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ADVANCE Perspective: Respiratory Views

A Tale of Two Tests

Published July 7, 2014 2:32 PM by Pam Tarapchak

Severe fatigue. That's the only way I could describe to my physician the symptoms I was feeling over the past few months.  Sleeping 10 hours at night; napping on the weekends. Yet, I was never rested.  As the editor of a respiratory website, I've read plenty about sleep apnea, and I've been warned by family members that I snore, so I suggested this diagnosis to my physician. After discussing my symptoms and the condition, he brought up the topic of home sleep testing.  I was desperate and thought that if I could get a diagnosis, this fatigue could be controlled. Sign me up.

I picked up my kit from the physician's office, which was supplied from a home testing company. The representative was a nurse practitioner who was very thorough in showing me how to set up the kit at home and accurately test my sleep patterns. For three nights I hooked myself up and basically just went to sleep. It was simple to use and after dropping my kit back at the physician's office, I had answers within about a week.  Results: no sleep apnea.

As a patient who has used this type of testing, I'm somewhat confused by how in-lab specialists react when asked about home sleep testing and boldly label in-lab tests as the gold standard.  To these healthcare professionals, it almost seems like home sleep tests are irresponsible and a disservice to the patient.

Before writing this editorial, I remember a friend of mine who had an in-lab sleep study done some years ago, so I wrote her and asked what her experience entailed.

"I arrived at the site of the sleep study a bit nervous about being expected to sleep in a strange room and knowing this sleep was going to be evaluated. The entire situation seemed impossible. How can you get a good night's sleep in a strange place while being nervous that the quality of that sleep is being evaluated?" she noted.

Not only was she nervous about the study, but she also didn't care much for tromping around in her pajamas so she could get probes and gadgets attached to her.  "What made it more discombobulating was the fact that by the time they finished you looked like Frankenstein with your hair full of goop, sticking straight out in places, and these probes sticking out of your body and head. Where I went for my study was at a prestigious university-run center, but I am surprised they did not provide private curtained areas where this process could be done.

"When I went for my study the only option was to have it done at the sleep center. I think I would have had an entirely different attitude toward the study had I been able to do it at home."

She did note one benefit of her in-lab sleep study: "When I went for my second study, I was fitted for a CPAP mask and went to sleep. I woke in the middle of the night because the mask was falling off. The technician then fitted me with a children's size mask and I fell asleep for about a half hour more and then woke feeling constricted because that mask was too tight. That was an advantage of being right there and having several sizes of masks available."

Unfortunately, due to her experience, she never did get a CPAP system. "I was so upset by the entire process I never pursued it."

Now, no doubt there are people who need in-lab sleep testing, especially those in staying in a hospital environment or perhaps older individuals who would have difficulties with accurately setting a home sleep test. But what I find most interesting is this divide that separates sleep professionals, one that can no doubt bring about confusion to both patients and other healthcare professionals in the care of sleep disorders. The future of healthcare holds many changes, and I believe being open to new technology and solutions is the first step in improving the health of future patients.

What are your thoughts about home sleep testing versus in-lab testing? Send me your thoughts. I want to learn more about this growing field.

9 comments

ADVANCE Perspective: Respiratory Views : A Tale of Two Tests

October 7, 2014 1:13 AM

I have several issues with how home testing is used and presented to patients.  My three biggest are:

1) it's not a home sleep test.  The doctor cannot tell when you are sleeping so it can be more accurately described as a home apnea test (not obstructive or central, just apnea).  It is irresponsible of doctors to give patients the impression it is a sleep study, which is synonymous with polysomnography in the medical field.  

2) when it is not a board certified sleep specialists deciding when to use the test, you are giving the non-expert less information to make a diagnosis.  How can this be better than true polysomnography?

3) my biggest issue is that you have a home study and it's negative...now what?!  You still have a problem and you don't know if it's related to your sleep or not.

As for the statement "Now, no doubt there are people who need in-lab sleep testing, especially those in staying in a hospital environment..." Sleep testing is explicitly contraindicated during phases of acute illness.

