SLEEP APNEA BLOG

Trucker Image Sleep Blog Post 1

A major threat to OTR (over-the-road) truck drivers—obstructive sleep apnea—is getting more attention from larger carriers, according to a recent article in Transport Dive.1 Drivers can be hesitant to complain about sleep problems or seek help from physicians over fear of losing their medical cards.*1,3 Combined with some skepticism about the sleep disorders in general and wariness of treatment cost, sleep apnea can often go undiagnosed in drivers.1

One trucking company steps forward

That may be about to change, thanks to initiatives from trucking carriers like Schneider.1 The company’s website states, “Schneider provides sleep apnea screening and treatment for all of its drivers in an effort to promote a healthier, happier lifestyle and prevent accidents caused by daytime drowsiness.”2

Many positives from corporate focus on sleep apnea in drivers

Tom DiSalvi, Schneider vice president of safety and loss prevention, outlined in the Transport Drive article how the company reduced delays in screening and found a supplier for CPAP machines.1 Three big positives from this corporate focus on the health and safety of its drivers are:  Schneider made the process cost-free to insured drivers, the result is a health cost savings to the company of $441 per month per driver, and drivers with apnea were retained at a 30% improvement rate.1

Many other trucking companies “on board”

A number of other companies have sleep apnea and “fatigue management” (as the industry often calls it) programs—including Marten, Maverick, Old Dominion, Saia, and Southeastern Freight, according to Mary Convey of SleepSafe Drivers, who was interviewed for the article.1

Undiagnosed sleep apnea in the driver population

Sleep apnea is known to be underdiagnosed in the general population but is believed to be much more so among long-haul truckers.1 A study by the Virginia Tech Transportation Institute (VTTI) found that as many as 47% of drivers are at risk for sleep apnea because of weight (BMI) or neck size.1 In the general population, diagnosis of sleep apnea is believed to be between 6 and 17%. Among truck drivers, it’s about 33%, according to the VTTI.1

Existing medical conditions can be made worse 

As dangerous as undiagnosed sleep apnea can be to the general population, in the driver population it may be worse; potentially causing memory problems, headaches, daytime fatigue, and difficulty focusing on the road, according to the American Sleep Apnea Association.1 Sleep apnea also contributes to comorbid conditions like weight gain or obesity, high blood pressure, and heart issues that many OTR drivers are documented to have, as well as Type 2 diabetes.4

Physicians offer telemedicine, disposable diagnostic machines, and hope

In addition to trucking companies, physicians are changing how they approach screening and diagnosis of sleep apnea by using more remote and disposable options.1 The use of home sleep apnea tests (HSATs) or holding virtual visits are trends that continue to grow.5 For example, Dr. Jordan Stern, a New York-based physician, said he conducts his test through telemedicine and his sleep tests can be done at home.1 Stern said his office mails the patient a disposable home sleep apnea test that can be self-administered while the patient sleeps, according to the article.1 Dr. Stern reassures his reluctant patients that he is “going to get you fixed.”1 This is a testament to the way home sleep apnea tests (and disposal devices) like the WatchPAT® ONE provide critically needed relief to those who are unable or unavailable to do an in-lab study, which is often the case for OTR drivers. With a career that keeps them on the road for the majority of the time, telemedicine and home sleep tests can offer screening, diagnosis, and a faster path to treatment—all without truckers having to miss out on work that is 100% travel-based.

Help from Washington?

With more serious focus on sleep apnea from the trucking companies and medical community, help may also be on the way from the federal government. The Federal Motor Carrier Safety Administration (FMCSA), an agency of the Department of Transportation, is working “to develop guidelines and materials that enable motor carriers to implement a comprehensive Fatigue Management Program (FMP) and means of delivering a FMP to motor carriers throughout North America.”3

Heading in the right direction

It began with awareness, but now there is a movement toward better, easier diagnosis and treatment of sleep apnea among truck drivers. That diagnosis and treatment is more affordable and comes with the support of employers and physicians.  A healthier, more alert OTR driving population should mean safer roads as well, which is better for everyone.

References: 

1. Jim Simpson, Sleep apnea:  a slow killer lurks among OTR truck drivers. Transport Dive. https://www.transportdive.com/news/OTR-truck-drivers-sleep-apnea-schneider-safety/594568/ February 25, 2021. Access date 4/3/2021.

2. Driver Experience Fact Sheet. Schneider. Schneider.com. https://schneider.com/resources/whitepaper/driver-experience-fact-sheet Access date 4/3/2021.

3. North American Fatigue Management Program. FMCSA. Fmcsa.dot.gov. https://www.fmcsa.dot.gov/research-and-analysis/research/north-american-fatigue-management-program Access date:  4/3/2021.

4. Maria R. Bonsignore, Pierpaolo Baiamonte, Oreste Marrone. Obstructive sleep apnea and comorbidities: a dangerous liaison. https://mrmjournal.org/mrm/article/view/10

Multidisciplinary Respiratory Medicine journal 14, Article number 8, 2019. Access date: 4/6/2021.

5. How to maintain momentum on telehealth after COVID-19 crisis ends. American Medical Association. https://www.ama-assn.org/practice-management/digital/how-maintain-momentum-telehealth-after-covid-19-crisis-ends. Andis Robeznieks. June 30, 2020. Access date: 4/6/2021. 

This material is subject to a disclaimer available here.

*A US DOT medical card is a document usually carried in a commercial driver’s possession that states that the driver has had a physical examination by a registered and qualified medical doctor and is medically certified and physically qualified to operate a commercial motor vehicle.

The FMCSA website: “A person with a medical history or clinical diagnosis of any condition likely to interfere with their ability to drive safely cannot be medically qualified to operate a commercial motor vehicle (CMV) in interstate commerce. However, once successfully treated, a driver may regain their “medically-qualified-to-drive” status. It is important to note that most cases of sleep apnea can be treated successfully.” [emphasis added]

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Seven days of national focus on sleep health

As we covered in our earlier blog posting this month, The National Sleep Foundation (NSF) is dedicated to improving health and well-being through sleep education and advocacy, and as part of that goal they have instituted National Sleep Awareness Week®—March 14-20, 2021.2 One of the many helpful programs of the NSF is the campaign coincides with the beginning of Daylight Savings Time, when many Americans lose an hour of sleep. Losing an hour of sleep during that time in combination with reported negative sleep health symptoms that could be a sign of sleep apnea could serve as a conversation starter for many types of physicians with patients who find this time of year especially difficult to feel rested and get through their routine easily or with little issue. 

