Product Line! Bottom Line! The New Paradigm for Medicine—Sleep Apnea

In the past 30 years the diagnosis of sleep apnea has gone from being an oddity to a mainline healthcare business.  Testing and prescribing has become a niche that provides lucrative revenue to specialized businesses.   As noted here:

It’s a condition shown to increase the risk of several serious illnesses, including heart disease, stroke and dementia. Critics, however, worry that overnight tests to diagnose apnea, particularly those done in sleep labs, may be over-prescribed, at great cost to the health care system.

Testing can be a lucrative business, and labs have popped up in free-standing clinics and hospitals across the country. Over the past decade, the number of accredited sleep labs that test for the disorder has quadrupled, according to the American Academy of Sleep Medicine.

At the same time, insurer spending on the procedure has skyrocketed. Medicare payments for sleep testing increased from $62 million in 2001 to $235 million in 2009, according to the Office of the Inspector General.

And:

It’s no secret that the sleep business can be lucrative for physicians. A website for Aviisha, a sleep testing company, has a special page for physicians showing a picture of a doctor with a stack of money in his lab coat pocket. And in February, the American Academy of Sleep Medicine is offering a seminar on the “business of sleep medicine for physicians” at a golf resort in Arizona.

Insurers are catching on and limiting the expensive on site testing encouraging  more use of home testing. 

What’s most interesting about this expenditure is that while there is extensive data showing a short-term improvement in symptoms with treatment there is no long term outcome data documenting effectiveness.  As noted in this presentation by Henry Glick of the University of Pennsylvania from the American Thoracic Society in 2010:

Given the large number of studies, why hasn’t the
question been satisfactorily answered?

• Shares with health problems such as obesity the fact that while it “makes sense” that treatment should avoid outcomes such as heart attacks and stroke, but no trial has ever demonstrated that treatment actually avoids these outcomes (Medicynical Emphasis)

Medicynical Note:  As noted in a 1999 article on the costs of sleep apnea,

We conclude that patients with undiagnosed sleep apnea had considerably higher medical costs than age and sex matched individuals and that the severity of sleep-disordered breathing was associated with the magnitude of medical costs. Using available data on the prevalence of undiagnosed moderate to severe sleep apnea in middle-aged adults, we estimate that untreated sleep apnea may cause $3.4 billion (probably ten times that amount today) in additional medical costs in the U.S.  Whether medical cost savings occur with treatment of sleep apnea remains to be determined.

Confusing any study of outcomes is the fact that of those treated with CPAP  machines (continues positive pressure) only a minority, perhaps a small minority, continue to use them.

I conclude then, that there is a problem called sleep apnea, caused to a great extent by obesity.   We know, also, that an expensive diagnosis and treatment industry has evolved to manage this problem.  Sleep apnea diagnosis has become a product line for many companies.   There is evidence that  treatments,  some surgical and permanent and others temporary with use of oral appliances and/or machines may (CPAP) improve some symptoms.  But there is no evidence, at this time, that these treatments prevent long term complications (cardiovascular or pulmonary) and death.   For all we know, people treated may have exactly the same outcome as those not treated.

This raising the question of what is a cost effective approach for this problem?  Is our current approach  the most medically effective or do we need to rethink the whole thing?