Authors' objectives:

This report investigates different aspects of sleep apnea from a medical and economical perspective. As well as investigating the cost and benefits of diagnosis and treatment, it also studies the consequences of the existing reimbursement scheme.

Authors' recommendations: Of the several techniques available for the diagnosis of sleep apnea, polysomnography is the most accurate and most expensive. Other studies have confirmed the efficiency of the step by step diagnostic strategy used in Germany. By applying diagnostic techniques in successive order beginning with the most economical, the cost of diagnosis can be significantly reduced without adverse effects on the patients' quality of life. Using social insurance data we show that step 3, the ambulatory screening of patients with portable devices (partial channel polysomnography, oximetry) was applied 145,000 times in 1997. Between 25 and 40% of patients moved on to step 4, in-patient polysomnography. The estimated per capita cost of pre-diagnostic techniques (step 1 to step 3) are DM 166. Polysomnography (step 4) costs about DM 1200 per case. The total medical cost of diagnosing sleep apnea in Germany amounts to DM 87,45 Mio per year, with an increasing trend. According to published literature the nasal continuous positive airway pressure (nCPAP) is the gold standard in the therapy of sleep apnea. The adjustment of this device on average requires a two-night residence in a sleep centre. According to experts, about half of all patients are tested positively at step 4. These patients undergo nCPAP treatment. We estimate that the therapy of sleep apnea on average costs DM 11,200 per case. In 1997, the total cost of diagnosis and treatment of sleep apnea in Germany amounted to DM 345 Mio. The study of in-patient data reveals long hospital stays in the therapy of sleep apnea. We interpret this observation as a consequence of the absence of diagnosis-related payments. The current reimbursement scheme, applying a flat rate per diem, does not enable hospitals to cover the cost of short-term treatment. For this reason patients stay too long and treatment capacities are not available for patients on the waiting list. The number of sleep centres has sharply increased. Between July 1995 and July 1999 the number rose from 53 to 170 centres, an annual growth rate of almost 50%. Although there are visible regional differences in supply and demand, there appear to be sufficient capacities for the diagnosis and therapy of sleep apnea. In the long run we expect the demand to decrease, since the current demand partly reflects an excess in prevalence over incidence. The ambulatory treatment of sleep apnea - under the current reimbursement scheme - is cheaper than treatment in hospitals. From an economic perspective, the production losses due to absence from work of patients spending unnecessary time in in-patient care have to be considered. The introduction of diagnosis-related payments would increase the flexibility in in-patient care and probably lead to both shorter hospital stays and shorter waiting periods. Since there is no medical legitimation for discriminating against the diagnosis and treatment of sleep apnea in an ambulatory setting, the current preference of in-patient care does not appear to be justified.

Authors' methods: Systematic review, Economic evaluation

Project Status: Completed

URL for project: http://www.dimdi.de/

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Germany

Organisation Name: German Agency for HTA at the German Institute for Medical Documentation and Information

Contact Address: German Agency for Health Technology Assessment at the German Institute for Medical Documentation and Information, Waisenhausgasse 36-38a, D-50676 Cologne Germany

Contact Name: dahta@dimdi.de

Contact Email: dahta@dimdi.de

Copyright: German Agency for Health Technology Assessment at the German Institute for Medical Documentation and Information