Noninferiority of Functional Outcome in Ambulatory Management of Obstructive Sleep Apnea

Rationale: Home portable monitor testing is increasingly being used to diagnose patients with obstructive sleep apnea (OSA) and to initiate them on continuous positive airway pressure (CPAP) treatment. Objectives: To compare functional outcome and treatment adherence in patients who receive ambulatory versus in-laboratory testing for OSA. Methods: Veterans with suspected OSA were randomized to either home testing or standard in-laboratory testing. Home testing consisted of a type 3 portable monitor recording followed by at least three nights using an automatically adjusting positive airway pressure apparatus. Participants diagnosed with OSA were treated with (PAP for 3 months. Measurements and Main Results: We measured the change in Functional Outcomes of Sleep Questionnaire score, with an a priori noninferiority delta of -1, and the mean daily hours of objectively measured CPAP adherence, with an a priori noninferiority delta of -0.75 hour/day. Of the 296 subjects enrolled, 260 (88%) were diagnosed with OSA, and 213 (75%) were initiated on CPAP. Mean +/- SD functional outcome score improved 1.74 +/- 2.81 in the home group (P < 0.001) and 1.85 +/- 2.46 in the in-laboratory group (P < 0.0001). The lower bound of the one-sided 95% noninferiority confidence interval was -0.54. Mean +/- SD hours of daily (PAP adherence were 3.5 +/- 2.5 hours/day in the home group and 2.9 +/- 2.3 hours/day in the in-laboratory group (P = 0.08). The lower bound of the one-sided 95% noninferiority confidence interval was 0.03. Conclusions: Functional outcome and treatment adherence in patients evaluated according to a home testing algorithm is not clinically inferior to that in patients receiving standard in-laboratory polysomnography.