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
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.
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
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).
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.
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.
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
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.
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.
Attach the chest sensor
Strap on the WatchPAT bracelet to their non-dominate hand
Slip on the finger probe
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.
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
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)
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 apnea testing with a home sleep apnea test is the latest ambulatory tool in the health professional’s arsenal.
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.
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.
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 testing for sleep apnea 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 apnea testing (HSAT). 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 sleep apnea testing at homefor 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 sleep apnea testing at home with 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.
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.
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.
 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).  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. CMS Pub 100-03 Medicare National Coverage Determinations (NCD) – Sleep Testing for Obstructive Sleep Apnea (OSA). Transmittal R103NCD March 3, 2009
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 a home sleep apnea test (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
Malhotra, A., Orr, J. E., & Owens, R. L. (2015). On the cutting edge of obstructive sleep apnoea: where next? The Lancet Respiratory Medicine, 3(5), 397-403.
Hilbert, J., & Yaggi, H. K. (2018). Patient-centered care in obstructive sleep apnea: A vision for the future. Sleep medicine reviews, 37, 138-147.