Home testing is a bad idea overall, not because it hurts in-lab business but, because people do not know how to use it properly.  The AASM has very specific guidelines but unfortunately most non-accredited test providers use them (in my experience).

I also want to say I agree with Cheri's last sentence 100%.

Thank you for posting the article.  Discussions like this will enable others to better understand home testing.

Chris, Cardiopulmonary - Director, Hackensack UMC at Pascack Valley July 29, 2014 12:09 PM
NJ

The simple answer is which test would a sleep professional want for a family member if both were offered to the family member.  I would want an in-lab test because of it's accuracy as well as the ability to quantify sleep time as well as secure any loose monitors that may be misread if the family member was not attended to as in a Home Sleep Test.... great screening device but not a sleep test!   Great comments by Mr NAY!

Brendan Duffy, Sleep - RPSGT-Coordinator July 29, 2014 12:05 PM
Port Jefferson NY NY

I applaud Neil Nay for his well said explanation of the home sleep testing process.  Home sleep testing is not regulated by any expert or professional field and is being exploited by the HST providers and non-qualified medical providers who are not providing accurate interpretations or treatment options that in the long run cost the insurance companies and the patients more money if not done properly.%0d%0aThe American Academy of Sleep Medicine (professional physician organization for sleep physicians) has been trying for years to assist in guiding medical providers with standards to make HST a viable tool  properly trained physicians.  The professionals in sleep medicine DO recognize the value of home sleep testing. This testing option needs to be regulated by sleep professionals working with the insurance companies to provide quality and cost effective care to the patients.

Joanne Hebding, RPSGT, RST, Sleep Medicine - Manager, Tallahassee Memorial Sleep Center July 23, 2014 9:52 AM
Tallahassee FL

I agree with Mr. Nay: At present, home studies have a limit to their usefulness.  They can rule IN OSA but cannot rule it OUT.  They do not reliably detect CSA or other sleep disorders.  They are often poorly interpreted or not interpreted at all.  I have learned to rely on them as a screening tool, or when trying to titrate someone with "garden variety" uncomplicated OSA, who cannot, for reimbursement reasons, return to a sleep lab.

Victoria Florentine, Private Respiratory Therapy - President, Select Respiratory Services July 20, 2014 12:42 PM
Fair Oaks CA

Under accepted clinical guidelines, home sleep testing (HST) is only accurate for use in patients with near certainty of having severe obstructive sleep apnea (OSA) by clinical signs and symptoms, and it is only appropriately used to confirm a diagnosis of severe OSA, i.e. it can rule IN the diagnosis of OSA but it CAN NOT rule it OUT. For this reason, and the fact that HST will miss the diagnosis in 1 of 5 patients with mild to moderate OSA (published data), all negative home tests must be followed by an in-lab sleep test (PSG) because the HST failed to produce the expected results in the presence of overt signs and symptoms of severe OSA. It would seem to me that your story classically illustrates what is both disturbing and dangerous about HST present day. It is commonly performed outside of accepted clinical guidelines. In your own case, you do not mention any follow-up testing or work-up performed after your "negative" HST results, and presumably your signs and symprtoms are still present. This avoidance of guidelines (as in your case) could potentially delay the treatment of a disease that causes hypertension, diabetes, heart disease, high risk of car accidents, to mention just a few consequences of untreated OSA, and recent publication of associated sudden death even in milder cases of OSA. This perfectly illustrates the issue that many sleep professionals have with HST (aside from the fact that sleep itself is not measured in a home "sleep" test), the clinical guidelines and appropriate scope of use in HST are being widely ignored, non-credentialled, unqualified practicioners are applying monitors and interpreting the results, HST equipment manufacturers are marketing the systems to primary care offices, dentists, and mail order start-up companies who do not explain the low accuracy outside of high suspician OSA cases, and do not follow up on negative studies or even explain to patients (or their physicians) that further follow-up testing is needed. I am wondering if this was expained to you or were you asssured that you do not have OSA? The most disturbing trend of all is that almost all of the commercial payors are taking advantage of public and primary care providers ignorance of the low accuracy by pushing all sleep testing in all patients to some type of HST via an onerous authorization process for anything other than HST, whether HST is appropriate for the individual patient or not. Even more harmful, there is no follow up on negative HSTs because it obviously benefits the bottom line of the payor in the near term, they can avoid the ongoing expense of treating a chronic disease (with PAP) by subverting the diagnosis or using a false negative. Payors actively avoid having their "covered lives" see a credentialled sleep specialist.

