Most clinicians would agree that the patients they care for are increasingly complex, with a growing list of medical problems, medications, and other considerations. In this issue of the Journal of Clinical Sleep Medicine, Colaco et al. present data suggesting that such increases in patient complexity extend to those referred to the sleep laboratory as well.1 Retrospectively examining a 10-year period (2005–2015), they abstracted diagnostic codes and calculated Charlson and Elixhauser comorbidity scores for each patient. They also scored the complexity of the study protocol (eg, standard polysomnography [PSG] assigned a lower score than bilevel titration) for all studies performed. They found small but significant increases in both patient and study complexity over time. Recognizing the potential impact of complex patients on their laboratory staffing, they developed a score, the PSG Clinical Index (PSGCI), to proactively adjust staffing to anticipated patient needs during the study. This index was found to track with the comorbidity indices, as one might expect.
There are a number of possible explanations for their findings. As their title implies, one major development during the examined timeframe is the proliferation of home sleep apnea tests. Since these unattended studies are intended for those with a high pretest probability of obstructive sleep apnea (OSA)2 and are dependent on self-administration, one would suspect that their increased usage has siphoned off the less complex patients and studies to home, leaving the remaining, more complicated patients, for testing in the sleep laboratory. However, this is only half the story. Total laboratory volumes remained steady during this time, suggesting that the overall complexity of patients referred for sleep evaluations has increased as well. A thought provoking finding is that specific groups of comorbidities saw increases in patient volumes while others did not. For example, do the increases in patient volume observed for those with coronary artery disease suggest that cardiologists have “bought in” to the importance of sleep disorders? Or is it simply an artifact of increased disease recognition or, particularly in an era of reimbursement concerns, increased documentation? Body mass index was noted to decrease, perhaps suggesting increased recognition of sleep apnea among those without obesity. There were also increases in study complexity paralleling the increases in patient complexity. Although it is not reported whether more complex patients were undergoing more complex studies, it seems likely that patients with underlying disease may have more advanced diagnostic and therapeutic requirements (eg, patients with OSA and chronic obstructive pulmonary disease [COPD] requiring measurement of carbon dioxide and noninvasive ventilation). Thus, it seems likely that the findings by Colaco and colleagues represent both a distillation of the most complex patients remaining for in-laboratory studies, as well as an increased number of complex patients overall.
While the findings of this study might not come as a surprise and confirm local anecdotal reports, the topic is one that should spur necessary planning throughout the sleep medicine field at all levels. We believe these data suggest a need to address the adequacy of current technician and physician training, laboratory staffing standards, and physician involvement with in-laboratory attended PSG. A salary and compensation study from the American Association of Sleep Technologists found that that 4 out of 8 sleep technicians have no formal education beyond high school.3 Sleep technicians still rely heavily on “on the job” training, which is highly dependent on the local environment, and which may not foster critical thinking. Registered Polysomnographic Technologists (RPSGTs) and sleep physicians alike may need more education about chronic diseases such as heart failure and COPD, advanced modes of ventilation, and the indications for these modes in various diseases. Alternatively, physicians may need to be more prescriptive in their orders regarding anticipated issues, and develop more comprehensive protocols. Perhaps incorporating indices such as the PSGCI will assist in dealing with this complexity by allowing individualization of resources, although such an approach requires further validation with respect to outcomes, cost, superiority to other methods, etc. The authors also bring up the excellent point that more complex care comes with increased costs. The calculus between insurance reimbursements and these costs will have implications for the viability of individual sleep laboratories and patient access, highlighting the need for additional advocacy with payors.
Unattended home testing was designed to improve access to care and reduce costs, especially given the field's focus on the apnea-hypopnea index,4 but was also disruptive with some laboratories abruptly closing.5 Ongoing developments in diagnostic and therapeutic technology in our field have the potential to further disrupt the current model of care. In general, we expect that such advancements will enable care for even some complex patients outside the laboratory. For example, patients with neuromuscular disease often require diagnosis and management of sleep-disordered breathing. However, bringing these patients to the sleep laboratory can be extremely challenging due to mobility issues and need for caregiver accommodations. On the other hand, there have been substantial advances in noninvasive ventilatory support with auto-titrating features and extensive device data outputs. As such, many clinicians use a home titration strategy for these patients, despite the American Academy of Sleep Medicine recommendation for in-laboratory titration.6,7 On the diagnostic side, home sleep apnea tests continue to evolve, with devices that are able to reliably detect central sleep apnea8 and algorithms that can determine individual physiological characteristics.9 Beyond these are a host of consumer-facing wearable or even touchless devices that purport to measure sleep and breathing. While the complexity of patients referred for sleep evaluation might rise, continued technological advancements are likely to contribute to additional shifts in in-laboratory patient characteristics and types of studies moving forward.
Given these multiple moving parts, it is hard to know exactly what the future holds for the sleep laboratory. While this study is a very useful first step, we still need clear data on the outcomes from in-laboratory PSG, including study “success” rates, safety issues, and perspectives from stakeholders including physicians, technicians, and patients. Additional research in this area will help determine whether we are successfully dealing with these advances in complexity, and how to plan for the future.
All authors have seen and approve this manuscript. Jeremy Orr was awarded the American Thoracic Society Foundation/ResMed Research Fellowship. Pamela N. DeYoung reports no conflicts of interest. Robert L. Owens has received honoraria and travel reimbursement from ResMed and Itamar Medical, and consulting fees from Novartis Pharmaceuticals.
Orr JE, DeYoung PN, Owens RL. The future of the sleep lab: it's complicated. J Clin Sleep Med. 2018;14(4):499–500.
Colaco B, Herold D, Johnson M, Roellinger D, Naessens JM, Morgenthaler TI. Analyses of the complexity of patients undergoing attended polysomnography in the era of home sleep apnea tests. J Clin Sleep Med. 2018;14(4):631–639
Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7):737–747. [PubMed Central][PubMed]
American Association of Sleep Technologists website. New AAST 2016 Salary and Benefits Survey Available! https://www.aastweb.org/blog/new-aast-2016-salary-and-benefits-survey-available. Published August 23, 2016. Accessed February 22, 2018.
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American Academy of Sleep Medicine website. AASM response to closing of Sleep HealthCenters facilities in New England and Arizona. https://aasm.org/aasm-response-to-closing-of-sleep-healthcenters-facilities-in-new-england-and-arizona/. Published January 27, 2013. Accessed February 18, 2018.
Berry RB, Chediak A, Brown LK, et al. Best clinical practices for the sleep center adjustment of noninvasive positive pressure ventilation (NPPV) in stable chronic alveolar hypoventilation syndromes. J Clin Sleep Med. 2010;6(5):491–509. [PubMed Central][PubMed]
Aboussouan LS, Mireles-Cabodevila E. Sleep-disordered breathing in neuromuscular disease: diagnostic and therapeutic challenges. Chest. 2017;152(4):880–892. [PubMed]
Penzel T, Rama A, Berall M, et al. Watch-Pat 200 is accurate in the diagnosis of central and obstructive sleep apnea in CHF patients [abstract 1061]. Sleep. 2016;39:A379
Orr JE, Sands SA, Edwards BA, et al. Measuring loop gain via home sleep testing in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2017 Nov 30. doi:10.1164/rccm.201707-1357LE. [Epub ahead of print].