Home Studies

[Lowell]

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Depending on where you read, 20 - 40 million Americans have a sleep disorder.

I don't know what proportion of that is sleep disordered breathing. Let's say it is greater than 50%, and that most of those patients are undiagnosed today.

There is a lot of work to be done. Presumably treating their OSA will also help comorbid conditions and reduce indirect cost to society.

Bascially, in my opinion, a good days work.

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Disclaimer: The remainder of this stream of consciousness is coming from a young physician who knows nothing about the business of medicine or politics or insurance etc...
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I think home studies should be embraced.

A sleep center should invest in several units, and perform these studies for the slam dunk OSAers (as previously described). Prescribe autotitrate CPAP, and f/u with PA and RN's.

And, as apathist has noted, complex or autotitrate failures, get lab studies. If the referal base is large enough this kind of flow should work.

In theory, the potential referal base should be HUGE (see my first sentence). The media is already working for us in terms of public awareness. It's just getting those PCP's and other docs to pull the referral trigger.

HERE IS THE KICKER: Does anyone know if lawmakers are protecting sleep-boarded MD's in regards to who interprets home studies?

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Thoughts?

 

[michaelrack]

HERE IS THE KICKER: Does anyone know if lawmakers are protecting sleep-boarded MD's in regards to who interprets home studies?

no, they're not.

 

[neurologist]

no, they're not.

. . . and that just means more business for "real" sleep specialists because more patients will have their initial evaluation and treatment mismanaged by people who don't really know what they are doing.

Not convenient for the patient, probably more expensive in the long run, but that's how it is going to be. Sleep docs will just see more of the "complicated-failed-CPAP" patients.

This pattern has already been well recognized in specialized epilepsy centers. 10 years ago they were getting tons of straightforward temporal lobe epilepsy patients for lobectomies. Now those patients are getting picked up and surgerized at community and other lower-level hospitals. So now the tertiary/quaternary centers are only getting the "failed surgery and everything else" referrals and no more slam dunks. Well, at least it keeps life interesting . . . 😉

 

[Lowell]

Is the AASM lobbying lawmakers on our behalf? Is there any lobbying going on regarding the interpretation of home studies?

Apathist - What does the "real" sleep specialists mean? The sarcasm is not lost upon me, but what exact group do you refer to? And what is not convenient for the patient - that the yahoo screws up their sleep care before they get to a real sleep doc?

Is there a bright side in this?

Is there a bright side in home studies?

I know there is one, some one please show me the light.

 

[neurologist]

Is the AASM lobbying lawmakers on our behalf? Is there any lobbying going on regarding the interpretation of home studies?

Yes, the AASM has been lobbying to try to restrict study interpretation to board-certified sleep specialists. That is really rather unlikely to happen, as my understanding is that there is really no other test for which interpretation is limited to any particular board certified specialty.

Apathist - What does the "real" sleep specialists mean? The sarcasm is not lost upon me, but what exact group do you refer to?

Board certified sleep specialists who spend a significant part of their practice doing sleep medicine.

And what is not convenient for the patient -

That optimal treatment is delayed and they may have to end up getting restudied.

Is there a bright side in this?

Is there a bright side in home studies?

I know there is one, some one please show me the light.

The bright side is that there will be a lot of volume (after all, you can only fit so many patients into a sleep center on any given night). Also, a good sleep center with an existing referral base will be well positioned to start offering home studies on appropriate patients.

I really don't think this is going to destroy sleep medicine. I mean, you don't see every family practice doc or general internist doing echocardiograms or pulmonary function tests, do you? Technically, they can if they want to . . .

 

[Stillwell]

Hello,

I am a neurology resident and am getting caught up on all this 'home vs center' PSG issue as I think about a sleep fellowship.

I am at a major academic/referral center, and unless a new patient comes to us with an EEG read by a trusted doc or another epilepsy center, we often will get our own EEGs. Attendings here just don't trust the non-epilepsy trained neurologist to read the EEG, as they want to get a trusted reading before doing intra/extracranial monitoring, WADAs, neuropsych testing, the whole 9 yards. So that brings me to my question - can the same thing not be done by sleep docs looking for properly read studies (ie, asking that PSGs be done at the lab to confirm findings of one done at home and read by someone else?). Seems there would still be plenty of LAB volume for the sleep docs still.

