Home Sleep Testing in the Age of COVID-19

Published July 28, 2020

The COVID-19 crisis caused major upheavals in all sectors of the economy, not least in the healthcare industry, where hundreds of hospitals abruptly canceled elective procedures and clinics furloughed or laid off thousands of employees. Many patients with serious health problems delayed seeking care. While many of these changes may be temporary, the COVID-19 crisis has provoked changes in the way healthcare is delivered that otherwise would have taken decades to evolve.

In particular, during the crisis, millions of patients discovered that they did not actually need to go to a clinic to receive medical care. Remote patient monitoring, home dialysis, and home medication infusions have been available for some time.  When care at home became a necessity rather than a choice, many patients experienced the benefits first-hand. Perhaps just as importantly, the Centers for Medicare and Medicaid Services (CMS) had already recognized this trend and began reimbursing providers for a wide variety of home-based services.

Like dialysis and infusions, home sleep testing has been available for a long while. In the context of COVID-19, the home sleep study transitioned from a choice to a necessity.

Why Study Sleep?

There are many reasons why a doctor would order a sleep study. Americans are famously under-rested—a phenomenon known as excessive daytime sleepiness. Americans sit in front of screens at all hours, perhaps drink alcohol late at night, and often suffer from thyroid problems and mood disorders. All these factors lead to poor sleep hygiene. A small number of patients have undiagnosed seizure disorders or other so-called “central” causes of sleep disturbance. A sleep study helps physicians sort out these various causes. One that sleep studies are very good at diagnosing is obstructive sleep apnea (OSA).

What is Obstructive Sleep Apnea?

OSA, “a disorder in which a person frequently stops breathing during his or her sleep”. When you sleep, muscles in your body become relaxed including the muscles that help keep your airway open. Normally, your throat remains open enough during sleep to let air pass by. Some people have a narrow throat, and when the muscles in their upper throat relax during sleep, the tissues close in and block the airway.

“Apnea” is the term for a stop in breathing. When this happens, the brain rouses the sleeper, to signal breathing to resume. Deep, restful phases of sleep cannot occur due to the many disruptions per night. Why this blockage occurs in some people and not others is not clear, but appears to develop more frequently among people who sleep on their back, are middle-aged, and are overweight.

OSA is a problem because individuals with OSA are more likely to cause motor vehicle accidents and suffer from poor productivity at work. Chronic OSA can also lead to severe health consequences, including hypertension, stroke, heart disease, and diabetes.

The primary method for diagnosing OSA is through a sleep study. Sleep studies performed in a facility-based sleep lab, known as nocturnal polysomnography, or at home via a home sleep test. Many patients suspected of having sleep apnea can receive a diagnosis at home. In addition to sleeping in the comfort of one’s bed, the home sleep test offers less intrusion, a better representation of one’s sleep in a home environment, quicker turnaround times from testing to results, and is less costly.

The Laboratory vs the Home

Laboratory sleep studies are only necessary for few conditions. For example, based on history taking and a physical examination, a physician may suspect a problem such as a seizure disorder, heart failure or emphysema; in such cases, laboratory-based sleep studies may be required. Some third-party payors will only reimburse providers for traditional sleep studies, however this is becoming less common with the expansion of Medicare Advantage plans.

Home sleep studies were endorsed the American Academy of Sleep Medicine (AASM) in 2007, when they issued a recommendation suggesting that a simplified version of the sleep study that did not require more involved testing such as electroencephalograms to rule out seizure disorders.  The AASM emphasized offering home testing only when there was a high pre-test probability that the patient had OSA. CMS quickly followed the lead of the AASM, and proposed guidelines allowing insurance coverage for home OSA testing.

Home sleep testing devices are small, portable and easily delivered to a patient’s home. They consist of three parts: an airflow sensor for the nose and mouth, elastic bands to measure chest and abdomen movement, and a finger probe to measure blood-oxygen levels. The device is easy to learn how to use, and patients report that it is comfortable to wear.

A No-Brainer in the Age of COVID-19

In the age of COVID-19, sleep testing at home allows the patient to avoid entering potentially infectious spaces. Hospitals are notoriously contaminated places, even in the pre-COVID-19 era. Every year, 99,000 Americans die of hospital-acquired infections and the number of non-fatal infections is much higher. For sleep laboratories located in hospitals, the risks to the patient may not outweigh the benefits, particularly when the likelihood of OSA is high and when accurate testing can be at home.

As Americans grow older and more obese, the prevalence of OSA will likely continue to grow. Its diagnosis is straightforward using a simple device delivered to a patient’s home. The long-term cost savings of successful treatment of OSA are substantial. Home sleep testing is an ideal example of the type of delivery of healthcare that may become the standard in the era of COVID-19.