Has OSA become a cash cow.

For the most part I agree with eevryone on here. The "NEED" for apap is an individual thing, treatment should be based on each persons individual circumstances. The posts on home based testing vs sleep lab testing I find interesting. One person posted that the majority of sleep disorders is uncomplicated thus home testing should be widely available. One has to wonder how the complicated cases would be detected if testing wern't done in a sleep lab or how much of a delay would be caused by having a home based test and continuing to have symptoms until someone thought to do a completed lab based sleep study. I think home based testing has a place, but I don't think it should be the norm. Again, it should be based on circumstances and I think as a last resort.

BlackSpinner wrote:So the reality is that a full sleep study for the majority of patients is a total waste of resources on an already over burdened system.

No, that's NOT the reality in terms of clinical Quality and Safety outcomes.

The correlation between SDB problems and a wide variety of other diseases is increasing year by year as more as more and more PSG data becomes available for research purposes, and that provides better clinical Quality and Safety outcomes that extend far beyond just treating simple OSA.

Focusing simply on Healthcare costs and ignoring Quality and Safety outcomes in just short sighted.

Cheers,

Bill

Personally, I wish my sleep doc had skipped the diagnostic. He could tell by looking at my Epworth, BMI, jaw, and pharynx that I had OSA (as could the receptionist and the cleaning lady, I'm sure), but he is used to insurance demanding proof rather than trusting his diagnosis, even in cases like mine.

In my opinion, guys like me should go straight to a lab/center for titration, skipping the diagnostic. Baselines are interesting, sure, but it doesn't make sense to me to run a $3000 test to see if it is worth buying me a $300 machine. The titration, on the other hand, was money well-spent. I needed bilevel and someone to make sure I stopped tap-dancing in my sleep.

Moo.

jeff

And what do you do for the tap dancing in your sleep, jnk? Or did the bi-level take care of that??

Slinky wrote:And what do you do for the tap dancing in your sleep, jnk? Or did the bi-level take care of that??

Limb movements calmed down once I was on bilevel. But for some, they remain, or are "unmasked," sort of like continuing centrals. And that is important for them to know.

I still go through a "spell" every few weeks where my legs will vibrate for a few nights, then it goes away. I wake up with sore hips and my wife tells me I was dancing.

But limb movements are one of many reasons I think titrations are more important than diagnostic PSGs, at least for some. It is the reaction to the pressure that can tell more about a patient than assessing the need for it, in many cases, as I understand it.

JNK - OUCH! I bet those tap shoes hurt when you dance on your wife's shins.

kteague wrote:JNK - OUCH! I bet those tap shoes hurt when you dance on your wife's shins.

I thought about you as I was writing that analogy. Hope you don't mind.

My dad is heavy into clogging down in Kentucky, so he was able to add taps to the footies of my snap on all-over PJs.

My wife is the dancer. And runner. Oddly enough she IS having trouble with shin splints right now. Maybe it's MY fault!

jnk wrote:

Slinky wrote:And what do you do for the tap dancing in your sleep, jnk? Or did the bi-level take care of that??

Limb movements calmed down once I was on bilevel. But for some, they remain, or are "unmasked," sort of like continuing centrals. And that is important for them to know.

I still go through a "spell" every few weeks where my legs will vibrate for a few nights, then it goes away. I wake up with sore hips and my wife tells me I was dancing.

But limb movements are one of many reasons I think titrations are more important than diagnostic PSGs, at least for some. It is the reaction to the pressure than can tell more about a patient than assessing the need for it, in many cases, as I understand it.

JNK

This is an interesting line. Can you add some more info re type of leg movements - did your problem include cramps - throbbing in the lower parts of your legs etc:

Also have you attributed or even guessed what aspect of bilevel has improved the problem. i.e. the size of the gap, or the level epap or ipap was set to etc: have you varied the settings & observed any variation ?

Am interested because of my own observations re aspects of this.

Tks

DSM

dsm wrote:

jnk wrote:

Slinky wrote:And what do you do for the tap dancing in your sleep, jnk? Or did the bi-level take care of that??

Limb movements calmed down once I was on bilevel. But for some, they remain, or are "unmasked," sort of like continuing centrals. And that is important for them to know.

I still go through a "spell" every few weeks where my legs will vibrate for a few nights, then it goes away. I wake up with sore hips and my wife tells me I was dancing.

