Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment

Predictors of Hypoglossal Nerve Stimulator Usage: A Growth Curve Analysis Study

OBJECTIVE

The purpose of this study is to evaluate the long-term usage of the hypoglossal nerve stimulator and identify predictors of usage over time.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic medical center and database.

METHODS

Single institution retrospective chart review was merged with Inspire SleepSync device usage data. Growth curve modeling was performed with a linear mixed-effects model to evaluate usage hours over time. A logistic regression analysis was also performed to assess the relationship between early adherence and adherence at 1 and 2 years.

RESULTS

A total of 352 patients were included in the study. Seventy percent were male and the mean age was 64 ± 12 years. Adherence at 6 months was significantly predictive of adherence at 12 (odds ratio [OR] 9.42, CI 3.23-28.76, P < .001) and 24 (OR 3.03, CI 0.96-9.05, P = .049) months. Older age (estimate = 0.019, SE 0.006, P = .002) and greater days of use per biweekly period (estimate = 0.142, SE 0.004, P < .001) were positive predictors of usage. Insomnia (estimate = -0.386, SE 0.128, P = .003) and higher device mean voltage amplitude (estimate = -0.348, SE 0.020, P < .001) were negative predictors.

CONCLUSION

Time since activation does not appear to have an impact on hypoglossal nerve stimulator therapy usage. Insomnia and higher device voltage were associated with a statistically significant negative trend in therapy usage, whereas older age and greater number of days used may be predictive of higher therapy usage. Identifying predictors of usage will enable identification of at-risk patients and allow for early implementation of targeted interventions to improve patient adherence and optimize long-term health outcomes.

Use of vouchers for CPAP therapy initiation - public and private health care could work together

PURPOSE

The increasing incidence of sleep apnea has led to an increased workload for healthcare professionals. Continuous positive airway pressure (CPAP) is the gold standard therapy for obstructive sleep apnea. To reduce the CPAP waiting list in public healthcare, we proposed a CPAP voucher for use in private clinics for CPAP initiation. This study evaluated the success rate of CPAP initiation via this voucher.

METHODS

We selected patients from our sleep apnea clinic referred to CPAP initiation aged 18-80 years with no significant physical or psychological comorbidity. Three private clinics (A, B, C) accepted the CPAP voucher.

RESULTS

A total of 1922 patients fulfilled CPAP voucher criteria. Of these, we included 1604 patients (38% women). Mean BMI was 32 kg/m2, mean age was 55 years, and mean apnea-hypopnea index was 34/h. Data were missing for 113 patients at the 1-year follow-up visit. Of the remaining 1491 patients, 1398 continued CPAP therapy beyond 1 year, indicating a CPAP therapy success rate of 94%. There were no significant differences between clinics in the number of patients staying on CPAP at 1 year after initiation.

CONCLUSION

A CPAP voucher may reduce the CPAP initiation waiting list in public healthcare with a good success rate.

Evaluation of continuous positive airway pressure adherence and its contributing factors

BACKGROUND

Continuous positive airway pressure (CPAP) adherence may vary based on the study design and country.

OBJECTIVES

To investigate long-term CPAP adherence and elucidate associated factors.

METHODS

A multicenter retrospective observational cohort study was conducted over two years. The study included patients diagnosed with obstructive sleep apnea who were prescribed CPAP (n = 1261). Adherence was assessed for 90 days and 365 days. Centers for Medicare and Medicaid Services (CMS) criteria (≥4 h/night on ≥70 % of nights) and research adherence criteria (≥4 h/night during the observational period) were used. Factors influencing CPAP adherence (CMS criteria) during 90 and 365 days were also evaluated. Continuous variables were categorized into low, middle, and high classes, and logistic regression analysis with interaction was performed.

RESULTS

CPAP adherence to CMS criteria for 90 and 365 days was 45.6 % and 44.7 %, respectively, whereas adherence to research criteria was 57.0 % and 54.1 %, respectively. Middle age, high age, and high apnea ratio independently increased CPAP adherence. Conversely, a high rapid eye movement apnea-hypopnea index ratio decreased CPAP adherence. Although high body mass index (BMI) had no independent effect on adherence, its interaction with high 3 % oxygen desaturation index increased 90-day CPAP adherence. However, high BMI decreased 90-day CPAP adherence in males. The interaction between middle age and high BMI was associated with decreased CPAP adherence over 365 days.

CONCLUSIONS

Adherence to CPAP in real-world settings is modest. Various factors influence CPAP adherence. BMI may exert varied effects on CPAP adherence depending on the accompanying factors.

Positive Airway Pressure, Mortality, and Cardiovascular Risk in Older Adults With Sleep Apnea

Importance

Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited.

Objective

To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US.

Design, Setting, and Participants

This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023.

Exposures

Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis.

Main Outcomes and Measures

All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors.

Results

Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.

Educational video demonstrating collapsibility of the upper airway during sleep improves initial acceptance of CPAP in patients with severe obstructive sleep apnea: a retrospective study

STUDY OBJECTIVES

We investigated whether an audiovisual educational video demonstrating collapsibility of the upper airway during sleep would influence initial continuous positive airway pressure (CPAP) acceptance among patients with severe obstructive sleep apnea.

METHODS

Between January 2017 and December 2018, a single-center retrospective study was conducted. We implemented an educational video demonstrating upper airway collapsibility during sleep in February 2018. We analyzed the medical records from 145 consecutive patients diagnosed with severe obstructive sleep apnea who underwent in-laboratory polysomnography both before and after implementing the educational video. Among them, 76 patients received standard care before the video's introduction (standard care group), and another 69 patients were managed after its implementation (video group).

RESULTS

Baseline characteristics including age, body mass index, educational level, occupation category, comorbidities, Mallampati score, Epworth Sleepiness Scale score, apnea-hypopnea index, and sleep time with SpO2 below 90% were not significantly different between the 2 groups. Acceptance of CPAP following an in-laboratory overnight titration study was significantly higher in the video group (80%) than in the standard care group (57%) (P = .003). Multivariate regression analyses revealed that watching the video was a strong predictor of initial CPAP acceptance (odds ratio, 4.162; 95% confidence interval, 1.627-10.646; P = .004). Both sleep time with SpO2 below 90% (odds ratio, 1.020; 95% confidence interval, 1.002-1.038; P = .029) and sleep efficiency (odds ratio, 1.052; 95% confidence interval, 1.023-1.083; P < .001) were weak predictors for initial CPAP acceptance. At 12 months, adherence among those who accepted the CPAP treatment was similar between the 2 groups (78% vs 74%; P = .662). However, within the initial cohorts, a significantly higher proportion of patients in the video group (62%) were using CPAP at 12 months compared with the standard care group (42%) (P = .015).

CONCLUSIONS

Among patients with severe obstructive sleep apnea, an educational video demonstrating upper airway collapsibility during sleep improved initial CPAP acceptance rates when compared with standard care.

CITATION

Tselepi C, Tsirves G, Exarchos K, et al. Educational video demonstrating collapsibility of the upper airway during sleep improves initial acceptance of CPAP in patients with severe obstructive sleep apnea: a retrospective study. J Clin Sleep Med. 2024;20(9):1423-1433.

