Often physicians order a diagnostic test that they have employed for their entire careers overlooking newer or alternative tests that may be have distinct advantages. Sleep studies are such an example. Out of habit or early training, physicians often refer patients with symptoms of sleep apnea to a sleep lab for an overnight polysomnogram (PSG), often at a cost of over $2,000 when there is a less costly alternative.
Although home sleep testing (HST) was first described over 30 years ago, it was only when accurate home sleep devices became mass-produced that HST became feasible. In 2013 the sleep literature favorably compared home and facility sleep testing, and shortly afterwards the American Association of Sleep Medicine (AASM) published evidence-based guidelines supporting HST. It was just a matter of time before some insurance companies launched prior authorization programs for sleep testing as a way to shift some patients to less costly home testing.
Home sleep testing has some obvious advantages over a facility study. Patients who have difficulty sleeping at home will usually have an even worse time sleeping in a clinical sleep lab. If your patient cannot fall asleep (in the lab) it is not possible to confirm a diagnosis of obstructive sleep apnea. Many patients claim to prefer testing in the comfort of their own home rather than going to an unfamiliar facility lab and some feel that the test equipment used for home testing are less intimidating than those used in sleep labs. Some vendors of home sleep devices even allow patients to re-test themselves for multiple nights, thus avoiding the “first night effect.” 1 Finally there is the cost advantage – HST costs just a fraction of a PSG.
Initially insurance companies implementing a home sleep study authorization program contracted with national vendors to provide the equipment. Home sleep devices (with instructions) were shipped to patients (with telephone backup) and thereafter interpreted by contracted sleep specialists. More recently, local sleep labs managed by sleep specialists have purchased and can provide home devices, making HST even more convenient.
So now that there is an alternative to facility sleep testing and guidelines by the AASM outlining indications and contraindications to home testing. Physicians and prior authorization companies are able to determine when a home study is indicated and when it is not. Following guidelines is the best way to make sure your patient will receive the most efficient and economical diagnostic testing, not to mention will help avoid a denied request and an unnecessary P2P call.
The easiest way to determine if a patient needs a sleep study is to follow ASSM guidelines. These are condensed into the RBM guidelines that are available on line. (https://www.evicore.com/implementationresourcesdocuments/2018-sleep.pdf)
A history and physical exam initially determines to the pre-test probability that a patient has OSA. This includes performing a patient-completed standardized sleep questionnaire such as the
• Epworth Sleepiness Scale
• STOP-BANG test
• Berlin questionnaire
• Insomnia severity index
A high score on any of these tests makes it likely that your patient has obstructive sleep apnea, which means a HST can be considered. Once pre-test probability has been determined, it is necessary to search for any contraindications to home testing.
Patients with certain co-morbid conditions should NOT have a home test and thus may be a candidate for facility testing. These conditions fall into three categories: sleep conditions, medical conditions or other circumstances. It takes only one condition to meet the criteria for a facility study.
Associated Sleep conditions
• Periodic limb movement disorder (PLMD) (not restless leg syndrome)
• Suspected or known central sleep disorder
To be concluded in Part 2
Lesson#17 Mass production of home sleep testing devices have allowed physicians who suspect obstructive sleep apnea to have a second diagnostic test option alternative to facility sleep labs. HST is appropriate in a large segment of patients, but not in all patients. This post and (the next one) highlight how to determine which patients with suspected OSA are candidates for a home study and which ones should have a facility test. Requesting the appropriate sleep test will ensure a rapid approval, avoiding denials, appeals and peer-to-peer calls.
1 First night effect” (FNE) is typically characterized by poor sleep quality and deficiency of REM stage sleep during a polysomnography (PSG) study. FNE is due to multiple factors: discomfort caused by electrodes, limitation of movements, and the unfamiliar environment of the sleep laboratory and is seen on the first night of a new sleep environment. FNE diminishes with repeated testing in the same environment.