SAN DIEGO – Home-based testing for obstructive sleep apnea averaged $564 less than laboratory-based testing and did not increase other costs or produce clinically inferior outcomes, based on data from a study of Veterans Affairs patients.
"If you do the home testing approach, that saves you money right off the bat, compared with laboratory testing," Dr. Charles W. Atwood said in an interview in advance of an international conference of the American Thoracic Society, where the research was presented.
Dr. Charles W. Atwood
"Everything else for the patients is pretty comparable," he said. "That’s a good thing for people in favor of home testing. People don’t have deleterious outcomes because they were evaluated in the home setting, or because treatment was initiated in the home setting instead of a laboratory setting. People don’t generate more health care bills because they were evaluated in the home instead of in a lab."
In what he characterized as the most comprehensive study of its kind, Dr. Atwood, associate professor of medicine at the University of Pittsburgh, and his associates enrolled 296 patients from two VA sites who were randomized to standard in-laboratory polysomnography testing (lab group) or unattended home testing (home group). Patients in the home group underwent overnight recording with an Embla type 3 portable monitor followed by at least three nights of using a Philips Respironics auto-titrating positive airway pressure apparatus.
The researchers obtained data from case report forms, staff logs, and VA records, and categorized the costs as sleep-related, pharmaceutical, lab, hospital, or "other." Next, they estimated costs per category using repeated measure generalized linear models reported in 2010 dollars and discounted at 3% per year.
The majority of study participants (95%) were male. Of the 296 patients, 223 (110 in the lab group and 113 in the home group) were initiated on continuous positive airway pressure (CPAP). Patients in the lab group were slightly younger, compared with their counterparts in the home group (an average of 52 vs. 55 years, respectively; P = .02), but no other baseline characteristics were significantly different between the groups.
After an average follow-up of 2.75 years, the researchers determined that home-based testing costs were $564 lower, compared with lab-based testing (an average per-patient cost of $4,057 vs. $4,621, respectively; P = .007). Differences in the other four categories of cost did not reach statistical significance, with P values ranging between .19 and .82. Results of the Functional Outcomes of Sleep Questionnaire revealed no statistical difference in clinical outcomes between the two groups.
"This is more evidence that supports the use of home sleep apnea testing, followed by initiation of CPAP in the home setting as opposed to the laboratory setting, for people with routine OSA," said Dr. Atwood, who is also director of the sleep disorders program for the VA Pittsburgh Health Care System.
One limitation of the study, he said, is that it was conducted in the VA hospital system and may not be generalizable to other practice settings. Also, "this was done mostly in men; there were relatively few women," he said. "So whether this would work as well in women we can’t really say. We did not exclude people with other comorbid conditions, so that’s actually in our favor. A lot of studies that have been done in the home testing arena have excluded people with a history of mental illness or behavioral health problems, and those with any degree of congestive heart failure or CPOD. We did not exclude people on the basis of those other disorders. In that sense, it’s a broader population than has been typically studied in the home setting."
Embla provided the portable monitors used in the study and Philips Respironics provided the auto-titrating CPAP apparatus. The study was funded by the VA’s Health Research and Development Service. Dr. Atwood said that he had no relevant financial conflicts to disclose.