Neighborhoods with Greater Prevalence of Minority Residents Have Lower Continuous Positive Airway Pressure Adherence

A multidisciplinary approach to the home management of continuous positive airway pressure therapy for obstructive sleep apnea: beyond usual care pathways (a narrative review)

Obstructive sleep apnea (OSA) is a common chronic condition that is growing in prevalence, associated with important comorbidities, and has several different phenotypes. Continuous positive airway pressure (CPAP) is the gold standard OSA treatment, but its effectiveness relies on consistent adherence, which can often be difficult to maintain. This narrative review discusses current challenges in the care pathways for CPAP therapy management in OSA, including fragmented care/lack of continuity, inadequate management of comorbidities, suboptimal implementation of digital medicine solutions, and existing reimbursement paradigms. Key tasks to be shared between the appropriate healthcare professionals and providers include technical CPAP follow-up (adherence, effectiveness, alert management), management of comorbidities, and multimodal non-invasive monitoring. What this looks like and who provides the different aspects of care should vary by OSA phenotype, ranging from simple follow-up in primary care (uncomplicated OSA with good CPAP adherence) to multidisciplinary specialist management (high-risk OSA with comorbidities), with regular reassessment to ensure continued alignment with the chosen care plan. In addition to better defining these pathways, how they are reimbursed also needs to be addressed. We suggest that there should be a multidisciplinary approach to symptom reduction and adherence, longitudinal assessment of patient-reported outcomes, and a focus on long-term cardiometabolic health as part of managing CPAP-treated patients with OSA. Facilitated by the appropriate use of digital technologies, these approaches should lead to more personalized care and greater patient engagement, resulting in better long-term adherence and treatment effectiveness. The ultimate goal should be to do better for less.

Racial-Ethnic Residential Segregation and Sleep Health among US Adults: Associations by Race and Ethnicity, Sex/Gender, and Neighborhood-Level Poverty

INTRODUCTION

Although racial-ethnic residential segregation (RRS) is hypothesized to contribute to sleep disparities by concentrating poverty and impairing sleep among minoritized racial-ethnic groups, feelings of belonging within relatively homogenous neighborhoods may be protective against poor sleep. Yet, empirical studies are sparse.

METHODS

To investigate RRS-sleep health associations and determine potential modifiers among US adults, we linked National Health Interview Survey data (2011-2017) to 2012 and 2017 American Community Survey census tract-level data. We used the local Getis-Ord Gi* statistic to categorize RRS (high, medium, low [reference]). Using survey-weighted, Poisson regression with robust variance, we estimated prevalence ratios (PRs) and 95% confidence intervals (CIs) for self-reported sleep health measures. We also performed Wald tests for interactions by race-ethnicity, sex/gender, race-ethnicity-by-sex/gender intersectional category, and neighborhood-level poverty.

RESULTS

Among 126,539 participants (mean age ± SE = 46 ± 0.1 years), high RRS was most common among non-Hispanic (NH)-Black (38%), followed by NH-Asian and non-Mexican Latine (34%), Mexican Latine (30%), and NH-White adults (17%). Across races-ethnicities and sexes/genders (both p-interaction > 0.05), high vs. low RRS was associated with a 6% lower prevalence of short sleep duration (< 7-h: PR = 0.94 [95% CI:0.91-0.97]), an 11% lower prevalence of long sleep duration (> 9-h: PR = 0.89 [0.80-0.99]), and a 2% higher prevalence of restorative sleep (PR = 1.02 [1.01-1.04]). Associations with a lower prevalence of trouble falling asleep were stronger among men vs. women. Race-ethnicity-by-sex/gender group membership and neighborhood-level poverty modified associations with sleep duration and quality without consistent patterns.

CONCLUSION

RRS was associated with more favorable sleep health among US adults with variation by key modifiers (e.g., sex). Strategies that leverage potentially protective social factors while promoting equitable resources across diverse neighborhoods may help address sleep health disparities.

