Factors predicting CPAP adherence in obstructive sleep apnea syndrome

Medicare volume and reimbursement trends in lingual and hyoid procedures for obstructive sleep apnea

OBJECTIVES

This study aims to analyze utilization and reimbursement trends in lingual and hyoid surgery for obstructive sleep apnea (OSA).

METHODS

Annual retrospective data on lingual and hyoid OSA surgeries was obtained from the 2000-2021 Medicare Part B National Summary Datafiles. Current Procedural Terminology (CPT) codes utilized included 21,685 (hyoid myotomy and suspension [HMS]), 41,512 (tongue base suspension [TBS]), 41,530 (radiofrequency ablation of the tongue [RFT]) and 42,870 (lingual tonsillectomy [LT]).

RESULTS

The number of lingual and hyoid OSA surgeries rose 2777 % from 121 in 2000 to 3481 in 2015, before falling 82.9 % to 594 in 2021. Accordingly, Medicare payments rose 17,899 % from an inflation-adjusted $46,958 in 2000 to $8.45 million in 2015, before falling drastically to $341,011 in 2021. As the number of HMSs (2000: 91; 2015: 84; 2021: 165), TBS (2009: 48; 2015: 31; 2021: 16), and LTs (2000: 121; 2015: 261; 2021: 234) only experienced modest changes in utilization, this change was largely driven by RFT (2009: 340; 2015: 3105; 2021: 179). Average Medicare payments for RFT rose from $1110 in 2009 to $2994 in 2015, before falling drastically to $737 in 2021.

CONCLUSION

Lingual and hyoid surgery for OSA has overall fallen in utilization among the Medicare population from 2000 to 2021. However, there was a brief spike in usage, peaking in 2015, driven by the adoption (and then quick dismissal) of RFT. The rise and fall in RFT use coincide with the rise and fall in reimbursement.

The Relationship between Leptin Levels and Continuous Positive Airway Pressure Treatment: A Cluster Analysis

Objective  Leptin is an appetite-suppressing hormone released by adipose tissue that plays an important role in severe obstructive sleep apnea syndrome (OSAS). However, it is unclear whether leptin levels are a useful biomarker for this syndrome. The present study aimed to assess the effect of continuous positive airway pressure (CPAP) treatment on the syndrome according to leptin levels, using a cluster classification based on clinical features of the syndrome. Materials and Methods  We performed a hierarchical cluster analysis of data from 97 OSAS patients diagnosed via polysomnography. We also evaluated the effect after 6 months of CPAP administration. Results  Clusters 1 (49 patients; 50.5%) and 2 (6 patients; 6.2%) presented normal leptin levels, and clusters 3 (11 patients; 11.3%) and 4 (31 patients; 32%) presented high leptin levels. Clusters 3 and 4 presented different leptin levels, but the same degree of obesity. After treatment, the levels of excessive daytime sleepiness improved in all clusters. In Cluster 3, leptin levels were significantly reduced after treatment. Conclusion  Using the conventional diagnostic method of the apnea-hypopnea index, it was not clear whether leptin is a useful biomarker for the CPAP treatment. However, it may be helpful for particular clusters, including obese women, and where particular populations require CPAP treatment.

Preferences and experiences regarding the treatment of obstructive sleep apnea with mandibular advancement splints - a cross-sectional pilot survey

OBJECTIVE

To obtain a current overview of the use of mandibular advancement splints (MAS) as a therapeutic option for obstructive sleep apnea (OSA) in the dental profession in Northern Germany.

METHODS

A questionnaire was mailed to 2431 dental professionals, and 8.3% responded. Descriptive data analysis was performed on each question separately.

RESULTS

Most of the surveyed dentists (51.7%) estimated the success rate of MAS therapy to be higher than 75%. Analysis of the relationship between the number of splints prescribed annually and the dental specialization (p = 0.22), work experience (p = 0.14), estimated success rate of MAS therapy (p = 0.96), and discontinuation of MAS therapy (p = 0.57) revealed no significant correlations.

CONCLUSION

Mandibular advancement splints seem to be a safe and successful therapy for OSA. There seems to be a lack of information on the patient side and a lack of education on the dentist side.

