CPAPtalk.com

Well, SAG must admit to dabbling in the "Black Art" of autonomic arousal (using heart rate, pulse transit time, etc. to identify sleep fragmentation). In this highly compressed graph of severe sleep apnea, the Heart Rate Response is clearly seen in the channel marked "ECG R-R", which measures the distance between the ECG peaks (the "R" wave) so consequently analyzes heart rate:



Large heart rate swings coinciding with frank apneas are clearly defined. In the absence of autonomic arousal, that channel should be basically flat.

So anyway, the WP100 correlation documentation comes out and shows:



Now SAG ain't no statistician, so he gets his crayon out and goes



and says to himself, "Self, if one goes in with a complaint of a sleep problem and it turns out the AHI is normal (or relatively so), then one would need PSG anyway because the problem is more likely with sleep and not sleep-disordered breathing; if one has severe SBD, then just about anything will work anyway; but if one falls into the moderate group (like about 15-40), then it looks like a much greater likelihood of missing the boat entirely. So how can this be a diagnostic tool and not a screening device?"

BASCONERO wrote:Hi James, I'm started enthused with this device after I've read your thread, but then I saw its price! Only 5,000.00 $!!! Isn't for me!!

Right, SAG is not quite ready to plunk down 5 G's just yet either.

SAG

StillAnotherGuest wrote:.........

BASCONERO wrote:Hi James, I'm started enthused with this device after I've read your thread, but then I saw its price! Only 5,000.00 $!!! Isn't for me!!

Right, SAG is not quite ready to plunk down 5 G's just yet either.

SAG

Look at split night sleep studies. Use this device for the first night and if it predicts sleep apnea for a patient, skip the first night in the sleep lab and go straight to a titration night.

Do this for 3 patients and the device has paid for itself!

As an RRT and RpsgTE who has worked both sides of this equation (HME and Sleep labs)1) I agree with Sag on his point*
2) what is the percentage of people with co- morbidities who have suspected SA ? in my experience very high ,over
50% in which case watchpat would be considered inadequate for testing 3) Medicare and most private ins will not pay
an HME supplier ( read the LCD's online) rightly so because many of them ( not all) only want to sell Pap machines.
This is a prescription for fraud and abuse. 4) the algorithims used in autopaps are not perfect by a long shot .If you
read the sleep literature and you have extensive enough experience with them you will realize this.
Lastly as Sag said they are grossly overpriced. There are other much cheaper technologies that may be used to
"screen" for SA if there are issues with pay , time , severity etc. these would be in the minority of situations ,at least
in my experience. To sum up, these devices have a much smaller pt population they can be used on compared to what
the manufacturers and the cpap makers would have you believe.

* sometimes , always, never

carigen@aol.com wrote:..........
2) what is the percentage of people with co- morbidities who have suspected SA ? in my experience very high ,over
50% .......

Are you speaking of co-morbidities whose primary means of diagnosis are through PSGs? If so, it is very surprising news to me. Please specify what these major co-morbidities are?

If you are speaking of co-morbidities which are typically diagnosed outside of a sleep lab, then your argument regarding Watch-PAT is not valid.

This is about medical practice and health, but it also about economics as are all medical and health issues.

carigen@aol.com wrote:As an RRT and RpsgTE who has worked both sides of this equation (HME and Sleep labs)1) I agree with Sag on his point*
2) what is the percentage of people with co- morbidities who have suspected SA ? in my experience very high ,over
50% in which case watchpat would be considered inadequate for testing

* sometimes , always, never

you mean those comorbidity our sleep doctors seem to always never ever treat? Most patients that come here and post their NPSG don't know what it says on their reports because their doctor never bothered to explain what was seen. I would take what SAG says over any doctor any day of the week. I had 4 NPSG's before I was finally allowed to discuss what was seen by the RPSGT the next morning and I would say my Sleep Doc was pretty good, very stubborn but good. He owned the Accredited Clinic and there was 3 other doctors in his practice. But it wasn't until I got to speak directly with the Tech did I learn what happened with my sleep, only took the tech about 5 minutes tops to explain to me what those arousals meant and where they were possibly coming from. But in main stream the tech is not allowed to tell the patient much of anything, that is where things get swept under the rug.

If the patient was given a guide that explained everything seen on their PSG by the Sleep Clinic of medical significance, then the Patient is given a PSG report by their doctor, they could use that guide and understand what is up with their sleep. Then there wouldn't be all these repeat PSG's needed and patients giving up on therapy because they feel just as tired as before they started all this mess.

