Testing for pediatric obstructive sleep apnea when health care resources are rationed.
OBJECTIVE
Evaluation of pediatric obstructive sleep apnea in resource-limited health care systems necessitates testing modalities that are accurate and more cost-effective than polysomnography.


OBJECTIVE
To trace the clinical pathway of children referred to our sleep laboratory for possible obstructive sleep apnea who were evaluated using nocturnal pulse oximetry and the McGill Oximetry Score.


METHODS
This was a retrospective cohort study of children 2 to 17 years old with suspected obstructive sleep apnea due to adenotonsillar hypertrophy, conducted at a Canadian pediatric tertiary care center.


METHODS
Nocturnal pulse oximetry studies scored using the McGill Oximetry Score.


METHODS
For children who underwent adenotonsillectomy we determined the length of time from oximetry to surgery, postoperative length of stay, postoperative readmissions, and emergency department visits in the month following surgery and major surgical complications. We analyzed these outcomes by oximetry result. We compared the cost savings of our diagnostic approach with those of other diagnostic models.


RESULTS
Among 362 children, the median age was 4.8 years (interquartile range, 3.3-6.7), and 61% were male. Two-hundred-sixty-six (73%) and 96 (27%), respectively, had inconclusive and abnormal oximetry results. Eighty of 96 of children with abnormal oximetry results (83%) and 81 of 266 children with inconclusive oximetry results (30%) underwent adenotonsillectomy. Thirty-three of 266 children (12%) underwent further evaluation with polysomnography; of 14 diagnosed as having OSA, 12 underwent adenotonsillectomy. Children with abnormal oximetry results were operated on soonest after testing and triaged based on oximetry results. No child with an inconclusive oximetry result required hospitalization for more than 1 night postoperatively; 14% of children (11 of 80) with an abnormal oximetry result required hospitalization for 2 or 3 nights (χ2 = 12.0; P = .001). Rates of readmissions and emergency department visits were low, irrespective of oximetry results (whether inconclusive or abnormal). We show that our oximetry-based diagnostic approach results in considerable cost savings compared with a polysomnography-for-all approach.


CONCLUSIONS
Oximetry studies evaluated with the McGill Oximetry Score expedite diagnosis and treatment of children with adenotonsillar hypertrophy referred for suspected sleep-disordered breathing. When resources for testing for sleep-disordered breathing are rationed or severely limited, our proposed diagnostic approach can help maximize cost-savings and allows sleep laboratories to focus resources on medically complex children requiring polysomnographic evaluation of suspected sleep disorders.
Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Linda
L
Horwood
Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Robert T
RT
Brouillette
Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Christine D
CD
McGregor
Department of Otolaryngology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
John J
JJ
Manoukian
Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Evelyn
E
Constantin
D000233:Adenoidectomy; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D017046:Cost Savings; D019091:Critical Pathways; D005260:Female; D015276:Health Care Rationing / Q000191:economics*; D006801:Humans; D008297:Male; D010092:Oximetry / Q000191:economics; D017286:Polysomnography; D012189:Retrospective Studies; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis* / Q000601:surgery; D013997:Time Factors; D014068:Tonsillectomy