Can You Diagnose Sleep Apnea with an Over-the-Counter Test?

Sleep apnea affects over twenty-five million people in the United States. But up to 80% of cases go undiagnosed, which for a condition that has major health ramifications if left untreated but can very effectively be managed, isn’t great.Why? Oftentimes people don’t realize they have sleep apnea, so they don’t get tested. And getting diagnosed and treated isn’t exactly a light lift, involving multiple appointments and a sleep test. Which leaves people like me, whose husband’s snoring makes it impossible to sleep, in a bit of a pickle. People who snore don’t always have sleep apnea, but it’s a pretty telltale calling card.Now, direct-to-consumer home sleep apnea tests (HSATs) are aiming to make diagnoses easier and faster. I recently shepherded my husband through the Happy Ring by Happy Health testing process that I ordered myself online. Here’s what experts say about whether you can trust these D2C at-home tests or not.Why sleep apnea can cause big problems for your healthThere are multiple types of sleep apnea, but the most common is obstructive sleep apnea (OSA).“When a normal person falls asleep who doesn't have sleep apnea, the airway stays open,” says Dr. Aatif Husain, Professor of Neurology and Chief of the Division of Epilepsy, Sleep, and Clinical Neurophysiology at Duke University Medical Center. “But in someone who has sleep apnea, the airway does not stay open and an individual stops breathing.”With each apnea, you don’t breathe for at least ten seconds. Your brain flags your body to wake up and start breathing but considering this cycle happens anywhere from five to over 100 times an hour, it’s no wonder people with sleep apnea don’t feel rested no matter how much sleep they think they got.“In more moderate to severe cases, cardiovascular disease starts to happen a lot sooner,” Dr. Husain adds. “Your risk for stroke, heart attack, cardiac arrhythmias, and so on and so forth increases.”How to get a sleep apnea diagnosis“The biggest hurdle we have [for more diagnoses] is having enough clinicians to help the process along,” says Dr. Daniel Barone, Director of Sleep Practice at Montefiore Medical Center and author of Let’s Talk About Sleep. “Depending on how much of a reputation the doctor has, it could be anywhere from a couple of weeks to two months or even longer for just the initial appointment.”Here’s how a diagnosis typically unfolds. Depending on insurance, you may need to get a referral to a sleep doctor, which means a primary care visit first. Then at the sleep doctor you’ll review your sleep history and symptoms, and they’ll prescribe a sleep study. These can happen in a sleep lab, but most doctors prescribe a HSAT today, which you pick up, take home and bring back when you’re done.And then, only then, will you get an official diagnosis and treatment recommendations, which typically include a prescription for a Continuous Positive Airway Pressure (CPAP) machine that pushes air into your lungs or an oral appliance that pulls your jaw forward to prevent your tongue from blocking your airway.A Durable Medical Equipment company (DME) gets your CPAP prescription with recommended air pressure settings and what mask to try first (there are over fifty options, Dr. Barone says). From there, you’ll check-in with your doc during the first three months on how it’s going. Your doctor can recommend different masks or pressure options if needed, but the DME will be the one you’ll actually get equipment from. Sigh, nothing like our healthcare system making folks jump through major hoops to try to improve their health, right?Do direct-to-consumer sleep apnea tests work to diagnose sleep apnea?My husband used Happy Sleep for his HSAT, although there are a number of these D2C tests, like Lofta, Daybreak and Sleep Doctor. Each company may operate differently so this review applies specifically to Happy Sleep.The ring looks pretty similar to an Oura or Whoop wearable. It’s FDA-cleared and uses biometric sensors to diagnose sleep apnea, and Dr. Jeff Durmer, Chief Clinical Strategy Officer for Happy Health says the technology is virtually identical to the HSAT a sleep doctor would prescribe.“When you compare this ring's ability to detect sleep states or detect apnea hypopneas, it's 98% sensitive,” he claims. “It's basically almost the same.”Skipping the initial appointment was a winI bypassed the initial appointment hurdles and ordered the Happy Ring directly by answering a sleep quiz, entering insurance information and paying $199. Based on the quiz, Happy Sleep determined my husband had a high likelihood of sleep apnea, which they used to code the ring as a medical device versus consumer device with insurance.That said, Dr. Durmer told me they may be moving away from this option and would require patients to virtually see a doctor before getting the ring. While this is most certainly a better way to get a more robust sleep history than filling out a quiz, it adds a frustrating step to the process.Remember, people with sleep apnea don’t always suspect they have it. Which