New Medicare reforms will help safeguard against the inappropriate use of home based sleep studies and misdiagnosis of obstructive sleep apnoea, experts say.
More than a year after delivering its recommendations to the MBS Review, the Thoracic Medicine Clinical Committee has welcomed news the government will approve all five of its recommendations which will see the creation of new MBS items and a greater role for GPs in testing and triaging patients with suspected respiratory conditions.
A major change is a new rebate for GP referrals for home-based sleep studies, but general practitioners can only order the test once they have established a high probability of moderate to severe obstructive sleep apnoea. The expectation is that they will use the STOP bang questionaire.
The government also accepted a recommendation that patients who are diagnosed with a sleep disorder (via a sleep study) should be “personally assessed by a medical professional who can advise on appropriate management”.
The idea is to place stronger medical oversight on a system which has until now allowed patients to be tested for obstructive sleep apnoea and sold a continuous positive airway pressure (CPAP) machine – which can cost up to $2000 – without being examined by a doctor.
The diagnostics services industry that has emerged in recent years has been operating with “immense conflict of interest and business self interest” according to Professor Christine Jenkins who chaired the thoracic clinical committee.
“From what the sleep physicians told us…there was excessive prescribing of a follow-up [sleep] study, excessive purchase of autoset machines and many patients who abandoned using machines because it didn’t help them,” said Professor Jenkins, a clinical professor at Concord Clinical School in Sydney.
“In some instances, that’s because they had a quite different sleep disordered breathing problem, central sleep apnoea obesity hypoventilation syndrome, parasomnias of various kinds so they really needed specialist sleep physicians’ advice, or they didn’t have OSA or it could have been addressed in a very different way.
“(The industry) needs to change and the entities that have made very substantial profits from this approach will have to reconsider. And I don’t feel particularly apologetic for that.”
The recommendations aim to ensure that once patients have undergone the sleep test, they return to their GP who will consider the test results and clinical history to make a decision on the best course of action.
“That might be to go on to have a pressure determination study for CPAP. But it’s not automatically to go on to have a pressure determination study then be recommended to buy a device from that same provider.”
Another reform to be approved in November will see the rebate for GPs to perform spirometry doubled to $40.
While likely not enough to offset costs, Professor Jenkins hopes it will encourage GPs to perform the test – or at least provide a referral for one – which studies have shown is underutilised.
Professor Jenkins’ said her research, published in the MJA, found about 30% of people who said they had been told they had COPD did not have obstructive spirometry while about 25% of people who had obstructive spirometry did not have a diagnosis.
“We think there is very inaccurate diagnosis of airways disease, and given the prevalence of COPD and asthma affecting in the vicinity of 12% of adults over 40 we think it’s really inappropriate that you might be prescribed medications you don’t need, or that you don’t get the test you need to be prescribed in an evidence-based way.”