The NSF has a focus on research in sleep, and began in 2013 to develop a “a survey instrument to assess general sleep health.”1This became the Sleep Health Index (SHI). 

The development of the SHI involved “assembling a task force, identifying specific topic areas, developing and testing questions, surveying a beta version of the instrument, refining the instrument, and developing and testing the index.”1 This SHI is in addition to their annual National Sleep in America Poll where more specific symptom-related questions and patient response to symptom questions are a part of the study. 

These focused on disturbed sleep or daytime sleepiness—worthy topics to be sure, but not the specific benchmark of trends desired by the NSF to assess sleep health or sleep disorders like sleep apnea in the general population.2 Those allude to sleep apnea and other disorders, but do not provide definitive answers or indicators that point to a definite diagnosis or an immediate screening need. Part of the problem, is that sleep health is so broad that many patients do not view any symptoms they may be having as part of any disorder like sleep apnea, but merely a feeling they must manage their way through without medical intervention.3 

What is sleep health? 

Surprisingly, no uniform or accepted definition of “sleep health” exists (although the NSF is working on developing its own).1 Sleep health is “not merely the absence of a sleep disorder or problem.”1 Overall sleep health may include the quantity, quality, and impact of sleep—which are all essential, especially for the large portion of the population that does not suffer from sleep pathologies.1 Because of that fact, the burden of communication and awareness around sleep apnea and its effects on not only cardiac health but overall health and wellness is on you as the clinician. 

How did America do?

In simple terms, the SHI measures three separate but related elements of sleep health—duration, quality, and disorders. Americans earned an overall score of 76/100 (higher score reflects better sleep heath). The sub-index scores were 81/100 in disordered sleep, 79/100 in sleep duration, and 68/100 in sleep quality.1 The strongest independent predictors of sleep health were self-reported stress and overall health, which were also the strongest predictors of sleep quality.1 

How sleep clinicians can use this information in relation to sleep apnea

According to the NSF: “Research consistently demonstrates that sleep is a significant component of physical and mental health, as well as overall well-being.”1 The importance placed in the Sleep Health Index on self-reported stress and overall health for both sleep quality and sleep health emphasizes the need to include general practitioners, cardiologists, sleep clinicians and doctors of all other specialties in the discussion around sleep and sleep health. 


A huge start toward seeing improvements in the findings from the NSF’s SHI is to normalize the consideration of regularly screening for possible sleep disorders like sleep apnea with patients who are not viewing sleep as a part of their overall health considerations. Further fine-tuning of who to ask, what to ask and when to ask is evident with just these three predictors from the index alone. Furthermore, with up to 80% of moderate cases of sleep apnea still remaining undiagnosed, interest in sleep studies of this nature continues to be important across specialty. These studies and surveys are a way to open lines of communication with patients and justify clinical opinions or recommendations of running a sleep study even if the patient remains on the fence that they have a problem. 

Luckily, with the advent and the growing usage of home sleep test options, these recommendations for a sleep study are a lot less burdensome than they have been in previous years where an in-lab sleep study was needed just to scratch the surface in terms of exploring the implications of less than perfect sleep patterns in patients. Screening for disorders like sleep apnea can now be done with the help of a home sleep apnea test where a patient can easily follow the instructions and administer their own test in their own home. 

Every survey or study on sleep health, whether done by the NSF or another organization, is likely welcome to our community of medical professionals, especially those who specialize in sleep and have a deeper understanding of how a patients’ sleep patterns may lead down a road to more serious conditions like hypertension, narrowing or arteries, atrial fibrillation, or even heart failure. In summary, while the NSF’s SHI is eye opening for many types of clinicians to get the conversation started about the importance of screening and the possible implications of the symptoms of sleep disorders like sleep apnea. Knowledge is power, and more knowledge on how our patients are sleeping and responding to their poor sleep is more power. And that is a plus for the patients being treated as a result of these studies.

References: 

1. Sleep Health Journal,  The National Sleep Foundation’s Sleep Health Index. https://www.sleephealthjournal.org/article/S2352-7218(17)30102-X/fulltext#secst0005  Kristen L. Knutson, PhD  Julie Phelan, PhD (co-primary authors) Michael J. Paskow, MPH  Anita Roach, MS  Kaitlyn Whiton, MHS  Gary Langer, BA  Sunshine Hillygus, PhD. Michael Mokrzycki, BS  William Broughton, MD  Sudhansu Chokroverty, MD, FRCP. Kenneth Lichstein, PhD  Terri E. Weaver, PhD, RN, FAAN  Max Hirshkowitz, PhD, DABSM. June 19, 2017.

2. The National Sleep Foundation, Press Release. “National Sleep Foundation prepares for Sleep Awareness Week 2012” https://www.thensf.org/national-sleep-foundation-prepares-for-sleep-awareness-week-2021/  February 19, 2021.

3.   American Academy of Sleep Medicine. Press Release. https://aasm.org/aasm-response-to-screening-for-obstructive-sleep-apnea-in-adults-evidence-report-and-systematic-review-for-the-us-preventive-services-task-force/ February 24, 2021.

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Alarming findings from new survey

A new poll from the National Sleep Foundation (NSF) has revealed alarming findings about sleep health in America1—with significant implications for sleep apnea diagnoses—both obstructive sleep apnea and central sleep apnea. The Sleep in America® poll showed two particularly pertinent pieces of information that have implications for clinicians concerned with sleep health and disorders like sleep apnea:

  • Americans feel sleepy on average three times a week
  • 62% of those sleepy people cite “shaking it off” as their primary response

In summary, the Sleep in America poll shows a rising level of sleepiness and a low level of action to address it. These results understandably could cause concern for everyone in sleep medicine especially those clinicians who make sleep apnea screening, diagnosis and treatment a goal. While the sleep apnea symptoms and number of respondents who admitted to having the symptoms are something that clinicians might consider to be important, a concern that is even arguably more concerning is the perception of the respondents around these symptoms and a lack of action toward them. 

NSF’s Sleep in America poll—a comprehensive study

The Sleep in America poll has been conducted annually since 1991 by the NSF. The NSF is dedicated to improving health and well-being through sleep education and advocacy.1 The organization shines a light on sleep apnea and other sleep disorders throughout the year, but with a special emphasis in March. 

Sleep Awareness Week—seven days of focus on sleep health

One of the many NSF education programs is Sleep Awareness Week®, March 14th-20th.2 The week is held leading up to the start of Daylight Savings Time, when most Americans lose an hour of sleep. It comes at a time that is especially pertinent. As specific parts of the poll along with the perceptions that the patients have communicated through the poll, prove the importance of awareness around sleep as an integral piece of the overall health puzzle. 