Peer-Driven Intervention for Care Coordination and Adherence Promotion for Obstructive Sleep Apnea: A Randomized, Parallel-Group Clinical Trial

Rationale: Obstructive sleep apnea (OSA) is a common condition that is usually treated by continuous positive airway pressure (CPAP) therapy, but poor adherence is common and is associated with worse patient outcomes and experiences. Patient satisfaction is increasingly adopted as a quality indicator by healthcare systems. Objectives: We tested the hypothesis that peer-driven intervention effected through an interactive voice response (IVR) system leads to better patient satisfaction (primary outcome), care coordination, and CPAP adherence than active control. Methods: We performed a 6-month randomized, parallel-group, controlled trial with CPAP-naive patients recruited from four centers and CPAP-adherent patients who were trained to be mentors delivering support through an IVR system. Measurements and Main Results: In 263 patients, intention-to-treat analysis of global satisfaction for sleep-specific services was better in the intervention group (4.57 ± 0.71 Likert scale score; mean ± SD) than in the active-control group (4.10 ± 1.13; P < 0.001). CPAP adherence was greater in the intervention group (4.5 ± 0.2 h/night; 62.0% ± 3.0% of nights >4 h use) versus the active-control group (3.7 ± 0.2 h/night; 51.4% ± 3.0% of nights >4 h use; P = 0.014 and P = 0.023). When compared with the active-control group, the Patient Assessment of Chronic Illness Care rating was moderately increased by an adjusted difference of 0.33 ± 0.12 (P = 0.009), Consumer Assessment of Healthcare Provider and Systems rating was not different (adjusted difference, 0.46 ± 0.26; P = 0.076), and Client Perception of Coordination Questionnaire was mildly better in the intervention group (adjusted difference, 0.15 ± 0.07; P = 0.035). Conclusions: Patient satisfaction with care delivery, CPAP adherence, and care coordination were improved by peer-driven intervention through an IVR system. New payor policies compensating peer support may enable implementation of this approach. Clinical trial registered with www.clinicaltrials.gov (NCT02056002).

Sleep Health Disparities

Sleep is an important and potentially modifiable determinant of many severe health outcomes. Sleep health disparities exist and are exemplified by reported differential rates of prevalence, severity, and outcomes among minority groups and low-socioeconomic-status backgrounds. In this review we highlight the concept of sleep health, review the evidence for disparities in sleep health, examine risk factors and consequences of poor sleep health, and discuss policy implications.

Tracking continuous positive airway pressure adherence in obstructive sleep apnea patients before, during, and after the COVID-19 lockdown

BACKGROUND

This study aimed to examine the impact of the COVID-19 lockdown on adherence to continuous positive airway pressure (CPAP) therapy among Saudi patients with obstructive sleep apnea (OSA). It also sought to assess the influence of demographic variables and comorbidities on CPAP adherence.

METHODS

A prospective cohort study was conducted at the University Sleep Disorders Center at King Saud University Medical City. The study included 67 OSA patients who exclusively used CPAP for treatment across three distinct intervals: prelockdown, during lockdown, and postlockdown. Adherence to CPAP therapy was objectively measured using "mask-on on-time monitoring" data from the CPAP machines.

RESULTS

The study found a significant decrease in the number of days with CPAP usage during the lockdown period, which persisted postlockdown. Approximately half of the patients adhered to CPAP treatment throughout the three study intervals. The decrease in CPAP usage days during lockdown was particularly noticeable among patients younger than 50 and older than 65 years of age. The presence of comorbidities, body mass index, and sex did not significantly influence CPAP treatment adherence.

CONCLUSION

The COVID-19 lockdown significantly impacted CPAP treatment adherence among OSA patients, with a decrease in adherence persisting postlockdown. This highlights the need for interventions to support CPAP adherence during challenging times such as a pandemic. Further research is needed to understand the long-term effects of the pandemic on CPAP therapy adherence.

