One of the things that has challenged sleep medicine is the debate about which diagnostic study to use for the diagnosis of OSA. It is as if there was only one strategy possible that is appropriate for all patients. Diagnosis is, however, only one part, and indeed a relatively small part, of the total strategy for care.
There is little doubt that home sleep studies can be used for the diagnosis of OSA. This is supported by randomized trials1-3 comparing the outcomes of an in-laboratory pathway for diagnosis and CPAP titration to an out-of-laboratory pathway. These studies focused on outcomes of care as advocated by a trisociety report.4 These studies were similar in design using a parallel group strategy to compare outcomes of an in-laboratory pathway to that from an out-of-laboratory home pathway. The in-laboratory pathway used the standard laboratory polysomnography followed by technologist-directed CPAP titration. The out-of-laboratory pathway used a home sleep study without EEG followed by autoadjust CPAP titration for several nights at home before being switched to fixed CPAP. Outcomes assessed at follow-up include changes in the Epworth Sleepiness Score,5 the Functional Outcomes of Sleepiness Questionnaire,6 and CPAP adherence. Outcomes at 6 weeks in one study1 and 3 months in two others2,3 were essentially identical between the in-laboratory and in-home pathways. Kuna et al2 found that CPAP adherence was higher but not significantly so in the in-home pathway while Rosen et al3 did find significantly higher CPAP adherence in the in-home pathway compared with the in-laboratory pathway.