Are Home Sleep Tests the Death of the Sleep Lab?

In recent years, the landscape of sleep diagnostics has undergone a seismic shift. Home sleep tests (HSTs) have emerged as a convenient and cost-effective alternative to traditional in-lab polysomnography (PSG), challenging the very foundation of sleep laboratories. This evolution begs the question: Is the rise ofHSTs signaling the demise of the sleep lab, or is it paving the way for a more integrated approach?

The Rise of Home Sleep Tests

HSTs have gained traction due to their accessibility and affordability. Patients can now undergo sleep assessments in the comfort of their homes, avoiding the often-daunting experience of spending a night in a clinical setting. This convenience has led to a significant increase in the utilization of HSTs. A 2021 survey by Itamar Medical revealed that 93% of sleep professionals incorporated HSTs into their practices, with 66% reporting that HSTs accounted for more than half of their daily test volume.¹

As HST usage has surged,  the number of in-lab sleep studies has declined. Data from the Centers for Medicare and Medicaid Services indicate that from 2011 to 2021, sleep service utilization among Medicare beneficiaries decreased by 13.6%, with attended sleep studies nearly halving during this period. Conversely, unattended type 3 studies—synonymous with HSTs—grew by 632.6%, becoming the predominant diagnostic tool for sleep disorders.²

Advantages of Home Sleep Tests

Proponents of HSTs emphasizes several key benefits:

• Cost-effectiveness: HSTs are generally less expensive than in-lab studies, making them more accessible to a broader patient population.
• Patient comfort: Conducting the test at home allows patients to maintain their usual sleep environment, potentially leading to more accurate assessments. They don’t require all the leads and wires used in-lab making them more user friendly.
• Increased accessibility: HSTs can reach patients in remote or underserved areas where sleep labs are not readily available.

Limitations and Concerns

Despite their strengths, HSTs are not without drawbacks:

• Limited diagnostic scope: Most HSTs primarily focus on diagnosing sleep-disordered breathing and may not detect other sleep disorders such as narcolepsy, parasomnias, or periodic limb movement disorders.³
• Data accuracy: The absence of a trained technician during the test can lead to issues with sensor placement and data collection, potentially compromising the accuracy of the results.⁴
• Patient compliance: Proper usage of HST equipment relies on patient adherence to instructions, which can vary and affect the quality of the data collected.

A Collaborative Future

While HSTs have certainly impacted traditional sleep labs, these facilities remain indispensable for many diagnostic scenarios. In-lab PSGs provide detailed assessments of various sleep parameters, including brain activity, muscle movements, and heart rhythms, enabling the diagnosis of a wide range of sleep disorders.

Certain patient populations—such as those with complex medical histories or comorbid conditions—may require the thorough evaluation that only an in-lab study can provide. Therefore, while HSTs serve as a valuable tool for diagnosing straightforward cases of OSA, they are not a one-size-fits-all solution.

Rather than viewing HSTs as a replacement for sleep labs, it’s more constructive to see them as part of a complementary diagnostic strategy in sleep medicine. A tiered approach to diagnosis integrates the strengths of both methods:

1. Initial screening: HSTs can serve as a first-line diagnostic tool for patients with a high pre-test probability of OSA.
2. Comprehensive evaluation: Patients with negative or inconclusive HST results but persistent symptoms—or those with complex sleep issues—can be referred for in-lab PSGs for a more detailed assessment.

This dual-pathway approach optimizes resource utilization, allowing sleep labs to focus on complex cases requiring detailed analysis and using HSTs to handle more straightforward assessments to ensure timely care for a broader range of patients.

Conclusion

The advent of HSTs has undeniably reshaped the field of sleep diagnostics, offering convenience and cost savings that benefit both patients and providers. However, even though HSTs have led to a decline in the utilization of sleep labs for certain cases, they do not render them obsolete. Instead, HSTs and sleep labs can coexist, each serving distinct roles in a comprehensive diagnostic framework. By embracing this complementary evolution, the sleep industry can enhance patient care, improve accessibility, and ensure accurate diagnosis across the spectrum of sleep disorders.

By: Dr. Haramandeep Singh

Source: SleepWorld Magazine November/December Issue

 References

1. Itamar Medical. At-home sleep tests by the numbers. Published 2021. Accessed Nov. 26, 2024. https://www.apneamed.org/blogs/info/at-home-sleep-tests-by-the-numbers.
2. Braun M, Coughlin S, Schneider H. Long-term trends in utilization of sleep diagnostic tests among Medicare beneficiaries. Sleep. 2024;47(Suppl 1): A472-3. https://doi.org/10.1093/sleep/zsae067.1101.
3. Sleep Resolutions. 7 problems with home sleep tests (and how to avoid them). Published 2024. Accessed Nov. 26, 2024. https://www.sleepresolutions.com/blog/home-sleep-test-problems-solutions.
4. Neurolaunch. Home sleep testing drawbacks: Limitations and potential pitfalls. Published 2024. Accessed Nov. 26, 2024. https://neurolaunch.com/disadvantages-of-home-sleep-testing/