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Point and Counterpoint |

Rebuttal From Dr FreedmanRebuttal From Dr Freedman FREE TO VIEW

Neil Freedman, MD, FCCP
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From the Division of Pulmonary, Critical Care, Allergy and Immunology, NorthShore University Health System.

CORRESPONDENCE: Neil Freedman, MD, FCCP, 2151 Waukegan Rd, Bannockburn, IL 60015; e-mail: Neilfreedman@comcast.net


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2015;148(2):311-312. doi:10.1378/chest.15-0480
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Dr Pack1 makes several excellent points, and unlike most pro-con debates, I tend to agree with most of his arguments. I would summarize and respond to his comments as follows.

I agree that home sleep testing (HST) has a role in the management of OSA, especially for symptomatic patients with a high pretest probability of OSA. A recent large-scale study would suggest that most patients who are undergoing HST in a real-world setting are appropriate candidates for this type of testing.2 HST should not be used in patients with comorbidities that may predispose them to more complex sleep-disordered breathing as the data do not support its use in these patient populations.

Dr Pack1 notes that since HSTs as a group of technologies are less sensitive by nature than polysomnography (PSG), some patients with OSA who could benefit from therapy may be missed when HST is used as the exclusive method of testing. While I agree, this conclusion is in part dependent on several factors, including the type of device, patient population, and clinicians who are managing the patients. Clinicians must realize that they are not limited to HST when test results are discordant with the clinical scenario and should proceed with formal PSG when clinically appropriate.

I agree with Dr Pack1 that looking at the cost of the test alone without looking at the potential cost of poorer outcomes based on missed diagnoses is short sighted. On the other hand, the “preferred” delivery model that primarily utilizes PSG for diagnosis and treatment decisions also leaves up to 80% of patients with OSA undiagnosed. Given its reduced cost, HST could allow more at-risk patients to undergo diagnostic testing, thus potentially offsetting its reduced sensitivity and other limitations compared with PSG.

While I agree that many primary care providers (PCPs) do not want to manage OSA in real-world settings, this is not related to the type of diagnostic test, but is more related to their time constraints, requirements for documentation, compliance with quality metrics, and lack of adequate support to navigate the complicated payor and durable medical equipment networks. I disagree with Dr Pack1 that there is little reason for PCPs to perform studies if they are not committed to appropriately managing patients. As noted previously, it is not that PCPs cannot manage patients with OSA, but the current reimbursement and delivery systems have made it difficult for them and most specialists to adequately manage these patients.

In summary, it is not about the test as the technology itself does not determine the outcome.3 The clinician who understands the various technologies and uses the appropriate test in the appropriate situation is much more important to achieving better patient outcomes. I strongly agree with Dr Pack1 that the focus should not be on the test, but on defining better strategies that emphasize chronic care management and improved patient outcomes.

References

Pack AI. Point: does laboratory polysomnography yield better outcomes than home sleep testing? Yes. Chest. 2015;148(2):306-308.
 
Cairns A, Poulos G, Bogan R. Who is getting tested for obstructive sleep apnea using a portable recording system? Test results from 193,221 patients. J Clin Sleep Med. 2014;10(11):1193-1198. [PubMed]
 
Collop NA. Home sleep testing: it is not about the test. Chest. 2010;138(2):245-246. [CrossRef] [PubMed]
 

Figures

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References

Pack AI. Point: does laboratory polysomnography yield better outcomes than home sleep testing? Yes. Chest. 2015;148(2):306-308.
 
Cairns A, Poulos G, Bogan R. Who is getting tested for obstructive sleep apnea using a portable recording system? Test results from 193,221 patients. J Clin Sleep Med. 2014;10(11):1193-1198. [PubMed]
 
Collop NA. Home sleep testing: it is not about the test. Chest. 2010;138(2):245-246. [CrossRef] [PubMed]
 
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