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Rebuttal From Dr BrownRebuttal From Dr Brown

Lee K. Brown, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine and the Program in Sleep Medicine, Health Sciences Center, The University of New Mexico.

Correspondence to: Lee K. Brown, MD, FCCP, Department of Internal Medicine, School of Medicine, The University of New Mexico, 1101 Medical Arts Ave NE, Bldg #2, Albuquerque, NM 87102; e-mail: lkbrown@alum.mit.edu


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Brown serves on the Polysomnography Practice Advisory Committee of the New Mexico Medical Board and on the New Mexico Respiratory Care Advisory Board. He currently receives no grant or commercial funding pertinent to the subject of this article. Dr Brown was a member of the American Academy of Sleep Medicine Board of Directors when “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients” was developed and approved.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(6):1756-1758. doi:10.1378/chest.13-1698
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Extract

Dr Gay’s1 first and foremost argument in favor of allowing physicians without board certification in sleep medicine to prescribe CPAP on the basis of the home sleep testing (HST) is the potential cost savings. That would be a cogent argument if the cost-benefit ratio of HST with interpretation and clinical decision-making by a non-board-certified physician was sufficiently superior to laboratory polysomnography (PSG) interpreted by a sleep specialist. However, HST subjected to cost-benefit analysis may not represent the best value even in expert hands. Economic modeling demonstrated that laboratory PSG, rather than HST, provided the most cost-effective strategy for diagnosing moderate to severe OSA, largely due to frequent false-negative HST results.2 Moreover, the literature suggests that utilizing HST in a community setting requires significant expertise in data collection and scoring, with careful overreading by an adequately trained physician. For instance, the Sleep Heart Health Study used highly trained technologists for scoring and rigorous quality control to demonstrate intraclass correlations > 0.90.3 In contrast, Collop4 reported on variability in identifying respiratory events by technologists in nine different sleep laboratories scoring 11 identical PSG recordings. Apnea-hypopnea indices varied significantly, and wide disparities in interpretation and management would have resulted. For one particular recording, apnea-hypopnea indices from different scorers ranged from supporting the presence of severe OSA to no disease at all. Clearly, overreading by a well-trained interpreting physician is important, even assuming scoring of HSTs by highly trained technologists.

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