Also, it's interesting how this issue draws comparisons to 'home vs center' EEGs. Ambulatory EEGs are still employed - we'll request a few a week sometimes, even up to 72 hours. This was probably hailed as the bane of outpatient EEGs since they could be recorded for days vs a 20-30 minute EEG (despite the artifacts/technical issues). And EMUs (monitoring units) are thriving and while they are a bit of a different animal, the point is that ambulatory studies don't seem to have made a big dent in the epileptologists' life, so why will home studies be different for sleep docs?

[I realize that you can justify re-ordering an EEG to capture interictal abnormalities that were missed the first time around, but could not a similar thing be true for PSGs, necessitating a PSG be done in the LAB and read by the sleep doc? Seems if that can be done by Epileptologists, why not you guys?]

thanks.

 

[neurologist]

I am at a major academic/referral center, and unless a new patient comes to us with an EEG read by a trusted doc or another epilepsy center, we often will get our own EEGs. Attendings here just don't trust the non-epilepsy trained neurologist to read the EEG, as they want to get a trusted reading before doing intra/extracranial monitoring, WADAs, neuropsych testing, the whole 9 yards. So that brings me to my question - can the same thing not be done by sleep docs looking for properly read studies (ie, asking that PSGs be done at the lab to confirm findings of one done at home and read by someone else?). Seems there would still be plenty of LAB volume for the sleep docs still. . . . .

[I realize that you can justify re-ordering an EEG to capture interictal abnormalities that were missed the first time around, but could not a similar thing be true for PSGs, necessitating a PSG be done in the LAB and read by the sleep doc? Seems if that can be done by Epileptologists, why not you guys?]

You've made some very interesting observations here, -- but there are three significant differences between EEG/epilepsy and PSG/sleep.

First of all, because epilepsy is a paroxysmal condition, the yield of finding something on EEG increases with the number of EEGs done. If the patient has events suggestive of seizures but one or two normal EEGs, your chance of finding something increases with another study (assuming, of course that it's "real" epilepsy). This is not true of most sleep disorders: Sleep apnea, the "bread and butter" of sleep centers, is more or less a fixed anatomic condition -- if you have it one night, you'll have it every night. It might vary somewhat, but it's not like the frequently ephemeral neuroelectrical potentials that you look for in an epilepsy EEG. Same for periodic limb movements. They'll probably be there anytime you look. There are some valid reasons for repeating a study -- long interval since last study, significant weight change, new cardiopulmonary complications, etc, but just to repeat a recent study because you think somebody missed something is kind of questionable in my mind.

The second difference is complexity. Interpreting sleep apnea on a PSG is not really rocket science, where as with EEG there can be very subtle differences between some epileptic patterns and "normal variants." That's where the bias for epileptologists reading their own studies comes in. Many a patient with funky spells has been diagnosed with "epilepsy" and stuck on meds because someone miscalled some wicket waves or RTTD.

The final, and by no means least, issue is cost. Ask your institution what it bills for a routine sleep/wake EEG versus what it bills for an overnight polysomnogram. Then ask the insurance companies which one they wouldn't mind repeating. And, as I have posted somewhere before in this forum, keep in mind that the home studies are not meant as screening tests that funnel into attended PSGs -- they are intended to replace the attended lab PSG, so, no insurer is going to routinely pay for a home PSG and then automatically fork over another 2 grand to get a lab study because the portable was abnormal. The "cheap quicky screen" for OSA is a home overnight oximetry, not a home PSG.

Also, it's interesting how this issue draws comparisons to 'home vs center' EEGs. Ambulatory EEGs are still employed - we'll request a few a week sometimes, even up to 72 hours. This was probably hailed as the bane of outpatient EEGs since they could be recorded for days vs a 20-30 minute EEG (despite the artifacts/technical issues). And EMUs (monitoring units) are thriving and while they are a bit of a different animal, the point is that ambulatory studies don't seem to have made a big dent in the epileptologists' life, so why will home studies be different for sleep docs?

