Sleep Apnea: Current Issues in Medicine

This article originally appeared online at Dr.Pullen.com, part of the HCPLive network.

It seems like every decade we have a new silent killer. Obstructive sleep apnea (OSA) is not really silent, actually the snoring associated can be pretty loud and the clue something is wrong, but it has gone under recognized until recently. OSA is also a good example to use to look at some of the issues we are facing as a society in medical care. We are learning that OSA is linked to uncontrolled hypertension, daytime drowsiness and accidents including motor vehicle accidents, sudden death, poor diabetes control, and multiple other major medical problems. Obstructive sleep apnea occurs when the airway, usually in the back of the throat, becomes obstructed, i.e. blocked, during sleep so that air passage is inhibited, oxygen levels in the bloodstream drop, peripheral vascular resistance increases, and the patient needs to shift position in order to open the airway and start to successfully move air in and out of the lungs. This can recur over and over throughout the night, leading to non-restful sleep, daytime drowsiness, and medical complications related to the low oxygen levels. OSA is directly related to obesity. Increased neck circumference is directly related to the risk of having OSA. Most patients with OSA snore loudly, and often bed partners note that they stop breathing frequently, and make snorting and strangling noises as they try to breathe again.

OSA is usually diagnosed by doing a sleep study in a sleep laboratory. The patient sleeps while connected to monitors that measure oxygen levels, EKG, EEG, blood pressure, breathing efforts, and involuntary movements. This requires observation, often video documentation, and evaluation by a physician trained in sleep medicine. The cost of these studies can be $6-8000 or more. Then if diagnosed with OSA, the patient can be treated, usually with a device to put positive air pressure on the back of the throat and keep the flow of air from becoming obstructed while they sleep. This CPAP (or BIPAP and other types of positive pressure devices) is often very effective, though some patients may not tolerate the masks, and long term compliance rates are low. Weight loss, dental appliances, surgery, and other treatment modalities are also often used.

One of the big problems for the primary care physician in managing sleep apnea is deciding which patients should be referred for sleep study testing. On the one hand OSA is common, and diagnosis of OSA can be very important, improving quality of life for our patients, and improving control of some refractory medical problems like hypertension and fatigue. On the other hand it is part of our job to not recklessly spend the patient’s and health system’s dollar on sleep study testing which is very expensive. There are newer more limited and much less expensive testing modalities just now coming to use. One of the most interesting is combining overnight pulse oxymetry, peripheral vascular resistance, and heart rate. These relatively inexpensive testing techniques have shown to correlate very well with full in-lab sleep studies. They can be done through the primary care office, and in many straight forward cases of OSA are in my opinion adequate to make the decision to treat a patient with CPAP. The patient can then have the CPAP pressure levels determined by home auto-titration devices, and avoid the cost and inconvenience of one or two overnight sleep lab stays. Sounds simple right? Maybe not. Let’s look at this example as a way to look at some of the problems we are facing.

1. Third party reimbursement. Medicare is just starting to pay for OSA testing other than formal sleep lab testing evaluated by certified sleep medicine specialists.
2. Turf battles: Sleep medicine specialists have been very resistant to the use of newer techniques that may reduce the need for their services, and therefore impact their income. Especially if they have invested in their own sleep labs.
3. Does every patient need the “best” care: This is a problem we face all the time. What is the best care. Is it adequate care at the best price? Is it the absolute best care and price be damned? Admittedly in lab sleep studied give more data, and can give us more information about things like restless legs syndrome, central sleep apnea, and other uncommon problems. Does this mean we should offer every patient in lab sleep studies, or should we use less expensive and usually adequate outpatient testing in cases where the issues seem straightforward.
4. Fear of litigation: As a family physician I need to make a decision as to when to ask consultation, and “cover myself” from the potential of litigation by getting the “gold standard” testing, and when to save costs, limit patient inconvenience, and do the simpler testing.
5. Self-referral and over testing: If as a primary care physician I order the outpatient testing for OSA, and interpret the results, I bill for the testing and interpretation myself. This makes it a potential revenue source. As such there is the potential for overutilization. This is the other side of the turf issues in #2 above.

Regardless of how the testing is done, and how the diagnosis is made, OSA has become an important health problem, and diagnosis and treatment is important.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at DrPullen.com — A Medical Bog for the Informed Patient.