OBJECTIVES: The diagnostic assessment for sleep apnea in the German outpatient sector is regulated by directives from the Joint Federal Committee (G-BA). Under those directives, patients with a high pre-test probability receive a home sleep apnea test (HSAT), followed by an in-lab polysomnography (PSG) if the HSAT is inconclusive. Both tests are reimbursed by the public insurance (GKV). Home-PSG (hPSG), which records signals comparable to an in-lab PSG test at home, is currently not approved by the G-BA and cannot be reimbursed. The aim of this study is to evaluate the potential effects of introducing home-PSG into the diagnostic pathway for sleep apnea.

METHODS: A decision-tree model was developed to simulate and compare two clinical pathways: Standard of care and hPSG, in which HSAT are omitted and home-PSG introduced as a first line test, followed by in-lab PSG if required. Effects on waiting times, costs and test volumes were evaluated, using the model parameters pre-test probability, test success rate, acquisition costs and waiting times. Probabilistic sensitivity analysis was conducted to assess second-order uncertainty

RESULTS: In the best-case scenario, introduction of the hPSG pathway for diagnostic assessment of sleep apnea led to an 87.8% reduction in waiting time (range -100.0% to +27.5%), 12.8% lower diagnostic costs (range -37.0% to +67.3%), and 31.3% lesser diagnostic tests (range - 40.3% to +19.4%), compared to Standard of care. Sensitivity analysis showed that assumptions around test waiting times, acquisition costs and test success rate had the largest effects on simulation results.

CONCLUSIONS: Introduction of home-PSG has the potential to optimize diagnostic pathways for patients with sleep apnea by shortening waiting times, the time to diagnosis, reducing costs and reducing the number of tests. A validation of the model in a clinical setting is required to confirm the simulations and evaluate further applications for other sleep disorders.