Referring for sleep studies

[TheTruckGuy]

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Looking for a primary care perspective. What is your approach to sleep study referral and why? I've seen some docs look for any and every excuse to order one (regardless of STOPBANG/ESS), and I've seen others look for every excuse not to. I've seen some patients fishing for a diagnosis of sleep apnea (for military disability rating), and others hope they don't have it because they can't imagine having to sleep with a CPAP.

 

[tylerb1800]

Excessive daytime sleepiness or obesity/persistent fatigue/snoring in the presence of difficult to control HTN/a fib/HF

 

[VA Hopeful Dr]

My most common is fatigue with non-restorative sleep, +/- snoring/obesity.

 

[Sushirolls]

I'm Psych. So patient are already coming to me for depression, anxiety, poor focus, ADD, Substances, etc and then on screening discover they snore.

Snoring -->see sleep, unless young and female then needs BMI 30+. All others snoring is direct referral to Sleep Medicine.

I've only had 3 come back negative for OSA. One was late 20's guy, who was lower BMI, but likely had snoring secondary to Alcohol UD that was now in remission the other 2 were early 20's almost obese females.

OSA is such a treatable and important condition, don't wait, refer early. Snoring--> Sleep Medicine consult.

 

[Elixir6]

I'm Psych. So patient are already coming to me for depression, anxiety, poor focus, ADD, Substances, etc and then on screening discover they snore.

Snoring -->see sleep, unless young and female then needs BMI 30+. All others snoring is direct referral to Sleep Medicine.

I've only had 3 come back negative for OSA. One was late 20's guy, who was lower BMI, but likely had snoring secondary to Alcohol UD that was now in remission the other 2 were early 20's almost obese females.

OSA is such a treatable and important condition, don't wait, refer early. Snoring--> Sleep Medicine consult.

What??? Snoring does not equal Sleep medicine consult. That's like saying feels sad equals Psych consult.

I think you need to go to do a minimal amount of thought and at least do a STOPBANG, and do screening with overnight oximetry and then if positive refer to Sleep for full evaluation. If you aren't trained or feel comfortable doing that then refer back to PCP who can surely take care of that. And as you mentioned snoring related to alcohol or benzo should not go to Sleep.

 

[Sushirolls]

LOL. You don't know what you are talking about. I've done sleep medicine rotations. STOPBANG isn't the be all end all. The patients I refer, are approrpriate and three (3), out of hundreds, in years of practice have my referrals not yielded an AHI indicative of OSA. I do put in the modicum of thought in full clinical history evaluation for risk stratification.

 

[Chemist0157]

Not PCP, but I recommend it it to docs and patients for resistant HTN and if their stories are clinically suspicious for OSA.

 

[Sushirolls]

Doing an overnight oximetry for out patient primary care or psychiatry is ludicrous.

Clinically my high rate of Sleep Medicine referrals are picking up the slack my local PCPs have been missing. Recently I even had an older guy with stroke, smoking history, depression, HTN, lower CHF, oh and history of A-fib... who wasn't referred to sleep medicine. These are people post stroke who get stat preference in sleep clinics.

OSA has notable depression and anxiety overlap. Until OSA is diagnosed and managed there is lowered efficacy to psychotropics. This is part of my general medical work up. Too many patients get the merry-go-round treatment of psychotropics and their PCPs never thought to refer.

It's very sad how under utilized sleep consults are.

Snoring is enough of a symptom to say, "You need a consult with a Sleep Medicine specialist to rule out Sleep Apnea."

 

[VA Hopeful Dr]

Doing an overnight oximetry for out patient primary care or psychiatry is ludicrous.

Clinically my high rate of Sleep Medicine referrals are picking up the slack my local PCPs have been missing. Recently I even had an older guy with stroke, smoking history, depression, HTN, lower CHF, oh and history of A-fib... who wasn't referred to sleep medicine. These are people post stroke who get stat preference in sleep clinics.

OSA has notable depression and anxiety overlap. Until OSA is diagnosed and managed there is lowered efficacy to psychotropics. This is part of my general medical work up. Too many patients get the merry-go-round treatment of psychotropics and their PCPs never thought to refer.

It's very sad how under utilized sleep consults are.

Snoring is enough of a symptom to say, "You need a consult with a Sleep Medicine specialist to rule out Sleep Apnea."

So you don't order your own sleep studies, just refer straight to sleep medicine?

 

[Sushirolls]

Correct. I've long since opted to skip that step. I don't want to deal with insurance PA for sleep studies, nor remembering who covers in lab versus out of lab versus who needs split night, MSLT, etc, etc. Nor do I want to deal with the follow up questions about mask fitting, and DME hassles.

Snoring gets the people in the door with Sleep Medicine, they do the rest of their consult and pick up the additional symptoms they need to justify "medical necessity" to an insurance bureaucrats. It also provides a more seamless care process for patients, if its more than garden variety OSA, because now they have their foot in the door with Sleep Medicine.

I'm aware some departments permit FM/IM/Psych to direct refer/order HST or in lab studies to bypass the consult, but these days I feel that leads to a lower quality of care. Sadly, the increase in midlevels to departments doing initial consults is lowering the quality metric and I have to be a bit more vocal in my referrals, or simply refer to the independent physician only practices.

 

[aafisahar]

I'm in cardiology, everyone has OSA or CSA until proven otherwise. I refer basically 100% of my patients to sleep clinic. I don't order sleep studies because it's a pain in the ass to coordinate the prior auths, machine malfunctions, mask problems, etc etc. I did enough of that in residency where you have to do that garbage. Let the guy who's actually interested in sleep medicine deal with that.

 

[VA Hopeful Dr]

In the 2 years I've been ordering them, I have yet to have insurance cause any trouble with a home sleep study.

I put in the order, get the results a few weeks later. If it says anything other than "no evidence of osa", off to sleep medicine they go.

It's surprisingly easy.

 

[chessknt]

In the 2 years I've been ordering them, I have yet to have insurance cause any trouble with a home sleep study.

I put in the order, get the results a few weeks later. If it says anything other than "no evidence of osa", off to sleep medicine they go.

It's surprisingly easy.

See that's part of the problem--a negative home sleep study needs a psg to rule out osa.

Are you telling your patients they don't have osa without a sleep consult based on the hsat?

 

[VA Hopeful Dr]

See that's part of the problem--a negative home sleep study needs a psg to rule out osa.

Are you telling your patients they don't have osa without a sleep consult based on the hsat?

Haven't had a completely negative one yet. Maybe I'm lucky, but the interpretations I get back even if they don't meet criteria for OSA will point out if anything remotely abnormal was noticed. Those, as I said, get a referral.