Shift in Diagnosis, Treatment of Obstructive Sleep Apnea A Challenge for Otolaryngologists

Others, like Pell Ann Wardrop, MD, medical director at the Saint Joseph Sleep Center in Lexington, Ky., and an ENTtoday editorial board member, are concerned that some insurance companies may choose not to follow CMS guidelines when it comes to the decision on when in-lab PSGs are warranted. “We really have to strongly advocate for patients, or do a home study and note that it didn’t tell us what we need for proper diagnosis,” she said.

“Overall, home sleep studies are a reasonable next step in the evolution of treatment for patients with OSA,” said Dr. Yaremchuk. “We have an aging population with an increased awareness of the prevalence of OSA, and there aren’t enough qualified sleep labs to do all of the inpatient studies we’d like to see done. However, in some ways insurance companies and the authorization process have interposed themselves into the doctor-patient relationship, and that can be problematic.”

APAP vs. CPAP Titration

The increase in home sleep studies is accompanied by the growing replacement of CPAP titration studies with APAP. Part of this upswing in use is due to a reduction of insurance payment coverage for titration studies, says Dr. Wardrop. “In the past, patients had an in-house PSG and then were brought back for a titration study,” she said, “If results were overwhelmingly positive, CPAP titration to set the pressure of the airflow on the machine was done the same visit in a split-night study.” Instead, APAP machines use a pressure range, eliminating the need for an exact titration—and, to some degree, the need to send OSA patients to the lab.

“If a patient has severe OSA, there is a way to send an APAP machine home as a therapeutic trial,” said Dr. Ishman. “We look to see what kind of pressure patients are using 90 percent or more of the time to determine a starting pressure when we transition them to a traditional CPAP. Most patients end up converting—CPAPs are less expensive, so insurance often encourages patients to switch. And although the APAP works well for some patients, others may not sleep as well with a range rather than an exact setting.”

Dr. Wardrop has seen movement toward skipping sleep studies entirely and directly moving to prescribing APAP machines to patients with a high probability of OSA. For certain patients, this can work, she said, although it may not be a good alternative for those with mild to moderate OSA.