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Nights are far from peaceful for Michael Messex. He snores. He stops breathing dozens of times each hour. And his wife says it's getting worse.

A doctor warned Messex that he might have obstructive sleep apnea, a serious disorder that not only robs millions of Americans of restful sleep but raises their risk of heart disease and diabetes.

Diagnosing the disorder traditionally has meant having the patient spend the night in a sleep lab hooked up to monitors. But Messex was diagnosed at home -- using a less-expensive test that's gaining ground across the nation, thanks largely to a push by insurance companies and mounting evidence of its effectiveness.

"You get to sleep in your own bed with your own pillow," said Dr. Laddie Tackett, medical director for Anthem Blue Cross and Blue Shield in Kentucky. "It makes testing more accessible. It makes it more affordable. It makes it more convenient."

But many doctors are skeptical. They say in-home tests -- which make up a small percentage of overall sleep tests -- aren't as thorough as lab testing. However, they are less than half the price -- up to $400 for a home test, compared with as much as $1,300 in a hospital.

"We order some at-home tests. ... But unfortunately, a lot of that is driven by insurance. It's increasingly difficult to have studies done in the lab," said Dr. Subin Jain, a partner at Louisville Pulmonary Care and director of the Baptist Health Louisville Sleep Disorders Center. "The amount of data (from a home study) is significantly less than what you'd get in the lab."

And the stakes are high.

Obstructive sleep apnea -- where the upper airway is obstructed, causing breathing to halt -- is one of the most common sleep disorders, affecting up to 7 percent of adult men, up to 5 percent of adult women and similar percentages of children. Untreated sleep apnea is linked to problems as serious as heart attack and stroke.

"You don't want to walk around with untreated sleep apnea, because it wreaks havoc on your body," said Cheryl Holbrook, a sleep analyst at Baptist. "It's going to start breaking your body down little by little."

But it can be costly to diagnose and treat.

In 2010, Harvard Medical School researchers estimated that the annual cost of the condition nationally ranged from $65 billion to $165 billion, reflecting diagnosis, treatment and the impact on other diseases and motor vehicle accidents.

'Just as good'

Tackett said home equipment varies, but generally it measures things such as air flow, the effort people make during respiration and oxygen saturation. The kits are small and portable.

Patients place an air-flow sensor under their nose, put on a belt and attach a clip to their finger before going to sleep. During the night, data is recorded for analysis. Tackett said the equipment is relatively easy to use, and patients usually sleep well.

Home sleep tests cost about $200 to $400, Anthem officials said, compared with lab tests that can range from $600 in a free-standing sleep center to around $1,300 in a hospital. For patients with a co-pay of 20 percent, that could mean out-of-pocket costs of as little as $40 for home study compared with as much as $260 for lab tests.

"It certainly is less expensive, and a much better value for the member," Tackett said. "And when you look at health care costs across the country, that makes a difference to everyone."

Other home study proponents pointed out that it can be especially helpful for patients who live far from sleep centers or who are intimidated by laboratory settings.

Anthem officials estimate that home testing is likely appropriate for up to 80 percent of policyholders with suspected sleep apnea.

Doctors say it's useful for patients with a high probability of moderate to severe apnea, who have no other significant illnesses and who are not also suspected of having another sleep disorder.

"If obstructive sleep apnea is suspected ... the test can be just as good at home," Tackett said. "If you want to look for other things, such as narcolepsy or periodic limb movement, the lab test is appropriate."

Other experts echoed that viewpoint. A June 2012 study in the journal Sleep found that home testing was "not inferior in terms of acceptance, adherence, time to treatment and functional improvements."

Lab advantages

Still, skeptics say lab studies are the right choice for patients who have serious health problems or who may have another sleep disorder in addition to apnea.

Dr. David Hasselbacher, a physician with Chest Medicine Associates & Sleep Medicine Specialists associated with Norton Brownsboro Hospital, said lab studies offer much more information.

The equipment is extensive, including about 25 sensors on the head, legs and other areas of the body, two belts to monitor breathing and respiratory effort, and snoring microphones. It measures breathing and air flow, respiratory effort, heart rate, oxygen levels, brain waves, snoring and leg movements.

Holbrook said it can detect 80 types of sleep disorders.

Hasselbacher said it's a misconception that patients always sleep better at home.

"Frankly," he said, "a lot of people do sleep really well in the lab."

Doctors said another advantage is that medical staff monitor lab tests. Hasselbacher said patients get help attaching the equipment instead of having to hope they do it correctly themselves -- which doesn't always happen.

Dr. David Hiestand, director of the sleep lab at University Hospital, said constant monitoring of lab tests also allows for equipment adjustments if, for example, sensor leads fall off during sleep.

Doctors said some patients who receive home studies still need lab tests, particularly before receiving CPAP machines, which gently blow air into the throat.

"I'm not saying home sleep studies don't have a role to play," Jain said. "But I think we're still working through the process of what their role is going to be."



ABOUT SLEEP APNEA

What is it? A common disorder in which a person experiences one or more breathing pauses or shallow breaths while sleeping. The most common type is obstructive sleep apnea, in which the airway collapses or becomes blocked. It can range from mild to severe.

Symptoms: Snoring, daytime sleepiness, morning headaches, memory or learning problems or not being able to concentrate, feeling irritable or depressed, waking up frequently to urinate, dry mouth or sore throat upon waking.

Dangers: Untreated sleep apnea can increase the risk of high blood pressure, heart attack, stroke, obesity and diabetes; worsen heart failure; make irregular heartbeats more likely; and increase the chance of having work-related or driving accidents.

Causes: The throat muscles and tongue relax more than normal; the tongue and tonsils are large compared with the opening in the windpipe; the person is overweight.

Who's at risk? About half of people with sleep apnea are overweight. The condition is more likely among men than women and in older people than younger people -- although children with enlarged tonsils are at risk.

Diagnosis: Physical exam, medical and family histories, home or in-lab sleep study.

Treatment: Lifestyle changes such as losing weight or quitting smoking; mouthpieces to adjust the lower jaw and tongue to help keep airways open; breathing devices such as the continuous positive airway pressure machine, which uses a mask and gently blows air into the throat; surgery to widen breathing passages.

Source: National Institutes of Health

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