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Home Sleep Testing Clinical Evidence

Home sleep testing (HST) has been used for many years in Europe, Australia and Canada. Contrary to this practice, U.S. insurers have considered it 'experimental' or 'investigational' and have required in-lab polysomnography to diagnose OSA. Today, however, U.S. insurers are changing their opinion of HST in a big way!

CLINICAL REASONING FOR CMS DECISION TO SUPPORT HST FOR OSA TESTING: The March 2008 review of CPAP policy by the Centers of Medicare and Medicaid services was prompted by a letter from the American Academy of Otolaryngology Head and Neck Surgery who argued that:

"Home sleep testing is a validated alternative and an important step in improving recognition and control of OSA"...and further that "the current paradigm of high reimbursement for PSG and low reimbursement for treatment is not only a waste of precious resources, but also discourages more appropriate focus on rapid diagnosis and effective treatment for OSA."

During this review, the idea that PSG should be considered a "gold standard" was challenged based on the fact that data recorded by PSG (AHI, arousals, sleep efficiency, frequency and severity of desaturations) correlate only weakly with symptom severity, response to CPAP therapy, utilization rates for CPAP and overall prognosis. Further weakening the case for in-lab PSG as the only option for testing is the known night-to-night variabilty in patients. This variability results in: a change in diagnosis in more than 40% of borderline OSA cases; reader and technician scoring variability; and altered sleep states vs. sleeping at home. Another concern was the limited recorded sleep time prior to treatment initiation for patients undergoing split night sleep studies, and the fact that despite the growing number of labs nationally, more than 80% of patients remain undiagnosed.

CMS ultimately determined in the decision memo and the new coverage policy, that while HST is not THE definitive test, overall outcomes in appropriate patients are certainly comparable to the more expensive alternative. The bigger issue in management of OSA is the high relative percentage of patients that do not use their CPAP. The method of diagnostic testing was deemed to be unlikely to affect that, and it was determined that it was more important to tie long-term payments for PAP therapy to documented compliance. This motivates HME providers to show more interest in whether or not patients are using their masks and improving clinically with therapy. It also encourages vendors to develop better technology for tracking usage remotely and should create a comprehensive, team-based approach to ensure improved outcomes for newly diagnosed patients.  

Background articles mentioned above:

HST vs. PSG: Comparison of Recorded Data from Sleep Heart Health Study

Night to Night Variability as Recorded on PSG

Evidence regarding risk of untreated sleep apnea:

Epidemiology of Adult Obstructive Sleep Apnea

Sleep Disordered Breathing and Mortality: An 18-Year Follow-Up

Physiological Explanation Why OSA is Dangerous (news article)

Studies supporting the HST model:

Home Testing Equal to In-lab PSG in Treatment Results -http://www.sleepreviewmag.com/sleep_report/2010-05-26_01.asp

HST + Autotitration vs. PSG

Unattended Home Diagnosis and Treatment of OSA

Diagnosing and Managing OSA without PSG: Canadian Model

Articles on identification of OSA for PCPs:

Gender Differences Sleep Apnea Symptoms

Importance of Screening for Sleep Problems in Primary Care Settings