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Sterling KL, Alpert N, Malik AS, Pépin JL, Benjafield AV, Malhotra A, Piccini JP, Cistulli PA. Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation. J Am Heart Assoc 2024; 13:e030679. [PMID: 38700039 DOI: 10.1161/jaha.123.030679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 03/01/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation. METHODS AND RESULTS Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively). CONCLUSIONS These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.
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Affiliation(s)
| | | | | | - Jean-Louis Pépin
- Institut National de la Santé et de la Recherche Médicale (INSERM) U 1300, HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University Grenoble France
| | | | | | - Jonathan P Piccini
- Duke Heart Center, Department of Medicine Duke University Medical Center Durham NC
| | - Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney Australia
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Alpert N, Cole KV, Dexter RB, Sterling KL, Wickwire EM. Performance of Claims-Based Algorithms for Adherence to Positive Airway Pressure Therapy in Commercially Insured Patients With OSA. Chest 2024; 165:1228-1238. [PMID: 38215934 DOI: 10.1016/j.chest.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/20/2023] [Accepted: 01/07/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Positive airway pressure (PAP) therapy is first-line therapy for OSA, but consistent use is required for it to be effective. Previous studies have used Medicare fee-for-service claims data (eg, device, equipment charges) as a proxy for PAP adherence to assess its effects. However, this approach has not been validated in a US commercially insured population, where coverage rules are not standardized. RESEARCH QUESTION In a commercially insured population in the United States, how well do claims-based algorithms for defining PAP adherence correspond with objective PAP device usage? STUDY DESIGN AND METHODS Deidentified administrative claims data of commercially insured patients (aged 18-64 years) with OSA were linked to objective PAP therapy usage data from cloud-connected devices. Adherence was defined based on device use (using an extension of Centers for Medicare & Medicaid Services 90-day compliance criteria) and from claims-based algorithms to compare usage metrics and identify potential misclassifications. RESULTS The final sample included 213,341 patients. Based on device usage, 48% were adherent in the first year. Based on claims, between 10% and 84% of patients were identified as adherent (accuracy, sensitivity, and specificity ranges: 53%-68%, 12%-95%, and 26%-92%, respectively). Relative to patients who were claims-adherent, patients who were device-adherent had consistently higher usage across all metrics (mean, 339.9 vs 260.0-290.0 days of use; 6.6 vs 5.1-5.6 d/wk; 6.4 vs 4.6-5.2 h/d). Consistent PAP users were frequently identified by claims-based algorithms as nonadherent, whereas many inconsistent users were classified by claims-based algorithms as adherent. INTERPRETATION In aggregate US commercial data with nonstandardized PAP coverage rules, concordance between existing claims-based definitions and objective PAP use was low. Caution is warranted when applying existing claims-based algorithms to commercial populations.
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Affiliation(s)
| | | | | | | | - Emerson M Wickwire
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine; and Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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Wickwire EM, Cole KV, Dexter RB, Malhotra A, Cistulli PA, Sterling KL, Pépin JL. Depression and comorbid obstructive sleep apnea: Association between positive airway pressure adherence, occurrence of self-harm events, healthcare resource utilization, and costs. J Affect Disord 2024; 349:254-261. [PMID: 38159653 PMCID: PMC10922426 DOI: 10.1016/j.jad.2023.12.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/08/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Previous studies have shown that treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy in patients with depression may improve depression symptoms and response to antidepressant therapy. We investigated the association between PAP therapy adherence, self-harm events, healthcare resource utilization (HCRU), and costs over 2 years in a national sample of patients with pre-existing depression and newly diagnosed comorbid OSA. METHODS Administrative claims data were linked to objective PAP therapy usage. Inverse probability treatment weighting was used to compare outcomes over 2 years across PAP adherence levels. The predicted numbers of emergency room (ER) visits and hospitalizations by adherence level were assessed using risk-adjusted generalized linear models. RESULTS 37,459 patients were included. Relative to non-adherent patients, consistently adherent patients had fewer self-harm events (0.04 vs 0.05, p < 0.001) after 1 year, and significantly (all p < 0.001) fewer ER visits (0.66 vs 0.86) and all-cause hospitalizations (0.13 vs 0.17), and lower total ($11,847 vs $11,955), inpatient hospitalization ($1634 vs $2274), and ER visit ($760 vs $1006) costs per patient in the second year of PAP therapy. Consistently adherent patients showed lower risk for hospitalizations and ER visits. LIMITATIONS Using observational claims data, we were unable to assess clinical characteristics including sleep, sleepiness, and daytime symptoms, or important social determinants of health. We were limited in assessing care received outside of the included health plans. CONCLUSION Consistent adherence to PAP therapy over 2 years was associated with improved HCRU outcomes for patients with pre-existing depression newly diagnosed with comorbid OSA.