Americans open up about sleep problems

Nearly half of all respondents in the NSF’s Sleep in America poll1 reported feeling sleepy three to seven days a week, with many saying sleeplessness impacts their daily activities, mood, mental acuity, productivity and more. Headaches and irritability are also mentioned. These findings in combination with studies showing that up to 80% of sleep apnea cases are undiagnosed, increases the awareness around a problem that has been ongoing for a number of years. 

But what will study participants do about sleeplessness?

What is not mentioned by respondents is any kind of a permanent solution—or recognition that a solution may be needed. The overwhelming answer to the poll question “Do you think you have a sleep problem, or not?” was No. Second was Maybe and trailing was Yes.1 This specific point within the poll alludes to a need for increased patient awareness around what sleeplessness and other sleep-related symptoms could mean for their overall health.  

Unrecognized sleep disorders and undiagnosed sleep apnea

Obstructive sleep apnea (OSA) is a highly prevalent disease that remains underdiagnosed and undertreated.3 The reasons for that may be as complex as the disease. A lack of public knowledge about just what sleep apnea is, along with low awareness of sleep apnea tests and sleep apnea devices, may likely be significant reasons why. A possible consideration for sleep clinicians, general practitioners, cardiologists, and even dental professionals is to make talking points about sleep a part of their routine patient consultations, just as they would discuss diet or exercise in the context of overall health.

Another tool for sleep clinicians in the battle against sleep disorders

In addition to raising awareness with their patients, there are options that would make the screening, diagnosing, and treatment process much easier than the traditional protocol of the in-clinic PSG. An at-home sleep apnea test like the WatchPAT® ONE is a reliable, affordable, disposable option.4,5In the time of the COVID-19 pandemic, an at-home diagnostic could likely be more welcome to patients and clinicians alike. Once the simple test is delivered to the patient’s home and completed in their own beds, physicians can review the automatic results through the CloudPAT® and discuss them with the patient. This means that with home sleep tests like the WatchPAT® ONE, there is potential for getting a sleep apnea patient diagnosed without the need for any in-office visits. Quick, painless, accurate, and no risk of infection. An at-home diagnostic test like the WatchPAT®ONE is an important first step toward better sleep health. 

The time to act is now

The NSF’s Sleep in America poll is a comprehensive study of sleep health in the country.1 Beyond the numbers, it also highlights areas of concern. The two most alarming areas of concern are the two highlighted previously. This combination—high reported levels of sleeplessness, together with low reported levels of action regarding that lack of sleep—is two roads going in the wrong direction. Sleep clinicians could be leading the way toward addressing this troubling trend, and the NSF’s intention of increasing patient awareness could encourage other types of clinicians to include this frequently ignored area of health into their typical protocols. Everyone could sleep better knowing that.

References: 

  1. National Sleep Foundation Press Release. https://www.thensf.org/2020-sleep-in-america-poll-shows-alarming-level-of-sleepiness/  March 9, 2020.
  2. National Sleep Foundation Press Release. https://www.thensf.org/national-sleep-foundation-prepares-for-sleep-awareness-week-2021/  February 19, 2021.
  3. American Academy of Sleep Medicine. Press Release. https://aasm.org/aasm-response-to-screening-for-obstructive-sleep-apnea-in-adults-evidence-report-and-systematic-review-for-the-us-preventive-services-task-force/ January 24, 2017.
  4. Itamar Medical Blog. WatchPAT—Home Sleep Study Device https://www.itamar-medical.com/patients/watchpat-home-sleep-testing
  5. American Academy of Sleep Medicine. FDA clears disposable home sleep apnea test. https://aasm.org/fda-clears-disposable-home-sleep-apnea-test/  February 18, 2020.
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On December 1st, 2020, the Centers of Medicare and Medicaid Services (CMS) issued revisions to the Physician Fee Schedule (PFS) which outlines payment policies, rates, and quality provisions for services provided under Medicare.2 

The goal of the CMS revision was to prioritize primary care, chronic disease management and telehealth services. The revisions were designed to:2

  • Allow non-physician practitioners to provide care that they are licensed and trained to perform 
  • Expand coverage for telehealth services adding 144 services that will be covered through the end of COVID-19 pandemic
  • Increase payment rates for in-office and outpatient face-to-face evaluations and management (E/M) visits for chronic conditions

Then, on December 29th, 2020, some additional adjustments were made that amounted to the following items:1 

  • Provided a 3.75% increase in MPFS payments for CY 2021
  • Suspended the 2% payment adjustment (sequestration) through March 31, 2021
  • Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
  • Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024


Q: What does that mean for HSAT reimbursement?

A: These revisions led to reimbursement changes for different services and procedures, including home sleep apnea testing (HSAT). HSAT devices that include sleep time, such as the WatchPAT® Home Sleep Apnea Tests , saw an increase in the reimbursement level while traditional airflow tests without sleep time saw a decline in reimbursement.

cpt codes

Q. Do Medicare and third party payers have any restrictions on who can bill for HSAT? 

A: Yes. Medicare Administrative Contractors (MACs) require that physicians who interpret the sleep study have a sleep certification issued by specific specialty boards, or be an active member of an accredited sleep center or laboratory. Some MACs also require physicians that provide the sleep study to be credentialed. Check the LCD of your MAC for their requirements. Medicare also restricts durable medical equipment suppliers from providing any component of sleep testing. Third party payers make autonomous decisions in the development of their medical policies and the limitations they set. While some third party payers include sleep certification or accreditation requirements for HSAT in their policies, most do not. Please check payer policies for applicable limitations. 

Q. How often can HSAT be performed and qualify for reimbursement? 

A: Payers vary on the number of sleep studies that are considered medically necessary per year. Most payers allow two sleep studies per year unless it is medically necessary to repeat a study. It is recommended to seek prior authorization if the payer’s established frequency limitation is exceeded. 

Q. How many consecutive nights of study may be performed and reimbursed? 

A: Medicare and third party payers state that if you perform two or three nights of study it will only be reimbursed as one night of study. Third party payers may reimburse more than one night of study depending on your specific contract.