Bed partner perception of CPAP therapy on relationship satisfaction and intimacy-A European perspective from the ESADA network

Obstructive sleep apnea increases morbidity and mortality risks. The most common treatment is continuous positive airway pressure, with nasal mask usage being important, but not always optimal. While most research on treatment adherence focuses on the patient, the bed partner's involvement may be detrimental. Our study aim is to obtain a European-wide picture of the bed partner's attitude and support towards continuous positive airway pressure therapy, including effects on relationship satisfaction and intimacy. The English translation of a German bed partner questionnaire, assessing relationship satisfaction and three major components (general attitude, perceived mask looks, intimacy effects) was distributed within the European Sleep Apnea Database Network and translated in participating countries' local language. Data were collected for 2 years. In total, 10 European countries (13 sleep centres) participated with 1546 questionnaires. Overall, 91% of bed partners had a positive attitude towards continuous positive airway pressure therapy, 86% perceived mask looks not negative, 64% stated no negative intimacy effects. More specifically, 71% mentioned improved sleep quality, 68% supported nightly device usage. For 41% of bed partners, relationship satisfaction increased (no change for 47%). These results were significantly more pronounced in Eastern/Southern Europe compared with Middle Europe, especially regarding intimacy effects. However, increased continuous positive airway pressure therapy length affected attitude negatively. These results provide necessary information to improve treatment strategies by including educational couple-focused approaches. Among others, we revealed that negative intimacy effects are not considered a barrier to continuous positive airway pressure adherence. These results may inspire more research identifying regional gaps with need for treatment adjustments.

Health Inequalities in the Diagnosis and Treatment of Obstructive Sleep Apnea in Children and Adults

Our understanding of the prevalence of obstructive sleep apnea (OSA) in the United States is confounded by significant inequalities in diagnosis and treatment based on gender, race and socioeconomic status. Health literacy and cultural norms contribute to these inequities. Large gaps in data exist, as certain populations like Native Americans, Pacific Islanders, and sexual minorities have been sparsely studied, or not at all. Future research should aim to develop more inclusive diagnostic strategies to address OSA in diverse populations.

Positive Airway Pressure Therapy Predicts Lower Mortality and Major Adverse Cardiovascular Events Incidence in Medicare Beneficiaries with Obstructive Sleep Apnea

Background

Obesity is associated with obstructive sleep apnea (OSA) and cardiovascular risk. Positive airway pressure (PAP) is the first line treatment for OSA, but evidence on its beneficial effect on major adverse cardiovascular events (MACE) prevention is limited. Using claims data, the effects of PAP on mortality and incidence of MACE among Medicare beneficiaries with OSA were examined.

Methods

A cohort of Medicare beneficiaries with ≥2 distinct OSA claims was defined from multi-state, state-wide, multi-year (2011-2020) Medicare fee-for-service claims data. Evidence of PAP initiation and utilization was based on PAP claims after OSA diagnosis. MACE was defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights estimated treatment effects controlling for sociodemographic and clinical factors.

Results

Among 888,835 beneficiaries with OSA (median age 73 years; 43.9% women; median follow-up 1,141 days), those with evidence of PAP initiation (32.6%) had significantly lower all-cause mortality (HR [95%CI]: 0.53 [0.52-0.54]) and MACE incidence risk (0.90 [0.89-0.91]). Higher quartiles of annual PAP claims were progressively associated with lower mortality (Q2: 0.84 [0.81-0.87], Q3: 0.76 [0.74-0.79], Q4: 0.74 [0.72-0.77]) and MACE incidence risk (Q2: 0.92 [0.89-0.95], Q3: 0.89 [0.86-0.91], Q4: 0.87 [0.85-0.90]).

Conclusion

PAP utilization was associated with lower all-cause mortality and MACE incidence among Medicare beneficiaries with OSA. Results might inform trials assessing the importance of OSA therapy towards minimizing cardiovascular risk and mortality in older adults.

Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance

Obstructive sleep apnea (OSA) is the most common respiratory sleep disorder in the United States in preschool and school-aged children. In an effort to continue addressing gaps and variations in care in this patient population, the American Academy of Sleep Medicine (AASM) Quality Measures Task Force performed quality measure maintenance on the Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea (originally developed in 2015). The Quality Measures Task Force reviewed the current medical literature, including updated clinical practice guidelines and systematic literature reviews, existing pediatric OSA quality measures, and performance data highlighting remaining gaps or variations in care since implementation of the original quality measure set to inform any potential revisions to the quality measures. These revised quality measures have been implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous quality improvement, specifically in outcomes associated with diagnosing and managing OSA in the pediatric population.

CITATION

Lloyd RM, Crawford T, Donald R, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance. J Clin Sleep Med. 2024;20(1):127-134.

[Factors affecting adherence to CPAP therapy in patients with obstructive sleep apnea syndrome]

OBJECTIVE

Analysis of factors affecting adherence to continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA).

MATERIAL AND METHODS

The literature search was carried out using the databases PubMED, Google Scholar, E-library, Cyberleninka for the period 2013-2023 and included reviews and original articles.

RESULTS

The main groups of factors affecting adherence to CPAP therapy in patients with OSA have been established. These include sociodemographic and socioeconomic factors, the severity of OSA and the severity of clinical symptoms, and psychosocial factors. Strategies that can improve adherence were identified (educational technologies for patients, telemedicine technologies, behavioral therapy, modern technical interventions).

CONCLUSION

Factors that improve adherence to CPAP therapy are high levels of education and income, more severe OSA forms accompanied by daytime sleepiness, support from the patient's spouse and social support. Factors such as low levels of education and income, smoking, symptoms of depression and hypochondria, as well as side-effects worsen adherence to CPAP therapy, including refusal to continue treatment. It should be noted that all the identified factors are very closely associated with each other, so it is necessary to evaluate them comprehensively in each patient with OSA.

Accessibility to manage the obstructive sleep apnea within the Brazilian Unified Health System

OBJECTIVE

To measure the average time for the diagnosis and for the therapeutic prescription of Continuous Positive Airway Pressure (CPAP) at a hospital in Botucatu Medical School - State University São Paulo, UNESP.

METHOD

A retrospective observational study was carried out by collecting data from the electronic medical records of patients over 18-years of age, who had a diagnostic polysomnography testing scheduled between January and December 2017.

RESULT

Of the 347 patients eligible for the study, 94 (27.1%) missed follow-up and 103 (29.7%) had a referral for CPAP use. Until February 2021, only 37 (35.9%) of these patients had already acquired and were using the device, the remaining 66 (64.1%) were waiting or gave up the therapy. The mean value of the waiting time interval between the referral of the diagnostic test and its performance was equivalent to 197 days (6.5 months). The mean time between diagnostic polysomnography and CPAP prescription was 440-days (14.5-months), with a total mean time of 624 days (21-months).

CONCLUSION

As in other services, the diagnostic-therapeutic flow proved to be highly inefficient, with a long waiting period, difficult access to treatment and a high dropout rate. These findings highlight the need to establish new patient-centered strategies with measures that speed up the flow and facilitate access to CPAP, in order to reduce the morbidity and mortality associated with this condition.

LEVEL OF EVIDENCE

Level 3 - Non-randomized controlled cohort/follow-up study Recommendation B.

Nocturnal positive pressure ventilation improves relationship satisfaction of patients with OSA and their partners

OBJECTIVE

Continuous positive airway pressure (CPAP) ventilation is considered the therapeutic standard for obstructed sleep apnea (OSA). Therapy success may also be affected by the patient's bed partner. A questionnaire was developed and tested that measures the attitude of the bed partner towards CPAP therapy and relationship effects.

METHODS

A new questionnaire to capture bed partners' attitude towards CPAP mask therapy was used with an anonymous sample of 508 bed partners. Possible constructs underlying the attitude of the bed partner towards mask appearance have been investigated by means of a Principal Components Analysis.

RESULTS

The survey revealed bed partners' positive attitude towards their partner's CPAP therapy (over 90% of bed partners were happy with the therapy, over 75% would recommend the therapy). Importantly, the bed partners' satisfaction with the relationship increased significantly during CPAP therapy (before therapy: 49% were satisfied, after therapy initiation: 70%; p<.001). There was a strong correlation between support for CPAP therapy and improved sleep quality of bed partners (r = 0.352, p>.001). Furthermore, the validation of the questionnaire through principal components analysis revealed three major factors: Attitude (of the bed partner towards CPAP therapy), Looks (of the mask perceived by the bed partner), Intimacy (effect of CPAP therapy on relationship and intimacy).

