Frequently Asked Questions by Physicians
How will HST help my practice?
Less hassle - The referral process is extremely simple. Your staff can save time by not having to get approval for a specialist referral or a more expensive in-lab study. They will spend less time communicating back and forth with the insurance company to justify the test, provide documentation, clinical notes, etc. Most insurers, including many HMOs, will not require prior approval for HST if the order is coming from the PCP.
Happier patients - HST is preferred by patients over in-lab studies. They appreciate being able to sleep in their own beds with no one watching them from another room. Cost is also a very big issue for patients, particularly those with high co-pays and deductibles. In these hard economic times, patients appreciate being given alternatives that don’t impact their wallet. Older patients in particular prefer not to have to drive in the dark. Standard arrival and departure times at sleep labs don’t consider that. See the patient education section of this website for more benefits to patients.
More revenue per patient - Medicare requires at least two office visits; one prior to HST to confirm the patient is a candidate and a follow-up between the 31st and 91st day on CPAP to determine if the patient is showing clinical improvement. If response is not optimal, modifications to therapy such as switching to Bi-PAP or auto-titration should be made and another visit scheduled to assess treatment response. These are great opportunities to learn what else is going on with your patient and strengthen the doctor-patient relationship.
Interpretation by a boarded sleep doctor – Sure the AHI is the key number, but what is the relevance of the other graphs in the report? Our panel of boarded sleep physicians reviews each study and makes treatment recommendations on how to proceed.
Faster results - Many hospital-based and free-standing sleep labs require a consult with the sleep physician prior to testing. IDS not only allows you to refer directly, but provides results in as few as 5 days. Patients are usually treated and on therapy in less than a week, compared with months later in many sleep programs.
How reliable is home sleep testing technology?
HST technology has been around for more than two decades. It has effectively lowered healthcare costs in Australia, Europe and Canada. Just within the past five years, improvements to the technology have made it even more reliable, including faster sampling rates on the oximetry channels (better correlation between channels) and simpler setup procedures for patient self-application.
It's difficult to do direct comparisons between the lab and the home because of intra-individual differences from night to night, but HST is probably slightly less reliable for patients with a borderline AHI because sleep time is not measured. That is why Medicare and other insurers have said that it cannot be used as a screener; it should only be to confirm sleep apnea in patients with clinical symptoms.
For peer-reviewed articles supporting HST and the historical perspective, refer to the section on Clinical Evidence.
Who is a candidate for HST?
HST is intended for patients who present with clinical symptoms of OSA. Patients with other sleep disorders (i.e. narcolepsy, REM-behavior disorder), co-morbid conditions which may impact the diagnostic relevance of the SaO2 data such as COPD or CHF, and patients in whom you only mildly suspect sleep apnea are not candidates for HST. Patients with hypertension or diabetes ARE candidates, as are those that present with symptoms of insomnia. In fact, middle-aged women with OSA may present as sleep maintenance insomniacs – and their OSA could be made worse with hypnotics (Reference: Shepertycky et al.). Signs to watch out for include:
- Loud snoring
- Witnessed apnea events
- Excessive daytime sleepiness
- Morning headaches
- History of high blood pressure
- Memory problems or poor judgment
- Depression
- Gastroesophageal reflux
- Impotence
- Nocturia
- Difficulty concentrating
- Personality changes or irritability
How do I do the clinical assessment?
First, you will uncover OSA risk in one of three ways. They are:
Have the patient complete the Epworth Sleepiness Scale
Have the patient complete the Berlin Questionnaire
Ask the patient the Five Simple Questions for OSA Screening which include:
Do you snore?
Are you excessively tired during the day?
Have you been told you stop breathing during sleep?
Do you have hypertension?
Is your neck size greater than 17 inches (male) or 16 inches (female)
Or, you can measure their neck size yourself. If they answer "yes" to at least two questions they are candidates for HST.
Do a cardiopulmonary assessment to rule out exclusionary disorders such as COPD and CHF, examine the upper respiratory airway looking for enlarged tonsils, obvious asymmetries or blockage of the nasal passages and document your findings in the patient’s chart.
How fast can I get the report?
IDS usually contacts the patient and ships a device the same day the order is received. IDS processes the data and provides an interpretation within a matter of hours of it being returned by the patient. Results are available within an average of 5 days.
What is the cost to the patient?
The patient responsibility for Medicare patients without a secondary insurance is just $28. For patients without insurance, the charge is $300. To put it in perspective, an HST will be between 1/5 to 1/10 the cost of an in-lab study.
What data will I get?
IDS uses the ApneaLink device which records four channels from two sensors. A nasal pressure cannula records airflow and snoring, while a finger sensor records oxygen saturation and heart rate. The type III ApnaeaLink device, which should be available in 2009, will also record respiratory effort. See the section on Sample Reports for more specific examples.
Will my older patients be able to follow instructions?
IDS provides a video on how to apply the device and very explicit, detailed written instructions which have been developed based on our success in home overnight oximetry. The instruction page also contains several professionally drawn sketches developed just for IDS patients unable to read. It includes diagrams showing them removing nail polish, applying the nasal cannula, sliding on the finger pulse sensor, confirming the device is working and packing equipment back in the envelope. We also provide a toll-free, 24/7 support line staffed by qualified sleep technologists for patients who still experience difficulties and encourage them to use it when scheduling. Our success rate of 98% easily exceeds published industry standards.
Can I do follow up studies?
Medicare, and possibly other insurers, will only allow the new HST code to be billed once per year. However, an overnight oximetry can be done to determine whether a patient still has oxygen desaturations while on CPAP.
A DME in my area is doing the testing themselves. Can they do that?
For Aetna and private pay patients, they can. However, Medicare excludes a company or its affiliate from diagnosing and treating a patient. Unlike oximetry testing in which the DME can deliver the device and act as a "courier of equipment", the DME is not to be involved in home sleep testing in any way according to CMS rules.
IDS is the only company that, as an independent diagnostic testing facility (IDTF) without any co-ownership ventures with DMEs, can test patients with any insurance, in any state without risk of penalties.
Another company is including the clinical evaluation as part of their HST service. Isn't that a better option?
Medicare has made it clear that both the evaluation and the follow-up visits must to be done by the treating physician (there are allowances for nurse practitioners to be involved under the treating physician). These services are fine for private pay patients or insurers whose policies differ from Medicare's, but it's difficult to keep track of which ones those are.
The intent of the IDS program is to help primary care physicians become more comfortable talking with their patients about their sleep. Treating sleep apnea has been shown to improve glucose control in diabetics, lower blood pressure, reduce the risk of heart disease and stroke and increase energy allowing patients to exercise and lose weight. With discussions at the nation's capital focusing on pay-for-performance and the medical centered home, we believe this approach benefits patients and makes primary care physicians more likely to succeed should such changes be implemented.
What's going to happen to the sleep labs? My hospital just spent a lot of money to build one.
HST is for uncovering sleep apnea specifically. We expect that as physicians begin asking questions about sleep, other issues which require a comprehensive evaluation will be uncovered.
Where can I find guidelines for administering Auto-Titrating Positive Airway Pressure - APAP - treatment following a positive test and clinical evaluation?
The AASM (American Academy of Sleep Medicine) provides practice parameters on their website. The latest at the time of updating this FAQ on 11/2/2009 are (please review the AASM site for updated parameters):
http://www.aasmnet.org/Resources/PracticeParameters/PP_Autotitrating_Update.pdf