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Home Sleep Studies vs. In-Lab
I understand a study has been published in the August issue of Chest concluding that diagnosis and titration at home with portable equipment is as effective as in-lab studies. If someone has a subscription, maybe they want to comment further.
"After 4 weeks, there was no significant difference between the two groups in regard to any sleep measures or CPAP compliance. Researchers conclude that select subjects with suspected OSA could be diagnosed and treated at home"
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Replies to This Discussion
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Permalink Reply by Mike on
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When I was at the American Thoracic Society meeting this year, I saw a study presented that arrived at the same conclusion. This is solid science. Lab-based sleep labs should offer the home test and not resist this development in technology.
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Permalink Reply by 99 on
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i am with jnk in his reasoning and conclusions
you alway have a rouge factor which PSG can spot but would have been missed by home test
j n k said:Note that conclusions that portable monitoring is "as good as" are usually about OSA only, not the many other disorders that sleep studies often catch. The records from my PSGs are particularly valuable to me. I think all patients should have that level of healthcare when a sleep disorder is suspected.
My opinion (and you knew I had one) is that attended PSG remains the gold standard for screening for sleep disorders, and OSA is only ONE of those. At this point, having someone watch the patient sleep is a crucial part of increasing the likelihood of any patient having the most successful, accurate, and reliable sleep study possible that will screen the patient for the largest number of sleep disorders.
Yes, there are reasons to use home tests in certain circumstances that the AASM outlines. (http://www.aasmnet.org/jcsm/AcceptedPapers/PMProof.pdf) But, still, whenever possible, shouldn't we all be fighting for better medicine, better tests, and better treatment, not cheaper/easier/worse?
-jeff
ps-Note in the guidelines from the AASM that if they are followed, PM would not save much money or be used on very many patients. Most patients with a high likelihood of moderate-to-severe OSA would also have a high likelihood of comorbidities, and the involvement of techs and docs is recomended to remain basically the same as in-lab PSG, other than direct observation during sleep.
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agreed that the home test is not "as good" for the diagnosis of sleep disorders other than OSA. also, I think in-lab is the "gold standard" for titration studies, but for the diagnosis of plain, run-of-the-mill OSA, i think in-lab is an unnecessary extravagance. put another way, if someone told you that they gasped for air at night, were heavy snorers and woke up feeling tired even after many hours of sleep, would you think an in-lab test was required? or could we get that person into the system with a home test and see if the person's symptoms improve with OSA treatment before running a more sophisticated test? to me, on those facts, it seems like an in-lab test would be taking a sledgehammer to a nail.
j n k said:Note that conclusions that portable monitoring is "as good as" are usually about OSA only, not the many other disorders that sleep studies often catch. The records from my PSGs are particularly valuable to me. I think all patients should have that level of healthcare when a sleep disorder is suspected.
My opinion (and you knew I had one) is that attended PSG remains the gold standard for screening for sleep disorders, only one of which is OSA. At this point, having someone watch the patient sleep is a crucial part of increasing the likelihood of any patient having the most successful, accurate, and reliable sleep study possible that will screen the patient for the largest number of sleep disorders. Yes, there are reasons to use home tests in certain circumstances that the AASM outlines. (http://www.aasmnet.org/jcsm/AcceptedPapers/PMProof.pdf) But, still, whenever possible, shouldn't we all be fighting for better medicine, better tests, and better treatment, not cheaper/easier/worse?
-jeff
ps-Note in the guidelines from the AASM that if they are followed, PM would not save much money or be used on very many patients. Most patients with a high likelihood of moderate-to-severe OSA would also have a high likelihood of comorbidities, and the involvement of techs and docs is recomended to remain basically the same as in-lab PSG.
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Permalink Reply by Rooster on
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Wow jeff, I never found so much with which to disagree with you.
jnk said, “The records from my PSGs are particularly valuable to me.” And “having that objective baseline is very important for assessing what should be done.”
The portable home equipment also creates records and copies can be given to the patient. You will have an “objective baseline”.
jnk said, “But, still, whenever possible, shouldn't we all be fighting for better medicine, better tests, and better treatment, not cheaper/easier/worse?”
Absolutely not. That is one of the biggest problems we now have in U.S. healthcare. Everyone wants the “latest, most technologically advanced, most in the news, most sure,” treatment and wants the government or an insurance company to pay for it. Economics should be considered in every decision or you continue to perpetuate the mess we are in now. This is why so many people do not have insurance, pay an arm and a leg for insurance, or turn to Medicare/Medicaid and drive our national debt through the roof. Whether we like it or not, this will have to change because eventually our debtors will quit financing our terrible spending habits.
jnk said, “Note in the guidelines from the AASM that if they are followed, PM would not save much money or be used on very many patients.”
