Opposing views determine whether sleep studies should be performed in the home.

Sleep Studies SHOULD Be Performed in the Home

by Patrick J. Dunne, MEd, RRT, FAARC

An important first step in any discussion of alternate site testing for sleep disorders is to define what is meant by the term “sleep studies.” In today’s parlance, the term embodies three distinct activities: portable sleep testing (the basic screening study); portable polysomnography (wherein sleep is actually staged); and titration of nasal continuous positive airway pressure (CPAP). Traditionally, all three of these activities were originally performed in the tightly regulated and structured hospital-based sleep disorder center/laboratory. At one point, it was thought that only the basic screening study would lend itself to home testing. However, for a variety of reasons, we now see all three of these activities being performed in alternate sites, most specifically, in the subject’s home.

A major impetus for this transition has to do with advances in equipment design and software programming. The monitors, recorders, and smart CPAP devices that are available today for in-home sleep studies, unlike their earlier counterparts, are highly accurate and very reliable. Moreover, the techniques of interfacing the subject with the equipment have been greatly refined as well. Also, the retrieval and scoring of the recorded data are likewise very sophisticated. When one couples these technological advances with a better trained professional staff, home sleep studies can be every bit as effective as what one would expect from the traditional institution-based sleep disorder center/laboratory for the majority of those individuals suspected of having obstructive sleep apnea (OSA).

Another compelling force promoting the growth of in-home sleep studies is subject preference. Simply stated, individuals will sleep best in the comfort and safety of their own bedrooms. Even with the best design, layout, and intentions, hospital-based sleep centers/laboratories still introduce an environmental artifact. The layout of the room will be different; the size and firmness of the mattress will be different, as will the sounds and smells. With so many obstacles to sleep, it is not difficult to understand why the vast majority of individuals requiring a sleep study prefer the test to be conducted in their homes.

Another often-overlooked reason propelling the growth of in-home sleep studies is the backlog currently being experienced in the more traditional sleep disorder centers/laboratories. It is very difficult to expect an individual who has finally learned that there may be a medical basis for their years of daytime sleepiness, to wait an additional 6 weeks for an appointment. And, if a split-night study is not performed, there may be another 4- to 6-week wait for a titration study. With renewed focus on hospital cost-effectiveness, it is unlikely that we will see many more sleep centers/laboratories established, so the backlog will only get worse.

Finally, there is the matter of pure economics. Even with the expense of acquiring all of the needed equipment, supplies, personnel, and support services, it is still substantially less costly to perform in-home sleep studies than it is to test in a stand-alone sleep disorder center/laboratory. Managed care organizations have clearly recognized this advantage and many now openly promote in-home sleep studies.

Notwithstanding the foregoing, however, there still remain serious issues surrounding the practice of performing in-home sleep studies. Perhaps the most important issue is the perception by the traditionalists that certain companies and individuals promoting and providing in-home sleep studies cut corners and, by so doing, seriously compromise both the quality and effectiveness of the entire testing process for sleep disorders. There is also the very real issue of certain companies performing only the basic screening test and then using the results to justify a prescription for nasal CPAP. To be sure, there have been such incidents, but the advent of more sophisticated and portable equipment has effectively “raised the bar” in terms of accountability and effectiveness. It is also important to recognize that many formally trained and professionally credentialed polysomnographers have themselves left the traditional sleep centers/laboratories and now provide in-home sleep studies. This influx of highly competent and knowledgeable sleep medicine professionals into the in-home sleep study market has likewise helped to restore technical and medical credibility.

As the number of individuals needing sleep studies continues to increase as a result of the heightened awareness of OSA throughout the general public and mainstream medical community, the accuracy, convenience, availability, and economics of in-home sleep studies will result in this option soon becoming the rule rather than the exception. It will therefore be incumbent on all of those individuals and organizations providing in-home sleep studies to ensure that all data and information obtained are of sufficient rigor that clinical decisions made rival those that are made with data obtained from traditional sleep centers/laboratories.

It is also important that those individuals and companies offering in-home sleep studies fully recognize that there may well be situations where a referral should be made to a traditional sleep center/laboratory for more extensive testing and follow-up. While in-home sleep studies do indeed offer certain advantages, it would be inappropriate to suggest that this option will completely replace testing in sleep centers/laboratories. In fact, an intriguing scenario would be for traditional sleep centers/laboratories to start their own in-home testing programs, a situation that would represent the best of both possible worlds. Given the continuing pressures to make health care delivery processes more cost-effective, traditional sleep centers/laboratories may well find their own survival dependent on developing such nontraditional alternatives.

Patrick J. Dunne, MEd, RRT, FAARC, is affiliated with HomeTech Medical Services Inc, Fullerton, Calif, a regional home care company that performs in-home sleep studies in one of its locations.

 Sleep Studies SHOULD NOT Be Performed in the Home

by Pamela Minkley, RRT, CPFT, RPSGT

When we think of any diagnostic test being performed in the home, there is an assumption that the test is likely to be simple, easy, and relatively inexpensive. The assumptions are far from reality. The risk of performing sleep studies in the home can be gleaned from “horror stories” reported in the literature and from personal experience.