Air pollution, weather and positive airway pressure treatment adherence in adults with sleep apnea: a retrospective community-based repeated-measures longitudinal study

We assessed the relation between air pollution, weather, and adherence to positive airway pressure (PAP) therapy in a retrospective community-based repeated-measures study of adults with obstructive sleep apnea who purchased PAP devices from a registered provider between 2013 and 2017 (Ottawa, Ontario, Canada) and had at least one day of data. Daily PAP-derived data, air pollution, and weather databases were linked using postal code. The exposures were mean nocturnal (8:00 p.m. to 8:00 a.m.) (i) residential concentrations of nitrogen dioxide (NO2), fine particulate matter <=2.5 μm (PM2.5), ozone (O3), and Air Quality Health Index (AQHI), and (ii) temperature, relative humidity, and barometric pressure. Covariates in the main model were demographics, season, exposure year, and PAP therapy mode. We analysed 8148 adults (median age of 54 years and 61% men) and 2,071,588 days of data. Based on daily data, the median (interquartile range) daily PAP usage was 416 (323-487) min. Using mixed-effect regression analyses to incorporate daily data and clustering by individuals, we found a statistically significant decrease in adherence for increased levels of NO2, PM2.5, and AQHI. The largest effect was for NO2: a decrease in daily PAP use while comparing the highest versus lowest quartiles (Qs) was 3.4 (95% confidence interval [CI] 2.8-3.9) min. Decreased PAP adherence was also associated with increased temperature (Q4 versus Q1: 2.6 [95% CI: 1.5-3.7] min) and decreased barometric pressure (Q1 versus Q4: 2.0 [95% CI 1.5-2.5] min). We observed modest but statistically significant acute effects of air pollution and weather on daily PAP adherence.

Effect of 10-minute oropharyngeal exercise on the apnoea-hypopnoea index

Previously reported oropharyngeal exercises are long and difficult to perform. Therefore, we created a 10-min daily oropharyngeal exercise program and conducted a study to confirm its effectiveness. Twenty-five participants whose apnoea-hypopnoea index (AHI) values were greater than 5 were enrolled. All of the participants performed 10 min of exercise per day for 12 weeks and were evaluated for AHI values, tongue pressure, lip closure pressure, snoring, and Mallampati scores before and after the exercise. Twenty-two participants (88% of all participants) completed the oropharyngeal exercise. Another patient was unable to attend the last evaluation session due to illness. The AHI value improved significantly from an average of 20.9 to 16.9 times/hour in patients with a pre-exercise AHI of 5 to 30 (P = 0.0317). The AHI improvement group included younger participants than did the AHI deterioration group (P = 0.0498). Although the tongue pressures in the AHI improvement group did not improve significantly (P = 0.354), the lip closure pressures tended to increase from a median of 17.6 N to 21.3 N with oropharyngeal exercises (P = 0.0677). This novel oropharyngeal exercise may be appropriate for younger SAS patients with an AHI less than 30.

Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

We investigated the therapeutic effects of exercise in patients with obstructive sleep apnea, aiming to identify the subgroups that benefit the most and determine the optimal exercise protocol.

METHODS

Major databases were searched for randomized controlled trials involving patients with obstructive sleep apnea performing aerobic exercise and/or resistance training. The investigated outcomes included apnea-hypopnea index (AHI), Epworth Sleepiness Scale, body mass index, and peak oxygen consumption during exercise (VO2peak). The pre- and postintervention unstandardized mean difference (USMD) of these parameters was compared between the exercise and control groups.

RESULTS

Twelve studies involving 526 patients were included. Exercise training significantly reduced AHI (USMD = -7.08 events/h, 95% confidence interval: -9.98 to -4.17, P < .00001), Epworth Sleepiness Scale (USMD = -2.37, 95% confidence interval: -3.21 to -1.54, P < .00001), and body mass index (USMD = -0.72 kg/m2, 95% confidence interval: -1.22 to -0.22, P = .005) and enhanced VO2peak (USMD = 3.46 ml·kg-1·min-1, 95% confidence interval: 1.20 to 5.71, P = .003). Subgroup analyses revealed that in continuous positive airway pressure-adherent patients, exercise significantly improved VO2peak but did not reduce AHI and Epworth Sleepiness Scale. A trend was observed that combining resistance training with aerobic exercise resulted in greater AHI reduction and VO2peak enhancement. Notably, exercise improved AHI, Epworth Sleepiness Scale, body mass index, and VO2peak regardless of the baseline AHI or body mass index.

