Vol. 17 •Issue 1 • Page 8
First Thoughts
Bringing Sleep Testing Home
It’s a job hazard of being a medical journalist. No, it isn’t writer’s cramp or paper cuts. Each time I begin researching a disease process for an article, I become convinced that myself or a loved one has the symptoms.
Could that cramp in my calf be a precursor to a pulmonary embolism? Is my 2-year-old’s wheezing a sign of asthma? Will the doctors link my grandfather’s chronic cough to silicosis from his years as a quarryman?
Fortunately, most of my suspicions are unfounded. But there’s one I’m certain is on target. My husband has all the nighttime indicators of obstructive sleep apnea: the snoring, the gasping, the choking. I’ve shaken his shoulder countless times when he seemed to have stopped breathing for an eternity. He has the daytime tiredness, too.
Problem is he won’t take my word for it. He’s also resisted my pleas to visit a sleep center for an evaluation. He never has enough time to schedule an appointment. He wouldn’t be comfortable sleeping in a strange place. His excuses are as long as his apneic episodes.
So when the news broke in December that Medicare issued a proposal to allow at-home diagnosis of OSA, I was thrilled as an exhausted sleep partner. This proposal would change the Center for Medicare & Medicaid Service’s policy specifying that only polysomnography tests done in a sleep lab are acceptable to diagnose patients with OSA and prescribe a continuous positive airway pressure device. While this rule covers Medicare patients, private payers often follow CMS’ lead.
My response as an editor is more cautious. Sleep professionals and the organizations representing them are wide apart in their views of the policy. Quality control is at the heart of the debate. More affordable and accessible methods of testing sleep disorders are a necessity, but only if patient care isn’t sacrificed. Some critics worry that abuse and overutilization of home testing could lead to the sleep profession’s demise.
Pam Ryan, BS, RPSGT, a sleep manager and new ADVANCE blogger, summed up the pros and cons. On the positive side, portable monitoring would increase access to sleep diagnostic services for the estimated 18 million Americans affected by OSA.
On the negative side, portable monitoring has a huge potential for misuse. “The big fear is that underqualified physicians will run a quick home study, make a rapid, respiratory-only diagnosis (missing possible contribution of other sleep pathologies), and then slap a self-titrating PAP device on the patient and call it a done deal,” she wrote in a Dec. 18 blog entry. “Many patients might be misdiagnosed.” (Read more at www.Respiratory-care-sleep-medicine.advanceweb.com. Click “Community” tab.)
As we await Medicare’s final coverage determination in March, it appears portable monitoring ultimately will broaden clinicians’ diagnostic armamentarium. Once this technology is in your hands, you’ll need to ask: “What is the most responsible way to implement this approach?”
Michael Coppola, MD, who is recognized as a leading expert in portable testing for sleep apnea, has faith in sleep professionals. “In my opinion, many patients will be well-served by portable monitoring with the patient now at the center of the management paradigm,” he writes in this month’s Equipment Review column. “Knowledgeable clinicians will find the best applications for these methodologies, manufacturers will continue to innovate, and the portable recorder will become a tool of the sleep specialist rather than an alternative to the sleep lab.”
Once I convince my husband he’s the center of the management paradigm, my next challenge is figuring out how to keep our dog and preschoolers from getting tangled up in all those electrodes.
Sharlene George, Editor, [email protected]