But the fact remains, get past your basic OSA and greater than 50% of these sleep doctors don't have a clue what to do, the other half couldn't turn on a CPAP machine much less set the time on one.

You will have a hard sell on your thoughts about how bad Autopaps are here, setting one up to eliminate OA is no different than straight CPAP. In fact, I'd bet money that people that go away from here go away with a much lower AHI then they came with and a better understanding of their disorder and therapy.

Our hands are not tied to any ethical protocol yours is.

Well, I continue to look at the Portable Initiatives with great fear and trepidation because the accurate assessment of sleep disorders requires time, effort and knowledge regardless of the actual testing methodology utilized. Clearly, the more abbreviated the test results are, the sharper you have to be in order to accurately interpret them.

If the whole conversation goes like this:

Patient: My wife says I have a problem sleeping.

Physician: Wear this thing tonite and bring it back in the morning.

(Next morning) Physician: Well, your RDI is 10.1. What do you want to do?

the only advantage is that in Portable Testing, you've thrown less money down the toilet.

rooster wrote:Are you speaking of co-morbidities whose primary means of diagnosis are through PSGs? If so, it is very surprising news to me. Please specify what these major co-morbidities are?

Insomnia (if the device doesn't measure actual sleep), medication effect, moderate to severe pulmonary disease, the nocturnal myoclonuses (myocloni?), neuromuscular disease, congestive heart failure and "central dysregulation" (although this is getting tossed around a little too freely. The going estimate of CompSAS hovers around 15%, but what is actually clinically significant is probably much less than that) come to mind.

BTW, the whole concept of peripheral arterial tone (PAT) is truly fascinating, and rather than being relegated to portable testing, should be included in "formal testing" (or at least, look at some measure of autonomic arousal).

Since the above-noted correlation study, published in

Evaluation of a Portable Device Based on Peripheral Arterial Tone for Unattended Home Sleep Studies, Amir Bar, MD; Giora Pillar, MD, DSc; Itsik Dvir, DSc; Jacob Sheffy, PhD; Robert P. Schnall, DSc and Peretz Lavie, PhD; Chest. 2003;123:695-703.

I understand that there were improvements in the algorithm, and

Validation a Portable Monitoring Device for Sleep Apnea Diagnosis in a Population Based Cohort Using Synchronized Home Polysomnography Ding Zou, MD; Ludger Grote, MD, PhD; Yüksel Peker, MD, PhD; Ulf Lindblad, MD, PhD; Jan Hedner, MD, PhD; SLEEP, Vol. 29, No. 3, 2006

showed better results in that mild to moderate results range.

SAG

carigen@aol.com wrote:As an RRT and RpsgTE who has worked both sides of this equation (HME and Sleep labs)1) I agree with Sag on his point* 2) what is the percentage of people with co- morbidities who have suspected SA ? in my experience very high ,over 50% in which case watchpat would be considered inadequate for testing 3) Medicare and most private ins will not pay
an HME supplier ( read the LCD's online) rightly so because many of them ( not all) only want to sell Pap machines.
This is a prescription for fraud and abuse. 4) the algorithims used in autopaps are not perfect by a long shot .If you
read the sleep literature and you have extensive enough experience with them you will realize this.
Lastly as Sag said they are grossly overpriced. There are other much cheaper technologies that may be used to
"screen" for SA if there are issues with pay , time , severity etc. these would be in the minority of situations ,at least
in my experience. To sum up, these devices have a much smaller pt population they can be used on compared to what
the manufacturers and the cpap makers would have you believe.

* sometimes , always, never

Huh?? What?? Where do you get your info dude? I hope your boss does not read about your vast sum of knowledge.

=What comorbidities have more than 50% prevalence of sleep apnea- hypertension? rheumatoid arthritis? cad?
Let's see the info please.

= How do you know watch pat will be inadequate for dx in patients with comorbidities? Is there any study showing that? Obviously you don't want to study patients with severe CHF at risk for central rather than obstructive events using a portable device. Seems like a decent device for millions of run of the mill cases which a sleep lab would see regularly.

=Medicare is happy to pay for this device: LCD: Coverage of a PAP device for the treatment of OSA is limited to claims where the diagnosis of OSA is based upon a Medicare-covered sleep test (Type I, II, III, IV or Watch-PAT 100). A Medicare-covered sleep test must be either a polysomnogram performed in a facility-based laboratory (Type I study) or a home sleep test (HST) (Types II, III, IV, or Watch-PAT 100).

=What do the algrithms used in autoPAP have to do with this device? It is a completely different technology!!