Obstructive Sleep Apnea
One of the easiest sleep disorders to diagnose in the home is probably obstructive sleep apnea (OSA). A patient may complain of a number of sleep symptoms but if OSA is likely, all too often other symptoms get ignored. When sleep studies are done outside the sleep center environment, the possibility that all sleep complaints and symptoms will be diagnosed and addressed may be reduced. The availability of inexpensive equipment that records minimal data, mostly aimed at whether or not a patient is breathing, may give negative results for OSA while other sleep disorders are not recognized.

Environment
One argument for performing sleep studies in the home is that it is the patient’s normal sleep environment. Is it? When strangers invade the bedroom with gizmos and gadgets, it is no longer “home,” especially in the bedroom, the most private area of our home. In addition, that environment is not controlled, and if the study is not attended by a technologist, artifacts can jeopardize study results without anyone recognizing it. Could the patient’s arousals be due to their bed partner’s kicking legs or OSA? How about the family pet jumping on and off the bed? Is the equipment safe? How many cables can a dog or cat chew in a night? Might a curious bed partner wear the oximeter probe while the other parameters are recorded from the patient? Would minimally trained personnel downloading the recorded sleep study recognize any of the above? How valid would the report be?

You say home studies can be attended studies. Are the technologists we send into the home safe? Any respiratory therapist working in the home care environment can tell you horror stories about their visits. Visits primarily at night could bring additional risks. And when a lone technologist is staying the night, just outside the bedroom, what additional risks are there for the technologist and the patient?

A number of abstracts and studies have indicated that patients who were studied in the home were less likely to be followed up by their physicians, receive their results, and in general be satisfied with their results.

Medical Education
The National Commission on Sleep Disorders Research indicated that medical education about sleep and its disorders is nearly nonexistent in US medical schools. The quicker and easier it is to do sleep studies in the home, the simpler it appears and the more likely that inexpensive equipment will be available to use in the home, and that physicians untrained in sleep medicine will be ordering and interpreting the study. Will they recognize artifactual data? If the study is negative for OSA, will the patient’s symptoms still be addressed? Will there be any follow-up or case management? What about treatment recommendations and options?

Goals of a Sleep Study
• diagnosis;
• intervention;
• patient education;
• interpretation and recommendation;
• follow-up;
• integrated, cost-effective system.

Do Home Sleep Studies Meet the Objectives?
• accessibility may be better;
• diagnosis questionable;
• immediate intervention often not available;
• treatment and follow-up questionable;
• patient education questionable;
• case management questionable;
• cost-effectiveness questionable.

Cost
Providers and third-party payors have a tendency to select the least expensive diagnostic options regardless of medical indication or efficacy. The availability of sleep studies in the clinical environment may be reduced or eliminated by those responsible for reimbursement if anyone, anywhere, can do any kind of “sleep study” in the home at very low cost.

One has to ask the question: Is a sleep study cost-effective if the objectives are not met? If treatment interventions are not available in the home, a second study may be required, which could have been avoided in an attended, center-based study. Underestimating the complexity of the technical aspects of polysomnography can lead to hiring inexperienced people who can be taught to mechanically place electrodes and transducers on patients. In an effort to keep costs down for the “home studies,” technical competence may be sacrificed. This is less likely in a center-based study where other technologists and physicians are likely better trained in sleep medicine and technology, and technologists rarely work alone at night. Studies have shown that compliance with continuous positive airway pressure (CPAP) therapy is proportional to the education a patient receives about OSA and the use of CPAP. The sleep center environment provides an atmosphere more likely to provide education, while the home environment is distant from clinical and diagnostic services, so education may be minimal. If patients often do not get the results of their studies, one might argue they are left untreated and therefore health care dollars are wasted. If patients are not adequately treated, are not compliant with their treatment, or are improperly diagnosed, then their symptoms are not resolved and they remain equally at risk for all the morbidity and mortality associated with untreated OSA and sleepiness.

The entire debate can be summed up in one sentence. There is a big difference between “cost effective” and cheap, and all too often home sleep studies are nothing but cheap.

Conclusion
This article has been presented as a debate where each side has to argue in absolute terms. In real life, of course, this is not the case. While there is some risk that if inexpensive/cheap “sleep studies” are performed in the home, third-party payors may demand all sleep studies be performed at similar cost, there is a place for more than center-based polysomnography in the diagnosis and treatment of sleep disorders. The key to cost-effective sleep studies is having well-trained physicians and technologists accurately and efficiently match the appropriate sleep study diagnostic tools, level of attendance, and testing environment with each patient’s needs; provide skilled scoring, interpretation, and recommendations; and follow up their patients to assess adequacy of treatment.

Pamela Minkley, RRT, CPFT, RPSGT, is a member and past president of the Association of Polysomnographic Technologists, and is team leader of the Sleep/Wake Center at Ingham Regional Medical Center, in Lansing, Mich.