title: Decision Modeling in Sleep Apnea: The Critical Roles of Pretest Probability, Cost of Untreated Obstructive Sleep Apnea, and Time Horizon.
abstract: OBJECTIVE
  Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and treatment with positive airway pressure (PAP) is cost-effective. However, the optimal diagnostic strategy remains a subject of debate. Prior modeling studies have not consistently supported the widely held assumption that home sleep testing (HST) is cost-effective.
  
  
  METHODS
  We modeled four strategies: (1) treat no one; (2) treat everyone empirically; (3) treat those testing positive during in-laboratory polysomnography (PSG) via in-laboratory titration; and (4) treat those testing positive during HST with auto-PAP. The population was assumed to lack independent reasons for in-laboratory PSG (such as insomnia, periodic limb movements in sleep, complex apnea). We considered the third-party payer perspective, via both standard (quality-adjusted) and pure cost methods.
  
  
  RESULTS
  The preferred strategy depended on three key factors: pretest probability of OSA, cost of untreated OSA, and time horizon. At low prevalence and low cost of untreated OSA, the treat no one strategy was favored, whereas empiric treatment was favored for high prevalence and high cost of untreated OSA. In-laboratory backup for failures in the at-home strategy increased the preference for the at-home strategy. Without laboratory backup in the at-home arm, the in-laboratory strategy was increasingly preferred at longer time horizons.
  
  
  CONCLUSIONS
  Using a model framework that captures a broad range of clinical possibilities, the optimal diagnostic approach to uncomplicated OSA depends on pretest probability, cost of untreated OSA, and time horizon. Estimating each of these critical factors remains a challenge warranting further investigation.
authors.affiliation: Neurology Department, Massachusetts General Hospital, Boston, MA.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Moro
authors.affiliation: Neurology Department, Massachusetts General Hospital, Boston, MA.
authors.forename: M Brandon
authors.initials: MB
authors.lastname: Westover
authors.affiliation: Neurology Department, Massachusetts General Hospital, Boston, MA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Kelly
authors.affiliation: Neurology Department, Massachusetts General Hospital, Boston, MA.|Division of Sleep Medicine, Harvard Medical School, Boston, MA.
authors.forename: Matt T
authors.initials: MT
authors.lastname: Bianchi
mesh_terms: D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data; D003661:Decision Support Techniques; D006801:Humans; D017286:Polysomnography / Q000191:economics / Q000379:methods*; D011336:Probability; D012648:Self Care / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis* / Q000191:economics* / Q000628:therapy; D013995:Time
keywords: PSG; cost; effectiveness; home sleep test; obstructive sleep apnea