5 Things You’ll Know About Home Sleep Testing (HST) After Doing it 5,000 Times
After decades in the sleep medicine industry, it was a little over a year ago that my company decided to stop using outside sleep labs altogether and do all of our own Home Sleep Testing (HST) using only Portable Sleep Monitors.
We recently completed our 5,000th HST and I’d like to believe I have some insight that might be valuable to the physicians and dentists out there who are considering testing their own patients with Portable Sleep Monitors or referring them to one of the many home sleep testing providers around.
One size definitely does not fit all. I have personally been tested on a multitude of different units and can find reasons to argue for or against almost any of them. The unit most commonly found in a doctor’s office, the Watermark Ares, is fairly easy to use, but some patients just can’t stand that it’s attached to their head, while others will prefer that to a chest strap. The Nox T3 Portable Sleep Monitor is the other unit we most commonly use, as it’s versatile in the types of tests that can be performed (Baseline, Oral Appliance/CPAP Titration, Seep Bruxism Monitor, etc) and it’s FDA approved for pediatric patients.
If you’re looking to purchase your own units, don’t put all your eggs in one basket. Consider using a variety of units. At the very least, make sure you have a relationship with a lab that can handle the patients that your primary testing device can’t.
Sleep labs and interpreting physicians are well aware of the first night effect, in which a patient’s sleep is typically more fragmented and Rapid Eye Movement (REM) time is diminished during the first night in the lab due to the patient being in an unfamiliar setting. HST does reduce the first night affect, but certainly doesn’t remove it. We ask all of our patients to use the unit for at least 2 consecutive nights, and the variation from one night to the other can be significant.
First Night Effect aside, the fact remains that we sleep differently every night, and Apnea Hypopnea Index (AHI) is affected by a host of factors that can change from one night to the other. If you are only testing a patient for one night, not only do you risk an equipment or user error leaving you with zero useful data, you’re also doing the patient a disservice by using results that we reasonably believe are not truly representative of their typical night sleep.
Every HST device includes a pulse oximetry channel because heart rate and blood oxygen levels are probably the two most important pieces of data we look at (with airflow in a very close third place).
However, the pulse ox is also the sensor that is most likely to fail during the test, and when it does, a retest is required in almost every case. Most units rely on a finger probe type sensor and when a patient complains about being uncomfortable, they mention the pulse ox more often than anything else. The Nox T3 Portable Sleep Monitor uses Bluetooth to transmit the signal from the wrist to the unit without the need for a wire running up the patient’s arm, and that helps a lot with patient comfort. However the issue of the sensor failing during sleep is about the same on all units.
The simplest insurance policy is a band-aid or a little piece of tape that goes around the patient’s finger and the wire that comes out of the finger probe between the first and second knuckle (the two closest to the wrist). This helps prevent the probe from falling off of the finger and rendering itself useless.
After Hours Support
We have round the clock tech support for our patients, and from a business stand point, it saves us more time and money than anything else we do. Getting a problem solved quickly so we don’t lose a night of testing is obviously very important to us, but the real benefit is keeping the patient’s frustration level as low as possible. Even though we could easily address the patient’s issue the next day during business hours, by then the patient is upset and doesn’t want to have anything to do with the test any more. That’s not good for us, for the patient, or for the doctor. In addition, by keeping a record of every problem we have, we can work to prevent the most common issues before they happen.
A Sense of Urgency
I’ve spoken to a lot of doctors who have purchased a home sleep testing unit with the expectation that they’ll be able to have it in use 10 or 20 nights per month. That couldn’t be farther from the truth.
In reality, a patient who is supposed to use a Portable Sleep Monitor for two nights will often hold onto it for a week or more, and we do have occasions where a patient keeps it for over a month. Luckily, we have hundreds of units, but this could cause a serious problem for a doctor who owns only one or two. Many patients will say they want to wait until the weekend, or until they get a break in their hectic schedule before they do the test. But for the most clinically accurate information, we want the patient to test in the situation that they sleep in most often.
From a business standpoint, we want the patient to test as soon as possible and get the unit back. The best way to accomplish this is to make the patient understand from conversation number one, that they are to use the device as soon as they receive it and are only allowed to keep it an extra night if they get prior clearance from the lab or provider.