="they are grossly overpriced": Compared to what: Your wife telling you that you have sleep apnea? PSG can cost anywhere between $800-3000 (Stanford). And that in addition to buying the equipment. This device is $5000 down + 60 bucks or so for the disposable probe for each patient. You don't have to be an economics professor to see the cost-savings (did you think medicare changed is guidelines as a charity for the portable machine manufacturers?). You can get portable machine for $3000, but most of them are not as well validated as this device (see this month's SLEEP- Richard Berry's article).

But I am sure that you have made up your mind, so no fun confusing you with facts. Enjoy!

StillAnotherGuest wrote:Well, I continue to look at the Portable Initiatives with great fear and trepidation because the accurate assessment of sleep disorders requires time, effort and knowledge regardless of the actual testing methodology utilized. Clearly, the more abbreviated the test results are, the sharper you have to be in order to accurately interpret them.

If the whole conversation goes like this:

Patient: My wife says I have a problem sleeping.

Physician: Wear this thing tonite and bring it back in the morning.

(Next morning) Physician: Well, your RDI is 10.1. What do you want to do?

the only advantage is that in Portable Testing, you've thrown less money down the toilet.

Ummm......Why would knowing about you RDI be money down the drain? Obviously it has to be taken in contect of your symptoms, your risk for cardiovascular morbidities and so on? So in that manner, it is like any other test. What do inverted K waves on EKG or a lung nodule on a CT scan mean? If you or your doctor suffer from simultanagnosia (mental mast... about what a tree is doing in front of you, rather than seeing it as a part of the forest), then pretty much everything is money down the toilet? As is knowledge about an RDI of 50 in a 90 yr old man with no symptoms apart from snoring or a RDI of 5 in a 20 yr old guy with 2 near misses because of sleepiness.

Thank you, NooneInParticular. We do not have the resources in the U.S. to perform PSGs on the millions of undiagnosed simple OSA cases. We need a simple and cheap diagnostic tool and the Watch-PAT seems to be a big step in the right direction.

StillAnotherGuest wrote:Well, I continue to look at the Portable Initiatives with great fear and trepidation because the accurate assessment of sleep disorders requires time, effort and knowledge regardless of the actual testing methodology utilized. .........

Sorry, the resources to address this huge health problem with PSGs just aren't there. We can talk about diagnosing a few cases very accurately or we can diagnosis less accurately and treat successfully millions.

Rooster wrote:Sorry, the resources to address this huge health problem with PSGs just aren't there.

Present resources are quite capable to provide laboratory testing on a timely basis, and I think this was nicely summarized by Dr. Chediak in testimony before MedCAC during portable testing hearings:

Testimony Before the Medicare Evidence and Development and Coverage Advisory Committee (MedCAC)

Rooster wrote:We can talk about diagnosing a few cases very accurately or we can diagnosis less accurately and treat successfully millions.

I disagree. How can less accurate diagnosis lead to successful treatment? My point was, and continues to be, while portable testing has a place, indiscriminate use by untrained and/or unknowledgeable personnel will result in far worse outcomes and ultimately cost more, not less.

NooneInParticulsr wrote:Huh?? What?? Where do you get your info dude? I hope your boss does not read about your vast sum of knowledge.

=What comorbidities have more than 50% prevalence of sleep apnea- hypertension? rheumatoid arthritis? cad?
Let's see the info please.

= How do you know watch pat will be inadequate for dx in patients with comorbidities? Is there any study showing that? Obviously you don't want to study patients with severe CHF at risk for central rather than obstructive events using a portable device. Seems like a decent device for millions of run of the mill cases which a sleep lab would see regularly.

=Medicare is happy to pay for this device: LCD: Coverage of a PAP device for the treatment of OSA is limited to claims where the diagnosis of OSA is based upon a Medicare-covered sleep test (Type I, II, III, IV or Watch-PAT 100). A Medicare-covered sleep test must be either a polysomnogram performed in a facility-based laboratory (Type I study) or a home sleep test (HST) (Types II, III, IV, or Watch-PAT 100).

=What do the algrithms used in autoPAP have to do with this device? It is a completely different technology!!

="they are grossly overpriced": Compared to what: Your wife telling you that you have sleep apnea? PSG can cost anywhere between $800-3000 (Stanford). And that in addition to buying the equipment. This device is $5000 down + 60 bucks or so for the disposable probe for each patient. You don't have to be an economics professor to see the cost-savings (did you think medicare changed is guidelines as a charity for the portable machine manufacturers?). You can get portable machine for $3000, but most of them are not as well validated as this device (see this month's SLEEP- Richard Berry's article).

