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Ruminations on Home Testing's Emergence in the Market
excerpting from a private conversation i had with a friend (on a no-names basis to protect the identity of the innocent ;-)
"I support the HST as an additional tool. I also see it as an easier way to get more people diagnosed. If the insurance companies use it as a replacement to the PSG instead of an additional tool I see more problems on the horizon for sleep. You have to see that this system is about what is best for the insurance companies, and has very little to do with pt care. I support the HST, but I am not so sure about the Watermark program. If this program were to catch on I believe it would be a step backwards in pt care as far as sleep is concerned. Everything would be done remotely via the primary care physician and Watermark. Under their system not once in the process would the pt talk to an educated sleep anything. I believe that this system would give the DMEs more power while crushing all sleep labs other than hospital based. I understand that the HST may enable more people to get diagnosed. That is huge, but what will be the sacrifice? I wish I knew. What I do know is that it will not fall on Watermark, the physician, or the insurance company. That only leaves one player in this game to take the hit. The patient.
The key to getting more people diagnosed and treated is lowering the price of the REQUIRED test. Not coming up with cheaper versions that only encompass one sleep disorder. I know that 85% of all sleep patients are inflcted with simple apnea. 40% of those have other underlying sleep problems. If the HST and auto titration become gold standard a huge number of people may never get the treatment they need.
It is all about the pts. If you take care of them emotionally, mentally, and physically then they will take care of you financially. There are no shortcuts when we are gambling with lives. "
The key to getting more people diagnosed and treated is lowering the price of the REQUIRED test. Not coming up with cheaper versions that only encompass one sleep disorder. I know that 85% of all sleep patients are inflcted with simple apnea. 40% of those have other underlying sleep problems. If the HST and auto titration become gold standard a huge number of people may never get the treatment they need.
It is all about the pts. If you take care of them emotionally, mentally, and physically then they will take care of you financially. There are no shortcuts when we are gambling with lives. "
Views: 146
Replies to This Discussion
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Permalink Reply by RChatty on
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Back to the subject.......
I think that home testing would drop the quality of the service you receive. This may be a very controverisal subject, but with the health care plan, doctors would no longer need to compete with each other over prices, thus decreasing their quality. In a way, home testing would be wonderful because you're in a natrual envoronment. But at the same time, you wouldn't have a highly trained doctor interpereting the results. That's what would bother me. I'd rather pay more to get it done right.
Just my 3 cents.
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Permalink Reply by Banyon on
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RChatty said:Back to the subject.......
I'd rather pay more to get it done right.
Just my 3 cents.
I support your right to make that choice.
Do note that published studies show HST results are very comparable in accuracy to sleep-lab PSGs.
Do we want to discuss home titration? Two titration nights in two accredited sleep labs did not get my pressure titrated correctly and cost much money and much of my time. I did eventually get it right with my own CPAP machine in my own bed, so you can guess where I stand on the issue of home titration.
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Permalink Reply by RockRpsgt on
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You are an enigma though Banyon. The majority of PAP patients do very well after their titrations. That is if they continue with their therapy. I applaud your efforts as most would have dumped the machine in the closet. With that said your OSA is far from simple. The forums are filled with pts that have problems with PAP. They actually only represent a small % of those diagnosed and on treatment.
There need to be more studies on the HST units. I am not saying that they do not work. I want them to work! They are just not as accurate as they keep telling you. I have used them quite a bit. They are not as accurate as a PSG. Most if not all of the techs on this site will agree with me. i am not saying this for job security. The RPSGT's place in sleep medicine is safe. Jobs for us are going to continue to grow. Maybe in the controlled environments of those studies they did exactly as they were supposed to. In the real world they are not as accurate as they say.
Banyon said:RChatty said:Back to the subject.......
I'd rather pay more to get it done right.
Just my 3 cents.
I support your right to make that choice.
Do note that published studies show HST results are very comparable in accuracy to sleep-lab PSGs.
Do we want to discuss home titration? Two titration nights in two accredited sleep labs did not get my pressure titrated correctly and cost much money and much of my time. I did eventually get it right with my own CPAP machine in my own bed, so you can guess where I stand on the issue of home titration.
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Here is 4 cents back to you Rock.
Your in-lab PSGs are not accurate. False negatives are a big problem for labs.
Dr. Barry Krakow has stated publicly that false negatives are such a problem in his lab that it has often taken three nights to diagnose patients.
Dr. Mack Jones has written about the extensive problems he had getting a diagnosis from in-lab PSGs.
You use equipment in your labs to make a diagnosis. The HST uses equipment to make a diagnosis.
Using infrared cameras and microphones to watch and listen to people sleeping rarely adds to the diagnosis.
People come into your lab anxious about a foreign experience in a strange envrionment. They do not sleep the same way, if at all, in your sleep lab as they sleep at home. Since they are not sleeping like they normally do, you have great problems with proper diagnosis and accurate titration.
Docs using in-lab PSGs and titrations give people a prescription for a pressure and if they become compliant, it is assumed everything is fine. The great majority of all patients could improve their therapy if they had a little education and a data-capable machine and patient software to use at home.