CONCLUSIONS

Exercise, including resistance and aerobic training, should be part of treatment for patients with obstructive sleep apnea of all severities, regardless of obesity status, and even for those who are already under continuous positive airway pressure.

CITATION

Lin C-F, Ho N-H, Hsu W-L, Lin C-H, Wang Y-H, Wang Y-P. Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(11):1839-1849.

Assessing the Pathophysiology, Morbidity, and Mortality of Obstructive Sleep Apnea

The basic definitions of obstructive sleep apnea (OSA), its epidemiology, its clinical features and complications, and the morbidity and mortality of OSA are discussed. Included in this treatise is a discussion of the various symptomatic and polysomnographic phenotypes of COPD that may enable better treatment and impact mortality in persons with OSA. The goal of this article is to serve as a reference for life and disability insurance company medical directors and underwriters when underwriting an applicant with probable or diagnosed sleep apnea. It is well-referenced (133 ref.) allowing for more in-depth investigation of any aspect of sleep apnea being queried.

Oral appliance therapy and hypoglossal nerve stimulation as non-positive airway pressure treatment alternatives for obstructive sleep apnea: a narrative expert review

This perspective on alternatives to positive airway pressure (PAP) therapy for the treatment of obstructive sleep apnea (OSA) summarizes the proceedings of a focus group that was conducted by the Sleep Research Society Foundation. This perspective is from a multidisciplinary panel of experts from sleep medicine, dental sleep medicine, and otolaryngology that aims to identify the current role of oral appliance therapy and hypoglossal nerve stimulation for the treatment of OSA with emphasis on the US practice arena. A secondary aim is to identify-from an implementation science standpoint-the various barriers and facilitators for adoption of non-PAP treatment that includes access to care, multidisciplinary expertise, reimbursement, regulatory aspects, current treatment guidelines, health policies, and other factors related to the delivery of care. The panel has contextualized the review with recent events-such as a large-scale PAP device recall compounded by supply chain woes of the pandemic-and emerging science in the field of OSA and offers solutions for multidisciplinary approaches while identifying knowledge gaps and future research opportunities.

A systematic review on adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in individuals with mild cognitive impairment and Alzheimer's disease dementia

Obstructive sleep apnoea (OSA) is highly prevalent in mild cognitive impairment (MCI) and Alzheimer's disease (AD). The gold standard treatment for OSA is continuous positive airway pressure (CPAP). Long-term, well-powered efficacy trials are required to understand whether CPAP could slow cognitive decline in individuals with MCI/AD, but its tolerability in this group remains uncertain. The present review investigates CPAP adherence among individuals with OSA and MCI/AD. Electronic searches were performed on 8 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Six independent studies and four secondary analyses included 278 unique participants (mean age = 72.1 years). In five of the retained studies, around half of participants (45% N = 85 MCI, 56% N = 22 AD) were adherent to CPAP, where ≥4 h use per night was considered adherent. Three of the retained studies also reported average CPAP use to range between 3.2 and 6.3 h/night. CPAP adherence in individuals with MCI and AD is low, albeit similar to the general elderly population. Reporting adherence in future studies as both average duration as well as using a binary cut-off would improve our understanding of the optimum CPAP use in dementia clinical trials and care.

CPAP resumption after a first termination and impact on all-cause mortality in France

BACKGROUND

Continuation of continuous positive airway pressure (CPAP) therapy after initial prescription has been shown to reduce all-cause mortality versus therapy termination. However, there is a lack of data on the rates and impact of resuming CPAP in patients with obstructive sleep apnoea (OSA). This analysis determined the prevalence of CPAP resumption in the year after termination, characterised determinants of CPAP resumption, and examined the impact of CPAP resumption on all-cause mortality.