Indications for Dental Specialists for Treating Obstructive Sleep Apnea with Mandibular Advancement Devices: A Narrative Review

Obstructive sleep apnea (OSA) syndrome is characterized by repeated airway collapse during sleep. It determines cardiovascular, pulmonary, and neurocognitive consequences and is associated with several daytime and nighttime symptoms that influence the patient's quality of life. The contribution of the dental specialist in the clinical management of OSA patients entails participating in the screening process as diagnostic sentinels and providing adequate treatment using mandibular advancement devices (MADs). Since the treatment of OSA requires a multidisciplinary approach, including different medical specialists, dentists should have a comprehensive understanding of medical and dental factors that influence the strategy and effectiveness of OSA treatment with MAD. Such expertise is crucial in determining the appropriate treatment indications and helps clinicians establish a consolidated position within the multidisciplinary OSA team. In this regard, this review summarizes the evidence of the clinical indications for MAD treatment and provides the dental specialist with helpful information about medical, functional, and other relevant factors that should be considered during diagnosis, treatment plan, and follow-up stages. Information retrieved was organized and discussed, generating specific domains/queries oriented to the clinical management of OSA patients from the clinical perspective of dental specialists.

Predictors of Continuous Positive Airway Pressure Adherence and Comparison of Clinical Factors and Polysomnography Findings Between Compliant and Non-Compliant Korean Adults With Obstructive Sleep Apnea

OBJECTIVE

Continuous positive airway pressure (CPAP) is the preferred treatment for obstructive sleep apnea (OSA). However, compliance with CPAP therapy varies among studies, and studies on its predictors are insufficient in Korea. This study aimed to identify factors that predict compliance with CPAP therapy in patients with OSA.

METHODS

We retrospectively reviewed medical records, polysomnography (PSG) records, and self-report questionnaires of patients w ith OSA. Criteria for compliance was the use of CPAP devices for ≥4 h per night for ≥70% of the consecutive 30 nights (i.e., 21 days) during the first 3 months of treatment initiation. The patients were classified into two groups: compliant and non-compliant. Logistic regression analyses were performed to identify the clinical factors and PSG parameters associated with CPAP compliance.

RESULTS

Of the 188 participants, 80 were classified into the compliant group and 108 into the non-compliant group. The ratios of stage N1 (p=0.011) and health insurance coverage (p=0.007) were significantly associated with compliance with CPAP, with an explanatory power of 18.6% (R2=0.186, p<0.001).

CONCLUSION

Stage N1 ratio and health insurance coverage were significant predictors of CPAP compliance. It is necessary to confirm whether the relationship between a high stage N1 ratio and compliance can be reproduced in a larger sample and in individuals from other countries.

The Role of Obstructive Sleep Apnea in Vision-Threatening Diabetic Retinopathy-A National Register-Based Study

INTRODUCTION

we investigated the association between OSA and vision-threatening diabetic retinopathy (VTDR).

METHODS

we used three nationwide registers to identify subjects with and without OSA and patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM). The Danish Civil Registration System was used to link OSA with diabetes diagnosis. The primary outcome was the occurrence of VTDR in diabetic patients with and without OSA. The secondary outcome was the prevalence of diabetes mellitus in patients with and without OSA.

RESULTS

we included 532,828 diabetic subjects comprising 13,279 patients with OSA (2.5%) and 519,549 without OSA (97.5%). Diabetic patients with OSA had a 57% lower risk of VTDR compared to diabetic patients without OSA (OR 0.43, 95% CI 0.38-0.50, p < 0.0001).

CONCLUSIONS

our findings indicate that OSA is associated with a lower risk of VTDR. Since we did not adjust our outcomes for diabetes duration, hypertension control and hemoglobin A1c, future studies are needed to confirm our findings.

Adherence to Continuous Positive Airway Pressure Therapy in Pediatric Patients with Obstructive Sleep Apnea: A Meta-Analysis

Introduction

Obstructive sleep apnea (OSA) is a public health problem that affects children. Although continuous positive airway pressure (CPAP) therapy is effective, the CPAP adherence rate in children is varied. This study aimed to evaluate the CPAP adherence rate and factors associated with CPAP adherence in children with OSA using a systematic review.