means they might not be super keen to put effort into getting tested (see: my husband, who has said he’ll get an appointment for two years now). But as the person knowingly losing sleep, it was extremely easy for me to take the reins to jumpstart the diagnosis process.But there was a delay in actually starting the sleep test.Right now, there’s a clunky two-step process ordering the Happy Sleep ring. You’ll get mailed a ring fit kit first before getting the actual product. Happy Health is rolling virtual sizing, though, which should make this process much less annoying.All in all it was about a two week turnaround before he could start testing, but this should drop with a virtual sizing option.The test itself was easy, as was scheduling the follow-up appointmentYou’ll wear your ring for three-to-five nights before meeting with one of Happy Health’s medical professionals. There’s no real work involved except remembering to ‘start’ and ‘finish’ your test each night in the app.My husband couldn’t get the ring to work initially, and the help section on Happy Sleep’s website is woefully lean right now. Thankfully, their support team quickly answered our email, saying he should put on a little lotion or try wearing it with slightly damp hands, which worked.The app automatically prompted us to schedule an appointment after three nights. We met with a Nurse Practitioner 48 hours later, significantly faster than the more traditional route.Not surprisingly, my husband has sleep apneaThe result? Moderate sleep apnea. My husband averaged 17 apneas each hour. The NP reviewed different treatment options, we settled on trying the CPAP, and she sent a prescription to a DME.Did it feel a bit transactional? Yes. But when you’re pretty sure about the diagnosis and just need to go through the bloody steps insurance requires to get help, does it really matter if it feels transactional? To me, no, but to others it might.My husband has an eight-week follow-up appointment scheduled, but can schedule an appointment sooner if he has questions. These appointments will be billed to insurance or $99 out of pocket, although the company did not respond to emails asking if these appointments would always be with the same NP. He can also email their support team, which is answered by different agents.Experts say D2C at-home sleep apnea tests are relatively accurateDoctors have been using HSATs for over 15 years. Granted, the D2C options look a little different, but function similarly. In 2007, Dr. Carolyn D’Ambrosio, Professor of Clinical Medicine and Associate Vice Chair of Medicine for Education at the University of Miami, helped review HSAT efficacy for Medicare. “Sleep laboratories were not that available and they’re very expensive,” she says, pointing out people in rural areas had to drive hours for a lab test and would often have to miss work. “Were they really necessary?”The answer: no. The report concluded HSATs are “decent” at detecting obstructive sleep apnea. And now, consumer HSATs are using similar technology. “These tests provide yet another way to look at sleep apnea,” says Dr. Husain, “They are a screening test and that means that if it's positive, that's great.”At-home tests can produce false negativesWhere these HSAT or D2C tests fail, Dr. D’Ambrosio says, is if the test is negative. “It's just not as detailed of a test [compared to a lab test],” she says. “If it says no sleep apnea, you shouldn't trust it and then you have to get the in-laboratory sleep study.”Patients can be bad at following through on a lab test if their HSAT is negative, Dr. D’Ambrosio says. Remember, if you’re taking a HSAT it’s probably because you or someone you know highly suspects you have sleep apnea, so you should suck it up and do an in-lab test if your HSAT is negative.You may trade a deeper relationship for efficiencyYes, D2C HSATs can be as accurate as one your doctor prescribes and can give you a quicker diagnosis. But Dr. Barone cautions on trading a deeper relationship with your doctor for efficiency’s sake. “You gotta remember, sleep apnea, if it is there, it's a chronic condition” he says. “It's not a thing that's going to hurt you waiting one night or even one month. It takes years for that to have an effect.”Waiting a few more weeks to meet with a doctor in person, he argues, may mean better long-term care. “No one loves wearing a CPAP machine and if patients don't understand why they need it, what the implications are of not using it, and how to get it to optimally work, they're much more likely to give up on it,” adds Dr. Husain. “I would like to think that you're much more likely to get that information if you have a personal consultation with a physician as opposed to a short online conversation.”The bottom linePerhaps the most important thing here is to get tested for sleep apnea if you suspect you may have it. Using a D2C HSAT like Happy Health is likely to give you a similar result as the HSAT test you’ll get visiting the doctor’s office. It’s not a perfect experience, and may mean a shallow long-term relationship with a doctor, but it’s quick and easy.