METHODS

French national health insurance reimbursement system data for adults aged ≥18 years were used. CPAP prescription was identified by specific treatment codes. Patients who resumed CPAP after first therapy termination and continued to use CPAP for 1 year were matched with those who resumed CPAP then terminated therapy for a second time.

RESULTS

Out of 103 091 individuals with a first CPAP termination, 26% resumed CPAP over the next 12 months, and 65% of these were still using CPAP 1 year later. Significant predictors of CPAP continuation after resumption included male sex, hypertension and CPAP prescription by a pulmonologist. In the matched population, the risk of all-cause death was 38% lower in individuals who continued using CPAP after therapy resumption versus those who had a second therapy discontinuation (hazard ratio 0.62, 95% CI 0.48-0.79; p=0.0001).

CONCLUSION

These data suggest that individuals with OSA who fail initial therapy with CPAP should be offered a second trial with the device to ensure that effective therapy is not withheld from those who might benefit.

Association of language concordance and restraint use in adults receiving mechanical ventilation

PURPOSE

Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes.

METHODS

We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect).

RESULTS

Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common.

CONCLUSIONS

We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

Improved Quality of Life After Mandibular Advancement by Bilateral Internal Ramus Distraction

BACKGROUND

Obstructive Sleep Apnea (OSA) is a significant health issue due to noncompliance with continuous positive airway pressure treatment. Therefore, evaluating alternative treatments is crucial.

PURPOSE

Analyze the impact of maxillomandibular advancement using bilateral internal ramus distraction (BIRD) on quality of life (QOL) in OSA patients.

STUDY DESIGN, SETTING, AND SAMPLE

A prospective cohort study was conducted at the Oral and Maxillofacial Surgery Department of the University Hospital "La Princesa." The study included patients with moderate to severe OSA who were treated with the BIRD approach.

PREDICTOR VARIABLE

Changes in measured variables were analyzed at three time points: before surgery (T1), after mandibular advancement (T2), and after maxillary advancement (T3).

MAIN OUTCOME VARIABLE(S)

QOL changes measured by Quebec Sleep Questionnaire and the Epworth Sleepiness Scale. Secondary outcomes included: apnea-hypopnea index (AHI), oxygen desaturation index, and percentage of time with saturation below 90%.

COVARIATES

Age, sex, continuous positive airway pressure treatment, cephalometric variables and cardiovascular risk parameters were considered.

ANALYSES

Statistical analysis employed the Friedman test and χ2 test, with a significance level of P ≤ .05.

RESULTS

The study included 32 patients (22% with moderate OSA, 78% with severe OSA). Epworth Sleepiness Scale scores significantly decreased between T1 (13.4 ± 4.4) and T2 (5.8 ± 3.6) and T3 (1.9 ± 1.8) (P < .001). QOL improvements were observed in all domains: daytime sleepiness T1 (3.0 ± 1.3) T2 (5.4 ± 1.4) T3 (6.3 ± 1.0); diurnal symptoms T1 (2.5 ± 1.4) T2 (5.2 ± 1.3) T3 (6.2 ± 1.1); nocturnal symptoms T1 (2.5 ± 1.1) T2 (5.6 ± 1.1) T3 (6.5 ± 0.8); emotions T1 (2.6 ± 1.6) T2 (5.3 ± 1.4) T3 (6.5 ± 0.9); and social interaction T1 (2.5 ± 1.6) T2 (5.4 ± 1.6) T3 (6.3 ± 1.2) (P < .001). AHI decreased between T1 (47.9 ± 23.1) and T2 (14.4 ± 14.3) and T3 (4.7 ± 5.6) h-1 (P < .001), with a final cure rate of 81.2% (defined as final AHI<5 h-1). Oxygen desaturation index and percentage of time with saturation below 90% also showed significant reductions (P < .001).

CONCLUSIONS AND RELEVANCE

BIRD approach for OSA demonstrated a high cure rate and significant QOL improvements. It shows promise as an effective surgical option. Further research and long-term follow-up are needed.