Another good point, but again, a couple of problems with the comparison. First, ambulatory EEGs are not really as common as you might think. Where I trained they were anathema -- nobody would even consider them. Largely because of the artifact issues -- you're adding a lot of junk to muddy up something that can already be hard to interpret.

Also, given the highly specialized training you need to interpret EEG, plus the time needed to read them, plus the general "neuro-phobia" of most non-neurologists, I doubt anyone ever lost sleep about ambulatory EEG cutting into epileptologists practices. PSG, on the other hand, is not all that sophisticated -- heck, psych residents pick it up pretty quick in sleep fellowships all the time. If they can do it, anyone can! (The complicated part of sleep is not reading the study -- it's realizing that you have to put the study in the proper clinical context and make sure you are treating the patient properly for the correct problem.) Hence the concern about sleep labs losing business. But, for reasons I noted in other threads, I really don't think that will happen.

 

[michaelrack]

This is not true of most sleep disorders: Sleep apnea, the "bread and butter" of sleep centers, is more or less a fixed anatomic condition -- if you have it one night, you'll have it every night. .

unless it's position dependent and there was no supine sample
unless it's related to alcohol and the patient didn't drink on the night of the study
unless its related to allergies and the patient's allergies were better than normal that night
unless the sleep lab uses only a thermistor and not a nasal pressure transducer.

A good sleep doc, however, after talking to/examining the patient and looking at the sleep study report from an outside lab, can usually figure out if any of the above are true (although not all sleep study reports indicate how airflow is measured- i.e, if a nasal pressure transducer is used).

Interpreting sleep studies is usually simple if you're a board certified sleep doc, but not something that can be done well if you just rotate through a sleep lab for a few months as a psych resident.

 

[neurologist]

unless it's position dependent and there was no supine sample
unless it's related to alcohol and the patient didn't drink on the night of the study
unless its related to allergies and the patient's allergies were better than normal that night
unless the sleep lab uses only a thermistor and not a nasal pressure transducer.

Yeah, agreed, but these are really more the "exceptions that prove the rule."

Perhaps I am too "optimistic" about the quality of some labs . . . but some of these (allergy, ETOH, position) should be uncovered in a decent history and others (position, thermistor) should be seen on the report.

A good sleep doc, however, after talking to/examining the patient and looking at the sleep study report from an outside lab, can usually figure out if any of the above are true (although not all sleep study reports indicate how airflow is measured- i.e, if a nasal pressure transducer is used).

Interpreting sleep studies is usually simple if you're a board certified sleep doc, but not something that can be done well if you just rotate through a sleep lab for a few months as a psych resident.

Yeah, I meant in the setting of a fellowship.

 

[Stillwell]

Thanks for the good feedback. I actually kind of expected the answers you gave, especially since as you mentioned, data gleaned from one PSG is more likely to be helpful than 1 or even 2 or 3 EEGs that are overall cheaper. But I thought it would be good to bounce my questions off someone more familiar with sleep med.

I've seen my attendings order ambulatory EEGs - as maybe you have - when the patient can't afford the time in the hospital (eg due to kids at home that need care) or if the patient is too complicated (eg an MR/CP patient needing someone with them 24 hours a day, which RNs can't do). But even then, the docs first push for EMU studies, and they explain that it is a more optimal place than home with less chance for technical problems.

Guess if I were a sleep doc, I would similarly explain it that way, that if time and money is going to be invested in a study, they should get it done in the best possible place, ie the sleep lab. If the patient still wants a home study, so be it. Of course, this is assuming the insurance company doesn't refuse the lab study, forcing the study be done at home.

Anyway, thanks.

 

[cathyz]

What would be the best to overcame this sleep disorder?

 

[Joanhabety]

I don't have much thoughts about it. But your post is really nice.

 

[angelinadiaz]

sleeping pill is harmful for health.so plz tell me anyone for other treatment for sleep disorder.
Thank you.

 

[michaelrack]

sleeping pill is harmful for health.so plz tell me anyone for other treatment for sleep disorder.
Thank you.

It depends on the specific sleep disorder that a person has.

 

[angelinadiaz]

It depends on the specific sleep disorder that a person has.

Thank you for your reply.I think i have some insomnia kind of problem.