Methods

The inclusion criteria were observational studies conducted in children with OSA and assessed adherence of CPAP using objective evaluation. The literature search was performed in four databases. Meta-analysis using fixed-effect model was conducted to combine results among included studies.

Results

In all, 34 studies that evaluated adherence rate and predictors of CPAP adherence in children with OSA were included, representing 21,737 patients with an average adherence rate of 46.56%. There were 11 calculations of factors predictive of CPAP adherence: age, sex, ethnicity, body mass index, obesity, income, sleep efficiency, the apnea-hypopnea index (AHI), severity of OSA, residual AHI, and lowest oxygen saturation level. Three different factors were linked to children with adherence and non-adherence to CPAP: age, body mass index, and AHI.

Conclusion

The CPAP adherence rate in children with OSA was 46.56%. Young age, low body mass index, and high AHI were associated with acceptable CPAP adherence in children with OSA.

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.

Therapieadhärenz drei Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA)

Einleitung Die nächtliche kontinuierliche positive Überdruckatmung (CPAP) gilt als therapeutischer Goldstandard einer obstruktiven Schlafapnoe (OSA). Die CPAP-Therapie stellt zumeist eine Dauertherapie mit geringen Nebenwirkungen dar. Trotzdem ist die Therapietreue unbefriedigend. In dieser Arbeit wurden die Therapietreue betrachtet und typische Probleme katalogisiert.

Methode 1078 OSA-Patienten wurden nach diagnostischer Polygrafie (PG) oder Polysomnografie (PSG) auf eine CPAP-Therapie eingestellt. Die Therapietreue wurde nach 3 Monaten nachverfolgt. Folgende Therapieadhärenz-Gruppen wurden festgelegt: 1. gute CPAP-Einstellung und Nutzung, 2. CPAP-Abbruch nach anfänglicher Nutzung, 3. mangelnde CPAP-Nutzung wegen Nebenwirkungen, 4. Abbruch aufgrund fehlender Motivation/geringem Leidensdruck, 5. Masken-Unverträglichkeit, 6. CPAP-Versagen aufgrund fehlenden Therapieeffekts, 7. Umstellung auf anderes Beatmungsverfahren, 8. keine Kontrolle erfolgt.

Ergebnisse Von 1078 CPAP-Patienten erschienen 830 Patienten (77 %) zur Therapiekontrolle. Hiervon waren 450 Patienten (54,2%) in Gruppe 1, 216 Patienten (26%) in Gruppe 2, 71 Patienten (8,5%) in Gruppe 3, 35 Patienten (4,2%) in Gruppe 4, 14 Patienten (1,7%) in Gruppe 5, 3 Patienten (0,4 %) in Gruppe 6 und 41 Patienten (4,9%) in Gruppe 7. Ein geringer obstruktiver Ereignisindex, niedriger CPAP-Druck und tendenziell auch ein geringer Epworth-Sleepiness-Score waren Prädiktoren für CPAP-Versagen. Für die Therapietreue konnten keine signifikanten Prädiktoren dargestellt werden.

Diskussion Eine effektive Therapienutzung von 54% nach 3 Monaten ist ein suboptimales Ergebnis. Prädiktoren für CPAP-Versagen waren Parameter, die vor Therapie auf geringen Leidensdruck der Patienten deuteten. Trotz großer Patientenkohorte konnten keine signifikanten CPAP-Adhärenz-Prädiktoren durch anthropometrische oder PSG-Daten dargestellt werden. Vielmehr könnten Erfahrungen in den ersten Therapietagen ausschlaggebend sein. CPAP-Geräte bieten Komforteinstellungen, die kenntnisgerecht auf den Patienten individualisiert werden müssen. Eine große Auswahl an unterschiedlichen Maskenformen erfordert Erfahrung und Training bei der patientenorientierten Maskenanpassung. Eine 3-monatige Wiedervorstellung erscheint zu lang, um Therapieprobleme zeitnah mit dem Patienten zu besprechen. Telemedizinische Möglichkeiten oder kurzfristige telefonische Beratungsoptionen sollten in Betracht gezogen werden.

Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.

[Adherence to CPAP Three Months after Starting Therapy in 1078 Patients with Obstructive Sleep Apnea (OSA)]

INTRODUCTION

 Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified.

METHODS

 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out.

RESULTS

 Out of 1078 OSA patients a therapy control was performed in 830 patients (77 %). Of these, 450 patients (54.2 %) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9 %) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth- Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy.

DISCUSSION

 An effective treatment use of 54 % after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients' needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

Machine learning-based preoperative datamining can predict the therapeutic outcome of sleep surgery in OSA subjects

Increasing recognition of anatomical obstruction has resulted in a large variety of sleep surgeries to improve anatomic collapse of obstructive sleep apnea (OSA) and the prediction of whether sleep surgery will have successful outcome is very important. The aim of this study is to assess a machine learning-based clinical model that predict the success rate of sleep surgery in OSA subjects. The predicted success rate from machine learning and the predicted subjective surgical outcome from the physician were compared with the actual success rate in 163 male dominated-OSA subjects. Predicted success rate of sleep surgery from machine learning models based on sleep parameters and endoscopic findings of upper airway demonstrated higher accuracy than subjective predicted value of sleep surgeon. The gradient boosting model showed the best performance to predict the surgical success that is evaluated by pre- and post-operative polysomnography or home sleep apnea testing among the logistic regression and three machine learning models, and the accuracy of gradient boosting model (0.708) was significantly higher than logistic regression model (0.542). Our data demonstrate that the data mining-driven prediction such as gradient boosting exhibited higher accuracy for prediction of surgical outcome and we can provide accurate information on surgical outcomes before surgery to OSA subjects using machine learning models.

The role of acetazolamide in sleep apnea at sea level: a systematic review and meta-analysis

STUDY OBJECTIVES

The recognition of specific endotypes as drivers of sleep apnea suggests the need of therapies targeting individual mechanisms. Acetazolamide is known to stabilize respiration at high altitude but benefits at sea level are less well understood.

METHODS

All controlled studies of acetazolamide in obstructive sleep apnea and/or central sleep apnea (CSA) were evaluated. The primary outcome was the apnea-hypopnea index.

RESULTS

Fifteen trials with a total of 256 patients were pooled in our systematic review. Acetazolamide reduced the overall apnea-hypopnea index (mean difference [MD] -15.82, 95% CI: -21.91 to -9.74, P < .00001) in central sleep apnea (MD -22.60, 95% CI: -29.11 to -16.09, P < .00001), but not in obstructive sleep apnea (MD -10.29, 95% CI: -33.34 to 12.77, P = .38). Acetazolamide reduced the respiratory related arousal index (MD -0.82, 95% CI: -1.56 to -0.08, P = .03), improved partial arterial of oxygen (MD 11.62, 95% CI: 9.13-14.11, P < .00001), mean oxygen saturation (MD 1.78, 95% CI: 0.53-3.04, P = .005), total sleep time (MD 25.74, 95% CI: 4.10-47.38, P = .02), N2 sleep (MD 3.34, 95% CI: 0.12-6.56, P = .04) and sleep efficiency (MD 4.83, 95% CI: 0.53-9.13, P = .03).

CONCLUSIONS

Acetazolamide improves the apnea-hypopnea index and several sleep metrics in central sleep apnea. The drug may be of clinical benefit in patients with high loop gain apnea of various etiologies and patterns. The existence of high heterogeneity is an important limitation in applicability of our analysis.

SYSTEMATIC REVIEW REGISTRATION

Registry: PROSPERO; Name: The effect of acetazolamide in patients with sleep apnea at sea level: a systematic review and meta analysis; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020163316; Identifier: CRD42020163316.

The long-term impact of expansion sphincter pharyngoplasty treatment on blood pressure control and health-related quality of life in patients with obstructive sleep apnea and hypertension

PURPOSE

To assess how expansion sphincter pharyngoplasty (ESP) impacts blood pressure (BP) and health-related quality of life (HRQOL) in hypertensive patients with obstructive sleep apnea (OSA).

