Use of drug-induced sleep endoscopy in Germany—an analysis based on claims data

The clinical value of DISE has been proven in multiple trials and it is recommended as a diagnostic tool in patients with OSA seeking PAP alternatives, especially in screening for MAD and HNS or for planning of surgical interventions on the upper airway [13, 14]. As expected, the examination is used in Germany, but in the absence of a specific procedure code, it was not possible to estimate the actual use until now. This study provides a first analysis of routine clinical practice in German hospitals, and presents some interesting findings.

Although DISE was introduced many years ago, its relevance as a diagnostic tool for patients with OSA in Germany is limited. In 2021, only 2765 examinations were conducted in the hospital sector, which represents 4.5% of all admissions for OSA. Other countries that use DISE in routine clinical practice report remarkably higher use. A recent analysis from the Netherlands, for example, stated 7090 examinations in 2018, while this country has only a fifth of the German population [15].

With most cases performed by hospitals with more than 800 beds, DISE is a method that is largely provided by clinics with a higher level of specialization. Though no data are available on the medical discipline that conducts the examination, it is likely that these will be mainly larger otorhinolaryngology or pneumological departments that specialize in advanced diagnosis and treatment of OSA. As interpretation of DISE findings and subsequent therapeutic decision-making requires training and experience, it seems reasonable that this examination is mainly provided by specialized centers with higher caseloads.

Patients receiving DISE are often admitted for a combination of examinations or interventions. Interestingly, 15% of patients receiving DISE were admitted with a main diagnosis of nasal septum deviation and 18% received DISE in combination with some type of nasal surgery. Though it does not seem logical to admit a patient with such a diagnosis for DISE, which is not obviously linked to OSA, there are a few reasons that could explain the high number of patients with nasal main diagnoses undergoing DISE. First, snoring is one of the leading symptoms in OSA and patients might be admitted with this diagnosis before OSA is confirmed, i.e., in a hospital stay that combines polysomnography and DISE. Secondly, as DISE is conducted largely by otorhinolaryngologists, concurrent septal deviation or other nasal conditions that require treatment are performed in the same hospital stay and under the same general anesthesia as the DISE to reduce the burden for the patient and streamline the treatment process. Conducting DISE at the same time as other surgeries also explains the relatively long mean hospital stay of 4.3 days, which would not be required for DISE alone. With its low invasiveness, the examination is commonly carried out as an outpatient procedure in other healthcare systems [8]. Due to limitations to reimbursement within the German statutory health insurance system, this is possible only in private or self-paying patients, and those cases are not documented in any statistic. With introduction of the specific OPS code, reimbursement of DISE is now possible in hospitals via DRG payments. Given constant budget constraints, it remains to be seen whether the new code will lead to improved funding of this examination technique. Based on anecdotal feedback from some clinics providing DISE, payers often deny claims ex-post, even if proper coding was used and the procedure was conducted per standards of care.

The population receiving DISE consists largely of male patients of the typical age groups in which symptoms become apparent. Although patients present with the typical comorbidities, they tend to be rather healthy, with only few classified as more complex in the respective higher PCCL groups. As such, the population receiving DISE can be considered healthier when compared to the general population admitted for OSA. This is supported by the significantly higher rates of all comorbidities investigated in the population of all admitted OSA patients.

Of particular interest is the distribution of obesity levels across the two groups: patients with higher levels of obesity are underrepresented among patients receiving DISE. Given that accumulation of fat tissue in the upper airway can lead to more complex anatomical situations, it is surprising that DISE is not used more often in this population, since it could lead to improved understanding of the pathophysiology and thus better decision-making. Specific reasons cannot be derived from the available data, as the particular indication for the examination and the phase of the patient in their disease journey is not documented. Potentially, DISE is mainly used in patients who undergo screening for treatments that have specific BMI limits, such as MAD or HNS therapy. Another explanation could be that DISE is mainly used in cases with low adherence to PAP therapy to evaluate potential second-line treatments, which is more common in patients with lower levels of obesity [16]. Additionally, use of DISE will certainly be influenced by individual patient preferences, daytime symptoms, and treatment motivation. Given the fact that this examination is mainly provided by larger hospitals, accessibility across the country will likely also drive demand from patients.

Limitations

This study is subject to certain limitations, which are mainly related to the dataset that was available for analysis. First, the specific OPS code was only implemented in the analyzed year. Some providers might not have been aware that DISE can be documented with this code and some cases could have been performed using the nonspecific coding that was available beforehand. Second, the study only includes DISE cases performed during a hospital admission that led to billing of a DRG. Hospitals with specific agreements for ambulatory care or which use other reimbursement schemes could not be obliged to use the new code. Since DISE is also offered by physicians in the outpatient sector for privately insured or self-paying patients, these cases are also not included, as there is no requirement to report them. As such, there could be an underreporting of the actual DISE cases performed in 2021. As reimbursement of DISE by statutory insurance is only available for hospitals and these payers covers 88% of the German population, we believe, however, that the dataset covers the vast majority of examinations [17]. Another limitation is the completeness of the dataset itself, which provides information at only an aggregated level and in limited granularity; therefore, a more advanced analysis including patient pathways and disease journeys was not possible. This would, however, be interesting to further evaluate this technique for diagnosis of patients with OSA.

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