For more information about the CMS decision, visit the CMS website. And for additional questions regarding reimbursement with the Watch PAT® Home Sleep Apnea Test download our 2021 Reimbursement Guide

References: 

  1. Physician Fee Schedule. CMS. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched. Accessed February 26, 2021.
  2. Press release Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients. CMS.gov. https://www.cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-expansion-medicare-telehealth-services-and-improved-payment.
  3. Sleep Medicine Codes. AASM.org. https://aasm.org/clinical-resources/coding-reimbursement/sleep-medicine-codes/. Published December 14, 2018. Accessed January 31, 2021.
  4. Physician Fee Schedule Search. CMS.gov Centers for Medicare & Medicaid Services. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed January 31, 2021. Published December 1, 2020. Accessed January 31, 2021.
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There is little doubt that the year 2020 will be remembered for the devastating Covid-19 pandemic and the way it has negatively affected our world in ways many thought unimaginable just a short while ago. And while we could comment on the travel restrictions or the difficulties of attending large gatherings, we decided to close this year in a positive way, highlighting favorable trends that are currently happening within our space as well as celebrating the success we were able to achieve during this challenging time. 


The changing landscape of sleep studies

For most patients in years past, it was more common to complete a sleep study at a facility rather than at home due to several factors. Estimates showed that approximately 70% of sleep studies were done outside the home. However, for the last couple of years, we began to see a gradual decline in the number of PSG tests being requested versus HSAT. 

With Covid-19, the ratio has completely flipped, with 70%+ HSAT tests being administered vs ~30% for the more common PSG. At Itamar®, we are hopeful that over time, this ratio will move to a 50-50 split between PSG and HSAT. We also are aware that the better our diagnostic process, the more we can positively affect patient conditions and outcomes.  

Our WatchPAT® ONE made a huge difference during this crisis and we are excited to see so many sleep clinics see it as their primary choice for their patients, selecting it first over other competitors in the marketplace. 

Looking at CMS reimbursement

On the subject of CMS reimbursement – with the recently announced 2021 physician fee schedule, we are happy to note that HSAT reimbursement code 95800 which WatchPAT® falls under with its PAT® technology and sleep time was not affected compared to the dramatic (-13.9%) reduction in current rates for competitive Home Sleep Apnea Testing (HSAT) devices. This should also provide additional confidence to WatchPAT® users.

Clinical validation

WatchPAT® technology was recently validated thanks to a study published in the December 2020 edition of Nature and Science of Sleep. Entitled ‘WatchPAT is Useful in the Diagnosis of Sleep Apnea in Patients with Atrial Fibrillation’, the study concluded that WatchPAT®, based on PAT® technology can diagnose sleep apnea events in AFib patients with and without nocturnal active AFib episodes with accuracy similar to the general population, with significant correlation to PSG testing outcomes. 101 patients from the US, Canada, Germany, and Israel took part in the use of WatchPAT® against in-lab polysomnogram (PSG) testing in the diagnosis of sleep apnea in patients with atrial fibrillation (AF). The study concluded that WatchPAT is a viable alternative to PSG for confirmation of clinically suspected sleep apnea that is based on peripheral arterial tone signal’s amplitude and rate, oxygen saturation, and actigraphy.

Advancing sleep technology

Finally, the National Sleep Foundation (NSF) awarded the team at Itamar® Medical with the 2020 SleepTech® Award. This honor recognizes our innovative efforts in advancing sleep technology while addressing the needs of consumers during this difficult time. 

“We are honored and delighted to receive the 2020 SleepTech® Award and to be recognized by the NSF for our achievements in the field of sleep medicine and technology. Sleep Apnea is a serious disease with serious consequences. We are very proud of the home-based innovative technology and the digital health platform we have built to deliver simple and reliable solutions for the diagnosis and management of this condition,” said Gilad Glick, CEO, Itamar Medical. 

The future

With 2020 almost behind us, we are now looking forward to continued success in 2021. As we move forward with the increased demand for home sleep testing, stable CMS reimbursement compared to airflow HSAT devices, and the clinical validation and awards our technology has garnered, we see a bright future on the horizon. 

Diabetes Awareness Month

Each year, The American Diabetes Association designates November as American Diabetes Month. This annual campaign lasts throughout the month, and is focused on a number of projects, including raising funds for research, increasing awareness about diabetes, supporting those who already suffer from its affects, and educating those who are potentially at risk for being diagnosed. 

As a physician responsible for the diagnosis and treatment of obstructive sleep apnea, or OSA, it’s important to note that Type 2 diabetes can develop due to the effects of OSA. As this study in Diabetes Spectrum summarizes:

Obstructive sleep apnea (OSA) alters glucose metabolism, promotes insulin resistance, and is associated with development of type 2 diabetes. Obesity is a key moderator of the effect of OSA on type 2 diabetes. However, chronic exposure to intermittent hypoxia and other pathophysiological effects of OSA affect glucose metabolism directly, and treatment of OSA can improve glucose homeostasis.

Both potential and active patients need to know that diabetes, just like OSA, can be treated. The possible effects of not doing so include heart disease, stroke, blindness, kidney damage, and lower extremity amputation. Offering to actively screen for OSA could give you the insight needed to make an effective plan for treatment, leading to a successful outcome that reduces the chance of a diabetes diagnosis.  


Season effects and the stress of 2020

As we all move toward the holiday season and the winter months ahead, the chances that your patients will consistently make good food choices while taking part in outdoor activities dramatically drops. Knowing that those already suffering from OSA are greatly increasing their risk of becoming diabetic should embolden you to offer guidance, encouragement, and support. These little moments could be all that’s needed to help someone make better choices. 

By taking the opportunity to screen patients for OSA with our WatchPAT®home sleep apnea devices, along with educating patients about the potential risks for diabetes early on, you can change the outcomes for many in your care. Impress on them the need to proactively care for themselves, and those that they love. After all, diabetes, just like OSA, is a preventable disease. Reaching out today just might make all the difference in someone’s life. 

Learn more about diabetes and how you can help at www.ada.org

Diabetes Spectrum 2016 Feb; 29(1): 14-19

sleep apnea vector

by Shiri Shneorson

VP & general manager, digital health business unit, Itamar Medical 

Until quite recently, anyone aiming to track their sleep outside a laboratory setting lacked access to any technology more sophisticated than a pen and notebook.

Now, amid a plethora of mobile apps, wearable devices, and sensors, we’ve seemingly entered a new era of greater precision and sophistication in tracking our sleep. These advances come at a time when they’re sorely needed: According to the Centers for Disease Control and Prevention, more than a third of Americans sleep less than the recommended seven or more hours per day, putting them at risk of heart disease, stroke, high blood pressure, mental illness, and other conditions.

But while more people are turning to sleep-tracking devices in a bid to improve their overall wellbeing, these devices come with major technological and medical limitations. While they may do a decent job measuring the timing and duration of our sleep, they still come up short when it comes to tracking the quality of our sleep, let alone serving as diagnostic tools. 

