The Pluses and Minuses of Home Sleep Studies

New areas in the field of sleep medicine have resulted in more controversy than the validity and usefulness of unattended home sleep studies versus in-laboratory sleep studies. We decided to study this problem from a financial as well as a philosophical point of view in New York City where we are one of about 10 AASM-accredited facilities and an unknown number of unaccredited laboratories. These may be both hospital-based or freestanding.

The reasons usually given for embracing or utilizing home studies include: long waits to get into stationary laboratories; absence of stationary laboratories in a geographic vicinity; using them as a screening tool followed by study in a stationary laboratory; and cost—allegedly lower than in a stationary laboratory.

We maintain that long waits or the absence of facilities over a wide geographic area remains problematic and reflects a lack of understanding that the importance and value of sleep disorders is a cause of potentially life-threatening pathology.

Third-party payors need to consider the value of patient wellness where sleep is concerned. Diagnosing and treating sleep disorders early prevent myriad, expensive hospital admissions for life-threatening situations. Hospitals and other providers need to understand that the incidence of sleep disorders as well as the underlying problems they cause are vastly underestimated and that an investment in a stationary sleep laboratory should be no more or no less than they would consider investing in a radiology department, respiratory department, or clinical laboratory. Home studies in areas where there are a dearth of stationary laboratory beds are better than nothing. Some mobile sleep laboratory providers have developed innovative strategies, producing hybrid mobile/stationary facilities by booking patients into adjoining hotel rooms or suites with two bedrooms and a central parlor. A single technician rolls in the equipment and is thereby able to achieve the economy of testing two patients at once. Some physicians, frustrated by being unable to access any kind of services, have turned their offices into sleep laboratories at night by wheeling out folding beds and bringing in a night technician and the requisite equipment to perform an attended study on one or two patients. We predict that more hospitals will establish sleep laboratories and train appropriate staff to perform sleep testing. Such staff obviously may include respiratory therapists, critical care nurses, and electroencephalographic/electrocardiographic technologists seeking a respite or change from their current occupations.

Public relations efforts by national organizations are mainly directed toward consumers. Heightened awareness by the public is an extremely important part of the solution since it creates consumer demand. Additional efforts need to be directed toward hospital administrators and operators as well to meet this demand. There is little point in creating a demand that cannot be serviced.

Home Studies
The justification of a home study on the grounds that it be used as a screening mechanism is, in our opinion, inane. This is a marketing ploy with no absolutely financial justification. We have studied the use of a simple questionnaire coupled with a 2-second cursory rating of the oropharyngeal airway with a flashlight as a screening tool. Only about 1.5% of the patients who are tested in our stationary hospital-based laboratory turn out to be negative. In other words, a simple questionnaire and a few seconds looking at a patient’s posterior oropharynx produce a 97.5% rate of positive prediction for obstructive sleep apnea (OSA) All one needs is a penlight and a pencil to screen a patient. Other sleep disorders such as periodic limb movement syndrome, restless leg syndrome, or restless breathing disorder are similarly predicted on the basis of patient history and are almost always nearly 100% confirmed by in-laboratory testing. A home test costing upwards of $900 is an unnecessary and wasteful use of financial resources for the sole purpose of “screening” a patient. Home sleep testing providers need to work with local health care facilities on establishing economical, stationary-attended facilities. This is, and will continue to be, an important role for such entrepreneurs. Physicians and hospital administrators need to be educated and the former trained to properly interpret and render sleep-related testing, care, and treatment. There are vast areas in rural America served by small community hospitals and a small nucleus of physicians and support staff that need to be brought into the mold.

Financial Impact
Finally, we have looked at the financial impact of home versus attended in-laboratory testing and found that home studies are truly not nearly as cost-effective as they are touted to be. Proponents of home studies claim that they are just as good as in-laboratory testing and that they cost less.

We studied the financial impact on a group of 2,484 in-laboratory tested patients versus a hypothetical group of the same number of home-tested patients. Our in-laboratory group patients were screened by the aforementioned questionnaire and a physical examination. Of these, 1,687 demonstrated enough hypopneas and apneas (by definition) to warrant a split night study. The remaining 797 patients completed a full night diagnostic study without a continuous positive airway pressure (CPAP) titration for a variety of reasons including insufficient number of qualifying events, events showing up too late in the test to perform an adequate titration, or refusal and/or failure to tolerate CPAP during a familiarization trial period. Of the full-night patients, 622 were brought back for a successful full night CPAP titration. The total cost for the in-laboratory treated group was $3,207,600.

We then applied the same sequence of occurrences to the hypothetical home-treated group. Predictably, home-studied patients all require 2 nights, a diagnostic night and a therapeutic night, as it is impossible to perform a split-night protocol in an unattended study. The total cost of testing and treating this identical group on this basis was $4,566,500 or $1,358,900 more than the patients initially studied in an attended in-laboratory setting. We conclude, therefore, that if a patient is properly screened prior to any testing, it is far more economical to perform an attended, in-laboratory study in accordance with the split-night protocol than to perform a home study for screening (diagnosis), knowing full well that patients with OSA will have to be retested for the purposes of establishing CPAP or bilevel therapy on an appropriate basis later. In addition to the extra cost involved, there is also an inevitable delay in obtaining treatment due to the need for rescheduling the second or therapeutic night of testing. We maintain that properly screened patients in a majority of cases can be successfully diagnosed and titrated in a single night of in-laboratory attended testing at an ultimately lower cost than a patient studied at home.

The fact that the validity and economy of home testing are clearly subject to debate regrettably does not eliminate the “better than nothing” argument, which is the ultimate and perhaps only justification for any kind of home testing. We need to put aside this mind-set and continue to promote the gold standard methods of testing and treating patients whenever and wherever possible. Other than its availability in areas not served by stationary facilities, home testing, in our view, is a technological framework in search of a true purpose. We urge practitioners and third-party payors who have the option of both to be skeptical of cheap, quick fixes such as all night snoring recording analysis and other variations involving avowedly low technical, over-simplified approaches to what may end up as problems requiring far greater levels of complexity to solve.

We applaud and encourage grass-roots efforts throughout this country in bringing the gold standard to fruition by establishing courses, training programs, consumer awareness campaigns, in addition to incessantly hammering away at physicians and health care facilities to make these services possible. We also need to lobby health insurers that sleep testing and treatment exemplify preventative as well as interventional medicine.

Finally, we applaud Medical World Communications for creating this publication, which, with the support of its advertisers, makes information widely and freely available. Efforts of this type are giving voice and a platform to the existing sleep community whereas before there was little or none.

Thomas M. Kilkenny, DO, FAASM, is medical director at the Sleep Apnea Center, Staten Island University Hospital, Staten Island, NY.