But limb movements are one of many reasons I think titrations are more important than diagnostic PSGs, at least for some. It is the reaction to the pressure than can tell more about a patient than assessing the need for it, in many cases, as I understand it.

JNK

This is an interesting line. Can you add some more info re type of leg movements - did your problem include cramps - throbbing in the lower parts of your legs etc:

Also have you attributed or even guessed what aspect of bilevel has improved the problem. i.e. the size of the gap, or the level epap or ipap was set to etc: have you varied the settings & observed any variation ?

Am interested because of my own observations re aspects of this.

Tks

DSM

According to the PSG tech dude, my arms and legs thrashed as he raised pressure. As he put it, my body "seemed to be trying to fight off the pressure." According to him, as soon as he flipped the switch to bilevel, I settled down and all but smiled. I haven't verified the story by going to the video tape, though.

Interestingly, he found I settled right down with a mere 2 cm gap that night. One small slice of anecdotal observation, that.

I haven't noticed any relationship to anything other than that it seems to happen every few weeks. I can go two weeks or I can go a month without them. They come when they come, and do not seem to relate to where my pressure is or what it does. They last about three or four days before they go.

I have filed them under aftereffect of my decades of severe sleep deprivation and desaturation with untreated OSA. I'm sure it isn't the only part of my nervous system that has been affected.

If it ever gets worse, it might be worth pursuing. If it goes away, I'll be happy. If it stays the same, I can deal with it. It hasn't made my personal top-ten-biggest-health-concerns list yet, but one day it might.

I used to get bad leg cramps at night all the time. PAP therapy fixed that for me. It has only happened once since I started PAP.

jeff

Jeff
Thanks for those insights. The cramps problem was one I started noticing in about 2003. Was getting worse - I thought at the time it was releted to jogging exercise - upped intake of magnesium/iron/calcium etc:

Dr had commented to me that nocturnal cramps can be different to daytime (exercise cramps) and that in his expertise there was not a clear cut cause but that quinine was considered to be effective in reducing them. But, that drug has side effects to do with blood platelet levels & there are health warnings saying use it with care.

Cpap didn't really seem to get rid of the cramps & bilevel also didn't. My breakthrough was in realising over a long period that using a Bipap Auto SV reduced the cramps markedly whereas a Vpap Adapt SV didn't !. I thought I had both machines set to mimic each other's pressure (using a dial manometer both were deliviering similar pressures to the mask for epap & ipap).

When I increased the 3CMs gap while using the Vpap Adapt SV, the cramps reduced & largely went away. Am still trying to prove that this has made a difference & it may need another year or so where I can show that adjusting the gap increase/decreases the likelihood of cramping. My own uneducated guess is it relates to blood CO2 levels & that this might explain why the results were so different between the two brands of SV.

You comments made me wonder if this was related.

Thanks

DSM

dsm wrote:Jeff
Thanks for those insights. The cramps problem was one I started noticing in about 2003. Was getting worse - I thought at the time it was releted to jogging exercise - upped intake of magnesium/iron/calcium etc:

Dr had commented to me that nocturnal cramps can be different to daytime (exercise cramps) and that in his expertise there was not a clear cut cause but that quinine was considered to be effective in reducing them. But, that drug has side effects to do with blood platelet levels & there are health warnings saying use it with care.

Cpap didn't really seem to get rid of the cramps & bilevel also didn't. My breakthrough was in realising over a long period that using a Bipap Auto SV reduced the cramps markedly whereas a Vpap Adapt SV didn't !. I thought I had both machines set to mimic each other's pressure (using a dial manometer both were deliviering similar pressures to the mask for epap & ipap).

When I increased the 3CMs gap while using the Vpap Adapt SV, the cramps reduced & largely went away. Am still trying to prove that this has made a difference & it may need another year or so where I can show that adjusting the gap increase/decreases the likelihood of cramping. My own uneducated guess is it relates to blood CO2 levels & that this might explain why the results were so different between the two brands of SV.

You comments made me wonder if this was related.

Thanks

DSM

Personal experiments can pay off for us individually with our own individual health, within reason.

Sometimes anxieties in the form of personal stresses during the day, or even during our sleep, may play a role, I think. My body/brain apparently found bilevel to be a calming sensation at a time when it was having a difficult time figuring out what was going on--a titration. But other nervous systems might be wired differently as far as what causes what.

