Needs and costs of sleep monitoring.

Sleep disorders have a high prevalence in the general population: insomnia (10-20% of adults), sleep apnoea syndromes (4-6%). They are responsible for high costs of investigations and treatment modalities. The investigations are usually done in sleep laboratories at the expense of cost in personnel and long waiting lists. Remote monitoring could be an alternative to sleep laboratory studies. The first aim was to determine the need for sleep remote recording in sleep medicine in Europe, to improve health delivery and to reduce investigation costs. An enquiry was sent to 500 sleep medicine providers in Europe. Response rate was 11%. Analysis showed that the main diagnosis is obstructive sleep apnoea in adults. Currently 2/3 of sleep studies are performed in laboratory: In-lab studies: Average cost for the health care is 390 EURO/study. The range is from 700 in Finland and Germany and 180 in Greece, Belgium and Sweden are around the mean. Ambulatory studies with EEG: Average cost is around 120 EURO/study i.e. 30% of in-lab cost. The range is from 180 EURO in Portugal to 70 EURO in Germany. 50% of users are not satisfied with their current practice of ambulatory monitoring although they have a clear need for this technique to increase monitoring capacity (88%), reduce cost of investigation (85%), improve sleep quality (60%), and obtain better acceptance from the patient (76%). The expectations from ambulatory monitoring are: high diagnostic sensitivity (86%) high reliability of equipment (92%) low interference with patient's habits (94%) It is worth noting that 74% of users do not expect a fully automated interpretation of data. The indications cited are screening and follow-up of SAS, epilepsy, Periodic Leg Movements and also insomnia and narcolepsy. As a second aim, a validation study has been set-up for an ambulatory recorder. The reproducibility of the system has been evaluated in 14 patients by 2 consecutive home recordings and was satisfactory in terms of total sleep time and apnoea-hypopnea index. Nevertheless a failure rate of 7% was observed which should be improved by a better ergonomy of the system. The third aim was a socio-economical analysis in Paris, in order to define the actual standard mean cost of a polysomnography in the lab (500 EURO) and in ambulatory (238 EURO) i.e. less than one half of the laboratory cost. The monography of the health care process for sleep medicine in Paris showed a delay of more than 10 years for diagnosis of SAS in 25% of the patients and up to 5 physicians visited before referral to the sleep lab. In 48% of the cases the primary physician visited is a GP. In conclusion, there is a clear need for ambulatory monitoring of sleep disorders to decrease the burden of cost and long waiting lists which is not well satisfied with the current health care system and commercially available equipment.