Disparities in Sleep-Disordered Breathing: Upstream Risk Factors, Mechanisms, and Implications

Sleep-disordered breathing (SDB) refers to a spectrum of disorders ranging from habitual snoring without frank episodes of obstructed breathing or desaturation during sleep to obstructive sleep apnea, where apneas and hypopneas repetitively occur with resultant intermittent hypoxia, arousal, and sleep disruption. Disparities in SDB reflect its overall high prevalence in children and adults from racially and ethnically minoritized or low socioeconomic status backgrounds coupled with high rates of underdiagnosis and suboptimal treatment.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Pilot study of positive airway pressure usage, patient journey and program engagement for users of a digital obstructive sleep apnea program

Purpose

This single-arm, decentralized pilot study assessed patient journey, positive airway pressure (PAP) usage and program satisfaction for users of an entirely virtual telemedicine program for obstructive sleep apnea (OSA) diagnosis and management. This analysis focuses specifically on the subset of participants in the program who were diagnosed with OSA and prescribed PAP therapy.

Methods

The Verily Clinical Studies Platform was used for virtual screening, consent, and enrolling eligible patients from North Carolina and Texas. After completing the virtual OSA diagnosis process, participants diagnosed with OSA and prescribed PAP therapy downloaded the program's mobile app. The app featured tools such as educational content, live coaching support, and motivational enhancement.

Results

Of the patients included in this analysis (N = 105), the majority were female (58%), and white (90%). The mean time from first televisit to PAP initiation was 29.2 (SD 12.8) days and f 68 out of the 105 patients (65%) reached 90-day adherence. On average, patients used their PAP device for 4.4 h per day, and 5.4 h on days used. Engagement with the app was associated with higher rates of PAP adherence. Adherent individuals used the mobile app 52 out of the 90 days on average, compared to non-adherent individuals who used the app on 35 out of the 90 days on average (p = 0.0003).

Conclusions

All of the 105 patients in this program diagnosed with OSA and prescribed PAP therapy were able to efficiently complete the entire OSA diagnostic pathway. The majority of these individuals also were able to adhere to their prescribed PAP therapy and had clinically meaningful PAP usage rates over the 90 days of therapy. Future studies might further evaluate the impact of this type of end-to-end virtual program on longer-term adherence and clinical outcomes over time.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04599803?term=NCT04599803&draw=2&rank=1, identifier NCT04599803.

Race and Socioeconomic Status: Interlinked Drivers of Sleep Health Disparities

The effect of race and socioeconomic status on sleep disorders has significant effects on the availability of healthcare and health outcomes. This paper examines how race and SES contribute to sleep health disparities, emphasizing the importance of understanding their impact on sleep disorders and treatment particularly in minority populations and veterans.

Remote Monitoring of Positive Airway Pressure Data: Challenges, Pitfalls, and Strategies to Consider for Optimal Data Science Applications

Over recent years, positive airway pressure (PAP) remote monitoring has transformed the management of OSA and produced a large amount of data. Accumulated PAP data provide valuable and objective information regarding patient treatment adherence and efficiency. However, the majority of studies that have analyzed longitudinal PAP remote monitoring have summarized data trajectories in static and simplistic metrics for PAP adherence and the residual apnea-hypopnea index by the use of mean or median values. The aims of this article are to suggest directions for improving data cleaning and processing and to address major concerns for the following data science applications: (1) conditions for residual apnea-hypopnea index reliability, (2) lack of standardization of indicators provided by different PAP models, (3) missing values, and (4) consideration of treatment interruptions. To allow fair comparison among studies and to avoid biases in computation, PAP data processing and management should be conducted rigorously with these points in mind. PAP remote monitoring data contain a wealth of information that currently is underused in the field of sleep research. Improving the quality and standardizing data handling could facilitate data sharing among specialists worldwide and enable artificial intelligence strategies to be applied in the field of sleep apnea.

Severity, comorbidities, and adherence to therapy in Native Hawaiians/Pacific Islanders with obstructive sleep apnea

STUDY OBJECTIVES

Considerable disparities in the prevalence, diagnosis, and management of obstructive sleep apnea (OSA) exist for minority groups in the United States. However, the impact of OSA on Native Hawaiian/Pacific Islanders (NHPIs) has not been evaluated.

