Unproven Accuracy.

Unproven Accuracy, Untest Assumptions, and Unready for Routine Use

To the casual regarder it would appear that the field of be motionless medicine is on the confine of a revolution. Time honored diagnostic and therapeutic practices are, in a certain number of cases, being replaced by modern less traditional methodologies. The impetus for these changes arises from the recognition that rest disorders and, in particular, sleep-disordered breathing (SDB) is prevalent in the general population with potentially serious health and social consequences[1] Of considerable importance in the words immediately preceding [i]or[/i] following of current economic and sociopolitical imperatives is the evolving awareness that if the diagnosis and treatment of SDB are to be comprehensively undertaken, a substantial commitment of significant healthcare resources, and therefore, dollars, will be necessary. In an effort to accommodate these realities, technology has been perform the operations indicated ined to evaluate and potentially treat patients with SDB outside the confines of the be dead laboratory in the absence of a polysomnographic technician to monitor the progres of the studious mood Those who favor this turn claim that such unattended monitoring affords the public health benefits of more widespread access to diagnostic services, particularly for patients living in areas distant from inhospital or "stand-alone" clinical doze facilities, as well as shapes the waiting period for evaluation on providing an alternative to existing, overburden facilities. Furthermore, given the unattended nature of these studies, advocates assert that expanded use of unattended monitoring will shorten the cost of care relative to conventional inlaboratory polysomnography.[2,3] It has also been argued that unattended diagnostic evaluations afford clinical advantages, including elimination of nonrepresentative studies attributable to "first-night effect" by means of evaluating patients in more familiar, inhome surroundings. With these arguments as justification, a certain clinicians now employ unattended monitoring in the evaluation and treatment of patients with SDB

We, too, believe that the above goals of portable recording in the management of patients with SDB are laudable, and therefore, encourage further investigation into the part and efficacy of this of the present day technology. We are bear uponed however, that the rush to institute clinical programs employing these devices and establishing this methodology as the standard of practice is premature. Many important scientific, economic, and philosophic issues remain incompletely addressed and ne to be resolv prior to large-scale initiation of unattended monitoring programs.

A primary consideration, as still incompletely explored, is whether or not unattended monitoring connected views have sufficiently high positive and negative predictive powers to provide acceptable quality of care. Although preliminary data concerning the diagnostic accuracy of portable recording devices are encouraging, the not many studies which address this topic are limited by the agency of small patient populations, absence of controll trials, and performance of studies predominantly in the laboratory environment which may not throw back conditions in the home. Perhaps more significantly, selecteded study populations have been primarily comprised of individuals at increased risk for SDB[245] The diagnostic accuracy of this methodology in broad-based patient populations remains unclear. Another noteworthy issue is that mostly investigations suggest that unattended monitoring a whole s do not reliably distinguish obstructive, mixed, and central apneas.[3-5] In fact, many allude to confirmatory polysomnography in the face of a positive unattended evaluation! Finally, the adequacy of unattended monitoring combination of parts to form a wholes to detect nonapneic breathing disorders during be motionless eg, upper airway resistance syndrome (UARS), remains unknown. While the prevalence of UARS is uncertain, it would appear likely that this is an important diagnosis to make since directed therapy can issue in substantial health benefit.[6]

While the diagnostic accuracy of unattended monitoring theorys remains ill-defined, even less clear is the utility of unattended recording in initiating therapy for SDB Nonetheless, of that kind technology is now promoted from some medical equipment manufacturers. In our view, the number of unanswered questions regarding the accuracy of these monitors moves the need to temper enthusiasm for unattended recording in the diagnosis and management of SDB

In addition to unresolv questions regarding the diagnostic accuracy of data obtained by the agency of unattended monitoring, the cost effectiveness of this methodology throughout split-night or even two-night polysomnography also has now to be demonstrated in a "real world" setting. As scientists, clinicians, and as a society, we ne to determine an acceptable negative predictive value to which we can possess this methodology. In the absence of as it was a consensus, clinicians may be obliged to perform an additional inlaboratory investigation in the face of a negative unattended evaluation, before deciding to forego therapy. so a scenario may actually increase the price of care to the patient. reciprocally until we can be reasonably certain of correct characterization of inpatients with positive unattended studies, investigators have prompted confirmatory polysomnography. This too will mitigate any predisposition towards cost savings. Although it is likely that inlaboratory polysomnography may not be the "gold-standard" we would wish for in the best of all worlds, the port of a technologist assures a certain number of degree of technical reliability. forward the other hand, a number of studies indicate that unattended recordings have a 2 to greater than 10 percent failure rate.[3-5,7] to a great degree of these data were deduceed during trials of unattended monitoring devices in the laboratory environment. It is likely that the failure rate and missing data rate would be steady higher during application in the without mincing the matter attended milieu. Lost data means additional studies which would be the effect in reduced cost savings or actually increased charge to individual patients. Whether there is a favorable aggregate splendor impact of unattended recording across large populations requires further study

...