The Future of the Sleep Lab: It's Complicated

摘要

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 (20052015), 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