceed $1 billion if it accepted home diagnostic testing next year. “It appears that a sea change is afoot in the managed care sector, and we urge CMS to adopt the same quality standards of care and reap the same cost-savings for its Medicare beneficiaries,” she wrote.
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According to Getson, the most logical group to administer home sleep diagnostic testing to those patients who are suitable candidates (ie, those free of co-morbidities like neurological or seizure disorders, heart problems, complex or central apneas) are respiratory therapists employed by home care providers, such as her company, Apria. Sleep physicians would still interpret the results and prescribe treatment, but the test and the follow-up care would be the responsibility of home care providers.
However, the AASM feels strongly that all types of diagnostic sleep testing need to be conducted by sleep specialists. “It is our position that, if portable monitoring is to be used in the future for diagnosis of OSA, it should be restricted to studies performed in AASM accredited sleep facilities or by sleep specialists board certified in sleep medicine,” Silber wrote. “Only in this way will it be certain that patients are receiving comprehensive, appropriate, and cost effective care.”
In mid October, the ATS, AASM, ACCP, and European Respiratory Society will jointly sponsor a workshop on “Research Priorities in Ambulatory Management of OSA.” The outcome of this and of CMS’s national coverage decision process will be closely watched by the sleep medicine field.
Lena Kauffman is a contributing writer to Sleep Review. Contact her at email@example.com.