Then we have the wrong guidelines! Likely there is a vested interested in sleep labs behind the people who wrote these guidelines. As more information is known about home studies, new guidelines should be written by more objective people who understand medicine, statistics and economics.
jnk said, “Most patients with a high likelihood of moderate-to-severe OSA would also have a high likelihood of comorbidities,”
Please specify which comorbidities would require a very expensive night in the sleep lab to diagnose. I think that maybe 98% of the patients coming to the sleep lab have had their comorbidities diagnosed in a doctor’s office years earlier – heart disease, stroke, hypertension, type 2 diabetes, anxiety, depression, obesity. Which comorbidities are you referring to?
jnk said, “I think that it is the job of accredited sleep doctors to make the call as to when an in-lab study is needed.”
I disagree again. Medical decisions like this are the job of a doctor and patient, fully aware of the costs of both types of studies. I know that you personally, jeff, don’t let any of your doctors make unilateral decisions for you.
Overall and maybe most importantly, don’t forget that something like 90% of cases remain undiagnosed. That would be one hell of an expense and effort to get done in sleep labs. Let the market move forward at a rapid pace with portable home equipment.
Footnote: I don’t begrudge anyone who chooses an in-lab PSG over a home PSG, if they are paying for it with their own funds. But they need to be fully informed of the cost difference and the lack of difference in effectiveness for CPAP success.
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Did you give Andrew Breitbart your password?
jnk said, "But we agree more than we disagree if you say, as you do: " I don’t begrudge anyone who chooses an in-lab PSG over a home PSG."
That is not what I said.
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You just invented two implications.
Do you want to debate about the success and practicality of socialized medicine?
As far as "Rooster ruling", I have no desire to make economic and health care decisions for anyone (other than myself and my children). I very much want to leave those decisions to individual patients and individuals choosing to provide health care.
It is the people in the opposite pew who want to decide in a central planning way, who does what to whom and who pays what and who receives what monetary compensation. It is this type of system that has already driven medical care costs so high.
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never mind economics and costs
which one would you go for, for yourself and your family
Rooster said:You just invented two implications.
Do you want to debate about the success and practicality of socialized medicine?
As far as "Rooster ruling", I have no desire to make economic and health care decisions for anyone (other than myself and my children). I very much want to leave those decisions to individual patients and individuals choosing to provide health care.
It is the people in the opposite pew who want to decide in a central planning way, who does what to whom and who pays what and who receives what monetary compensation. It is this type of system that has already driven medical care costs so high.
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99,
You are living in a fantasy world if you ignore economics. Economics is a ever present fact that affects our quality of life (by traditional measures) and that includes our quality of health and vitality.
But I will hypothesize a little to appease you. Let's say I no longer feel well and am concerned that my CPAP therapy, despite a consistently low AHI, is no longer treating my condition properly. I absolutely would want a portable home study.
Portable home studies are gaining market share faster than you may realize. Medicare has approved their use and insurance companies are following quickly.
My sleep doc, who is certified and oversees a certified lab, has offered a portable home study to me if I want one. I have no reason to have a sleep study of any kind (unless jeff wants to pay for it just for fun), so I refused.
The AASM guidelines are three years old and rely on studies running from 1960 to 2007. As so often is the case with bureaucracies, they are badly out of date and out of touch with what is rapidly happening in the market. They rely heavily on reports and studies that were done between 1960 and 1994. 1994, the most recent year, is now 16 years past. The guidelines also rely in part on a 2005 government report that recommended against home devices which the government has since reversed.
Beyond being badly out of date, the wording and tone of the guidelines shows a clear bias against portable home equipment by people with investments in sleep labs. Luddites resisting technological change? Or "rich people" protecting their turf and money bags?
It doesn't really matter what we think, portable home testing will grow rapidly as long as governmental bodies don't interfere. And that will be a very good thing for those "non-rich" people who need sources of more efficient medical care.
And no jeff, I don't begrudge your having an in-lab PSG if your insurance paid for it. You earned money and paid premiums for the insurance. I don't begrudge you having it if Medicaid or Medicare paid for it. The programs are there and eligible people should use them. I don't begrudge your PSG if a church, other charity, friend, or relative paid for it.
I do begrudge the programs of Medicare/Medicaid because they are primarily responsible for the high cost and inefficient delivery of medical care we live with today.
