Home Sleep Testing: Are You Finally Ready to Catch The Wave?

Undoubtedly, the greatest changes to the practice of sleep medicine in the past several years have involved the portable diagnosis of obstructive sleep apnea. And although many sleep centers have thus far employed a “wait and see” approach regarding HST, it is now unequivocally clear that home sleep testing is here to stay.

The days of “wait and see” are over. Whether your organization is a physician owned lab, IDTF, hospital-based facility, or part of a larger sleep network, you are faced with very real choices regarding whether and how to incorporate home sleep testing into your operations.

The purpose of this article is to help you determine the best approach for managing HST in your practice. I will briefly present the three most common strategies, suggest key questions to consider as you formulate your approach, and as a case study, describe the development of our own HST program.

Option 1: Insource

There are many, many reasons why it’s a good idea to start your own in-house HST program. The most salient are quality assurance of patient care, patient and referring provider satisfaction, and revenue potential. It’s also important to consider that the larger sleep networks now have established HST programs, placing non-HST capable centers at a competitive disadvantage.

Comprehensive sleep centers should strive to provide the full range of sleep medicine services. Hence developing your own HST program is a logical extension to your continuum of patient care services. This will also help ensure your patients, referring providers, and the public think of you as the “one-stop-shop” for all things sleep medicine.

The same reasoning holds true for IDTFs or hospital-based labs: you want to be known as the place to go for all forms of sleep testing.

Although a complete HST how-to is beyond the scope of this article, the following key questions will help you plan and implement your own HST program.

Key Questions to Consider Prior to Starting Your Own HST Program

Equipment

Which testing device will you select?
Will you purchase or lease your equipment?
What are the consumables required for testing?

Clinical/Operational

Which patients will you test with HST (what will be your internal HST algorithm)?
When and where will patients retrieve their devices? Individually or in groups?
Will patients be required to leave a deposit for the HST device?
Who will educate patients and perform set-ups when needed?
What troubleshooting support will you offer, if any?
Who will download data from returned devices?
Will you download data onto a local hard drive, or seek a cloud-based solution?
Who will read studies?
Who will share results with patients?
How will physicians be compensated for interpretations?

Program Development

How will you leverage HST to promote and grow your program?
How will you track HST outcomes?
Will you seek accreditation?

Option 2: Outsource HST operations

Another option is to outsource your home sleep testing services. Much as medical testing companies administer home oximetry, home sleep testing companies can also administer tests to your patients. There are a variety of business models, and there are situations where after careful consideration, you might choose to establish vendor-partner relationship(s).

Reasons why “outsourcing proactively” might make sense include availability of known, high quality provider(s) with local presence, unique circumstances or opportunities, or simply being stretched too thin from a staffing perspective. In the vast majority of centers, HST will not support a full-time employee.

The biggest advantage to outsourcing is minimizing labor. Your assistant will simply fax the testing order, or request a home sleep test online. If all goes well, the testing company will handle the rest, including all related interaction with the patient.

However, this presumed convenience comes at a cost. First, because your patients perceive you as the orchestrator of their sleep care, they will look to you to ensure a smooth process. You will be held accountable for quality control, even though you have very limited power to resolve most issues. Second, you lose control of the testing and interpretation process. (For example, what happens to that raw data, and do you have access to it?) Third, you may lose referrals due to a perceived weakness in your offerings. Finally, you will lose the potential revenue from administering and interpreting the HSTs themselves.

In spite of those drawbacks, working with a high quality HST provider can be a good option in certain situations. The following questions will help you prepare for an outsourced vendor-partner relationship.

Key Questions to Consider for Proactively Outsourcing HST

Is there a cost to patients?
Who educates patients?
How to patients obtain their devices?
What troubleshooting support is available for patients?
What is the study turnaround time?
Who reads the studies?
How are negative studies handled?
What satisfaction or quality assurance measures are collected? Are reports available to you?
Do you have access to raw data if requested?
Are there any “red flag”/ STAT criteria?
Who shares results with patients and referring physician (eg, report primary care)?
Has this vendor-partner ever referred a patient for any other service or procedure other than that requested the physician?

Launching HST: A case study

At Howard County Center for Lung and Sleep Medicine, we began performing HST in earnest in 2012. For several years prior to this, we had administered HST sporadically to evaluate clinical effectiveness, monitor patient satisfaction, and codify and optimize our internal operations. Our sleep team developed our formal HST policies and procedures in 2012.

Our primary device is the Nox T3 screener, which we selected after careful and exhaustive review of all available devices from leading manufacturers. We chose the Nox T3 primarily for its ease of use and diagnostic accuracy—the device employs patient-friendly RIP, which can be used to estimate airflow in the event the nasal cannula is displaced. Indeed, we conducted a clinical case series to evaluate the Nox T3 relative to in-lab PSG, and results were impressive. (Our team presented this data at the annual SLEEP meeting.) To be clear, there are many solid devices on the market, and we have encouraged use of others than the T3 in certain circumstances.

To encourage accountability and program ownership, we appointed a daytime RPSGT as administrative lead for the HST program. This individual educates patients, performs hook-ups and troubleshoots as needed, and downloads data from returned devices. Data is uploaded to a local server, which can be accessed, reviewed, and interpreted by any of our sleep medicine providers. Just as with in-lab PSG, remote login is also possible.

To date, a couple hundred of our patients have completed HST. We track HST outcomes, including subsequent PAP adherence. Because of our highly hands-on approach, results are comparable to outcomes in our in-lab patients. (Careful monitoring enables us to intervene early for PAP non-adherence, as well as negotiate directly with payors.) A very small percentage of our HSTs are technically insufficient and need to be repeated. As in other areas of our practice, patient satisfaction is closely monitored and very high.

HST has not cannibalized our in-lab patient care. As a result of launching our HST program, we have been able to accommodate a broader range of patients, maintain end-to-end care of our patients, and satisfy insurance benefit management requirements to perform HST ourselves. HST is financially sustainable, and we are positioned to rapidly expand our HST services if required. We actively support primary care physicians in administering HST, as a way to ensure optimal patient care and increase our marketing gravity as a local center of excellence. We have considered a so-called “deployment model,” where we work with referring providers to be their outsourced HST partner.

Option 3: Be an ostrich

Chances are that you’re already well aware of the non-inferiority of HST and APAP for certain patients treated under the care of sleep-trained physicians. You understand industry trends regarding HST utilization. You’ve personally experienced or heard horror stories regarding payer requirements and pre-authorization.

So, why pretend that you can’t see the writing on the wall?

HST is here to stay.

Of course, “waiting and seeing” is tempting. And in the short-term, it is certainly the path of least resistance. But if you do nothing, your patients will be increasingly directed to contracted HST providers with whom you have no relationship. They will experience headaches, and be upset with you. They may be referred elsewhere. Their primary care physicians will be upset with you, because you are perceived as the expert in all things sleep. And you will sacrifice the opportunities both to build business relationships as well as to influence the practice of HST in your area.

It is not too late

As a result of the HST disruptive technology, the landscape of sleep medicine has changed forever. As painful as these changes may have been, more changes are coming. But the good news is that it is not too late. In fact, the time has never been better to clarify the vision for the future of your organization, and to decide how to align yourself with the insurmountable forces impacting our field. HST can help or hinder your organization. How you choose to proceed is up to you.