Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

The utility of home sleep apnea tests in patients with low versus high pre-test probability for moderate to severe OSA



Home sleep apnea tests (HSATs) are an alternative to attended polysomnograms (PSGs) when the pre-test probability for moderate to severe OSA is high. However, insurers often mandate use anytime OSA is suspected regardless of the pre-test probability. Our objective was to determine the ability of HSATs to rule in OSA when the pre-test probability of an apnea hypopnea index (AHI) in the moderate to severe range is low.


Patients who underwent HSATs were characterized as low or high pre-test probability based on the presence of two symptoms of the STOP instrument plus either BMI > 35 or male gender. The odds of HSAT diagnostic for OSA dependent on pre-test probability was calculated. Stepwise selection determined predictors of non-diagnostic HSAT. As PSG is performed after HSATs that do not confirm OSA, false negative results were assessed.


Among 196 individuals, pre-test probability was low in 74 (38%) and high in 122 (62%). A lower percentage of individuals with a low versus high pre-test probability for moderate to severe OSA had HSAT results that confirmed OSA (61 versus 84%, p = 0.0002) resulting in an odds ratio (OR) of 0.29 for confirmatory HSAT in the low pre-test probability group (95% CI [0.146, 0.563]). Multivariate logistic regression demonstrated that age ≤ 50 (OR 3.10 [1.24–7.73]), female gender (OR 3.58[1.50–8.66]), non-enlarged neck circumference (OR 11.50 [2.50–52.93]), and the absence of loud snoring (OR 3.47 [1.30–9.25]) best predicted non-diagnostic HSAT. OSA was diagnosed by PSG in 54% of individuals with negative HSAT which was similar in both pre-test probability groups.


HSATs should be reserved for individuals with high pre-test probability for moderate to severe disease as opposed to any individual with suspected OSA.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2


  1. 1.

    Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM (2013) Increased prevalence of sleep-disordered breathing in adults. Am Journal Epidemiology 177(9):1006–1014

  2. 2.

    Dement WC CM, Richardson G. Excessive daytime sleepiness in the sleep apnea syndrome. In: Guilleminault C DW, editor. Sleep apnea syndromes New York, New York: Alan R. Liss; 1978

  3. 3.

    Roth T, Hartse KM, Zorick F, Conway W (1980) Multiple naps and the evaluation of daytime sleepiness in patients with upper airway sleep apnea. Sleep 3(3–4):425–439

  4. 4.

    Olaithe M, Bucks RS (2013) Executive dysfunction in OSA before and after treatment: a meta-analysis. Sleep 36(9):1297–1305

  5. 5.

    George CF (2007) Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med 176(10):954–956. https://doi.org/10.1164/rccm.200605-629PP

  6. 6.

    Strohl KP, Brown DB, Collop N, George C, Grunstein R, Han F, Kline L, Malhotra A, Pack A, Phillips B, Rodenstein D, Schwab R, Weaver T, Wilson K (2013) ATS Ad Hoc Committee on Sleep Apnea, Sleepiness, and Driving Risk in Noncommercial Drivers. An official American Thoracic Society clinical practice guideline: sleep apnea, sleepiness, and driving risk in noncommercial drivers. An update of a 1994 statement. Am J Respir Crit Care Med 187(11):1259–1266. https://doi.org/10.1164/rccm.201304-0726ST

  7. 7.

    Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342(19):1378–1384. https://doi.org/10.1056/nejm200005113421901

  8. 8.

    Lavie P, Herer P, Hoffstein V (2000) Obstructive sleep apnoea syndrome as a risk factor for hypertension: population study. BMJ (Clinical Research ed) 320(7233):479–482

  9. 9.

    Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D’Agostino RB, Newman AB, Lebowitz MD, Pickering TG (2000) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study Jama 283(14):1829–1836

  10. 10.

    Grote L, Ploch T, Heitmann J, Knaack L, Penzel T, Peter JH (1999) Sleep-related breathing disorder is an independent risk factor for systemic hypertension. Am J Respir Crit Care Med 160(6):1875–1882. https://doi.org/10.1164/ajrccm.160.6.9811054

  11. 11.

    Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Leiby BE, Vela-Bueno A, Kales A (2000) Association of hypertension and sleep-disordered breathing. Arch Intern Med 160(15):2289–2295. https://doi.org/10.1001/archinte.160.15.2289

  12. 12.

    Roche F, Pepin JL, Achour-Crawford E, Tamisier R, Pichot V, Celle S et al (2012) At 68 years, unrecognised sleep apnoea is associated with elevated ambulatory blood pressure. Eur Respir J 40(3):649–656. https://doi.org/10.1183/09031936.00162710

  13. 13.

    Marin JM, Carrizo SJ, Vicente E, Agusti AG (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365(9464):1046–1053. https://doi.org/10.1016/s0140-6736(05)71141-7

  14. 14.

    Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O’Connor GT et al (2009) Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Medicine 6(8):e1000132. https://doi.org/10.1371/journal.pmed.1000132

  15. 15.

    Gottlieb DJ, Yenokyan G, Newman AB, O’Connor GT, Punjabi NM, Quan SF et al (2010) Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study. Circulation 122(4):352–360. https://doi.org/10.1161/circulationaha.109.901801

  16. 16.

    Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ et al (2008) Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 31(8):1071–1078

  17. 17.

    Martinez-Garcia MA, Campos-Rodriguez F, Catalan-Serra P, Soler-Cataluna JJ, Almeida-Gonzalez C, De la Cruz MI et al (2012) Cardiovascular mortality in obstructive sleep apnea in the elderly: role of long-term continuous positive airway pressure treatment: a prospective observational study. Am J Respir Crit Care Med 186(9):909–916. https://doi.org/10.1164/rccm.201203-0448OC

  18. 18.

    Hla KM, Young T, Hagen EW, Stein JH, Finn LA, Nieto FJ et al (2015) Coronary heart disease incidence in sleep disordered breathing: the Wisconsin Sleep Cohort Study. Sleep 38(5):677–684

  19. 19.

    Hermann DM, Bassetti CL (2016) Role of sleep-disordered breathing and sleep-wake disturbances for stroke and stroke recovery. Neurology 87(13):1407–1416

  20. 20.

    Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE (2004) Sleep-disordered breathing, glucose intolerance, and insulin resistance: the sleep heart health study. Am J Epidemiol 160(6):521–530

  21. 21.

    Togeiro SM, Carneiro G, Ribeiro Filho FF, Zanella MT, Santos-Silva R, Taddei JA et al (2013) Consequences of obstructive sleep apnea on metabolic profile: a population-based survey. Obesity (Silver Spring, Md) 21(4):847–851

  22. 22.

    Kent BD, Grote L, Ryan S, Pepin JL, Bonsignore MR, Tkacova R et al (2014) Diabetes mellitus prevalence and control in sleep-disordered breathing: the European sleep apnea cohort (ESADA) study. Chest 146(4):982–990

  23. 23.

    Yaffe K, Laffan AM, Harrison SL, Redline S, Spira AP, Ensrud KE et al (2011) Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. Jama 306(6):613–619

  24. 24.

    Chen YH, Keller JK, Kang JH, Hsieh HJ, Lin HC (2013) Obstructive sleep apnea and the subsequent risk of depressive disorder: a population-based follow-up study. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 9(5):417–423

  25. 25.

    Peppard PE, Szklo-Coxe M, Hla KM, Young T (2006) Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med 166(16):1709–1715. https://doi.org/10.1001/archinte.166.16.1709

  26. 26.

    Aloia MS, Arnedt JT, Smith L, Skrekas J, Stanchina M, Millman RP (2005) Examining the construct of depression in obstructive sleep apnea syndrome. Sleep Med 6(2):115–121. https://doi.org/10.1016/j.sleep.2004.09.003

  27. 27.

    Wheaton AG, Perry GS, Chapman DP, Croft JB (2012) Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005–2008. Sleep 35(4):461–467

  28. 28.

    Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW, Grunstein RR (2008) Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 31(8):1079–1085

  29. 29.

    Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V (2005) Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 353(19):2034–2041. https://doi.org/10.1056/NEJMoa043104

  30. 30.

    Molnar MZ, Mucsi I, Novak M, Szabo Z, Freire AX, Huch KM et al (2015) Association of incident obstructive sleep apnoea with outcomes in a large cohort of US veterans. Thorax 70(9):888–895. https://doi.org/10.1136/thoraxjnl-2015-206970

  31. 31.

    Kim RD, Kapur VK, Redline-Bruch J, Rueschman M, Auckley DH, Benca RM et al (2015) An economic evaluation of home versus laboratory-based diagnosis of obstructive sleep Aapnea. Sleep 38(7):1027–1037

  32. 32.

    Moro M, Westover MB, Kelly J, Bianchi MT (2016) Decision modeling in Ssleep apnea: the critical roles of pretest probability, cost of untreated obstructive sleep apnea, and time horizon. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 12(3):409–418

  33. 33.

    Department of Health and Human Services CfMaMS. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA). CAG#0093R2. . 2013 March 13, 2008. Report No.

  34. 34.

    Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ et al (2007) Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable monitoring task force of the American Academy of Sleep Medicine. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 3(7):737–747

  35. 35.

    El Shayeb M, Topfer LA, Stafinski T, Pawluk L, Menon D (2014) Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis. CMAJ : Canadian Medical Association J J de l’Association Medicale Canadienne 186(1):E25–E51

  36. 36.

    Qaseem A, Dallas P, Owens DK, Starkey M, Holty JE, Shekelle P (2014) Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from theAmerican College of Physicians. Ann Intern Med 161(3):210–220

  37. 37.

    Berry RB, Hill G, Thompson L, McLaurin V (2008) Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. Sleep 31(10):1423–1431

  38. 38.

    Skomro RP, Gjevre J, Reid J, McNab B, Ghosh S, Stiles M, Jokic R, Ward H, Cotton D (2010) Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest 138(2):257–263. https://doi.org/10.1378/chest.09-0577

  39. 39.

    Kuna ST, Gurubhagavatula I, Maislin G, Hin S, Hartwig KC, McCloskey S, Hachadoorian R, Hurley S, Gupta R, Staley B, Atwood CW (2011) Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med 183(9):1238–1244. https://doi.org/10.1164/rccm.201011-1770OC

  40. 40.

    Rosen CL, Auckley D, Benca R, Foldvary-Schaefer N, Iber C, Kapur V et al (2012) A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep 35(6):757–767

  41. 41.

    Berry RB BR, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL and Vaughn BV for the American Academy of Sleep Medicine. . The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Version 2.3.0 ed. Darien, Illinois: American Academy of Sleep Medicine; 2016

  42. 42.

    Flemons WW, Littner MR, Rowley JA, Gay P, Anderson WM, Hudgel DW et al (2003) Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of sleep medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest 124(4):1543–1579. https://doi.org/10.1378/chest.124.4.1543

  43. 43.

    Masa JF, Corral J, Pereira R, Duran-Cantolla J, Cabello M, Hernandez-Blasco L et al (2011) Therapeutic decision-making for sleep apnea and hypopnea syndrome using home respiratory polygraphy: a large multicentric study. Am J Respir Crit Care Med 184(8):964–971. https://doi.org/10.1164/rccm.201103-0428OC

  44. 44.

    Bianchi MT, Goparaju B (2017) Potential underestimation of sleep apnea severity by at-home kits: rescoring in-laboratory polysomnography without sleep staging. J Clinical Sleep Medicine : JCSM : Official Publication Ame Academy Sleep Medicine 13(4):551–555

  45. 45.

    Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP et al (2009) Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 5(3):263–276

  46. 46.

    Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K et al (2017) Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine Clinical Practice Guideline. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 13(3):479–504

  47. 47.