CONCLUSION

Both, the OSA patient and the bed partner benefit from CPAP therapy. This is the first bed partner questionnaire - interviewing the bed partner alone and anonymously - that showed that CPAP therapy also positively influences the relationship. We recommend that the bed partner be involved in the CPAP treatment from the start of therapy.

The firstly visited department affects the acceptance of CPAP in patients with obstructive sleep apnea: a cohort study

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is the first-line treatment for obstructive sleep apnea (OSA). However, the low acceptance rate of CPAP remains a challenging clinical issue. This study aimed to determine the factors that influence the acceptance rate of CPAP.

METHODS

This retrospective cohort study was conducted at the sleep center of Shuang-Ho Hospital. Initially, 1186 OSA patients who received CPAP therapy between December 2013 and December 2017 were selected, and finally, 1016 patients were analyzed. All patients with OSA received CPAP therapy for at least 1 week, and their acceptance to treatment was subsequently recorded. Outcome measures included patients' demographic and clinical characteristics (sex, age, BMI, comorbidities, history of smoking, and the medical specialist who prescribed CPAP treatment), polysomnography (PSG) results, and OSA surgical records.

RESULTS

Patients with a lower CPAP acceptance rate were referred from otolaryngologists (acceptance rate of otolaryngology vs. others: 49.6% vs. 56.6%, p = .015), in addition to having a lower apnea-hypopnea index (AHI) (acceptance vs. non-acceptance: 55.83 vs. 40.79, p = .003), rapid eye movement AHI (REM-AHI) (acceptance vs. non-acceptance: 51.21 vs. 44.92, p = .014), and arousal index (acceptance vs. non-acceptance: 36.80 vs. 28.75, p = .011). The multiple logistic regression model showed that patients referred from otolaryngology had a lower CPAP acceptance rate (odds ratio 0.707, p = .0216) even after adjusting for age, sex, BMI, AHI, REM-AHI, arousal index, comorbidities, and smoking status.

CONCLUSIONS

Before their initial consultation, patients may already have their preferred treatment of choice, which is strongly linked to the type of medical specialists they visit, and consequently, affects their rate of acceptance to CPAP therapy. Therefore, physicians should provide personalized care to patients by exploring and abiding by their preferred treatment choices.

Investigating associations between social determinants, self-efficacy measurement of sleep apnea and CPAP adherence: the SEMSA study

Study objectives

The prospective Self-Efficacy Measure for Sleep Apnea study (SEMSAS) is investigating thresholds for health literacy, self-efficacy and precariousness at obstructive sleep apnea (OSA) diagnosis to predict CPAP adherence. This paper describes the study protocol and presents baseline data from the ongoing study.

Methods

Eligible individuals had confirmed OSA and were referred to a homecare provider for continuous positive airway pressure (CPAP) therapy initiation. Data on patient characteristics and comorbidities were collected, along with baseline evaluations of self-efficacy [15-item Self-Efficacy Measure for Sleep Apnea tool (SEMSA-15)], precariousness [Deprivation in Primary Care Questionnaire (DipCareQ)], and health literacy (Health Literacy Questionnaire). CPAP adherence over 12 months of follow-up will be determined using remote monitoring of CPAP device data. The primary objective is to define an optimal SEMSA-15 score threshold to predict CPAP adherence at 3- and 12-month follow-up.

Results

Enrollment of 302 participants (71% male, median age 55 years, median body mass index 31.6 kg/m²) is complete. Low self-efficacy (SEMSA-15 score ≤ 2.78) was found in 93/302 participants (31%), and 38 (12.6%) reported precariousness (DipCareQ score > 1); precariousness did not differ significantly between individuals with a SEMSA-15 score ≤ 2.78 versus >2.78. Health literacy was generally good, but was significantly lower in individuals with versus without precariousness, and with low versus high self-efficacy.

Conclusion

SEMSAS is the first study using multidimensional baseline assessment of self-efficacy, health literacy and precariousness, plus other characteristics, to determine future adherence to CPAP, including CPAP adherence trajectories. Collection of follow-up data is underway.

Provider Perspectives on Sleep as a Determinant of Health and Housing Outcomes among Veterans Experiencing Homelessness: An Exploratory, Social-Ecological Study

Sleep problems are common among United States (U.S.) veterans and are associated with poor health, mental health, and functioning. Yet, little is known about insufficient sleep and factors contributing to sleep disparities among veterans experiencing homelessness. We conducted semi-structured interviews to better understand the clinical, environmental, and structural factors contributing to insufficient sleep among veterans and to improve care for this population. Interviews were conducted with 13 providers caring for veterans experiencing homelessness, including physicians, psychologists, nurses, social workers, and peer support specialists. Providers worked at a West Coast VA institution serving a large population of veterans experiencing homelessness. Interviews were analyzed for themes pertaining to sleep using the social-ecological model as a framework. On an individual level, factors influencing sleep included psychiatric disorders and use of substances. On an interpersonal level, factors included safety concerns while sleeping. On an environmental level, factors included noise and proximity to others as barriers to sleep. On the organizational level, logistical issues scheduling sleep clinic appointments and lack of transportation to attend sleep clinic appointments were identified as treatment barriers. These findings can inform future research studying the impact of sleep on health and housing outcomes and interventions addressing sleep among veterans experiencing homelessness.

The individual and societal price of non-adherence to continuous positive airway pressure, contributors and strategies for improvement

INTRODUCTION

Continuous positive airway pressure (CPAP) is the first line therapy for obstructive sleep apnea (OSA). CPAP is highly effective for improving symptoms and quality of life but the major issue is adherence, with up to 50% of OSA discontinuing CPAP in the first 3 years after CPAP initiation.

AREAS COVERED

We present the individual and societal cost of non-adherence to CPAP, factors associated with non-adherence to CPAP, as well as current strategies for improving adherence including telehealth, couples-based interventions and behavioral interventions. We also report on challenges and pitfalls for the visualization and analysis of CPAP remote monitoring platforms.

EXPERT OPINION

CPAP termination rates and adherence to therapy remain major issues despite technical improvements in CPAP devices. The individual and societal price of non-adherence to CPAP for OSA patients goes beyond excessive sleepiness and includes cardiovascular events, all-cause mortality, and increased health costs. Strategies for improving CPAP adherence should be individually tailored and aim to also improve lifestyle habits including physical activity and nutrition. Access to these strategies should be supported by refining visualization dashboards of CPAP remote monitoring platforms, and by disseminating telehealth and innovative analytics, including artificial intelligence.

Marketing factors associated with a continuous positive airway pressure machine purchasing in patients with obstructive sleep apnea

Aim: Obstructive sleep apnea (OSA) is related with several cardiovascular diseases. It should be treated with a continuous positive airway pressure (CPAP) machine. There is limited data on marketing factors on a decision of CPAP machine purchasing in OSA patients. Materials & methods: We enrolled adult patients aged over 18 years with OSA who tried a CPAP. Marketing factors were evaluated for a decision of CPAP machine purchasing. Results: There were 95 OSA patients participated in the study. Nice color CPAP machine and good knowledge and informative salesperson had adjusted odds ratio (aOR) of 4.480 and 9.478, the other two factors had aOR at 0.102 and 0.217. Conclusion: Marketing factors related to CPAP machine purchasing in patients with OSA.

Acceptability, adaptability and adherence to CPAP therapy among Aboriginal Australians with OSA - "The A5 study"

BACKGROUND

Studies examining how Australian Aboriginal people will accept, adapt and adhere to interventions such as continuous positive airway pressure (CPAP) therapy in the management of obstructive sleep apnoea (OSA) are sparsely reported.