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jnk said, " And right now the accepted standard is alive and well keeping patients just as alive and just as well. It is called a PSG."
Are you surprised if I don't agree? :)
What does this statement of yours say about the 90% undiagnosed?
What does this say about the 10% diagnosed in light of the following?
"It can also be stated that CPAP, the gold standard of treatments, has a horrible effectiveness rate across the population of sufferers. Compliance rates of CPAP are typically stated around 50% and compliance is defined as a minimum of four hours of usage five nights per week. And that is just using the CPAP, it says nothing about effectiveness during use because the great majority of patients have no efficacy data capability.
The compliance rates of CPAP also say nothing about the legions who refuse sleep studies because they "would never be able to wear a mask".
If you could boil this all down to the essentials, I believe you would find the true effective compliance rate for CPAP is somewhere between 10 and 25%." (Quoting myself from another discussion.)
My view of where we stand today over the whole population of sufferers is that it is a extremely poor situation. Could it be among the entire population that only 2.5% are getting good therapy? If so, should we be clinging to an old model that is this ineffective and inefficient?
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It would be nice to keep the whole bag of fruit from rotting, not just the 2.5% Red Delicious who educated themselves and have a good therapy working.
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you have skillfull side stepped my question just like polititions, what is your answer and are you a politition
Rooster said:99,
You are living in a fantasy world if you ignore economics. Economics is a ever present fact that affects our quality of life (by traditional measures) and that includes our quality of health and vitality.
But I will hypothesize a little to appease you. Let's say I no longer feel well and am concerned that my CPAP therapy, despite a consistently low AHI, is no longer treating my condition properly. I absolutely would want a portable home study.
Portable home studies are gaining market share faster than you may realize. Medicare has approved their use and insurance companies are following quickly.
My sleep doc, who is certified and oversees a certified lab, has offered a portable home study to me if I want one. I have no reason to have a sleep study of any kind (unless jeff wants to pay for it just for fun), so I refused.
The AASM guidelines are three years old and rely on studies running from 1960 to 2007. As so often is the case with bureaucracies, they are badly out of date and out of touch with what is rapidly happening in the market. They rely heavily on reports and studies that were done between 1960 and 1994. 1994, the most recent year, is now 16 years past. The guidelines also rely in part on a 2005 government report that recommended against home devices which the government has since reversed.
Beyond being badly out of date, the wording and tone of the guidelines shows a clear bias against portable home equipment by people with investments in sleep labs. Luddites resisting technological change? Or "rich people" protecting their turf and money bags?
It doesn't really matter what we think, portable home testing will grow rapidly as long as governmental bodies don't interfere. And that will be a very good thing for those "non-rich" people who need sources of more efficient medical care.
And no jeff, I don't begrudge your having an in-lab PSG if your insurance paid for it. You earned money and paid premiums for the insurance. I don't begrudge you having it if Medicaid or Medicare paid for it. The programs are there and eligible people should use them. I don't begrudge your PSG if a church, other charity, friend, or relative paid for it.
I do begrudge the programs of Medicare/Medicaid because they are primarily responsible for the high cost and inefficient delivery of medical care we live with today.
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Permalink Reply by Mark Douglas on
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I think this is great news. At home units might have some drawbacks, sure. But far more people may be checked -- and treated.
Putting it in homes could catch many sleep problems--- and catch them earlier. Why wait till you are obese, have heart failure, and are picking out your casket, before you start getting effective treatment.
By far the biggest problem with sleep disorders is that typically we victims go years, or even decades, without getting tested. We plug up our arteries, fatten our gut, and mess up every cell in our body. A lot of this is irreversible.
And SOMETHING is causing Cancer, ALS, MS, liver and kidney disease, etc. Could not improper oxygenation contribute to virtually every disease? I'm sure lack of oxygenation isn't HELPING anything.
Anything that can reduce the average age of those being tested is a good thing.
Plus this is just the first step -- wait 5 years. .This is a rapidly evolving field of study.
Sleep labs have been charging punishing prices --- which doesn't matter for people with great insurance, but not everyone has it. This might make them compete a little on price -- but who knows? And maybe the sleep doctor will call you back sooner. Oh - wait, lets not wish for too much. .
I hope they come up with a device you KEEP. I think these units for at home use, you RENT, for like 500.
But you watch -- that will change too. We might have to rent them at first, but as they mass produce them, we may be able to buy them.
If you own a device, you can use it repeatedly, and in your 'native" surroundings. That has to have some advantages.
Great news -- I wish they had it back when I was lad.
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