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Should primary care physicians and other nonspecialists who are not board-certified in sleep medicine be able to prescribe sleep apnea treatment after home testing?

No, , of the University of New Mexico in Albuquerque, argued in a point-counterpoint series in the December issue of Chest.

Board certification in sleep medicine should be required because board certification generally correlates with better quality of care, wrote Brown, who is board-certified in sleep medicine.

He cited the most recent systematic review, which found that 16 studies confirmed better outcomes for board-certified physicians across specialties, 14 failed to find any effect, and three actually showed worse outcomes compared with noncertified physicians. Several others since that review have also turned up positive for board certification.

In sleep medicine, a few studies have looked at the impact of board certification.

One study correlated treatment by certified physicians or in accredited centers with lower likelihood of discontinuing continuous positive airway pressure (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, , of the Mayo Clinic in Rochester, Minn., argued in the counterpoint.

Getting more patients into treatment is more important than the possibility of overdiagnosis 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.

"The endocrinologic, cardiovascular, mental health, and potential accident consequences of undiagnosed OSA are well known by clinicians, and any obstacles to diagnosis, such as restricted home sleep testing coverage, are unreasonable."

But home sleep testing suffers from frequent false-negatives that make it a less cost-effective strategy than lab-based polysomnography for diagnosing moderate-to-severe OSA, Brown countered.

More accurate diagnosis in the lab isn't a guarantee of treatment success, though, Gay pointed out.

Optimal management depends more on recognition and comprehensive therapeutic programs that result in long-term good adherence to treatment, he argued.

"There is no guarantee right now that the sleep-specialist performance of the home sleep testing is the key to this door, so restricting CMS coverage of home sleep testing to this much smaller group of clinicians merely provides another barrier to capturing vastly undertreated patients with as-yet undiagnosed OSA."

The best solution would be more education for primary care physicians and cooperation, rather than competition, Gay recommended.

The sleep specialty "needs to share knowledge and seek means of creating chronic disease management models that can be used in primary care provider arenas for better patient care outcomes," he concluded.

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