In search of a cut-off apnea-hypopnea index in type 3 home portable monitors to diagnose and treat obstructive sleep apnea: a mathematical simulation.

The American Academy of Sleep Medicine (AASM) uses similar apnea-hypopnea index (AHI) cut-off values to diagnose and define severity of sleep apnea independent of the technique used: in-hospital polysomnography (PSG) or type 3 portable monitoring (PM). Taking into account that PM theoretically might underestimate the AHI, we explored whether a lower cut-off would be more appropriate. We performed mathematical re-calculations on the diagnostic PSG-AHI (scored using AASM 1999 rules) of 865 consecutive patients with an AHI of ≥20 events/h who started continuous positive airway pressure (CPAP). For a PSG-AHI of ≥15 events/h re-scored using AASM 2012 rules (PSG-AHI AASM2012 ), a PM-respiratory event index (REI) AASM2012 cut-off point of ≥15 events/h resulted in a post-test probability of 100% of having the disease, but with negative tests in 57.1%. A PM-REI AASM2012 cut-off of 8 events/h, still resulted in a positive post-test probability of 100% but with negative tests in only 34.3%. Combination of the cut-off values with clinical estimation of being 'at high risk' based on Epworth Sleepiness Scale (ESS) and Berlin Questionnaire scores only resulted in a small reduction in the percentage of negative tests (respectively 52.7% and 32.7%). After 6 months, CPAP adherence was not lower using the PM-REI AASM 2012 cut-off ≥8 events/h in comparison to ≥15 events/h (median 5.7 vs. 5.8 h/night, p = 0.368) and the reduction in ESS was similar too (median -4 and -5 points, p = 0.083). Consequently, using a lower PM-REI AASM2012 cut-off could result in cost savings because of less negative studies and lesser need for a confirmatory PSG or a performance of a CPAP trial.