    Collop N (2012) Home sleep testing: appropriate screening is the key. Sleep 35(11):1445–1446

  48. 48.

    Brown LK (2007) Mild obstructive sleep apnea syndrome should be treated. Pro. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 3(3):259–262

  49. 49.

    Chung F, Abdullah HR, Liao P (2016) STOP-bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest 149(3):631–638

  50. 50.

    Chung F, Yang Y, Brown R, Liao P (2014) Alternative scoring models of STOP-bang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 10(9):951–958

  51. 51.

    Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. Deliberations of the sleep apnea definitions task force of the American Academy of Sleep Medicine. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 8(5):597–619

  52. 52.

    Morales CR, Hurley S, Wick LC, Staley B, Pack FM, Gooneratne NS et al (2012) In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly. Sleep 35(11):1491–1501. https://doi.org/10.5665/sleep.2196

  53. 53.

    Nerfeldt P, Aoki F, Friberg D (2014) Polygraphy vs. polysomnography: missing osas in symptomatic snorers—a reminder for clinicians. Sleep Breathing = Schlaf Atmung 18(2):297–303. https://doi.org/10.1007/s11325-013-0884-6

  54. 54.

    Guerrero A, Embid C, Isetta V, Farre R, Duran-Cantolla J, Parra O, Barbé F, Montserrat JM, Masa JF (2014) Management of sleep apnea without high pretest probability or with comorbidities by three nights of portable sleep monitoring. Sleep 37(8):1363–1373. https://doi.org/10.5665/sleep.3932

  55. 55.

    Guilleminault C, Black JE, Palombini L, Ohayon M (2000) A clinical investigation of obstructive sleep apnea syndrome (OSAS) and upper airway resistance syndrome (UARS) patients. Sleep Med 1(1):51–56. https://doi.org/10.1016/S1389-9457(99)00011-8

  56. 56.

    Campos-Rodriguez F, Martinez-Garcia MA, Reyes-Nunez N, Selma-Ferrer MJ, Punjabi NM, Farre R (2016) Impact of different hypopnea definitions on obstructive sleep apnea severity and cardiovascular mortality risk in women and elderly individuals. Sleep Medicine 27–28:54–58. https://doi.org/10.1016/j.sleep.2016.05.020

  57. 57.

    Guilleminault C, Hagen CC, Huynh NT (2009) Comparison of hypopnea definitions in lean patients with known obstructive sleep apnea hypopnea syndrome (OSAHS). Sleep Breathing Schlaf Atmung 13(4):341–347. https://doi.org/10.1007/s11325-009-0253-7

  58. 58.

    Cairns A, Poulos G, Bogan R Who is getting tested for obstructive sleep apnea using a portable recording system? Test results from 193,221 patients, 2014. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 10(11):1193–1198. https://doi.org/10.5664/jcsm.4198

  59. 59.

    Lin CM, Davidson TM, Ancoli-Israel S (2008) Gender differences in obstructive sleep apnea and treatment implications. Sleep Medicine Reviews 12(6):481–496. https://doi.org/10.1016/j.smrv.2007.11.003

  60. 60.

    Ye L, Pien GW, Ratcliffe SJ, Weaver TE (2009) Gender differences in obstructive sleep apnea and treatment response to continuous positive airway pressure. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 5(6):512–518

  61. 61.

    Guilleminault C, Stoohs R, Kim YD, Chervin R, Black J, Clerk A (1995) Upper airway sleep-disordered breathing in women. Ann Intern Med 122(7):493–501. https://doi.org/10.7326/0003-4819-122-7-199504010-00003

  62. 62.

    Greenberg-Dotan S, Reuveni H, Simon-Tuval T, Oksenberg A, Tarasiuk A (2007) Gender differences in morbidity and health care utilization among adult obstructive sleep apnea patients. Sleep 30(9):1173–1180

  63. 63.

    Myers KA, Mrkobrada M, Simel DL (2013) Does this patient have obstructive sleep apnea?: the rational clinical examination systematic review. JAMA 310(7):731–741. https://doi.org/10.1001/jama.2013.276185

  64. 64.

    Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P (1993) A cause of excessive daytime sleepiness. The upper airway resistance syndrome. Chest 104(3):781–787. https://doi.org/10.1378/chest.104.3.781

  65. 65.

    Bonnet MH, Doghramji K, Roehrs T, Stepanski EJ, Sheldon SH, Walters AS, Wise M, Chesson AL Jr (2007) The scoring of arousal in sleep: reliability, validity, and alternatives. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 3(2):133–145

  66. 66.

    Gottlieb DJ, Whitney CW, Bonekat WH, Iber C, James GD, Lebowitz M et al (1999) Relation of sleepiness to respiratory disturbance index: the sleep heart health study. Am J Respir Crit Care Med 159(2):502–507. https://doi.org/10.1164/ajrccm.159.2.9804051

  67. 67.

    Hedner J, Grote L, Bonsignore M, McNicholas W, Lavie P, Parati G, Sliwinski P, Barbe F, de Backer W, Escourrou P, Fietze I, Kvamme JA, Lombardi C, Marrone O, Masa JF, Montserrat JM, Penzel T, Pretl M, Riha R, Rodenstein D, Saaresranta T, Schulz R, Tkacova R, Varoneckas G, Vitols A, Vrints H, Zielinski J (2011) The European Sleep Apnoea Database (ESADA): report from 22 European sleep laboratories. Eur Respir J 38(3):635–642. https://doi.org/10.1183/09031936.00046710

  68. 68.

    Escourrou P, Grote L, Penzel T, McNicholas WT, Verbraecken J, Tkacova R et al (2015) The diagnostic method has a strong influence on classification of obstructive sleep apnea. J Sleep Res 24(6):730–738. https://doi.org/10.1111/jsr.12318

  69. 69.

    Zeidler MR, Santiago V, Dzierzewski JM, Mitchell MN, Santiago S, Martin JL (2015) Predictors of obstructive sleep apnea on polysomnography after a technically inadequate or normal home sleep test. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 11(11):1313–1318. https://doi.org/10.5664/jcsm.5194

  70. 70.

    Ho V, Crainiceanu CM, Punjabi NM, Redline S, Gottlieb DJ (2015) Calibration model for apnea-hypopnea indices: impact of alternative criteria for hypopneas. Sleep 38(12):1887–1892. https://doi.org/10.5665/sleep.5234

  71. 71.

    Ng Y, Joosten SA, Edwards BA, Turton A, Romios H, Samarasinghe T et al (2017) Oxygen desaturation index differs significantly between types of sleep software. J Clinical Sleep Medicine : JCSM : Official Publication Am Academy Sleep Medicine 13(4):599–605. https://doi.org/10.5664/jcsm.6552

  72. 72.

    Chowdhuri S, Quan SF, Almeida F, Ayappa I, Batool-Anwar S, Budhiraja R, Cruse PE, Drager LF, Griss B, Marshall N, Patel SR, Patil S, Knight SL, Rowley JA, Slyman A, ATS Ad Hoc Committee on Mild Obstructive Sleep Apnea (2016) An official American thoracic society research statement: impact of mild obstructive sleep apnea in adults. Am J Respir Crit Care Med 193(9):e37–e54. https://doi.org/10.1164/rccm.201602-0361ST

Download references


The authors wish to thank Ronald D. Chervin, MD, MS for advice on data analysis and review of the manuscript, and Casey Cox, RPSGT for assistance with database queries.

Author information

Correspondence to Cathy A. Goldstein.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (University of Michigan IRBMED) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Goldstein, C.A., Karnib, H., Williams, K. et al. The utility of home sleep apnea tests in patients with low versus high pre-test probability for moderate to severe OSA. Sleep Breath 22, 641–651 (2018). https://doi.org/10.1007/s11325-017-1594-2

Download citation


  • Obstructive sleep apnea
  • Home sleep apnea test
  • Polysomnogram
  • Pre-test probability