What are these devices’ shortfalls – and how, despite those flaws, can we harness these tools to live healthier, better rested lives?


Weighing the drawbacks

The current sleep tracking trend dates back nearly a decade. Fitness trackers like Jawbone and Fitbit and apps like Beddit – later acquired by Apple – have enabled users to monitor their nightly sleep habits albeit without delving into sleep quality or sleep cycles.

While existing sleep tracking apps have been able to provide some basic insights into the stages of sleep (light vs. deep), their overall effect has been to provide users a big-picture overview of how much they’re sleeping each night. That information is far from useless, of course, as for many users, this data alone can help them adjust their day- and night-time routines to promote healthier sleep habits.

But to understand the uses and limitations of these devices, it’s helpful to think about how they actually work. The technology used to measure sleep – like wrist-worn accelerometers, which monitor users’ movement throughout the night (with long periods of immobility characterised as sleep), movement-tracking bed sensors, or sleep-tracking headbands equipped with brain wave-reading electrodes – relies on a mixture of mobility and biomarker data like heart rate and respiration to evaluate users’ shut-eye. 

There are plenty of pitfalls to these methods: Restless sleepers who toss and turn, for instance, can easily confound motion-based monitors, tricking these devices into thinking they’re awake. Chronic insomniacs who remain motionless in bed for hours on end may be recorded as sleeping, despite being wide awake. Meanwhile, sleep technology experts say that movement and heart rate sensors fail to accurately measure sleep in the REM stage. While some products, including from Garmin and Fitbit, provide data on users’ sleep stages, they lack respiratory indices and the ability to diagnose conditions like sleep apnoea.

Indeed, sleep trackers generally fall significantly short in terms of diagnosing sleep conditions. In the diagnostic realm, polysomnography – not the most popular apps and devices – is the gold standard.  

Evaluating the overall merit of different sleep trackers is even more difficult given that most commercial products operate on undisclosed blackbox algorithms that determine what is and is not sleep. Sleep labs’ algorithms, on the other hand, are publicly shared, making it possible for independent experts to evaluate them.

Where these devices can help

For all their shortcomings, sleep tracking devices can still fulfil important functions. Rather than seeing the data generated by apps and wearables as the final word on all things sleep, users can treat it as supplementary information to help guide smarter decisions about when, where, and how they sleep. Users may find, for example, that they tend to sleep longer when they go to bed and wake up between certain times, or that they sleep better after an evening workout session. It’s also important to track variables like room temperature and diet, both of which can have a big impact on one’s ability to fall asleep and stay asleep.

Devices with snore-tracking features, while not to be treated as diagnostic tools, can help users determine whether they’re at risk of obstructive sleep apnoea; if so, they should seek further examine from their doctors. Indeed, the American Academy of Sleep Medicine, while noting that consumer products “are not substitutes for medical evaluation,” endorses consumer sleep technologies as tools that can “enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation.” In arming patients with preliminary data, these tools can also promote a sense of empowerment, which is vital for individuals looking to take charge of their own wellbeing.

Are sleep trackers sleeker and more innovative than the sleep journals of yore? Undoubtedly. Are they medical-grade diagnostic tools with flawless data capabilities? No – but to the extent that they make us more aware of sleep’s importance to our health, they can enable us all to live and sleep better.

Also Published at Med-Tec News

WatchPATone

There is little doubt that 2020 and the advent of COVID-19 will forever reshape the face of healthcare. From the meteoric rise in telemedicine to increasing stringency in infection prevention protocols, hospitals, clinics, and testing facilities must now adapt in order to succeed in the coming years.  And one prime example of adaptation is that of sleep apnea testing.

By its very nature, traditional sleep apnea testing is not only high-touch (thanks to the devices used and staff required) but also high exposure, due to the length of time patients are expected to spend within a clinic’s walls and the nature of aerosols spread during irregular breathing and snoring. While the area within these walls provides safety for patients during testing, the truth is that some studies show that the longer a person spends in a public setting – which a sleep clinic has to be – the more likely their chances of contracting the virus.

This is why doctors and clinics across the world are turning to home-based sleep apnea testing.

In order to get the clinical data necessary to treat their patients without compromising their safety, cardiologists and sleep physicians now see home testing as the preferred way to diagnose sleep apnea conditions, all in an environment that’s both safe and familiar to their patients.

However, while moving the location of the test from the clinic or hospital to the patients home is definitely a step in the right direction for patient safety, there are other areas of potential infection risk requiring more necessary actions to ensure the highest level of mitigation.


COVID, and the rise of disposable home sleep apnea tests

A second area of infection risk embedded with the home sleep testing devices that are typically dispatched from one patient home to the next.  

traditionally, all home sleep apnea testing devices on the market are designed to be re-used with some elements being disposable or washable, but this now serves as a potential risk of infection from previous patients or even staff to the next patients, as well as back again when the staff receives the device.

This creates vulnerability where there should be only a sense of safety, and is the driving force behind the recently issued American Association of Sleep Medicine “COVID-19 Mitigation Strategies” guideless and rise in demand for fully disposable home sleep apnea tests (HSATs).

WatchPAT®️ ONE – The first and only fully disposable HSAT

This need is exactly why Itamar Medical created WatchPAT®️ ONE, the first fully disposable HSAT. This one-time use device provides patients the comfort of sleep apnea testing in their own home and in their own bed, while ensuring they are never exposed to potential infection from reused devices and contamination transmitted from previous patients.

Patients simply:

  1. Attach the chest sensor
  2. Strap on the WatchPAT bracelet to their non-dominate hand
  3. Slip on the finger probe 
  4. WatchPAT ONE is connected with blue tooth to a simple smartphone app which in turn transmits the WatchPAT®️ ONE’s 7 channels of data to the cloud.  

As soon as the study is complete, the prescribing clinician or the assigned board-certified sleep physician can review the automatically scored study results and provide interpretation and the patient can safely throw the WatchPAT®️ ONE away. There is no need to mail the device or any part of it back, eliminating the chance that someone could be exposed to possible infection. Imagine, no delays in data transfer, which results in faster diagnosis, as well as protecting staff and patient alike.

And, since WatchPAT®️ has been clinically validated against the “Gold Standard”, polysomnography (PSG), with a documented correlation of up to 89%1, it provides not only outstanding patient compliance but also clinical reliability. 

In the COVID era, WatchPAT®️ is the answer sleep physicians and patients are searching for to provide the testing they need without compromising safety.  

