The Success of Home-Based Sleep Testing and Treatment
By Robert Koenigsberg, President of SleepQuest, Inc.
"What is the difference between home testing and laboratory testing?" I get asked this question all the time. The answers lie in looking at the fundamental differences between the way sleep care is delivered in the traditional laboratory setting as opposed to a home-based setting. Here are my thoughts on some of the frequent questions relating to this subject.
What does the SleepQuest model of home-based sleep care offer?
We are focused on one thing - sleep care - and we do it very well. We provide an innovative, complete "continuum of care" program that covers everything from the first test to treatment success and follow-up, and at a cost that is substantially lower than laboratories, often by as much as 50%.
These days everyone is pressed for time, so we jump through hoops to make sure that our patients and doctors don't have to wait for our services. We schedule our patients based on their convenience, not ours. They are scheduled within a few days of referral from their doctor who may be a primary care physician, a pulmonologist (lung and associated vessels), otolaryngologist (ear/nose/throat) or other specialist. Our test reports are sent back to the referring physician very quickly, within a few days of the test.
We employ only Board Certified Sleep Medicine Physicians to interpret our patients' test data. The reasons are very simple; sleep medicine is a complex specialty requiring a high degree of expertise. Referring doctors and patients place their trust in us and deserve the best that we can deliver.
We invest a lot of time and resource to provide high-quality education and training to our patients about sleep disorders so that they are well equipped to manage their condition. We excel at providing every aspect of CPAP therapy to patients and we utilize a comprehensive, proprietary, long term monitoring program that tells the referring physician how the patient is doing over their first year of treatment and addresses problems as soon as they appear. We are very proud of our results: 93% of our patients use CPAP successfully over the long term. The national average among patients is about 41%!
Finally, we make house calls! All of our testing, titration, patient set-up and education is done in the convenience of the patient's home. In fact, we will go anywhere, within the service area that we cover, that is convenient for the patient.
How does the traditional hospital-based/sleep laboratory model differ from the SleepQuest model?
Traditional sleep medicine is often fragmented in its approach to delivering care. The referring doctor determines that a patient needs to be tested. They refer the patient to a hospital-based sleep laboratory or independent sleep center that provides the diagnostic/titration services (usually a split-night test). A highly trained physician specializing in sleep medicine interprets the test data, consults with the patient and makes appropriate recommendations for further testing or treatment.
If the sleep physician prescribes treatment, then a home care or equipment supply company provides the treatment device (usually CPAP) for the patient. It should be noted that most of these companies are general suppliers of medical equipment like wheelchairs, hospital beds and oxygen, and have no special focus on sleep care.
Patients frequently tell us that under this model of sleep care they often wait weeks and sometimes months to be scheduled for these expensive tests. They have told us that sleeping in a laboratory setting is often inconvenient and does not offer the privacy, comfort and familiar setting of their own home. Once they start a treatment program, they often feel inadequately trained on their equipment and encounter difficulty getting questions answered. As a result they often discontinue the treatment program because of frustration with the whole process (national statistics indicate that more than 50% of CPAP users stop their treatment).
Do you measure the same things when doing home testing as you do in the laboratory?
In both home and laboratory testing the following critical factors are recorded during a sleep study: airflow, oxygen levels in the blood, body position, breathing motion, heart rate, snoring noise.
Although laboratories additionally measure EEG, EOG, and EMG, most sleep experts agree that (1) the majority of the patients seen in the sleep laboratory are referred for obstructive sleep apnea (OSA) and (2) OSA can be diagnosed without measuring these three additional activities and for these reasons they are not recorded under the SleepQuest home-based model.
Do you ever work with sleep laboratories and sleep physicians?
Yes. Sleep laboratory testing is vital for neurologically-based sleep disorders. When those kinds of conditions are suspected, the patient should be referred to a laboratory. When we get referrals for patients whose condition would be better studied in a lab setting, we will refer them to the appropriate center. We view our role as functioning in a cooperative way with sleep laboratories not a competitive one.
Is home testing as good as lab testing?
Home testing for obstructive sleep apnea has been clinically validated, uses devices approved by the FDA, and is generally accepted by the sleep medicine community. In fact, many sleep laboratories (in an effort to decrease their schedule backlog) provide home testing using equipment similar to what SleepQuest uses. Also, we frequently get patient referrals from sleep laboratories whose schedules are too crowded to accommodate patients needing studies immediately. If they didn't think it was clinically valid they wouldn't be doing it themselves nor would they refer patients to us.
The 1996 NIH Report of the National Center on Sleep Disorders Research made the following observation and subsequent recommendations:
"Currently, diagnosis of many sleep disorders and assessment of the magnitude of sleepiness is usually done using in-laboratory techniques, which can be expensive and inconvenient."
They recommended the following:
- Develop more cost-effective approaches (including in-home techniques) for diagnosis of obstructive sleep apnea.
- Develop ambulatory approaches (including those that can be delivered in non-laboratory settings) to assess the extent/level of sleepiness caused by sleep disorders.
- Develop approaches for in-home assessment of sleep disturbances and therapeutic effectiveness. Systems that communicate information about the use of treatments such as CPAP and intra-oral devices, sleep patterns of those with insomnia, and degree of movements during sleep would have important clinical value.
Conclusions from a 1998 study by Fry, et.al., at the Hahnemann School of Medicine state that "…unattended PSG (polysomnography) can be performed in the home with reliable and high quality recordings".
In Conclusion
The SleepQuest model of home-based care successfully educates patients and treats OSA. Our no-wait scheduling is a distinct advantage since most patients are juggling busy work and personal schedules. The high-quality follow-up care ensures treatment success and after all, that is the ultimate goal.
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