Sleep labs have no idea what the AHI of their treated patients is.
Your argument started out justifying in-lab PSGs with concern over the small percentage who don't have "simple" apnea. Now you find your argument crumbling, so in your latest post you reverse directions and are willing to disregard the "enigmas" as you now call them. Argue one way. Both doesn't work.
You know very well there is a huge population of undiagnosed. Getting them all in sleep labs for multiple night studies is extremely expensive and impractical and would take years while these people are left untreated.
Let's get multiple sets of HST equipment in every medical office in the country, get all the patients screened and send the positive screeners home with a HST unit.
Next we have to figure out a practical, inexpensive and quick way to get the positive testers titrated.
Don't get discouraged. There will be plenty of job opportunities for you in sleep medicine. Even if you want to continue doing lab PSGs, there will be plenty of job opportunities for you.
However, mass diagnosis of the population will not be done in labs. It will be done at home using HST or some other tools that have yet to be developed.
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First of all my argument is only crumbling in your eyes. I am still not ready to sacrifice anyone for the sake of anyone else. That is your way not mine. I agree that false negitives are a problem with the PSG. I do not think that this do to faulty equipment or the PSG as much as it is poorly trained techs, or techs that just do not care about what they do.
I am not speaking out against the HST despite what you think. All I said was that they were not as accurate as a PSG. Most of the studies that I have read have confirmed this. Even Watermark admits up to a 15% margin of error when compared to a PSG. Dr. Krakow, Dr. Mack's, and your own argument only add fuel to my argument. By your own admission as well as many other docs and studies there is a 20-25% chance of a false negative. Right? The HST has a 5-15% margin for error when compared to PSG.
http://www.watermarkmedical.com/ares_manuscripts.php
That means that your chance of having a false negative or positive are somewhere between 15 and 40% with an HST. This is what I have seen in the lab. This is what the data tells me.
Which insurance company do you work for Banyon?!
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I would be more than happy to talk about home studies vs lab studies if you like. Both present unique problems. A good tech knows how to educate and talk his patients through a study. I have NEVER had a pt that could not sleep. NEVER not once. Not everyone's experience is as bad as yours was. You should quit assuming that they were.
Doing the studies at home will not remove the anxiety that causes first night effect. It will still take more than one night for quite a few patients. How many times more do you think this will happen without someone monitoring the study? Your views only cover the current problems without taking into consideration the added problems. Your wallet is as corporate funded as your views.
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If more docs ordered sleep studies with split orders at AHI>10 the cost of the study would go way down. This would also free up more lab time for new pts.
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Permalink Reply by 99 on
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i agree with rock
you are trouble stirrer banyan
you are confusing the issue with facts
just like a politition with statistics banded about
Rock Hinkle said:I would be more than happy to talk about home studies vs lab studies if you like. Both present unique problems. A good tech knows how to educate and talk his patients through a study. I have NEVER had a pt that could not sleep. NEVER not once. Not everyone's experience is as bad as yours was. You should quit assuming that they were.
Doing the studies at home will not remove the anxiety that causes first night effect. It will still take more than one night for quite a few patients. How many times more do you think this will happen without someone monitoring the study? Your views only cover the current problems without taking into consideration the added problems. Your wallet is as corporate funded as your views.
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Permalink Reply by Laura on
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The inability of lab or home testing to accurately diagnose a patient has nothing to do with the device itself or the person scoring it, but the fact that patients sleep differently each night and no single night of recording can capture what is really going on. When Medicare finally approved home sleep testing, they did so not because the technology had improved since their last review, but they realized that PSG should not be considered a "gold standard" by which to measure any new technology. In sleep medicine, scoring rules, sensor technology and PAP follow up guidelines vary significantly from lab to lab. A patient can have an AHI of 4 at one lab and 23 at another. In my opinion, that is why we saw a policy change, not anything that Watermark or any other vendor said about home testing now being the same as lab studies.
For the same reason (patients sleeping differently each night), auto adjusting PAP units will likely continue to gain in popularity. Home testing plus an APAP just makes more sense to patients and primary care physicians who know they themselves would not sleep the same in a lab.
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Laura I agree with most of what you say. The lab variations will not change because the way we test changes. That will still rely on the knowledge of the interpreter. Until the standards are set across the board interscorer reliability will remain an issue. I am not against the HST. Far from it. I want them to work. I see my career as a tech going in a different direction in part to these units. I also want everyone to know the problems that come with this type of test. Just the same I do not have a problem with admitting the downfalls of in lab testing.
The HST in conjunction with an auto-pap used for selftitration will end more therapy than it begins. If this becomes the norm then we will fight to get back to a 40% noncompliance rating. There are 2 very important things needed for continued therapy. First and foremost is pt education. Next is an immediate improvement in sleep efficiency. This will not happen if this type of treatment becomes the norm.
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Rock Hinkle said:Laura I agree with most of what you say.
Oh Rock, you conceded the argument!
Thank you Laura for stating the case so well!
Bye.
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I did not concede anything. I still believe that there are unseen problems with these units.
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