METHODS

In this study, clinical, demographic, polysomnographic (PSG) and CPAP data were utilised to assess and predict acceptance and adherence to CPAP therapy among adult Aboriginal Australians diagnosed to have OSA.

RESULTS

Of the 649 Aboriginal patients with OSA, 49% accepted to trial CPAP therapy. Patients who accepted to trial CPAP showed more severe OSA (65vs.35% with severe OSA), reported higher daytime sleepiness (median 10vs.9), and had a higher BMI (83vs.73% obese). Of those who accepted to trial CPAP, 62% adapted to therapy (used the device for more than 30 days). Patients who adapted had more severe OSA (71vs.54% with severe OSA), and were more likely to live in urban areas (63vs.40%). Of those who adapted, 32% were adherent to therapy. Adherent patients were more likely to live in urban areas (84vs.53%), though there was no difference in OSA severity between adherent and non-adherent patients. In multivariate models remote location and more severe OSA predicted CPAP acceptance, while urban location and more severe OSA predicted adaptation, and urban location and higher oxygen saturation nadir predicted adherence.

CONCLUSIONS

Acceptance to trial CPAP therapy was observed in the presence of symptomatic and severe OSA. However, long term adherence to CPAP therapy was significantly influenced by patients' residential location, with patients residing in remote/rural settings demonstrating significantly lower adherence rates.

Calidad de vida relacionada con la salud y adhesión terapéutica a la presión positiva continua en la vía aérea (CPAP) en pacientes con apnea obstructiva del sueño (AOS)

Introduction

The benefits of CPAP in patients with obstructive sleep apnea (OSA) are not achieved without therapeutic adherence (TA). The perception of benefit is one of the main predictors of adherence. However, it is unknown whether the impact of CPAP on health-related quality of life (HRQoL) is related to TA.

Objective

1) To evaluate whether changes in HRQoL after initiating CPAP are associated with AT. 2) To analyze the influence of various TA determinants, including baseline HRQoL.

Methods

Prospective observational and longitudinal study on a cohort of patients with moderate-severe OSA and indication of CPAP. Baseline and after-therapy HRQoL were evaluated using the Quebec Sleep Questionnaire (QSQ), as well as other possible AT determinants. A multivariate analysis was performed.

Results

A total of 364 patients (78% men) were included, with mean age of 55 ± 11 years and apnea-hypopnea index of 42 ± 19/hour. 33.3% without TA. There was no association between HRQoL changes after 3 months of CPAP and AT and between QSQ baseline score and AT. A higher ODI4%, a global improvement and social interactions (QSQ), were associated with AT. Baseline anxiety-depressive symptoms, worsening anxiety, and side effects with CPAP were associated with worse AT.

Conclusions

The impact of CPAP on HRQoL with respect to the perception of social interactions seems to condition TA. The basal impact of the disease, in terms of HRQoL, is not associated with AT.

Predictors for short-term and long-term automatic PAP compliance

STUDY OBJECTIVES

Positive airway pressure (PAP) is considered a standard treatment for obstructive sleep apnea (OSA), but there are compliance issues. As compliance to PAP tends to decrease with time, it is necessary to consider reasons affecting compliance at each period. Therefore, this study aimed to define factors affecting short-term and long-term compliance to PAP therapy.

METHODS

One hundred eighty-seven patients with OSA who started PAP treatment between July 2018 to March 2020 were included. Acceptance and compliance rates were monitored. Demographics, polysomnography (PSG) profiles, cephalometric data, and physical examination results were analyzed to identify factors predictive of PAP compliance at short-term (3 months) and long-term (12 months) periods.

RESULTS

The acceptance rate of PAP was 92.5%. Compliance at 3 months and 12 months was 79.1% and 51.3%, respectively. Higher apnea-hypopnea index (odds ratio [OR] 1.018, P = .049) and older age (OR 1.032, P = .039) were predictive factors of good automatic PAP (APAP) compliance at 3 months. However, long-term compliance was affected by the percentage of duration with O2 desaturation of < 90% (CT90; OR 1.032, P = .011) and baseline self-reported symptom scores such as nasal obstruction (OR 0.819, P = .038) and awakening (OR 0.796, P = .045).

CONCLUSIONS

In PAP use, indicators of OSA severity such as apnea-hypopnea index affect short-term compliance. On the other hand, the mandibular plane to hyoid distance and self-reported symptoms such as nasal obstruction and awakening can affect long-term compliance.

CITATION

Park SI, Kim BK, Lee KE, Hong SD, Jung YG, Kim HY. Predictors for short-term and long-term automatic PAP compliance. J Clin Sleep Med. 2023;19(1):17-26.

Telehealth Technology Application in Enhancing Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea Patients: A Review of Current Evidence

Obstructive sleep apnea (OSA) is a common type of sleep-disordered breathing associated with multiple comorbidities. Continuous positive airway pressure (CPAP) is the first choice for moderate-severe OSA but poor compliance brings a great challenge to its effectiveness. Telehealth interventions ease the follow-up process and allow healthcare facilities to provide consistent care. Fifth-generation wireless transmission technology has also greatly rationalized the wide use of telemedicine. Herein, we review the efficacy of the telehealth system in enhancing CPAP adherence. We recommend applying telemonitoring in clinical practice and advocate the development of a biopsychosocial telemedicine model with the integration of several interventions. Big databases and promising artificial intelligent technologies make clinical decision support systems and predictive models based on these databases possible.

A meta‑analysis to identify factors associated with CPAP machine purchasing in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disease and related to several cardiovascular diseases. Treatment with a continuous positive airway pressure (CPAP) machine is effective. However, not all patients with OSA purchase a CPAP machine for personal use. Previous studies showed different predictors of CPAP machine purchasing in patients with OSA. The present study aimed to summarize and identify predictors of CPAP purchasing using meta-analysis. The study was conducted using factors associated with CPAP purchasing in patients with OSA. The types of studies conducted in adult patients with OSA included: Randomized controlled trials, observational studies or descriptive studies comparing factors between those who purchased CPAP and those who did not. A total of five databases, including PubMed, Central database, Scopus, CINAHL Plus and Web of Science, were searched, and the final search was performed on February 8, 2021. Predictors for CPAP purchasing were determined. There were 598 articles from five databases, which met the inclusion criteria. After duplicated article removal, 390 articles were included in the screening process. There were 12 eligible articles for full text evaluation, and of those, eight studies met the study criteria with 1,605 patients from four countries. There were 11 variables that were available for a comparison between those who purchased the CPAP machine and those who did not, and six factors were different between the two groups: Age, years of education, income, smoking, Epworth Sleepiness Scale (ESS) score and apnea hypopnea index/respiratory disturbance index (AHI/RDI). The AHI/RDI was significantly different between the two groups, with the highest mean difference of 10.40 events/h (95% CI, 4.95-15.86). Patients who purchased CPAP were older (1.11 years), had more years of education (0.93 years), smoked more (1.15 pack/year), and had both higher ESS (0.61) and AHI/RDI (10.40) than those who did not purchase CPAP. Additionally, those who purchased CPAP had a 1.47 times higher income than those who did not. In conclusion, specific personal customer and clinical factors were related to the decision of CPAP purchase in patients with OSA.

Representation of Race and Sex in Sleep Surgery Studies

OBJECTIVE

Obstructive sleep apnea (OSA) is a highly prevalent disorder with many treatment modalities, including surgical intervention. While OSA is known to be more prevalent in males and Black Americans, the representation of race and sex in sleep surgery studies is unknown. The aim of this systematic review is to assess the race and sex demographics represented in sleep surgery studies relative to known OSA demographics.

DATA SOURCES

PubMed, MEDLINE, and OVID databases.

