For William Suter, a good night’s sleep was an elusive dream. He snored all night and felt tired every day. His doctor suggested getting tested for obstructive sleep apnea, a common disorder in which people stop breathing many times a night, robbing them of rest and raising their risk of heart disease and diabetes.
In years past, diagnosing the problem meant spending the night at a sleep lab hooked up to monitors. But Suter took a simpler, cheaper and more convenient route: a home test that, studies show, often works as well for many patients as the varieties used in sleep labs. It’s part of a trend toward do-it-yourself exams that include a growing array of tests for genetics, fertility, blood cholesterol levels, thyroid stimulating hormone, urinary tract infections and more.
“I think it’s better because it’s your home, your environment. . . . I sleep with a fan on winter and summer, and it was no different during the test,” said Suter, 48, of Gordonsville, Va., who received a diagnosis of moderate sleep apnea about a year ago.
Sleep specialists say they expect more people to opt for home tests as insurers continue seeking to cut costs. Home sleep tests cost up to $300 or more, while hospital-based lab tests can reach $1,500 or more. Some doctors, though, suggest that while home tests have a place, particularly among relatively health patients with strongly suspected sleep apnea, they are not as thorough as lab tests, don’t provide as much data, sometimes miss less clear cases of apnea and can’t detect other problems such as narcolepsy or restless leg syndrome.
“The driver for all of this is cost and convenience. Lab tests are labor-intensive and costly,” said Safwan Badr, president of the American Academy of Sleep Medicine. “Insurance companies sometimes insist on home studies first. But patients would be much better off if insurers would allow doctors to use their best judgment.”
Susan Pisano, a spokeswoman for the trade group America’s Health Insurance Plans, said that while some plans consider home tests the first choice, doctors can often make a case to the insurer that a lab test is necessary and gain coverage for it.
“There is information that suggests these tests done with home sleep monitoring, in many instances, are getting to be as good as those done in a facility,” she said. “In general, the principal driver of coverage is that something is safe and effective.”
Sleep apnea affects up to 7 percent of adult men, up to 5 percent of adult women and similar percentages of children. In 2010, researchers at Harvard Medical School estimated the annual cost of the condition across the nation at $65 billion to $165 billion. It’s one of the main reasons so many Americans say they are sleep-deprived, along with insomnia, restless legs syndrome and a few other disorders. While home devices test only for apnea, lab testing can find a host of other sleep disorders such as narcolepsy and restless legs syndrome.
Sleep specialists say it’s not surprising that in-home testing has been growing in popularity, with various kits available, such as NovaSom, VirtuOx and Watermark Medical WM Sleep Portal. Patients can pick up and return kits to sleep centers or buy them and send them back to a company for analysis by a doctor.
“There’s been a real economic push to make home testing the standard of care,” said Chris Winter, a sleep specialist in Charlottesville. While he doesn’t think home testing is right for every patient, “I’m a supporter of it. I think it’s an important part of our arsenal as sleep specialists.” About a quarter of the tests his practice prescribes are home tests.
Home kits are designed to be easy for patients to use. Equipment varies, but it generally measures things such as air flow, oxygen saturation (a measure of how much oxygen the blood is carrying) and the effort people make during respiration. Home kits come with DVDs or simple instructions showing patients how to place an air-flow sensor under the nose, put on a belt that holds in place a device measuring breathing efforts and attach a clip to a finger before going to sleep.
The equipment can measure the number of times a person stops breathing during the night. (More than 30 times an hour is considered severe apnea.)
Deborah Gofreed of Arlington Sleep Medicine said home tests are especially useful for detecting moderate to severe apnea, but they are less accurate at catching mild cases.
Several doctors agreed with Suter that many patients sleep better at home.
“There’s a place for home sleep testing,” said Rachel Salas of the sleep center at Howard County General Hospital. “It’s more comfortable for patients.”
A growing body of research supports home testing.
A 2012 study found that home testing was “not inferior in terms of acceptance, adherence, time to treatment and functional improvements.” And in January, the New England Comparative Effectiveness Public Advisory Council, which evaluates medical innovations, said that home sleep testing was “functionally equivalent” to lab testing for diagnosing sleep apnea in appropriate patients.
Researchers and doctors pointed out that it’s important that a knowledgeable person interpret the results of a home test.
It worked for Suter. He is now using a continuous positive airway pressure, or CPAP, machine and getting a restful night’s sleep.
“My girlfriend said I haven’t snored lately,” he said.
Sensors and belts
Still, for some people home testing can’t replace lab testing as the gold standard for apnea diagnosis.
Winter said most home tests don’t measure brain waves or sleep stages. Salas said this can sometimes be a problem, since apnea can be worse during the REM stage of sleep.
In a sleep lab, equipment is extensive, including about 25 sensors on the head, legs and other areas of the body; two belts to monitor breathing and respiratory effort; and microphones to register snoring. The gear measures breathing and air flow, respiratory effort, heart rate, oxygen levels, brain waves, snoring and leg movements — and can detect dozens of sleep disorders.
Gofreed said it can also catch heart rhythm problems and is generally “a much more accurate way of knowing when a person is asleep or awake.”
Doctors said lab tests are always the right choice for people with serious health problems, such as heart failure or other conditions.“We would want in-lab testing for certain patients: those with extensive pulmonary problems, children, pregnant women,” Salas said. “The chances of them having a medical emergency [during sleep] are higher.”
Several doctors also said lab tests are more accurate, with some home tests incorrectly saying patients don’t have apnea.
“Sometimes you have to repeat the test [in the lab] anyway, because it comes out negative and the patient is still having problems,” Winters said. Then, “you’re not saving money.”