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Affiliation(s)
- E M Wickwire
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - K V Cole
- ResMed Science Center, San Diego, CA, USA
| | - R B Dexter
- ResMed Science Center, Halifax, Nova Scotia, Canada
| | - A Malhotra
- University of California San Diego, La Jolla, CA, USA
| | - P A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
| | | | - J L Pépin
- Univ. Grenoble Alpes, Institut National de la Santé et de la Recherche Médicale (INSERM) U 1300, HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University, Grenoble, France
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Sterling KL, Alpert N, Cistulli PA, Pepin JL, More S, Cole KV, Malhotra A. Healthcare resource utilisation and costs in patients with treated obstructive sleep apnea. J Sleep Res 2023:e14099. [PMID: 37964440 PMCID: PMC11090990 DOI: 10.1111/jsr.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023]
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disease that creates a large economic burden on the United States healthcare system. In this retrospective study, we tested the hypothesis that adherence to positive airway pressure (PAP) therapy, the 'gold standard' treatment for OSA, is associated with reduced healthcare resource utilisation and costs. We linked de-identified payer-sourced medical claims and objective PAP usage data for patients newly diagnosed with OSA. Inverse probability of treatment weighting was used to create balanced groups of patients who were either adherent, intermediately adherent, or non-adherent to PAP therapy. From a sample of 179,542 patients (average age 52.5 years, 61% male), 37% were adherent, 40% intermediate, and 23% non-adherent. During the first year, PAP adherence was significantly associated with fewer emergency room visits (mean [SD] adherent: 0.39 [1.20] versus intermediate: 0.47 [1.30], p < 0.001; versus non-adherent: 0.54 [1.44], p < 0.001), all-cause hospitalisations (mean [SD] adherent: 0.09 [0.43] versus intermediate: 0.12 [0.51], p < 0.001; versus non-adherent: 0.13 [0.55], p < 0.001), and lower total costs (mean [SD] adherent $5874 [8045] versus intermediate $6523 [9759], p < 0.001; versus non-adherent $6355 [10,517], p < 0.001). Results were similar in the second year of PAP use. These results provide additional evidence from a large, diverse sample to support the diagnosis and treatment of OSA and encourage long-term adherence to PAP therapy.
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Affiliation(s)
| | | | - Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jean Louis Pepin
- Institute National de la Sante et de la Recherche Medicale (INSERM) U 1300, HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University, Grenoble, France
| | - Suyog More
- ResMed Science Center, Halifax, NS Canada
| | | | - Atul Malhotra
- University of California San Diego, La Jolla, CA USA
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Martinot JB, Le-Dong NN, Borel AL, Tamisier R, Malhotra A, Pépin JL. Respiratory effort during sleep and the rate of prevalent type 2 diabetes in obstructive sleep apnoea. Diabetes Obes Metab 2023; 25:2815-2823. [PMID: 37312670 PMCID: PMC10527265 DOI: 10.1111/dom.15169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/15/2023] [Accepted: 05/24/2023] [Indexed: 06/15/2023]
Abstract
AIM To determine the association between total sleep time (TST) spent in increased respiratory effort (RE) and the prevalence of type 2 diabetes in a large cohort of individuals with suspected obstructive sleep apnoea (OSA) referred for in-laboratory polysomnography (PSG). MATERIALS AND METHODS We conducted a retrospective cross-sectional study using the clinical data of 1128 patients. Non-invasive measurements of RE were derived from the sleep mandibular jaw movements (MJM) bio-signal. An explainable machine-learning model was built to predict prevalent type 2 diabetes from clinical data, standard PSG indices, and MJM-derived parameters (including the proportion of TST spent with increased respiratory effort [REMOV [%TST]). RESULTS Original data were randomly assigned to training (n = 853) and validation (n = 275) subsets. The classification model based on 18 input features including REMOV showed good performance for predicting prevalent type 2 diabetes (sensitivity = 0.81, specificity = 0.89). Post hoc interpretation using the Shapley additive explanation method found that a high value of REMOV was the most important risk factor associated with type 2 diabetes after traditional clinical variables (age, sex, body mass index), and ahead of standard PSG metrics including the apnoea-hypopnea and oxygen desaturation indices. CONCLUSIONS These findings show for the first time that the proportion of sleep time spent in increased RE (assessed through MJM measurements) is an important predictor of the association with type 2 diabetes in individuals with OSA.