References: 

1- Yalamanchali S, Farajian V, Hamilton C, Pott TR, Samuelson CG, Friedman M. Diagnosis of obstructive sleep apnea by peripheral arterial tonometry: meta-analysis. JAMA Otolaryngol. Head Neck Surg. December 2013;139(12):1343-1350

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CPAP Machine. Image: shutterstock


The incidence of obstructive sleep apnea syndrome (OSA) is estimated to be 25% in the adult population. That’s one-quarter of adults who are at risk for the consequences of the disorder, including fatigue, high blood pressure, heart disease, type 2 diabetes, and more. And, although CPAP, the most common treatment for sleep apnea typically reduces the presentation of these symptoms and complications and improve sleepiness, residual sleep disordered breathing (SDB), or some level of sleep apnea events despite the use of CPAP,  can still occur. For example, if patients suffer from severe sleep apnea with 35 events per hour aka AHI (Apnea Hypopnea Index) and they use of CPAP reduces the events to 12 events per hour, it is great relief , but this patient still suffer from mild sleep apnea. 

This means that despite the use of CPAP to manage their sleep apnea, patients with SDB may not achieve the full benefits of their treatment and instead, continue to suffer from symptoms and damage of OSA. Additionally, residual sleep disordered breathing has been associated with reduced CPAP adherence, further complicating treatment.

This makes monitoring and detecting clinically suspected residual SDB vital to ensuring adequate treatment in patients with OSA vital for optimal and effective patient care.


CPAP Machines Subject to Error

Unfortunately, existing practice is to rely on the CPAP machines themselves in order to detect residual breathing issues, since these machines utilize proprietary algorithms to quantify respiratory events and detect and report residual or untreated apneas.

However, recent data shows that for both fixed and auto-adjusting CPAP machines, of multiple leading brands,  this quantification may be subject to significant error.

This is a fact that is glaringly evident when patients with acceptable CPAP data present with new or even worsening symptoms and comorbidities of OSA, signs highly associated with residual sleep disordered breathing.

Accurate Detection of SDB

That’s why research reported in the Journal of Clinical Sleep Medicine set out to determine if there was a better, more accurate way to monitor for and detect residual SDB in patients on CPAP for obstructive sleep apnea.

Patients included in the study were actively using CPAP and had an apnea-hypoxia index (AHI) of five or fewer event per hour on their CPAP data report. Yet each was clinically suspected of being inadequately treated for their apnea. 

Clinical criteria that led to a suspicion of SDB included:

  • Weight gain of more than 10 pounds
  • Worsening or persistent daytime sleepiness
  • Poor or worsening sleep quality
  • Recurrent apneas
  • New or worsening comorbidities such as hypertension or atrial fibrillation

Patients next underwent a single night of home sleep apnea testing using Itamar Medical’s WatchPAT®️ 200, simultaneous with CPAP use at the usual prescribed settings.

What is WatchPAT®️?

WatchPAT®️ is an innovative diagnostic Home Sleep Apnea Test (HSAT) that utilizes the peripheral arterial tone signal.  The device measures up to 7 channels (PAT® signal, heart rate, oximetry, actigraphy, body position, snoring, and chest motion) via sensors on the wrist, chest and finger. And WatchPAT provides AHI and other indices based upon True Sleep Time as well as Sleep Staging and is clinically validated with an 89%1 correlation to polysomnography (PSG).

The Results

After simultaneous WatchPAT and CPAP monitoring of 100 patients, divided into two groups with similar mix of age, sex, and body mass index, participants were divided into two groups:

  • Group 1: 52 patients with similar CPAP AHI and WatchPAT AHI (5 or fewer events/h)
  • Group 2: 48 patients with s WatchPAT AHI greater than their CPAP AHI (with median AHI difference? significantly greater at 11 events/h)

This means that WatchPAT AHI was significantly higher than the AHI detected with CPAP in nearly half of patients with clinically suspected residual sleep disordered breathing.

Additionally, WatchPAT revealed instances of moderate or severe REM AHI in both groups 1 and 2, which CPAP machines cannot detect, as well as instances of significant oxygen desaturation index and significantly lower nadir oxygen saturation in group 2.

The Conclusion

Overall, the researchers concluded that WatchPAT detected additional respiratory events beyond those detected by the CPAP machines, including rapid eye movement-related apneas, respiratory effort-related arousals, and hypoxemia.

The results of this study mean that physicians treating patients with obstructive sleep apnea, when clinical symptoms are present,  can no longer rely upon CPAP machines alone to ensure detection of residual SDB.

Instead, simultaneous monitoring with home sleep apnea testing, such as WatchPAT, even for patients with a normal CPAP AHI is necessary to ensure adequate treatment and prevent the long-term complications of sleep apnea.

References: 

1- Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apnea, Epstein et. Al, Journal of Clinical Sleep Medicine, Vol 16, No 7

WPONE Man Sleeping White Probe

Before the Covid-19 pandemic, potential sleep apnea patients were usually tested in an overnight facility, where their conditions were monitored and recorded, all overseen by a small team of medical professionals. They were asked to spend the night sleeping in a bed unfamiliar to them, in a noisy room surrounded with monitors and equipment, all while staff checked in on them throughout the duration of the test. It wasn’t perfect, but you could at least get an idea of what your patient was dealing with as they slept.
Now, with the pandemic continuing to affect everyone in one way or another, your patients are faced with far fewer options than in the past. Most, if not all testing facilities and clinics have severely cut back operations or have been forced to close outright. These facilities will need to make considerable changes to operations in order to open again and even then, most will likely choose to close at least in the short-term due to litigation concerns, insurance costs, and potentially higher levels of regulation and oversight. The road will be rough for many of these facilities, with many shutting their doors permanently.


Home as the New Diagnostic Center


No matter what happens, your patients will still need you to diagnose and treat their sleep disorders. The question becomes – how can you do it safely and effectively? The need for a new solution to both monitor and detect sleep apnea conditions in safe, familiar environment has never been greater. Your patients are looking to you for help. And up until now, a simple, effective, one-time use device that they can use in their own home while sleeping in their own bed did not exist.
Introducing the WatchPAT® ONE, the world’s first and only disposable HSAT from Itamar® Medical. This innovative, FDA-cleared wrist mounted device was created to diagnose Sleep Breathing Disorders (SBD) in the comfort of the patient’s own home. The WatchPAT®️ has been clinically validated against the “Gold Standard”, polysomnography (PSG), with a documented correlation of up to 89%.1 Its simple design is both comfortable easy to use for outstanding patient compliance. It is clinically reliable, with 98% success rate.2 It measures “True Sleep Time” for the most accurate AHI, RDI, ODI and delivers:
* Complete sleep architecture for a comprehensive diagnosis
* Increased infection control with single-use design
* Scalable, cost effective solution for high volume workflow
* Automatically generated reports for fast diagnosis and treatment turnaround
* zzPAT -software with an advanced automatic algorithm for scoring of respiratory events
* CloudPAT-cloud based IT solution for convenient sleep diagnosis and secure patient data transfer
In a post-COVID world, ensuring patients can receive the diagnostic testing they need in the safety and comfort of their own home simply makes sense. Reach out today and talk to your Itamar representative about how to optimize sleep management in your practice.