METHODS

We performed a retrospective review of patient records of NHPIs who underwent sleep apnea testing between 2014 and 2021 at a single center in Utah to characterize the distribution of comorbidities, disease severity, and treatment adherence.

RESULTS

140 of 141 NHPI patients who underwent sleep testing had OSA. High rates of obesity (94%) and other relevant comorbidities were found. OSA was mostly severe (57%), particularly in males with higher obesity. Adherence to continuous positive airway pressure was low (41% using for 4 or more hours on 70% of nights), and medical factors predicted whether adherence targets were met with modest accuracy (area under the curve 0.699).

CONCLUSIONS

NHPIs at a single sleep center had a high prevalence of comorbidities in association with OSA, a skewed distribution toward severe disease suggestive of barriers to care or unique disease characteristics, and low adherence to continuous positive airway pressure. These findings suggest a high burden of OSA in this population, and further work to characterize barriers to identifying and treating OSA in NHPIs can improve chronic disease outcomes in NHPIs.

CITATION

Locke BW, Sundar DJ, Ryujin D. Severity, comorbidities, and adherence to therapy in Native Hawaiians/Pacific Islanders with obstructive sleep apnea. J Clin Sleep Med. 2023;19(5):967-974.

Experiences with Continuous Positive Airway Pressure Among African American Patients and their Bed Partners

RATIONALE

Despite having a higher prevalence and severity of obstructive sleep apnea (OSA), African Americans have lower adherence to continuous positive airway pressure (CPAP) compared to other groups. Information regarding challenges faced by African Americans prescribed CPAP are lacking.

OBJECTIVES

To determine the barriers and facilitators to optimal management of OSA with CPAP among African Americans and to understand the role bed partners may play.

METHODS

We conducted semi-structured in-depth interviews via video conferencing with African American patients of an urban safety-net health care system with OSA prescribed CPAP and their bed partners. Recruitment continued until theoretical saturation was achieved. Verbatim transcripts were analyzed using the principles of thematic analysis.

RESULTS

15 patients (12 women) diagnosed with OSA and prescribed CPAP a mean 2.6 years prior along with 15 bed partners (3 women) were individually interviewed. Four themes emerged regarding impediments to CPAP use: 1) inadequate education and support, 2) CPAP maintenance and hygiene, 3) inconvenient design of CPAP interfaces, and 4) impediment to intimacy. Four themes emerged as facilitators to CPAP use: 1) provider and technical support, 2) properly fitted CPAP masks, 3) active support from partner and family, and 4) experiencing positive results from CPAP.

CONCLUSIONS

African American patients with OSA and their bed partners identified several unique barriers and facilitators to CPAP use. Active involvement by bed partners was considered by both patients and partners as helpful in improving CPAP adherence. Interventions to improve OSA outcomes in this population should focus on patients and their bed partners.

Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

Racial Differences in Positive Airway Pressure Adherence in the Treatment of Sleep Apnea

Although data are limited, studies suggest on average lower positive airway pressure use in Black, indigenous, and people of color (BIPOC) compared with Whites in most but not all studies. Most of these observational studies are certainly limited by confounding by socioeconomic status and other unmeasured factors that likely contribute to differences. The etiology of these observed disparities is likely multifactorial, due in part to financial limitations, differences in sleep opportunity, poor sleep quality due to environmental disruptions, and so forth. These disparities in sleep health are likely related to chronic inequities, including experiences of racism, neighborhood features, structural, and contextual factors. Dedicated studies focusing on understanding adherence in BIPOC are lacking. Further research is needed to understand determinants of PAP use in BIPOC subjects and identify feasible interventions to improve sleep health and reduce sleep apnea treatment disparities.

Does race-ethnicity affect upper airway stimulation adherence and treatment outcome of obstructive sleep apnea?