But I am sure that you have made up your mind, so no fun confusing you with facts. Enjoy!

Like this guy, for instance. Well, meet your new Portable Testing Tech. Really instills confidence, don't he?

SAG

StillAnotherGuest wrote:
Like this guy, for instance. Well, meet your new Portable Testing Tech. Really instills confidence, don't he?

SAG

Don't he? LOL. The only person who can instill confidence is self-appointed guardians of forums like you. Ah, but only if you were a veteran who has to wait 2 years to get a PSG 'cos you have symptoms but the lab don't have space for you (I assure you I have seen such hospitals [not as some tech or manufacturer or anything]- and they are not some small hospitals in some obscure towns). But hey Mr. Guardian, that is not your problem b'cos you read the Chediak testimony. I wish you knew how much politics went behind Medicare decision and the AASM response. But that don't matter to you (someone seems to be a PSG equipment manufacture, don't he?). Then Mr. Guardian , why do lot of VA hopitals perfom oximetries (more quaint that many of the portable devices) to diagnose sleep apnea? Guardian don't instill confidence in them about adequate resources? Let me say again, you have made up your mind, let me not confuse you with facts. I am sure you have more mud to throw-if someone has different views, throw mud on them. That looks good-don't it?

StillAnotherGuest wrote: ........Present resources are quite capable to provide laboratory testing on a timely basis, and I think this was nicely summarized by Dr. Chediak in testimony before MedCAC during portable testing hearings:

Testimony Before the Medicare Evidence and Development and Coverage Advisory Committee (MedCAC)

.....

I believe in excess of 90% of osa cases have yet to be diagnosed. The PSG industry cannot handle them if they all show up at the lab doors in the next five years.

Dr. Chediak is quite confident in the industry capabilities. He should have observed the three sleep studies I had in accredited labs and saw the totally ineffective prescriptions that resulted. My own apap and software were needed to finally figure out what the accredited labs did not figure out. This type of story I am hearing repeated many times by my friends and forum members here.

StillAnotherGuest wrote: ........the accurate assessment of sleep disorders requires time, effort and knowledge
.....

And that is why the method used to diagnose simple osa will change in a big way in the next 20 years. The overnight PSG will cease to be used to diagnose simple osa. Our total health costs are currently unbearable and growing. Things will change.

I have great respect for my primary physician. But he knows little about sleep medicine. I don't hold that against him; that's why we have sleep docs, specialists. One of the things for which I am most thankful to my primary physician is that he was smart enough to send me to a qualified sleep doc. That sleep doc knew my situation with a few questions and one look down my throat--but he still saw the importance of getting a PSG done by a trained technician to get a complete picture.

I agree with rooster that the long wait for PSGs may soon be a bigger problem than it is now. But the reason that is such a problem is because of the proven value of what happens in a real sleep study in a real lab. The last thing I want is for the weakest link in the entire chain, the DMEs, to have more of a role in the industry, and I'm afraid that could be what happens with home-diagnostic equipment.

As for family doctors, I think anyone who has gasped at night and is sleepy during the day should be sent to a specialist and should get a PSG, unless someone invents something that can take the place of that (and I can't imagine what that would be). The only value I see in the products like the one being discussed here may be for primary docs to use on people who have never been seen to gasp and who aren't all that sleepy. Maybe problems could be caught earlier with a Watch-PAT.

I think Snoredog made a profound point in his mentioning the value of his discussion with the tech. That's what is missing now. We need to move further in THAT direction--not in the direction of moving away from the one group of people who are presently doing the most good--the well-educated, experienced medical technicians with the right equipment.

That is only my not-so-educated opinion, based on my experiences alone.

jnk wrote:........ The last thing I want is for the weakest link in the entire chain, the DMEs, to have more of a role in the industry, and I'm afraid that could be what happens with home-diagnostic equipment.

.........

Don't forget cpap.com is a DME. Does that lessen your fear?

Serendipitously, a friend just emailed this link to me:

http://www.sleepingproblemsinfo.com/sle ... ep-problem

A federal report concluded that while 60 million Americans suffer from apnea, narcolepsy and other chronic sleep problems, the majority are undiagnosed and untreated. Despite its pervasiveness and impact upon the society, sleep-related problems are not recognized as a public health issue.

The most common and severe form, called obstructive sleep apnea, features extremely loud snoring interrupted by pauses and gasps.

Betcha 90%+ of them have simple osa. It would take a phenomenol amount of resources to conduct PSGs on 60 million people in the next five years.