1.Yalamanchali et al. JAMA Otolaryngnol Head Neck Surg, 2013, Diagnosis of Obstructive Sleep Apnea by Peripheral Arterial Tonometry (Meta-Analysis)

2. Data on file

By Gilad Glick

home sleep apnea test

Cardiologists have always been early adopters of home-based and telemedicine applications and telehealth tools. For example, the Holter monitor that gathered data on the heart rhythms of cardiac patients over an extended period of time from their homes was one of the earliest instances of telehealth. Consequently, cardiologists are already accustomed to remotely monitoring their patients through implantable cardiac devices such as pacemakers and defibrillators that continuously collect and transmit data back to clinicians together with their main tasks of keeping the heart beating.

Alongside the popularity of telemedicine for cardiac patients lies the rising awareness of the link between Sleep apnea and heart disease. With concern growing for the effects of sleep apnea on patients’ cardiovascular risk and cardiac disease progression, home sleep testing with a home sleep apnea test device is the latest ambulatory tool in the cardiologist’s arsenal.

The drawbacks of in-lab sleep testing

In-lab comprehensive sleep tests, also called polysomnography or PSG, was the first breakthrough in the diagnosis of sleep disorders. The first sleep clinic was set up at Stanford University in 1970; today, over 2,500 sleep centers are accredited by the American Academy of Sleep Medicine (AASM) to carry out sleep testing.

However PSG tests have their drawbacks:

  • Discomfort: Many intrusive tubes and wires make the experience off-putting for patients.
  • Expense: Even if the patient’s insurance covers part of the cost, an in-lab sleep test runs to thousands of dollars. With the trend for high deductibles on the rise, the patient may delay being tested for months.
  • Delay: The wait time for a sleep study ranges from a couple of weeks to several months and it takes another 2 weeks on average for the results to be prepared. This is a long time for cardiac patients scheduled for ablation or on the accelerated deterioration of their disease.
  • Patients with symptomatic cardiac disease are worried and pre-occupied with the uncertainty and discomfort they are experiencing. Asking them to add another cumbersome and effort heavy in-lab test drive many of them to ignore the referral and skip or delay it into the future.
at home sleep apnea test

The Home sleep apnea test is rising in popularity

In December 2007, an American Academy of Sleep Medicine (AASM) task force published guidelines on the use of unattended portable monitors (PMs) for the diagnosis of Obstructive Sleep Apnea (OSA) in adults. The shift to sleep apnea diagnosis at home began in full force in March 2008, when the Centers for Medicare & Medicaid Services (CMS) released its proposed decision for modification of National Coverage Determination (NCD) policy 240.4 pertaining to coverage of continuous positive airway pressure therapy (CPAP) for an adult with obstructive sleep apnea (OSA). The proposed modification allowed for an initial 12 week period of CPAP coverage when OSA was diagnosed based on unattended home sleep testing (HST).
CPAP would be subsequently covered for those diagnosed with OSA who benefit from CPAP during the 12-week trial.

In March 2017 in the wake of recent technological advances, the AASM revised guidelines and accepted home sleep tests (HST) which measure peripheral arterial tonometry (PAT) as well as oximetry and actigraphy as “technically adequate” for the diagnosis of Obstructive Sleep Apnea in patients.  Currently, WatchPat is the leading sleep apnea diagnosis device in a market place that uses this unique PAT technology.

The Advantages of taking a Home Sleep Apnea Test

Besides overcoming the drawbacks of PSG, home sleep apnea testing has the following advantages:

  • More and more insurance carriers only approve a Home Sleep Apnea Test (HSAT) as a first-line diagnosis for those that have a high pre-test probability of having obstructive sleep apnea (OSA).
  • Significantly lower out-of-pocket cost/deductible
  • Less stress in taking the test in a familiar environment.
  • A simpler HST is less uncomfortable and intrusive than an in-lab test.
  • Less time involved in traveling to a sleep clinic and undergoing various preparations.

The home sleep apnea test: advantages for clinicians

For the physician, an HSAT can be administered quickly and at times even right at the point care in the cardiology office and delivers results within a day or two. In this way, a cardiac patient can be diagnosed with OSA and begin treatment immediately, rather than watching their heart disease get worse while they wait for an in-lab sleep test.
The PSG can still be conducted and used for more detailed information when it is needed as a secondary comprehensive investigation.

Why is WatchPAT ideal for cardiologists?

WatchPAT®️ home sleep apnea test is an ideal solution for cardiologists who focus on improving outcomes and their patients’ health-related quality of life, to expand their service portfolio to include the speedy diagnosis and treatment of sleep apnea. WatchPATTM combines the simplicity of pulse oximetry together with the accuracy of PSG and the cost-effectiveness of an at home sleep apnea test.

As Prof. Andrea Natale from Austin mentioned in the 2016 HRS symposium “In the past, I used to convince the patient to do a sleep study. Many of them did not do it. Now they come to our office, they see the flyer about sleep apnea, they ask me to take the test because the test is so easy. Clearly, there’s benefit in the ease of the device to reach diagnosis”.

Dr. Randy Lieberman from Detroit was quoted saying that “Once we explain to the patients that identification of the sleep apnea can lead to a better quality of life or potentially better management of their cardiovascular disease component, then the question is; What kind of a sleep study? Patients are very reluctant to accept the information from an overnight sleep study outside their house. They tell us, they do not believe the data because they were uncomfortable in their bed and they couldn’t sleep. When they have a home sleep study done their own bed where it is minimally invasive, with a minimum amount of home sleep study equipment, then they much more open to accepting the diagnosis and the treatment”. As more medical tests are offered in the ambulatory settings, it’s easy for your patients to be tested more easily and keep on top of their health. Home sleep apnea tests empower patients and improve quality of care, while on a macroeconomic level telemedicine and home testing makes care more accessible while cutting operational costs and waiting times.