STUDY OBJECTIVES

Untreated obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness, decreased quality of life, and cardiovascular disease. Positive airway pressure is the first-line therapy for OSA; however, adherence is difficult. Upper airway stimulation is a Food and Drug Administration-approved treatment of OSA. The objective of this study was to evaluate for a difference in treatment efficacy and adherence of upper airway stimulation therapy for OSA between individuals who are White and non-White using data from the ADHERE registry.

METHODS

ADHERE registry is a multicenter prospective study of real-world experience of upper airway stimulation for treatment of OSA in the United States and Europe. Propensity score matching was used to create a balanced dataset between the White and non-White groups. t-Tests at a significance level of 5% were used to compare numeric values between groups.

RESULTS

There were 2,755 participants of the ADHERE registry: 27 were excluded due to not having a race identified, 125 participants identified as non-White, 2,603 identify as White, and 27 did not provide race information. Propensity score matching was used to select 110 participants, with 55 White and 55 non-White for the noninferiority analysis. We did not find a difference in adherence, treatment apnea-hypopnea index, changes in Epworth Sleepiness Scale score, or clinical global impression after intervention score between White and non-White individuals.

CONCLUSIONS

Our study found that there was no statistically significant difference in adherence or efficacy with upper airway stimulation therapy between White and non-White individuals. However, the percent of non-White people implanted is low, which suggests a need to expand access to this therapy for non-White populations with OSA who cannot tolerate positive airway pressure therapy.

CITATION

Khan M, Stone A, Soose RJ, et al. Does race-ethnicity affect upper airway stimulation adherence and treatment outcome of obstructive sleep apnea? J Clin Sleep Med. 2022;18(9):2167-2172.

A Health Communication Assessment of Web-based Obstructive Sleep Apnea Patient Education Materials

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Conclusion

Factors Affecting Long-Term Compliance of CPAP Treatment-A Single Centre Experience

Continuous positive airway pressure (CPAP) has been the standard treatment of obstructive sleep apnoea/hypopnoea syndrome (OSA) for almost four decades. Though usually effective, this treatment suffers from poor long-term compliance. Therefore, the aim of our one centre retrospective study was to assess factors responsible for treatment failure and long-term compliance. Four hundred subsequent patients diagnosed with OSA and qualified for CPAP treatment were chosen from our database and compliance data were obtained from medical charts. Many differing factors kept patients from starting CPAP or led to termination of treatment. Overall, almost half of patients ended treatment during the mean time of observation of 3.5 years. Survival analysis revealed that 25% of patients failed at a median time of 38.2 months. From several demographic and clinical covariates in Cox’s hazard model, only the presence of a mild OSA, i.e., AHI (apnoea/hypopnoea index) below 15/h was a factor strongly associated with long term CPAP failure. The compliance results of our study are in line with numerous studies addressing this issue. Contrary to them, some demographic or clinical variables that we used in our survival model were not related to CPAP adherence.

Improving CPAP Adherence in Adults With Obstructive Sleep Apnea Syndrome: A Scoping Review of Motivational Interventions

Objective: This scoping review aims to provide an accessible summary of available evidence on the efficacy of motivational interventions to increase adherence to Continuous Positive Airway Pressure (CPAP) among patients with Obstructive Sleep Apnea Syndrome (OSAS) and of their specific aspects and strategies by assessing adherence measures. Methods: A literature search was performed in PubMed, Scopus, Medline, PsycINFO, and Web of Science databases using the concepts of "obstructive sleep apnea syndrome," "continuous positive airway pressure," "motivational intervention," and "adherence." Rigorous inclusion criteria and screening by at least two reviewers were applied. Data were extracted to address the review aims and were presented as a narrative synthesis. Results: Search for databases produced 11 randomized controlled trials, all including naïve CPAP users. Findings showed that motivational interventions were more effective than usual care and educational programs in increasing adherence to CPAP, despite results were not always maintained over time across studies. Discussion: To our knowledge, this is the first scoping review of the literature aimed to explore the characteristics and impact of motivational interventions to promote adherence to CPAP in patients with OSAS. More research providing a detailed description of motivational strategies, and testing of their association with positive treatment outcomes via both direct and indirect measures are needed to increase awareness on active mechanisms of change.