The primary problem with HST, and the reason for its low accuracy, is that it does not measure sleep or sleep disturbance (micro-arousals), the common denominator for any sleep disturbance is total sleep time (TST) in hours, i.e. an index of 10 apneas-hypopneas per hour of sleep time (AHI), since the HST does not measure sleep time, the provider uses an educated guess so the index is also only an educated guess. i.e.: If you had 10 apneas during your sleep test and we presume you slept 10 hours, your index is 1 per hour, normal, but if you slept for only 1 hour, your index then becomes 10 per hour, not normal and certainly could result in a complaint of fatigue. In the face of severe OSA, sleep time matters very little, if the AHI is 40 per hour or more, sleep time becomes irrelevant, the patient needs treatment. Which is why HST is very useful and acceptably accurate to detect severe OSA, but no other types of apnea or sleep disorders. At best HST is only capable of detecting one type of one sleep disorder in its most severe form, and the method of its implemtation in the commercially insured patient population is being driven by cost reduction strategies of commercial insurers (and intermediaries who guarantee HMOs they will reduce their expeditures on sleep disorder eval and tx). After 30 years in the sleep disorders field, and now armed with evolving technology to diagnose and treat sleep disorders more successfully than ever before, I am watching my patients and their physicians actively and passively manipulated by payors, intermediaries, and HST equipment manufacturers into using a test far outside of its clinical guidelines or appropriate use by practicioners lacking credentials, training or experience, and with no follow-up of negative tests as is mandated by common sense and accepted protocols. Home sleep testing does have great value when used appropriately by caregivers who understand its limitations, but your individual case illustrates the downside and the dangers of home sleep testing used inapropriately, and I would urge you to pursue further work-up by sleep board certified medical and technical staff in an accredited facility (but sadly you will likely have to fight your own insurance company to accomplish that). Our facility (AASM accredited) assures both comfortable and private surroundings, an experenced credentialled technologist who has on hand every CPAP/BiPAP/ASV modallity coupled with every PAP interface that is available on the market, free support groups and clinics to help patients succeed with PAP therapy after diagnosis, etc. Even in the face of severe OSA, with claims that HST could speed up diagnosis and treatment, using an in-lab test we can rapidly test and treat severe OSA using a split study protocol and have the patient on appropriate therapy in less than 24 hours if the commercial payors will allow it, and also evaluate for the presence of 50 other sleep disorders (that can explain fatigue), and patients have their history and studies reviewed by board certified sleep specialists. Recent studies have shown that this is more cost effective than HST over the longer term, with increased accuracy and MUCH more rapid treatment. Thanks for reading!

Neal Nay, sleep - manager, Jupiter Med Center July 15, 2014 2:32 PM
Jupiter FL

I have been in the field of sleep for over 18 years.  Home sleep testing does have it's place.  It is best used for patients with suspected moderate to severe sleep apnea.  It is not appropriate for patients with mild sleep apnea because it is not accurate for the milder cases.  It is also only good for sleep apnea, while the in lab test may pick up other parasomonias and reasons for poor sleep.  Using a process for an excuse not to use CPAP which can save and prolong a person's life is very poor.  

Cheri Sellepack July 15, 2014 11:19 AM
West Palm Beach FL

I would be intrested to see what your results would have been in a facility based sleep lab? Are you still symptomatic?

John Childers July 15, 2014 11:17 AM
Bryan TX

My son has severe OSA ; wish we would have had some kind of home study kit  his diagnosis was missed  for months due to his unstable blood sugars.  However; safe way is  to go in initially for safety and accuracy of readings.  Mask size is a big big issue;  pressure settings are adjustable and variable but needs doctor order.  

linette lee, retired July 10, 2014 8:30 PM
shreveport LA

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