REVIEW METHODS

A systematic review was conducted to identify studies published between 2016 and 2020 that investigated sleep outcomes following nonnasal surgical intervention for OSA in adults. Pooled racial, ethnic, and sex data of the enrolled subjects in selected studies were analyzed.

RESULTS

The 148 included studies comprised 13,078 patients. Of the 137 studies that reported sex, 84.0% of participants were male, exceeding the population prevalence of OSA in males, which is estimated at 66%. Only 13 studies reported racial/ethnic demographic data. Of these, 87.8% of patients were White. Out of 30 studies of primarily American patients, only 4 reported race demographic data, with an average of 82.8% White participants.

CONCLUSION

There is a racial/ethnic and sex inclusion bias among sleep surgery studies. Future studies should better document the demographics of enrolled participants as well as recruit participants who better represent the demographics of adults with OSA in the general population.

The association of age with continuous positive airway pressure ventilation acceptance in an outpatient cohort of patients with obstructive sleep apnea

STUDY OBJECTIVES

This study examined the association between age and continuous positive airway pressure (CPAP) acceptance in a consecutive series of patients with obstructive sleep apnea being managed in a physician-led outpatient CPAP acclimatization program in Canberra, Australia.

METHODS

We performed a retrospective consecutive case series analysis of registry data collected from patients attending the Canberra Hospital PAP Acclimatization Clinic between 2011 and 2019. Data on patient demographics, diagnostic polysomnography results, CPAP device download parameters during acclimatization, and overall CPAP acceptance at the end of acclimatization were extracted from the Clinic Registry. Analysis of variance and chi-square were used to assess for associations between patient age, CPAP acceptance, and other clinical characteristics. Univariate and stepwise multiple logistic regression was used to identify predictors of CPAP acceptance.

RESULTS

We found that 1,075 consecutive CPAP trials among 1,043 patients were eligible for inclusion. CPAP acceptance was lower in those aged > 75 years compared with those aged ≤ 75 years (odds ratio: 0.57; 95% confidence interval, 0.36-0.92; P = .02). Patients aged > 75 years had lower body mass index, had higher initial and final visit 95th percentile mask leak, and were less likely to be CPAP naïve. Using univariate regression, younger age, severe obstructive sleep apnea, obesity, shorter trial duration, more clinic visits, higher initial visit CPAP usage, and lower final visit mask leak were predictors of CPAP acceptance. In a multiple logistic regression model, younger age, severe obstructive sleep apnea, shorter trial duration, more clinic visits, higher first visit usage, and lower final visit leak predicted acceptance.

CONCLUSIONS

Older age is associated with lower CPAP acceptance. The factors contributing to this association are unclear and require further investigation.

CITATION

Han M, Wee R, Shadbolt B, Huang H-CC. The association of age with continuous positive airway pressure ventilation acceptance in an outpatient cohort of patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(1):217-224.

Racial Differences in Functional and Sleep Outcomes with Positive Airway Pressure Treatment

It is unclear if the response to positive airway pressure (PAP) treatment is different between African American (AA) and European Americans (EA). We examined whether race modifies the effects of PAP on sleep and daytime function. We assessed Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire, Psychomotor Vigilance Task and actigraphy in 185 participants with moderate-to-severe obstructive sleep apnea before and 3–4 months after PAP treatment. The participants were middle-aged (mean, 55.1 years), 83.8% men and 60.5% AA. Linear regression models were used to examine the effect of race on outcomes. The AA had smaller reductions in ESS (mean change (95% confidence interval, CI) AA, −2.30 [−3.35, −1.25] vs. EA, −4.16 [−5.48, −2.84] and frequency of awakenings (AA, −0.73 [−4.92, 3.47] vs. EA, −9.35 [−15.20, −3.51]). A race × PAP usage interaction term was added to the model to examine if the change in outcomes per 1 h increase in PAP usage differed by race. AA exhibited greater improvement in wake after sleep onset (β (95% CI) AA, −8.89 [−16.40, −1.37] vs. EA, 2.49 [−4.15, 9.12]) and frequency of awakening (β (95% CI) AA, −2.59 [−4.44, −0.75] vs. EA, 1.71 [−1.08, 4.50]). The results indicate the importance of race in evaluating outcomes following PAP treatment.

The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report

Continuous positive airway pressure (CPAP) remains the major treatment option for obstructive sleep apnea (OSA). The American Thoracic Society organized a workshop to discuss the importance of mask selection for OSA treatment with CPAP. In this workshop report, we summarize available evidence about the breathing route during nasal and oronasal CPAP and the importance of nasal symptoms for CPAP outcomes. We explore the mechanisms of air leaks during CPAP treatment and possible alternatives for leak control. The impact of nasal and oronasal CPAP on adherence, residual apnea-hypopnea index, unintentional leaks, and pressure requirements are also compared. Finally, recommendations for patient and partner involvement in mask selection are presented, and future directions to promote personalized mask selection are discussed.

Obstructive sleep apnea in older adults: geographic disparities in PAP treatment and adherence

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is prevalent among older adults. Although treatment with positive airway pressure (PAP) lowers subsequent morbidity, PAP adherence is inconsistent. Socioeconomic disparities have been observed in OSA treatment, but regional differences in OSA care are unknown. This study examined geographic variations in PAP treatment and adherence among older Americans.

METHODS

This study utilized a representative 5% sample of all Medicare fee-for-service beneficiaries aged 65+ years. An OSA diagnosis, treatment, and PAP adherence were confirmed with International Classification of Diseases, Ninth Revision, HCPCS (Health Care Common Procedure Coding System) codes, and ≥2 HCPCS claims for PAP supplies respectively. Descriptive statistics were used to examine proportions of Medicare beneficiaries who obtained and adhered to PAP. Maps described the proportion of treated and adherent beneficiaries by state and hospital referral region.

RESULTS

For state-level data, PAP treatment and adherence proportions among beneficiaries with an OSA diagnosis ranged between 54-87% and 59-81%, respectively. Proportions of treated patients were higher in Midwest states (>80%), in comparison to Northwest, Northeast, and Southern states (<73%). Southern states and California had lowest proportions of PAP adherence (<70%). Within-state variability in treatment patterns were apparent along the East and West coasts. Correlations of PAP treatment and adherence proportions were low in Washington, DC, New York, and New Jersey. Discordant treatment and adherence proportions were observed in Alabama and Mississippi.

CONCLUSIONS

Significant state-level and regional disparities of PAP treatment and adherence among Medicare beneficiaries with OSA suggest gaps in delivery of OSA care for older Americans.

Socioeconomic Factors and Adherence to CPAP: The Population-Based Course of Disease in Patients Reported to the Swedish CPAP Oxygen and Ventilator Registry Study

Background

Early identification of poor adherence to CPAP treatment is of major clinical importance to optimize treatment outcomes in patients with OSA.

Research Question

How do socioeconomic factors influence CPAP adherence?

Study Design and Methods

Nationwide, population-based cohort study of patients with OSA receiving CPAP treatment reported to the Swedish quality registry Swedevox between 2010 and 2018 was cross-linked with individual socioeconomic data from Statistics Sweden. Socioeconomic factors associated with CPAP adherence were identified using a multivariate linear regression model, adjusted for age and sex.

Results

In total, 20,521 patients were included: 70.7% men; mean age ± SD, 57.8 ± 12.2 years; BMI, 32.0 ± 6.1 kg/m²; apnea-hypopnea index, 36.9 ± 22.1; Epworth Sleepiness Scale, 10.4 ± 5.0; and median nocturnal CPAP use, 355 min (interquartile range, 240-420 min). Adherence after 1.3 ± 0.8 years of CPAP use was significantly (all P < .001) associated with civil status (married vs unmarried: +20.5 min/night), education level (high, ≥ 13 years vs low, ≤ 9 years: +13.2 min/night), total household income (highest/third/second vs lowest quartile: +15.9 min/night, +10.4 min/night, and +6.1 min/night, respectively), and country of birth (born in Sweden with one native parent/born in Sweden with two native parents vs being born abroad: +29.0 min/night and +29.3 min/night, respectively).

