An Economic Evaluation of Home Versus Laboratory-Based Diagnosis of Obstructive Sleep Apnea

Abstract

Study objectives: We conducted an economic analysis of the HomePAP study, a multicenter randomized clinical trial that compared home-based versus laboratory-based testing for the diagnosis and management of obstructive sleep apnea (OSA).

Design: A cost-minimization analysis from the payer and provider perspectives was performed, given that 3-mo clinical outcomes were equivalent.

Setting: Seven academic sleep centers.

Participants: There were 373 subjects at high risk for moderate to severe OSA.

Interventions: Subjects were randomized to either home-based limited channel portable monitoring followed by unattended autotitration with continuous positive airway pressure (CPAP), versus a traditional pathway of in-laboratory sleep study and CPAP titration.

Measurements and results: From the payer perspective, per subject costs for the laboratory-based pathway were $1,840 (95% confidence interval [CI] $1,660, $2,015) compared to $1,575 (95% CI $1,439, $1,716) for the home-based pathway under the base case. Costs were $264 (95% CI $39, $496, P = 0.02) in favor of the home arm. From the provider perspective, per subject costs for the laboratory arm were $1,697 (95% CI $1,566, $1,826) compared to $1,736 (95% CI $1,621, $1,857) in the home arm, for a difference of $40 (95% CI -$213, $142, P = 0.66) in favor of the laboratory arm under the base case. The provider operating margin was $142 (95% CI $85, $202,P < 0.01) in the laboratory arm, compared to a loss of -$161 (95% CI -$202, -$120, P < 0.01) in the home arm.

Conclusions: For payers, a home-based diagnostic pathway for obstructive sleep apnea with robust patient support incurs fewer costs than a laboratory-based pathway. For providers, costs are comparable if not higher, resulting in a negative operating margin.

Clinicaltrialsgov identifier: NCT00642486.

Keywords: cost effectiveness analysis; cost minimization analysis; home sleep testing; obstructive sleep apnea; operating margin; out-of-center testing; portable monitor; sleep medicine.

Figure 1

Participant flow diagram for the HomePAP trial. Originally published in Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. SLEEP 2012;35:757–67. AHI, apnea-hypopnea index; CPAP, continuous positive airway pressure; PSG, polysomnography.

Figure 2

One–way sensitivity analysis of cost inputs. This one-way sensitivity analysis shows the amount by which the difference between the laboratory and home arm is affected by a change in the parameter listed on the Y-axis. For example, if MD reimbursement was decreased to 50% or increased to 200% of the value used in the base case, the difference would decrease to $81 or increase to $628, respectively, from the base case result of $264. *Ranges from 1 15-min call for every patient, to 1 call for every 10 patients. Base case was the rate of phone call support seen in the HomePAP trial (approximately a 12-min phone call for 95% of patients). † Inputs affect both PSG and PM costs. ‡ The left margin of the white bar represents the base case, or 100% of the additional cost of providing APAP to the home arm, and CPAP in the laboratory arm. The right margin reflects the case where the cost of APAP in the home arm is reduced to the point it is equivalent to CPAP in the laboratory arm. APAP, autotitrating positive airway pressure; CPAP, continuous positive airway pressure; HST, home sleep testing; PM, portable monitor; PSG, polysomnography.

Figure 3

Two-way sensitivity analysis of reimbursement. This two-way sensitivity breakpoint analysis shows the combinations of laboratory and home sleep reimbursement where the sleep laboratory has different levels of profitability, assuming that all patients are tested under the HomePAP home arm algorithm. The pink region indicates the combinations of reimbursement where a sleep laboratory realizes a net operating loss even after assuming that the sleep laboratory is reimbursed for providing every patient with continuous positive airway pressure/autotitrating positive airway pressure equipment (i.e., durable medical equipment [DME]). The blue region is where the sleep laboratory has a positive net operating margin only after DME reimbursement for all patients. The green region is where the sleep laboratory has a positive net operating margin before DME reimbursement is considered. Medicare reimbursement for FY2011 are used. HST, home sleep testing.