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Cost-Utility of Three Approaches to the Diagnosis of Sleep Apnea: Polysomnography, Home Testing, and Empirical Therapy

Ronald D. Chervin, MD, MS; Daniel L. Murman, MD, MS; Beth A. Malow, MD, MS; and Vicken Totten, MD, MS
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From the University of Michigan, Ann Arbor, Michigan; Michigan State University, East Lansing, Michigan; and Catholic Medical Center of Brooklyn and Queens, Brooklyn, New York.

Ann Intern Med. 1999;130(6):496-505. doi:10.7326/0003-4819-130-6-199903160-00006
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Background: Obstructive sleep apnea syndrome (OSAS) is usually diagnosed with overnight polysomnography in a sleep laboratory. Home sleep studies can be performed at lower cost, but results are somewhat less reliable. Bedside diagnosis of OSAS without any testing has also been discussed.

Objective: To model the costs and utility of laboratory polysomnography, home study, and no testing during the 5 years after initial evaluation for OSAS.

Design: Cost-utility analysis.

Data Sources: Published data.

Target Population: Hypothetical cohort of persons suspected of having OSAS.

Time Horizon: The 5 years after initial evaluation for OSAS.

Perspective: Societal.

Intervention: Nasal continuous positive airway pressure when OSAS was diagnosed.

Measurements: Quality of life, survival and charges (as proxies for costs) for each diagnostic method.

Results of Base-Case Analysis: Under almost all modeled conditions, polysomnography provided maximal quality-adjusted life-years in the 5 years after the initial diagnostic evaluation. The incremental charges for polysomnography over home study or no testing were about $13 400 and $9200, respectively, per quality-adjusted life-year gained during this period.

Results of Sensitivity Analysis: Results were sensitive to the utility of treatment in the absence of OSAS.

Conclusions: The cost–utility of polysomnography instead of home study or no testing in the diagnosis of OSAS compares favorably with that of other procedures for which society judges the added utility per dollar spent to be worthwhile. More precise determination of certain key variables in this model should be a goal of future research.


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Figure 1.
Decision tree with quality-adjusted life-years, calculated for the 5 years after initial evaluation (QALY 5 ), as the outcome measure.Table 455CPAP55

Assumptions are those listed as baseline estimates in . Squares represent decision nodes, circles represent chance nodes, and triangles represent outcomes. Calculation of the total QALY s for the home study branch, for example, was as follows: (0.99)(4.104) + (0.01)(2.972) = 4.093 (QALY s for continuous positive airway pressure [ ] branch) and (0.23)(2.804) + (0.77)(3.538) = 3.369 (QALY s for no CPAP branch), then (0.81)(4.093) + (0.19)(3.369) = 3.955 (QALY s for home study branch). OSAS = obstructive sleep apnea syndrome.

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Figure 2.
Sensitivity of 1) quality-adjusted life-years, calculated for the 5 years after initial evaluation (QALY 5 ) [top]; 2) 5-year costs [middle]; and 3) cost–utility ratios (bottom) to the pretest probability of obstructive sleep apnea syndrome (OSAS).Table 4

The pretest probability of OSAS was varied while other variables were held at the baseline estimates listed in . In the top and middle sections, black bars represent polysomnography, striped bars represent home study, and white bars represent no testing. In the bottom section, white bars represent polysomnography compared with home study and striped bars represent polysomnography compared with no testing.

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