Interpretation

Civil status, educational level, household income, and foreign background predict CPAP adherence in a clinically significant manner and should be considered when treating OSA with CPAP.

Longitudinal changes in regional cerebral blood flow in late middle-aged and older adults with treated and untreated obstructive sleep apnea

Obstructive sleep apnea (OSA) is associated with abnormal cerebral perfusion at wakefulness, but whether these anomalies evolve over time is unknown. Here, we examined longitudinal changes in regional cerebral blood flow (rCBF) distribution in late middle‐aged and older adults with treated or untreated OSA. Twelve controls (64.8 ± 8.0 years) and 23 participants with newly diagnosed OSA (67.8 ± 6.2 years) were evaluated with polysomnography and cerebral ^99mTc‐HMPAO single‐photon emission computed tomography during wakeful rest. OSA participants were referred to a sleep apnea clinic and 13 of them decided to start continuous positive airway pressure (CPAP). Participants were tested again after 18 months. Voxel‐based analysis and extracted relative rCBF values were used to assess longitudinal changes. Untreated OSA participants showed decreased relative rCBF in the left hippocampus and the right parahippocampal gyrus over time, while treated participants showed trends for increased relative rCBF in the left hippocampus and the right parahippocampal gyrus. No changes were found over time in controls. Untreated OSA is associated with worsening relative rCBF in specific brain areas over time, while treated OSA shows the opposite. Considering that OSA possibly accelerates cognitive decline in older adults, CPAP treatment could help reduce risk for cognitive impairment.

Lower socioeconomic status and co-morbid conditions are associated with reduced continuous positive airway pressure adherence among older adult medicare beneficiaries with obstructive sleep apnea

STUDY OBJECTIVES

To examine rates of adherence to continuous positive airway pressure (CPAP) therapy among a representative sample of older adult Medicare beneficiaries with obstructive sleep apnea (OSA), and to identify demographic and health-related factors associated with CPAP adherence.

METHODS

Using a 5% sample of Medicare claims data, we utilized Medicare policy and CPAP machine charges as a proxy for CPAP adherence. A cumulative logit model was used to identify demographic, medical, and psychiatric predictors of CPAP adherence status.

RESULTS

Of beneficiaries who initiated CPAP (n = 3,229), 74.9% (n = 2,417) met the so-called "90-day Medicare adherence criteria," but only 58.8% of these individuals (n = 1,420) continued to use CPAP throughout the entire 13-month rent-to-own period. Anxiety, anemia, fibromyalgia, traumatic brain injury, and lower socioeconomic status (SES) were all associated with reduced CPAP adherence.

CONCLUSIONS

These results provide the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States. In addition, findings highlight the salience of medical and psychiatric comorbidity, as well as SES, as important markers of CPAP adherence among older adults in the United States. Future studies should seek to evaluate interventions to improve CPAP adherence among older adults of lower SES.

The impact of national health insurance on the compliance of positive airway pressure therapy in patients with obstructive sleep apnea

Objectives

Compliance with positive airway pressure (PAP) in patients with obstructive sleep apnea (OSA) directly affects its treatment efficacy. Since July 2018, polysomnography and PAP therapy have been covered by the national health insurance (NHI), which has reduced the price barrier and promoted PAP therapy in Korea. This study aimed to compare changes in PAP compliance before and after NHI implementation.

Methods

This study is a retrospective analysis in a tertiary hospital setting in Korea. From 2011 to 2019, patients with OSA (apnea-hypopnea index≥5) treated using a PAP device for ≥ 1 month were included. They were allocated to the pre-insurance (PI) (having started PAP before July 2018) and NHI groups (having received a PAP reimbursement by the NHI service). We collected and analyzed medical records and PAP use information for between-group comparisons of compliance. We defined compliance as (A) percentage of usage days, (B) percentage of days with usage for ≥ 4 night hours, and (C) average daily usage hours.

Results

We included 146 and 100 patients in the PI and NHI groups, respectively. Automatic positive airway pressure (APAP) mode and NHI were independent predictors of compliance B at the 3- and 9-month follow-up points. The NHI group showed significantly higher compliance A at 3, but not 9 months. For compliance B, the NHI group showed significantly higher compliance than the PI group at 1 month and 3 months, but not at 9 months. Compared with the PI group, the NHI group showed significantly higher compliance C only at 3 months.

Conclusion

The NHI has positively affected PAP therapy in patients with OSA. Insurance policy may affect compliance within the first 3 months.

Socioeconomic Disparities in Positive Airway Pressure Adherence: An Integrative Review

Nonadherence with positive airway pressure (PAP) therapy impedes the effectiveness of treatment and increases risk of mortality. Disparities in PAP adherence as a function of socioeconomic status (SES) are not well understood. A literature search identified 16 original publications meeting inclusion criteria that described effects of SES factors on objective PAP adherence; 69% of these articles found evidence of lower adherence as a function of SES. This integrative review provides a structured summary of the findings, highlights factors that may contribute to disparities among adult PAP users, and identifies future directions to improve equity in the management of OSA.

Acceptance of and six-month adherence to continuous positive airway pressure in patients with moderate to severe obstructive sleep apnea

BACKGROUND

Continuous positive airway pressure (CPAP) is the most effective treatment for moderate to severe obstructive sleep apnea (OSA). Acceptance of and adherence to CPAP are crucial for optimal treatment outcomes. The aim of this study was to investigate the factors influencing patients' acceptance of and adherence to CPAP treatment.

METHODS

One hundred eighty-eight patients with moderate to severe OSA who had received CPAP titration from October 2017 to September 2018 were recruited. They were interviewed at 2 weeks and at 6 months to assess CPAP use and barriers to acceptance and adherence.

RESULTS

One hundred fourteen patients (60.6%) accepted CPAP treatment. Disease severity, assessed by apnea-hypopnea index (AHI) (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.08), subjective satisfaction of titration (OR, 12.83; 95% CI, 3.83-42.99), initial intention of CPAP therapy (OR, 3.33; 95% CI, 1.05-10.51) and short-term home CPAP trial (OR, 9.40; 95% CI, 2.85-31.08) were associated with acceptance of CPAP treatment. Two-third of the 98 CPAP acceptors reported good CPAP adherence at 6 months follow-up. Average hours of CPAP use per day for the first 2 weeks (OR, 1.88; 95% CI, 1.28-3.04) and the global problems associated with CPAP use (OR, 0.82; 95% CI, 0.73-0.91) were independent predictors of the six-month CPAP adherence.

CONCLUSIONS

Nearly 40% of patients with moderate to severe OSA did not accept CPAP treatment, and one-third of those CPAP acceptors had poor adherence to CPAP treatment. Improvement in disease awareness, comfortable titration experience, short-term home CPAP trial may be of help to increase CPAP acceptance and early experience with CPAP is important for long-term adherence. The differences in predicting factors for CPAP acceptance and adherence highlight the importance of focusing on specific aspects during the whole process management of OSA.

A survey of positive airway pressure therapy preparedness and outcomes following Hurricane Irma in patients with obstructive sleep apnea

STUDY OBJECTIVES

Clinical benefit from positive pressure therapy is dependent on treatment adherence. Extreme weather events, such as floods, hurricanes, and tornadoes, can contribute to nonadherence by electricity loss and mandatory evacuation. We aimed to evaluate the concerns and behaviors of regular positive airway pressure users surrounding the extreme weather event Hurricane Irma.

