Abstract
BackgroundThe recent pandemic has made it more challenging to assess patients with suspected obstructive sleep apnea (OSA) with in laboratory polysomnography (PSG) due to concerns of patient and staff safety. The purpose of this study was to assess how Level II sleep studies (LII, full PSG in the home) might be utilized in diagnostic algorithms of suspected OSA using a theoretical decision model.MethodsWe examined four diagnostic algorithms for suspected OSA: an initial PSG approach, an initial LII approach, an initial Level III approach (LIII, limited channel home sleep study) followed by PSG if needed, and an initial LIII approach followed by LII if needed. Costs per patient assessed was calculated as a function of pretest OSA probability and a variety of other variables (e.g. costs of tests, failure rate of LIII/LII, sensitivity/specificity of LIII). The situation in British Columbia was used as a case study.ResultsThe variation in cost per test was calculated for each algorithm as a function of the above variables. For British Columbia, initial LII was the least costly across a broad range of pretest OSA probabilities (< 0.80) while initial LIII followed by LII as needed was least costly at very high pretest probability (> 0.8). In patients with a pretest OSA probability of 0.5, costs per patient for initial PSG, initial LII, initial LIII followed by PSG, and initial LIII followed by LII were: $588, $417, $607, and $481 respectively.ConclusionsUsing a theoretical decision model, we developed a preliminary cost framework to assess the potential role of LII studies in OSA assessment. Across a broad range of patient pretest probabilities, initial LII studies may provide substantial cost advantages. LII studies might be especially useful during pandemics as they combine the extensive physiologic information characteristic of PSG with the ability to avoid in-laboratory stays. More empiric studies need to be done to test these different algorithms.
Highlights
Obstructive sleep apnea (OSA) is a common respiratory disease characterized by recurrent upper airway collapse during sleep leading to nocturnal hypoxemia and sleep fragmentation (Laratta et al 2017)
When initial PSG was compared to initial Level III limited channel home sleep study (LIII) followed by PSG, PSG was less costly at lower pretest disease probabilities (< 0.6) but LIII was more cost-effective at higher probabilities
This is because a lower pretest probability resulted in more negative LIII tests that required PSG, thereby increasing costs if LIII was the initial test (Ayas et al 2010)
Summary
Obstructive sleep apnea (OSA) is a common respiratory disease characterized by recurrent upper airway collapse during sleep leading to nocturnal hypoxemia and sleep fragmentation (Laratta et al 2017). As a consequence, limited channel home sleep studies (Level III) have become more popular These involve collection of fewer physiologic signals at home (e.g., don’t usually collect electroencephalogram information). Sensitivity and specificity of Level III studies are high, ranging from 80 to 100% (Ross et al 2000) These studies are useful in confirming OSA in symptomatic moderate to high probability patients (Mulgrew et al 2007a). Compared to PSG, advantages include reduced costs and increased access; the major disadvantage is the limited amount of physiologic information available. Their usefulness in more complex patients (e.g. pre-existing cardiovascular and pulmonary disease) is questionable, and they typically cannot detect non-OSA diagnoses accurately (e.g. periodic limb movements, central sleep apnea) (Fleetham et al 2011). The purpose of this study was to assess how Level II sleep studies (LII, full PSG in the home) might be utilized in diagnostic algorithms of suspected OSA using a theoretical decision model
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