Why HST is Underutilized—and How to Fix It

As a sleep physician, one of the most frustrating realities I encounter is not a lack of diagnostic tools, but the barriers patients face in accessing them. Obstructive sleep apnea (OSA) is common, serious, and widely underdiagnosed. Estimates suggest that more than 30 million adults in the United States are affected, yet only a fraction have received a formal diagnosis or initiated treatment.1 The consequences of untreated OSA —cardiovascular disease, metabolic dysfunction, cognitive impairment, and worsening psychiatric symptoms — are well-established and extend far beyond the sleep clinic.2

Despite this, the path from clinical suspicion to diagnosis remains unnecessarily long for many patients. In-laboratory polysomnography (PSG) continues to play an essential role in sleep medicine, but overreliance on the sleep lab has created a bottleneck that our current health care infrastructure cannot support. Long wait times, limited geographic access, cost, and patient reluctance all contribute to delays in care.3 Home sleep testing (HST) was developed to help address these barriers, yet its adoption has been slower and more inconsistent than evidence would suggest.

HST is a proven, evidence-based tool that remains underutilized due to misconceptions, operational challenges, and cultural inertia. As sleep medicine continues to evolve, we must focus less on defending traditional models and more on improving access to care. By embracing home sleep testing as a core component of a patient-centered diagnostic strategy, we can help close the gap between suspicion and treatment for millions of individuals living with undiagnosed sleep apnea.

Misconceptions That Continue to Limit HST Adoption

One of the most common objections I hear from colleagues is that HST is somehow less reliable or clinically inferior to in-lab testing. This perception persists despite substantial data showing that modern, multi-channel home sleep apnea tests can accurately diagnose moderate-to-severe OSA in appropriately selected patients.4 When used according to established guidelines, HST provides clinically meaningful information that allows physicians to confidently initiate therapy.

The issue is not that HST lacks value, but that it is often misunderstood. HST was never intended to replace PSG in every patient. Rather, it is a targeted diagnostic tool designed for individuals with a high pretest probability of OSA and without significant comorbidities that would necessitate in-lab evaluation. When clinicians either apply HST indiscriminately or avoid it altogether, its true clinical utility is lost.

Education, Workflow, and the Real-World Practice Gap

Beyond misconceptions, practical challenges also play a significant role in underutilization. Many referring providers — particularly in primary care and dental settings — receive little formal training in sleep medicine and may be unsure how to appropriately select patients for HST or what to do once results are available.5 This uncertainty often leads to delayed referrals or, in some cases, no testing at all.

Even in practices that are supportive of HST, operational inefficiencies can undermine its effectiveness. Delays in device distribution, slow interpretation turnaround times, fragmented communication between testing providers and interpreting physicians, and inconsistent follow-up all contribute to frustration for both clinicians and patients. In a health care environment that increasingly values efficiency and patient experience, these barriers matter. HST works best when it is integrated into a streamlined diagnostic and treatment pathway, rather than treated as an isolated service.6

Reimbursement Concerns and Cultural Resistance

Reimbursement and compliance concerns further complicate adoption. Although Medicare and commercial coverage policies for HST are well-established, they are frequently misunderstood or perceived as overly burdensome.7 Fear of denials or audits can discourage practices from embracing HST, even when it may be the more practical option. In reality, when programs are structured appropriately, HST can simplify documentation and shorten the time to diagnosis.

There is also a degree of cultural resistance within sleep medicine itself. The specialty has historically been built around the sleep laboratory, and change can be uncomfortable. However, medicine has repeatedly adapted to new models of care when those models improve access and outcomes. Sleep medicine should be no exception.

Why This Matters from a Psychiatric Perspective

As someone who is a psychiatrist as well as a sleep physician, I am particularly concerned about the populations most affected by diagnostic delays. The relationship between sleep apnea and psychiatric conditions such as depression, anxiety, and cognitive dysfunction is well documented.8 Patients struggling with mental health disorders are often less likely to complete in-lab sleep studies due to anxiety, logistical challenges, or discomfort with the testing environment.

For many of these patients, HST offers a more realistic path to diagnosis. Improving access to testing in this population has the potential not only to treat sleep apnea, but also to meaningfully improve psychiatric outcomes. In this context, underutilizing HST represents a missed opportunity to address comorbidities more effectively.

Moving Forward

The underutilization of HST is not a failure of technology or evidence—it’s a failure of implementation. Addressing this gap does not require new guidelines or more validation studies. It requires clearer education, better workflows, and a willingness to adapt care delivery models to the realities of modern health care. Telemedicine has already demonstrated its ability to improve access and continuity in sleep care, and when combined thoughtfully with HST, it can significantly reduce diagnostic delays.9

Ultimately, the true measure of success in sleep medicine should not depend on where a test is performed, but by whether patients are accurately diagnosed, effectively treated, and able to sustain adherence to therapy. Shorter diagnostic timelines are consistently associated with higher rates of treatment initiation and long-term adherence.10 HST, when used appropriately, helps achieve these goals.

By Haramandeep Singh, MD, is a board-certified sleep physician and chief executive officer of iSleep Physicians, which offers sleep interpretation and telemedicine in all 50 states for both pediatric and adult patients. 

Source SleepWorld Magazine Jan/Feb 2026 Issue

References

1. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis. Lancet Respir Med. 2019; 7(8):687-98. 
2. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: An American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008; 52(8):686-717. 
3. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine Clinical Practice Guidelines. J Clin Sleep Med. 2017.
4. Rosen IM, et al. AASM clinical practice guideline for the use of home sleep apnea testing. J Clin Sleep Med. 2017;13(3):479-504. 
5. Watson NF, Rosen IM, Chervin RD; Board of Directors of the American Academy of Sleep Medicine. The past is prologue: the future of sleep medicine. J Clin Sleep Med. 201;13(1):127-35. 
6. Devani N, Aslan T, Leske F, Mansell SK, Morgan S, Mandal S. Integrated diagnostic pathway for patients referred with suspected OSA: a model for collaboration across the primary-secondary care interface. BMJ Open Respir Res. 2020;7(1):e000743. 
7. Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD) 33405: Polysomnography and Sleep Testing. Medicare Coverage Database. Updated July 1, 2020. Accessed January 23, 2026. 
8. Benca RM, Krystal A, Chepke C, Doghramji K. Recognition and management of obstructive sleep apnea in psychiatric practice. J Clin Psychiatry. 2023;84(2):22r14521. 
9. Singh J, Keer N. Overview of telemedicine and sleep disorders. Sleep Med Clin. 2020;15(3):341-6. 
10. Thornton CS, Tsai WH, Santana MJ, et al. Effects of wait times on treatment adherence and clinical outcomes in patients with severe sleep-disordered breathing: a secondary analysis of a noninferiority randomized clinical trial. JAMA Netw Open. 2020;3(4):e203088.