METHODS

A questionnaire on positive pressure concerns surrounding Hurricane Irma was completed by 117 patients with pre-hurricane objectively confirmed treatment adherence as defined by Medicare. Responses were tabulated to identify concerns and behavior in preparation for and after Hurricane Irma. Cloud-based monitoring, available on 50 (43%) cases, was used to determine the effect of self-reported electricity loss on treatment adherence before and after the storm. Quantitative use data pre- and post-Hurricane Irma was compared by t test with P < .05 considered statistically significant.

RESULTS

Post-hurricane 78 (67%) patients were unable to use treatment with mean duration of 4.3 days. Of these, snoring, choking, and sleepiness were reported in 64%, 19%, and 42%, respectively. Loss of electricity was identified as the cause of missed treatment in 71 patients. In those with cloud monitoring, mean 14-day pre- and post-hurricane use differed by 8 minutes (P =.056). Cloud-monitored cases with loss of electricity had a decline in mean use of 33 minutes for the first 7 days post-hurricane. There was a trend towards increased use post-hurricane in those that retained electricity. Many patients expressed dissatisfaction with the availability of preparedness guidelines.

CONCLUSIONS

Although common, loss of electricity was not the sole disruptor of positive pressure use after extreme weather events. Regular users of positive airway pressure experience both disruption in patterns of use and concerns regarding preparedness for extreme weather events.

Hospital screening for obstructive sleep apnea in patients admitted to a rural, tertiary care academic hospital with heart failure

BACKGROUND

Rural communities represent a vulnerable population that would significantly benefit from hospital-based OSA screening given these areas tend to have significant health-care disparities and poor health outcomes. Although inpatient screening has been studied at urban hospitals, no study to date has assessed this approach in rural populations.

METHODS

This study utilized the Electronic Medical Record (EMR) to generate a list of potential candidates by employing inclusion/exclusion criteria as screening. Subjects identified were then approached and offered information regarding the study. Screening for OSA entailed a tiered approach utilizing the sleep apnea clinical score (SAC) and portable sleep testing. Individuals identified as high risk (SAC ≥ 15) for OSA underwent evaluation with a portable sleep testing system while hospitalized. All participants with an apnea-hypopnea index (AHI) ≥5 events/h confirmed by a sleep medicine physician were considered screen positive for OSA. If approved/available, subjects screening positive for OSA were provided with an auto-titrating continuous positive airway pressure (PAP). Patient characteristics were analyzed using descriptive statistics. Categorical data were described using contingency tables, including counts and percentages. Continuously scaled measures were summarized by median with range. This study was registered with ClinicalTrials.gov. Identifier: NCT03056443.

RESULTS

Nine hundred and fifty-eight potential subjects were identified. The three most common reasons for exclusion included previous OSA diagnosis or exposure to PAP therapy (n = 357), advanced illness (n = 380), and declined participation by the individual (n = 68). The remaining 31 subjects underwent further evaluation for obstructive sleep apnea. Twenty-three subjects had a high sleep apnea clinic score. Per our study protocol, 13 subjects who screened positive for OSA were initiated on APAP therapy. Conclusion: Our study provides important insight into the burden of sleep-disordered breathing (SDB) and unique challenges of hospital-based OSA screening/treatment in a rural setting. Our study identified barriers to successful screening in a rural population that may be well addressed by adapting previous research in hospital sleep medicine.

Positional Sleep Apnea Among Regional and Remote Australian Population and Simulated Positional Treatment Effects

PURPOSE

To assess the prevalence of positional sleep apnea (POSA) and its predictors in patients diagnosed to have obstructive sleep apnea (OSA) in the regional and remote population of the Northern Territory of Australia over a two-year study period (2018 and 2019).

PATIENTS AND METHODS

Of the total 1463 adult patients who underwent a diagnostic polysomnography (PSG), 946 patients were eligible to be included in the study, of them, 810 consecutive patients with OSA (Apnea-Hypopnea Index (AHI) ≥ 5) who slept >4 h and had ≥30 min sleep in both supine and lateral positions were assessed. Patients were considered to have POSA if supine AHI to lateral AHI ratio ≥2. The likely comparative impact of use of continuous positive airway therapy (CPAP) or positional therapy (PT) on disease severity was evaluated using model simulation.

RESULTS

A total of 495/810 (61%) patients had POSA, the majority were males (68% vs 60%, p=0.013) and non-Indigenous Australians (93% vs 87%, p=0.004). POSA patients were younger (mean difference 2.23 years (95% CI 0.27, 4.19)), less obese (BMI mean difference 3.06 (95% CI 2.11, 4.01)), demonstrated less severe OSA (p < 0.001) and a greater proportion reported alcohol consumption (72% vs 62%, p=0.001) as compared to those with non-POSA. Using the simulation model, if patients with POSA use PT two-thirds (323/495, 65%) would obtain significant improvement of their OSA severity, with one in five (92/495, 19%) displaying complete resolution. Comparing this to simulated CPAP therapy, where the majority (444/495, 90%) will show significant improvement, and one-third (162/495, 33%) will display complete resolution.

CONCLUSION

POSA needs to be routinely recognised and positional therapy integrated in practice especially in the remote regions and in the developing world when effective methods are in place to monitor positional therapy.

A review of psychosocial factors and personality in the treatment of obstructive sleep apnoea

Effective treatment of obstructive sleep apnoea (OSA) is primarily determined by adherence to the selected intervention. The most common treatment pathways are mechanical devices such as continuous positive airway pressure (CPAP) or a mandibular advancement device, often combined with weight loss therapy. Weight reduction is usually an adjunct therapy but may be used as a secondary treatment in mild-to-moderate OSA when mechanical treatments cannot be tolerated. To enhance the uptake and adherence to treatment, clinicians may assess patient's personality profiles and psychological readiness. There is a paucity of evidence related to these aspects of patient care and this article outlines the current research in relation to patient presentation, treatment uptake and barriers, and methods to enhance treatment adherence.

This article disseminates personality traits observed in patients with OSA and identifies vulnerable groups who may require additional support to increase treatment adherence. It summarises the current evidence for treatment barriers in patients with OSA. Low self-efficacy in relation to CPAP and weight loss adherence will be explored as well as the potential to predict treatment responders and enhance therapeutic uptake and adherence. Extending personality traits into research and clinical practice could potentially result in more successful CPAP therapy and weight loss treatment outcomes.

Accessibility and adherence to positive airway pressure treatment in patients with obstructive sleep apnea: a multicenter study in Latin America

PURPOSE

Information on access and adherence to positive airway pressure (PAP) treatment is lacking at the regional level in Latin America. This study characterized access and adherence to PAP in patients with moderate-severe obstructive sleep apnea (OSA) in Latin America.

METHODS

Cross-sectional study, conducted at 9 sleep centers across Argentina, Brazil, Chile, Colombia, Mexico, and Peru. Adults diagnosed with moderate-severe OSA (apnea-hypopnea index [AHI] ≥ 15/h) in the previous 12-18 months were eligible. Anthropometrics, health coverage, and OSA severity data were collected. Data on access to therapy, barriers to access, adherence, and factors related to non-compliance were obtained via standardized telephone survey.

RESULTS

Eight hundred eighty patients (70% male, 54 ± 13 years, AHI 49 ± 28/h, body mass index 32 ± 7 kg/m²) were included. Four hundred ninety patients (56%) initiated PAP, 70 (14%) discontinued therapy during the first year (mainly due to intolerance), and 420 (48%) were still using PAP when surveyed. Health insurance was private in 36.9% of patients, via the social security system in 31.1%, and via the state in 13.3%, and 18.7% did not have any coverage; 49.5% of patients had to pay all equipment costs. Reasons for not starting PAP were unclear or absent indication (42%), coverage problems (36%), and lack of awareness of OSA burden (14%). Patients with better adherence were older (55.3 ± 13 vs 52 ± 13; p = 0.002) and had more severe OSA (AHI 51.8 ± 27 vs 45.6 ± 27; p = 0.001).

