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Original Investigation |

Testing for Pediatric Obstructive Sleep Apnea When Health Care Resources Are Rationed

Linda Horwood, MSc1; Robert T. Brouillette, MD1; Christine D. McGregor, RRT1; John J. Manoukian, MD2; Evelyn Constantin, MD, MSc(Epi)1
[+] Author Affiliations
1Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
2Department of Otolaryngology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
JAMA Otolaryngol Head Neck Surg. 2014;140(7):616-623. doi:10.1001/jamaoto.2014.778.
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Importance  Evaluation of pediatric obstructive sleep apnea in resource-limited health care systems necessitates testing modalities that are accurate and more cost-effective than polysomnography.

Objective  To trace the clinical pathway of children referred to our sleep laboratory for possible obstructive sleep apnea who were evaluated using nocturnal pulse oximetry and the McGill Oximetry Score.

Design, Setting, and Participants  This was a retrospective cohort study of children 2 to 17 years old with suspected obstructive sleep apnea due to adenotonsillar hypertrophy, conducted at a Canadian pediatric tertiary care center.

Interventions  Nocturnal pulse oximetry studies scored using the McGill Oximetry Score.

Main Outcomes and Measures  For children who underwent adenotonsillectomy we determined the length of time from oximetry to surgery, postoperative length of stay, postoperative readmissions, and emergency department visits in the month following surgery and major surgical complications. We analyzed these outcomes by oximetry result. We compared the cost savings of our diagnostic approach with those of other diagnostic models.

Results  Among 362 children, the median age was 4.8 years (interquartile range, 3.3-6.7), and 61% were male. Two-hundred-sixty-six (73%) and 96 (27%), respectively, had inconclusive and abnormal oximetry results. Eighty of 96 of children with abnormal oximetry results (83%) and 81 of 266 children with inconclusive oximetry results (30%) underwent adenotonsillectomy. Thirty-three of 266 children (12%) underwent further evaluation with polysomnography; of 14 diagnosed as having OSA, 12 underwent adenotonsillectomy. Children with abnormal oximetry results were operated on soonest after testing and triaged based on oximetry results. No child with an inconclusive oximetry result required hospitalization for more than 1 night postoperatively; 14% of children (11 of 80) with an abnormal oximetry result required hospitalization for 2 or 3 nights (χ2 = 12.0; P = .001). Rates of readmissions and emergency department visits were low, irrespective of oximetry results (whether inconclusive or abnormal). We show that our oximetry-based diagnostic approach results in considerable cost savings compared with a polysomnography-for-all approach.

Conclusions and Relevance  Oximetry studies evaluated with the McGill Oximetry Score expedite diagnosis and treatment of children with adenotonsillar hypertrophy referred for suspected sleep-disordered breathing. When resources for testing for sleep-disordered breathing are rationed or severely limited, our proposed diagnostic approach can help maximize cost-savings and allows sleep laboratories to focus resources on medically complex children requiring polysomnographic evaluation of suspected sleep disorders.

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Figure 1.
Representative Pulse Oximetry Tracings From Children in Our Study Cohort Illustrating McGill Oximetry Scores (MOS) 1 Through 4

Representative overnight pulse oximetry trend graphs from children in our study cohort evaluated for suspected obstructive sleep apnea (OSA). MOS 1 is inconclusive, neither ruling in nor ruling out OSA. MOS 2, 3, and 4 indicate abnormal oximetry, with progressively more severe OSA associated with clusters of desaturation and repetitive dips in oxyhemoglobin saturation (oxygen saturation) measured by pulse oximetry to less than 90%, 85%, and 80%, respectively. (See the Pulse Oximetry subsection and Nixon et al12 for additional details about grading oximetry using the MOS.)

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Figure 2.
Clinical Course of a Cohort of Children Evaluated for Suspected Obstructive Sleep Apnea (OSA) Following the Montreal Children’s Hospital’s McGill Oximetry Score (MOS)-Based Diagnostic Approach

The clinical pathway followed by patients in our study cohort, starting with the results of initial oximetry testing, and subsequent medical testing and/or surgical intervention. PSG indicates polysomnography; TA, adenotonsillectomy.

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Figure 3.
Theoretical Estimated Costs to Evaluate 1000 Children for Possible Obstructive Sleep Apnea (OSA) Using 4 Different Diagnostic Approaches

The estimated cost to evaluate 1000 children for OSA using oximetry and/or polysomnography (PSG) assuming $100 and $1000 for oximetry and PSG, respectively. The horizontal line indicates the cost to evaluate all children with PSG alone ($1 000 000); point A, the cost to evaluate all children with oximetry alone ($100 000); point B, the cost to evaluate all children with oximetry and 9.1% with PSG, as in the current series ($191 000); point C, the cost would be less than that for the PSG-for-all option if less than 90% of children proceed to PSG; point D, cost to evaluate if all children with inconclusive oximetry results in a proportion similar to the current series (73%) proceed to PSG ($830 000).

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