By Rhonda Welch, CPC

Home Sleep Apnea Tests (HSAT) have increased in utilization and based on recent estimates amount to about a third of all sleep apnea tests due to their cost effectiveness and accessibility in comparison to in lab, attend Polysomnography testing.  An HSAT is a preference for many patients since they can take the test at home in a more natural, relaxing and private environment that is also more likely to reflect the actual disease manifestation.

Today, the vast majority payers reimburse for HSAT and some recommend it as first line diagnosis for sleep apnea.  However their coding and billing requirements differ from payer to payer.  It is always best to check with your payer for their specific requirements, but this article will outline some of the basics.

With few exceptions, licensed medical doctors, regardless of the their specialty, can prescribe HSAT to patients who are suspected of sleep apnea based on sign and symptoms and testing positive for high risk on validated instruments such as the STOPBANG, Epworth Sleepiness and DOISNORE 50  questionnaires.  In addition, physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines1.

HSAT G Codes and CPT Codes

In 2007 the American Academy of Sleep Medicine (AASM) published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients”2 which differentiated the HSATs by type (defined by the AASM).  In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399 and G0400 which followed the AASM types. G codes are “carrier determined” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs).

G codes / Sleep Type Classification

G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation.

G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation.

In 2009, CMS issued a National Coverage Determination (NCD) which called out the WatchPAT as a covered test. 
Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400
to report WatchPAT.

In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (ie WatchPAT).  Note that WatchPAT records sleep time so CPT 95800, not 95801 should be used to report HSAT using WatchPAT. Most commercial payers request the use of 95800 to report WatchPAT.

CPT Codes

95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg. by airflow or peripheral arterial tone), and sleep time.

95801 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg. by airflow or peripheral arterial tone).

In 2017 AASM clarified their position in a guideline, noting that the types classification fails to consider new technologies such as peripheral arterial tonometry (PAT).  They proposed another classification scheme but acknowledged that it has not been utilized by many.  The AASM concluded that devices that measure PAT, actigraphy, and oximetry are technically adequate to diagnose OSA and therefore recommended that physicians use such HSATs to diagnose OSA.3

The bottom line is that there are multiple codes that can be used to report HSAT.  Typically, CMS requests that WatchPAT be reported with G0400 and commercial payers request 95800.  Since HSAT may reported by more than one code, it is best to refer to the payer’s medical policy to ensure you are reporting the correct code.

In upcoming newsletter editions, we will explore additional topics including when to bill the global, technical and professional components of the code, credentialing and accreditation issues.

[1] Kapur et al., Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline, 13 J. Clin. Sleep Med. 479 (Mar. 15, 2017).
[2] Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients. JCSM Journal of Clinical Sleep Medicine, Vol. 3, No. 7, 2007.
[3]CMS Pub 100-03 Medicare National Coverage Determinations (NCD) – Sleep Testing for Obstructive Sleep Apnea (OSA). Transmittal R103NCD March 3, 2009

By Efrat Magidov

Obstructive sleep apnea (OSA) is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, and the diagnosis procedure and its availability keep improving. The use of home sleep apnea testing (HSAT), also known as portable monitoring (PM), for the diagnosis of OSA is continuing to grow as a viable option for sleep professionals. Currently, available HSAT devices are user-friendly, easily portable, and most importantly- reliable. Numerous randomized studies comparing ambulatory and laboratory-based approaches have generally found HSAT non-inferior to a laboratory approach in adults with OSA, especially in patients with a high likelihood of moderate-severe disease. Consequently, HSAT is growing to be the go-to approach for patients with a high likelihood of OSA without other significant medical conditions.

HSAT is a favorable approach also due to the convenience it offers. HSAT allows patients to avoid the overnight stay at the sleep center, with fewer attached wires and access to the comforts of home. HSAT also provides more access to the testing; Sleep centers may not be accessible due to location or even scheduling. Home testing devices can be sent home from the doctor’s office, and thus offer a quicker diagnostic turn-around time. Moreover, since In-lab testing requires paying for space, technicians, and scoring, HSAT is typically more cost-efficient for both the patients and the healthcare system. However, despite all these numerous advantages of HSAT over laboratory-based testing, most ambulatory devices still have some notable limitations:

  • Most commonly used home testing devices do not record sleep duration. Practitioners are therefore reliant on total recording time rather than total sleep time to calculate time-derived indices such as apnea-hypopnea index (AHI). If the patients sleep poorly or have comorbid insomnia or even nocturia, the frequent awake periods (in which it is not likely for respiratory events to occur) can lead to a material underestimation of AHI and consequently misdiagnosis and misclassifications (add UPenn reference).
  • Not all HSAT devices record body position therefore overlooking diagnosis of supine predominant OSA and assessment of positional therapy (i.e. avoiding certain supine postures as a primary OSA relief strategy).
  • Most HSAT devices don’t have a reliable assessment of arousals. Since a growing body of studies demonstrates the effects of restorative sleep time and fragmentation on various health issues, this absence is notable.
  • Many HSAT devices require the patients to correctly set up a complex device on themselves. This equipment, including nasal cannula, chest and abdominal belts, EMG sensors and oximetry finger clamp can be detached during sleep, or be placed incorrectly, which leads to faulty results or no results, meaning significant disorders can be missed in up to 20% of times (add test completion reference).

In the future, HSAT might be the dominant approach to diagnosing and monitoring patients regularly, easily, and economically. Therefore it is crucial for the ambulatory devices to optimally account for all the mentioned limitations.

The use of home sleep apnea testing (HSAT), also known as portable monitoring (PM), for the diagnosis of OSA is continuing to grow as a viable option for sleep professionals. Currently, available HSAT devices are user-friendly, easily portable, and most importantly- reliable.

WatchPAT is easy to use, effective, and accurate HSAT device for OSA diagnosis. To date, WatchPAT with its innovative peripheral arterial tone (PAT) signal is the only FDA-approved HSAT device that measures true sleep time, all sleep stages (wake/arousal, light sleep, deep sleep, and REM sleep) and body position without the use of EEG. You may learn more about WatchPAT and our comprehensive “Total Sleep Solution” for Cardiology practices in www.cardiosleepsolutions.com

Sources:

Malhotra, A., Orr, J. E., & Owens, R. L. (2015). On the cutting edge of obstructive sleep apnoea: where next? The Lancet Respiratory Medicine3(5), 397-403.

Hilbert, J., & Yaggi, H. K. (2018). Patient-centered care in obstructive sleep apnea: A vision for the future. Sleep medicine reviews37, 138-147.