We are grateful to Dr. Bloch and colleagues for drawing attention to some important points for discussion regarding our article. We focused exclusively on high-probability patients in order to test our strategy first in patients who are most in need while minimizing the risk for misdiagnosis. Dr. Bloch and colleagues infer that our selection criteria excluded 97% of the patients from the trial (Figure 2). However, many patients could not participate in the trial because of time or distance constraints—not because of our stringent inclusion criteria. The proportion of eligible patients, based only on the characteristics of the disease, would be closer to 15%. Our trial protocol was rigorous to ensure patient safety, and we do not suggest replicating those conditions in clinical practice. Our suggested approach to patients in the clinic is included in the much-simplified clinical algorithm (Figure 5) that requires an initial consultation, a follow-up visit for initiation of CPAP after ambulatory diagnosis, and a follow-up visit after 2 weeks of CPAP to confirm efficacy.

Dr. Bloch and colleagues point to previous studies that tested diagnostic–therapeutic algorithms (1, 2). In Whitelaw and colleagues' study (1), all patients were placed on auto-CPAP, and Senn and colleagues' study (2) had no randomized component. An earlier study by Coppola and associates (3) was a small retrospective case series. The recommended approach to diagnosis and treatment of OSA involves 2 nights in the sleep laboratory—1 diagnostic study and 1 CPAP titration. We tested both components against an ambulatory strategy, and we believe that ours is the first study to do so in a randomized manner. Furthermore, our results allow for the separation of the components of our algorithm—the diagnostic and treatment strategies can be used independently. In many countries, a diagnosis of OSA is required before reimbursement for CPAP equipment; therefore, we felt that it was important to achieve a diagnosis before treatment. Our experience in the study supports the use of a 2-week CPAP trial as confirmation of the diagnosis of OSA, and we include that in our algorithm (Figure 5).

Finally, we agree with Bloch and colleagues that ambulatory approaches should be adopted as a first-line strategy for high-probability patients, with the caveat that patients who do not meet the criteria of the diagnostic algorithm or who do not respond favorably to CPAP should have polysomnography. Obstructive sleep apnea is undiagnosed in an estimated 82% of patients (4). The increasing awareness of OSA and increasing prevalence of obesity will probably make ambulatory strategies a necessity.