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Affiliation(s)
- Jean-Benoit Martinot
- Sleep Laboratory, CHU Université catholique de Louvain (UCL) Namur Site Sainte-Elisabeth, Namur, Belgium
- Institute of Experimental and Clinical Research, UCL Bruxelles Woluwe, Brussels, Belgium
| | | | - Anne-Laure Borel
- University of Grenoble Alpes, HP2 Laboratory, Inserm U1300, Grenoble, France
| | - Renaud Tamisier
- University of Grenoble Alpes, HP2 Laboratory, Inserm U1300, Grenoble, France
| | - Atul Malhotra
- University of California San Diego, La Jolla, California, USA
| | - Jean-Louis Pépin
- University of Grenoble Alpes, HP2 Laboratory, Inserm U1300, Grenoble, France
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Gentina T, Gentina E, Douay B, Micoulaud-Franchi JA, Pépin JL, Bailly S. Investigating associations between social determinants, self-efficacy measurement of sleep apnea and CPAP adherence: the SEMSA study. Front Neurol 2023; 14:1148700. [PMID: 37528857 PMCID: PMC10390224 DOI: 10.3389/fneur.2023.1148700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/29/2023] [Indexed: 08/03/2023] Open
Abstract
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.
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Affiliation(s)
- Thibaut Gentina
- Ramsey General Healthcare La Louviere Hospital, Lille, France
| | - Elodie Gentina
- IESEG School of Management, CNRS, UMR 9221 – LEM – Lille Economie Management, Univ. Lille, Lille, France
| | - Bernard Douay
- Ramsey General Healthcare La Louviere Hospital, Lille, France
| | - Jean-Arthur Micoulaud-Franchi
- SANPSY, UMR 6033, University of Bordeaux, Bordeaux, France
- Sleep Medicine Service, University Hospital, Bordeaux, France
| | - Jean-Louis Pépin
- HP2 Laboratory, INSERM U1300, Univ. Grenoble Alpes, Grenoble, France
- EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Sébastien Bailly
- HP2 Laboratory, INSERM U1300, Univ. Grenoble Alpes, Grenoble, France
- EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
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Cistulli PA, Malhotra A, Cole KV, Malik AS, Pépin JL, Sert Kuniyoshi FH, Benjafield AV, Somers VK. Positive Airway Pressure Therapy Adherence and Health Care Resource Use in Patients With Obstructive Sleep Apnea and Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2023:e028733. [PMID: 37421282 PMCID: PMC10382094 DOI: 10.1161/jaha.122.028733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/04/2023] [Indexed: 07/10/2023]
Abstract
Background Obstructive sleep apnea (OSA) is common in heart failure with preserved ejection fraction (HFpEF). However, current evidence is equivocal regarding the potential benefits of treating OSA with positive airway pressure (PAP) therapy in HFpEF. This study assessed the association between adherence to PAP therapy and health care resource use in patients with OSA and HFpEF. Methods and Results Administrative insurance claims data linked with objective PAP therapy usage data from patients with OSA and HFpEF were used to determine associations between PAP adherence and a composite outcome including hospitalizations and emergency room visits. One-year PAP adherence was based on an adapted US Medicare definition. Propensity score methods were used to create groups with similar characteristics across PAP adherence levels. The study cohort included 4237 patients (54.0% female, mean age 64.1 years); 40% were considered adherent to PAP therapy (30% intermediate adherent, 30% nonadherent). In the matched cohort, PAP-adherent patients had fewer health care resource use visits than nonadherent patients, a 57% decrease in hospitalizations, and a 36% decrease in emergency room visits versus the year before PAP initiation. Total health care costs were lower in adherent patients than nonadherent patients ($12 732 versus $15 610, P<0.001). Outcomes for intermediately adherent patients were most similar to those for nonadherent patients. Conclusions Treating OSA with PAP therapy in patients with HFpEF was associated with a reduction in health care resource use. These data highlight the importance of managing concomitant OSA in patients with HFpEF, and the need for strategies to enhance PAP adherence in this population.
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Affiliation(s)
- Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Australia
- Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney Australia
| | | | | | | | - Jean-Louis Pépin
- Institut National de la Santé et de la Recherche Médicale (INSERM) U 1300, HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University Grenoble France
| | - Fatima H Sert Kuniyoshi
- ResMed Science Center San Diego CA USA
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | | | - Virend K Somers
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
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