In a point/counterpoint section of the December issue of Chest, Lee K. Brown, MD, argues that primary care physicians and other nonspecialists (who are not board-certified in sleep medicine) should not be able to prescribe sleep apnea treatment after home testing.
“Point: Should Board Certification in Sleep be Required to Prescribe CPAP Therapy on the Basis of Home Sleep Testing? Yes”
Brown is a professor at the University of New Mexico in Albuquerque, and his view, is bolstered by a systematic review in which he found that 16 studies confirmed better outcomes for board-certified physicians across specialties. Several others since that review have also turned up positive for board certification.
A summary report stated that certified physicians, or those in accredited centers, increased the likelihood of continuing CPAP therapy. The other showed nearly an extra hour per night of CPAP compliance among patients who had a sleep medicine consultation before laboratory sleep testing compared with those who had a direct referral for testing.
“Decision-making in OSA [obstructive sleep apnea] is also complex, even in the most expert hands,” Brown said.
He cited a study showing only 85% agreement between home sleep testing and laboratory sleep testing determination of whether CPAP was indicated.
“Clinical data, rather than home sleep testing results, accounted for much of the variability in decision-making, highlighting the risks of permitting physicians without rigorous sleep medicine training to manage individual patients utilizing home sleep testing,” he explained.
However, there’s little to lose, Peter C. Gay, MD of the Mayo Clinic in Rochester, Minn., argued in the counterpoint. Getting more patients into treatment is more important than the possibility of over diagnosis by physicians who aren’t board-certified in sleep medicine, suggested Gay, who is also board-certified in sleep medicine.
Based on a federal report, “even CMS [the Centers for Medicare and Medicaid Services] concluded that there is little harm to be done in prescribing CPAP after misdiagnosing a patient who does not have obstructive sleep apnea, but the opposite is not true,” he wrote.