There are new changes to Medicare from November 1, 2018, which will affect how GPs can order sleep studies and how they follow up the results. These changes have been introduced by the MBS Review Taskforce and Government to improve doctor assessment and management of a patient having a sleep study.

What are the new Medicare changes?

From November 1 2018:

• GPs will need to administer screening questionnaires before directly ordering a Medicare rebatable sleep study.
• Only if these screening questionnaires are positive, can GPs refer directly for a Medicare rebatable sleep study test.
• The screening questionnaires restrict testing to patients with a “high probability for symptomatic, moderate to severe obstructive sleep apnoea”.
• Following sleep study testing, “the results and treatment options following any diagnostic sleep study should be discussed during a professional attendance with a medical practitioner before the initiation of any therapy”.

If the screening questionnaires are not positive, patients will need to be referred to Sleep or Respiratory Physicians for assessment and testing. Diagnostic sleep studies can only be rebated once a year.  

Why were the changes made?

 The MBS Review Taskforce noted a very large growth in sleep study testing, especially home sleep study testing, and were concerned that better access to testing has been associated with less appropriate referrals for testing. The Taskforce noted a lack of Sleep or Respiratory Physician review of patients for advice regarding the diagnosis and treatment of OSA. Related to this was a concern that some models of care were promoting home sleep study testing and then advising patients to proceed to CPAP “at lower apnoea-hypopnoea index (AHI) thresholds than is conventionally recommended as indicative of OSA requiring treatment.” The Taskforce commented that there may be a “commencement on CPAP which in some cases is not clinically indicated and does not address their sleep related problem. In this (later) scenario, patients purchase CPAP devices that may deliver little benefit, often based on advice from non-health professionals, and with no medical consultation involved.”  

What do GPs need to do differently?

For adult sleep disorders, GPs can refer to a Sleep or Respiratory Physician for further testing and management (unchanged). This is particularly relevant and important if the patient has atypical symptoms of OSA; have a BMI > 30 and obesity hypoventilation is suspected; or they have symptoms of non-OSA sleep disorders that require management (e.g. insomnia, parasomnias, restless legs syndrome, primary hypersomnolence, etc.) OR GPs can refer directly for a sleep study to investigate OSA (subject to the new specific rules below) Direct referral for a sleep study by a GP should be for patients who have a high probability for symptomatic, moderate to severe obstructive sleep apnoea using the following screening tools:

• An Epworth Sleepiness Scale score of 8 or more; AND
• One of the following
  • A STOP-BANG score of 4 or more; or
  • An OSA-50 score of 5 or more; or
  • A high risk score on the Berlin Questionnaire.

The screening questionnaires must be administered by the referring practitioner.  Unattended (home) sleep studies are suitable for many patients with suspected OSA but patients with other sleep disorders should undergo an attended (laboratory) study.  If GPs refer direct for sleep study testing, a doctor (GP or Sleep/Respiratory Physician) should see the patient after the test to discuss the results and advise on the best management for the patient’s sleep condition.  

The future for primary care and sleep disorders

GPs and Sleep Specialists need to work closely together to co-manage the range and high prevalence of sleep disorders. The new Medicare rules place a greater emphasis on medical assessment, before and after sleep study testing, and emphasise the important role that doctors need to take in managing these conditions.

Summary:

1. For a GP to refer directly for a sleep study, the relevant questionnaires need to be attached to the referral for it to be valid.
2. Sleep or Respiratory Physician referrals do not need the questionnaires to be filled in.
3. Patients must be seen by a doctor before the study for the questionnaires to be filled, and after the study,before any treatment is initiated.
4. The number of Medicare rebatable sleep studies per patient per year has been limited.

Screening questionnaires:

See link: http://www.sleepcentres.com.au/tl_files/PDF/referral_form_PDF.pdf See tables attached.  

Epworth Sleepiness Scale

               

OSA-50 Questionnaire

         

STOP-BANG Questionnaire

       

Berlin Questionnaire