Companies could potentially market home testing devices to non-sleep specialists, added Dr. Collop, who is also on the board of the AASM. The concern is that these companies will offer to set patients up with home monitoring, score the study, and then set them up on CPAP, while the physicians don’t have to do anything, she said.
Explore This IssueJuly 2008
In an ideal situation, a practitioner would know how to use the device, evaluate the test, and get the patient started on treatment, said Dr. Collop.
The CMS ruling also does not address what practitioners should do once they diagnose sleep apnea, said Dr. Collop. If ENTs are offering this type of diagnosis, then do they perform surgery or do they offer CPAP? she questioned.
If CPAP is used, physicians need to consider whether it should be autotritrating or empiric and whether it should be started immediately or if patients need to go to a sleep center for a CPAP study, she said.
Moreover, the CMS ruling states that after three months of CPAP, physicians should make sure patients are benefiting from treatment; however, what criteria should be used to measure this benefit-for example, improvement in blood pressure or lack of sleepiness-are not mentioned, said Dr. Collop.
Deciding Between At-Home Testing and In-Lab PSG
When deciding what form of sleep testing is best for their patients, otolaryngologists need to be aware of a number of factors, said the experts interviewed for this article.
For example, the suspected sleep disorder essentially determines whether patients should undergo home monitoring or in-lab PSG.
Specifically, only individuals with a high risk of moderate to severe sleep apnea are candidates for home sleep monitoring, said Dr. Collop, who is the lead author of the AASM’s clinical guidelines for using portable monitors to diagnose obstructive sleep apnea (J Clin Sleep Med 2007;3(7):737-747).
Patients who likely have mild forms of sleep apnea or interruptions in sleep architecture but no drops in oxygen during the night need testing in a sleep lab, added Dr. Collop.
Additionally, patients who have sleep abnormalities that do not appear to be sleep apnea should receive an in-lab PSG, said Dr. Davidson. For example, patients with symptoms of narcolepsy or parasomnias require testing that provides better information than that available through home monitoring, he said.
PSG is better at diagnosing a variety of sleep problems because it measures brain waves, explained Dr. Davidson. So when you have things that involve nightmares or dreams or sleep stage abnormalities, the PSG is only thing that is going to pick that up, he said.