CONCLUSIONS

Less than half moderate-severe OSA patients started and continue to use PAP. Unclear or absent medical indication and financial limitations were the most relevant factors limiting access to therapy.

Zolpidem and Eszopiclone Pre-medication for PSG: Effects on Staging, Titration, and Adherence

Introduction

The non-benzodiazepine sedative hypnotic (NBSH) eszopiclone improves polysomnography (PSG) quality and continuous positive airway pressure (CPAP) adherence. It is unclear whether zolpidem has the same effect and neither NBSH has been studied in populations with milder forms of obstructive sleep apnea.

Materials and Methods

We performed a retrospective analysis on patients undergoing level I PSG at our institution. Patients are pre-medicated with NBSHs at the discretion of the sleep physician. We compared PSG/CPAP titration quality and subsequent CPAP adherence for patients receiving NBSHs or no pre-study medication. We adjusted for obstructive sleep apnea pre-test probability (PTP), arousal threshold, and other factors showing differences at baseline.

Results

Data on 560 patients were analyzed. Mean age and body mass index were 42.2 ± 10.1 and 28.8 ± 4.5, respectively. Median apnea hypopnea index was 12.9 (6.4-25.3), 100 (18.0%) patients had normal studies, 97 (17.3%) were split, and 457 (81.6%) had a respiratory low-arousal threshold. After adjusting for differences at baseline, neither NBSH was associated with sleep efficiency, wake after sleep onset, or total sleep time on PSG. After adjustment, patients receiving eszopiclone had a higher apnea hypopnea index at the final CPAP pressure (β = 14.2; 95% confidence intervals (CI) 7.2-21.2; p < 0.001) and were more likely to have an unacceptable titration (odds ratio (OR) = 6.6; 95% CI 2.0-21.0; p = 0.002). When only split-night studies were examined, there were no differences in any adherence variables across or between categories.

Conclusions

In a population with predominantly mild obstructive sleep apnea, NBSHs did not improve PSG or CPAP titration quality and did not increase CPAP adherence. There was no difference in effect between eszopiclone and zolpidem.

Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease which impacts quality of life, mood, cardiovascular morbidity, and mortality. Continuous positive airway pressure (CPAP) is the first-line treatment for patients with moderate to severe OSA. CPAP ameliorates respiratory disturbances, leading to improvements in daytime sleepiness, quality of life, blood pressure, and cognition. However, despite the high efficacy of this device, CPAP adherence is often sub-optimal. Factors including: socio-demographic/economic characteristics, disease severity, psychological factors, and side-effects are thought to affect CPAP adherence in OSA patients. Intervention studies have suggested that augmented support/education, behavioral therapy, telemedicine and technological interventions may improve CPAP adherence. In this paper, we will extensively review the most common factors including age, gender, race/ethnicity, socioeconomic status, smoking status, severity of OSA, severity of OSA symptoms, psychological variables, social support, marital status/bed partner involvement, dry nose and mouth, mask leak, and nasal congestion that may predict CPAP adherence. We will also extensively review interventions that may increase adherence to CPAP.

The Effect of Sleeping Environment and Sleeping Location Change on Positive Airway Pressure Adherence

STUDY OBJECTIVES

Poor adherence undermines the effectiveness of positive airway pressure (PAP) therapy for sleep apnea. Disparities exist in PAP adherence by race/ethnicity and neighborhood socioeconomic status (SES), but the etiology of these differences is poorly understood. We investigated whether home environmental factors contribute to PAP adherence and whether identified factors explain disparities in adherence by SES.

METHODS

Adult patients with sleep apnea were surveyed at clinic visits about their sleep environment. Medical records were abstracted for demographic data, sleep apnea severity, comorbidities, and objective PAP adherence. We evaluated the association between aspects of home sleep environment with PAP adherence using multivariate linear and logistic regression, and assessed effect modification by SES factors.

RESULTS

Participants (n = 119) were diverse, with 44% nonwhite and 35% uninsured/Medicaid. After adjusting for age, sex, race/ethnicity, insurance, neighborhood SES, education, and marital status, participants who endorsed changing sleeping location once per month or more (18%, n = 21) had 77% lower odds of meeting PAP adherence criteria (> 4 h/night for 70% of nights) and less PAP use (median -11 d/mo, 95% confidence intervals -15.3, -6.5). Frequency of sleeping location change was the only environmental factor surveyed associated with PAP adherence.

CONCLUSIONS

Frequent change in sleeping location is associated with reduced PAP adherence, independent of sociodemographic factors. This novel finding has implications for physician-patient dialogue. PAP portability considerations in device selection and design may modify adherence and potentially improve treatment outcomes. Prospective investigation is needed to confirm this finding and inform design of possible interventions.

Impact of purchasing the CPAP device on acceptance and long-term adherence: a Belgian model

RATIONALE

In Belgium, patients with moderate to severe OSA (AHI > 20) who show less than 30 micro-arousals per hour slept (MAI) cannot benefit from CPAP refund by the social security (SS).

OBJECTIVES

To assess the influence of reimbursement on CPAP acceptance, and long-term adherence.

METHODS

OSA patients (AHI > 20) were included regardless of MAI. All patients were offered a CPAP trial of 3-5 days for habituation. Two groups were defined and compared: «Out of pocket money» patients (OOP) with MAI < 30 that were invited to purchase their device and «reimbursed group» that were offered a CPAP reimbursed by the social security.

RESULTS

812 patients were found: 59 in the OOP group, mostly females, sleepier and using more hypnotics. Out of the reimbursed group, 183 patients were matched to the OOP patients on the grounds of age, AHI and BMI. 90% of OOP and 94% of reimbursed patients (p 0.379) accepted a CPAP trial; 74% of OOP and 90% of reimbursed patients acquired a CPAP device (p 0.005) thereafter, whereas 82% and, respectively, 84% of those (p 0.254) were still on CPAP after a mean follow-up of 711 and 604 days with a mean ± SD daily compliance of 5.3 ± 3 and 6.1 ± 2 h, respectively (p 0.159). Only fatigue scale seems to influence the purchase of CPAP by OOP patients.

CONCLUSION

CPAP reimbursement influences the purchase of CPAP but once the device becomes available there is no difference with reimbursed patients in long-term adherence.

The effect of positive and negative message framing on short term continuous positive airway pressure compliance in patients with obstructive sleep apnea

Background

Continuous positive airway pressure (CPAP), the best available treatment for obstructive sleep apnea (OSA), requires long-term compliance to be effective. Behavioral interventions may be used to improve adherence to CPAP. We aimed to investigate whether positive or negative message framing impacts on CPAP compliance in patients with OSA, when compared to standard care.

Methods

Consenting patients with confirmed OSA were randomly allocated to receive along with their CPAP either positively or negatively framed messages (Pos; Neg), or standard care (Con). Standardized motivational messages were read out to patients during an initial teaching session and through weekly telephone calls. Patients' compliance data were reviewed 2 and 6 weeks following CPAP initiation.

Results

We randomized 112 patients to groups that were matched for age, BMI, and OSA severity. The positively framed group (Pos) showed greater CPAP usage after 2 weeks (total use 53.7±31.4 hours) as compared to the negatively framed and the control group (35.6±27.4 and 40.8±33.5 hours, P<0.05); however, no differences were seen at 6 weeks. There were more dropouts in the control group than in either framed groups (Pos n=5; Neg n=8; Con n=11; P<0.05).

Conclusions

Positively framed messages can improve CPAP adherence in patients with OSA in the short-term; however, strategies for implementing its long-term use need to be developed.