Nerves and hormones are funny things, especially when they interact. Add drugs to the mix (even simple caffiene and alcohol), and things can get confusing in a real hurry.

jeff

jeff

This has been an interesting discussion. The home vs. lab question I think is something to think about. A friend of mine had a similar situation with her health problem. Her blood tests suggested a certain condition. The dr told her that they could either do brain surgery to check something in the blood-brain barrier to diagnose it or they could try a less invasive test that's far less accurate but could give them an answer. The insurance co. said "no way" to the less invasive test. Their medical advisory board didn't deem this other test as effective. She couldn't understand why the ins co would prefer to cover a more expensive test and she really didn't want brain surgery. I think in her case it would be better to at least give the less invasive test a try. But as far as the home vs. lab sleep study... well, the lab doesn't crack open your skull so I think it might make sense to just go straight to the test that will give those conclusive answers. But there probably still is a place for the home test. Since I seriously doubted I have OSA because I don't snore a home test could've indicated whether further investigation into this condition was really needed.

Someone earlier suggested that we get the ins co's to be more restrictive with the providers to keep them from being scoundrels. But, that already happens to a certain degree. I find that it's far more important for us to be vigilant consumers. For instance, I work for a co that bills for anesthesiologists. When I had my 2nd daughter I had an epidural. When I got the bill I knew it was completely bogus (not one of our dr's). They charged over $2000 for what I calculated should've been about $800. The insurance paid it--no questions. I called the billing office for that dr and I let them know I wanted them to refund their "mistake" to the insurance co. They said, "Why do you care? They paid it!" Ughhh! So, I let them know that I was going to report their overbilling practices to the ins co... which I did. The amount was refunded and the insurance co sent me a "thank you" letter for pointing it out to them. Now, people don't usually know how much their anesthesiologist should be paid. But, whenever we do know that something's "funky" I think we need to make it right. That will keep costs down for everyone.

I went to see the RT the other night and talked to her about my desire to have a data reporting machine. I could see that she doesn't usually get this kind of request. As we discussed it she conceded that if I wanted to play a more proactive role in my therapy I should have that machine. She told me what I need to do to get it swapped out. But then she said something that makes a lot of sense to me. Most people don't care about all that stuff. If their therapy is making them feel better they're happy. And most people don't want things to be more complicated. (particularly the elderly). After that I could see a more legitimate reason the DME wouldn't just go straight to the more advanced machine.

But it definitely is a cash cow! But so is pain management or plastic surgery. I don't begrudge them their success as long as I think they're coming to it honestly.

My wife has cramp problems at times. She has been on cpap for 6 yrs at a fixed pressure of 7. Before I was diagnosed I told her she probably needed to get her pressure increased as she sometimes snores alot at night. She currently has a Resmed auto set spirit. The dme wants to get her a new machine this year I think she needs to try auto with a pressure range for a month or so. I suppose they will recommend she get a titration test as her split night was over 6 yrs ago. Will have a spare machine in case of emergency then.

cotech50 wrote:...currently has a Resmed auto set spirit...think she needs to try auto with a pressure range for a month or so

The AutoSet Spirit IS an auto, tho her's may be set to CPAP mode.

billbolton wrote:

BlackSpinner wrote:So the reality is that a full sleep study for the majority of patients is a total waste of resources on an already over burdened system.

No, that's NOT the reality in terms of clinical Quality and Safety outcomes.

The correlation between SDB problems and a wide variety of other diseases is increasing year by year as more as more and more PSG data becomes available for research purposes, and that provides better clinical Quality and Safety outcomes that extend far beyond just treating simple OSA.

Focusing simply on Healthcare costs and ignoring Quality and Safety outcomes in just short sighted.

Cheers,

Bill

Yes so what if OSA causes a wide variety of diseases it is still OSA and if a cheap simple home test catches it there is no reason to start off with an over priced cadilac. A home test is the starter that will catch most simple OSA in a cost effective method which means other people can have tests for big label issues or you can test 10 times the number of people.
Like I said, if you bothered to read it - if the cheap test is "failed" then those patients get the cadilac test. That is the protocol here - you get the big test, nobody will deny you. Like glucose tests - first you do the simple one then if something shows you do the big test. Sure if there was an infinite amount of money we could send everyone for a in lad sleep test every few years, every one could get the latest and greatest tests for what ever the might possibly have but our health care systems believes EVERYONE deserves health care not just a privileged few. Focusing on the best and most expensive tests for everyone is what is short sighted because it would bankrupt the system and then no one benefits.