METHODS

Patients were separated into two groups based upon whether or not they adhered to antihypertensive drug regimens. Patients underwent 24-h ambulatory BP monitoring before and at 6 months post-ESP, while clinical BP measurements and HRQOL questionnaires (SF-36) were conducted over the course of 24 months post-surgery.

RESULTS

We enrolled 62 patients, with 25 and 37 in the medicated and non-medicated groups, respectively. Mean 24-h BP differed significantly, with systolic and diastolic BP (SBP and DBP) decreases of 5.3 mmHg and 2.5 mmHg, respectively (P <0.01). Mean 24-h SBP and DBP decreases in the medicated group were 10.2 mmHg and 4.6 mmHg, respectively (P < 0.001), with significant decreases during the daytime of 8.6 mmHg, 3.0 mmHg, and nighttime of 12.3 mmHg, 7.7 mmHg (P <0.001). In the non-medicated treatment group, 24-h SBP and DBP decreases were 1.9 mmHg and 1.1 mmHg (P < 0.005) with significant decreases in mean nighttime BP values of 3.2 mmHg and 1.9 mmHg (P < 0.001). While pre- and postoperative SF-36 results differed significantly, no differences were observed between the two groups.

CONCLUSION

ESP decreases BP and improves HRQOL in OSA patients with hypertension, particularly in combination with antihypertensive drugs.

Which determinants are considered to be important for adherence to Negative Pressure Wound Therapy: A multimethods study

AIM

To explore the extent of patients that choose to cease Negative Pressure Wound Therapy (NPWT) prematurely in a clinical setting, and to explore the determinants of nonadherence.

METHOD

This study exists out of: (1) a retrospective study to assess the number of patients who ceased NPWT prematurely; (2) a narrative review (NR) to identify determinants of nonadherence; and (3) a survey among wound care specialists to explore specific determinants of nonadherence to NPWT.

RESULTS

(1) Based on the retrospective study, 20% ceased NPWT prematurely because of experienced limitations in daily activities. (2) Based on 22 studies, 23 determinants that might influence nonadherence were identified and added as questions in the survey. (3) Twenty-two percent (n = 136) wound care specialists completed the survey. Confidence with the healthcare team, consistency in therapy advices, coping with pain, former negative experiences with NPWT, a normal activity pattern, social support from family or friends, and support from the healthcare team were identified as highly relevant determinants of nonadherence to NPWT. Only religion scored distinctively lower.

CONCLUSION

This study is a first step in exploring the determinants of nonadherence to NPWT. In 20% NPWT was prematurely ceased at the request of the patient, this means that this therapy may have not been the best choice of therapy for this particular patient. The identification of potential determinants of nonadherence may help healthcare professionals in their dialogue with patients. The next step should be a prognostic study to assess which determinants best predict adherence to NPWT.

Utility of Multi-Theory Model (MTM) to Explain the Intention for PAP Adherence in Newly Diagnosed Sleep Apnea Patients

PURPOSE

The objective of this study was to assess the utility of a fourth-generation multi-theory model (MTM) in explaining the intention for initiation and sustenance of PAP adherence among newly diagnosed sleep apnea patients.

PATIENTS AND METHODS

For this cross-sectional study, data were collected at a private sleep center located in the Southeastern United States. A total of 138 newly diagnosed patients with sleep apnea who had been prescribed PAP therapy completed a valid and reliable 41-item MTM instrument. Stepwise multiple regression modeling was conducted to assess MTM based explanatory variables of PAP adherence in this study sample.

RESULTS

MTM constructs namely participatory dialogue (β = 0.17, p = 0.014), behavioral confidence (β = 0.48, p < 0.001), and changes in the physical environment (β = 0.26, p = 0.001) were statistically significant predictors of the intention for initiation of PAP therapy and accounted for 53.5% of the variance. Emotional transformation (β = 0.57, p < 0.001), changes in the social environment (β = 0.16, p = 0.016), and practice for change (β = 0.16, p = 0.047) were statistically significant predictors of the intention for sustenance of PAP therapy and accounted for 60.6% of the variance.

CONCLUSION

The MTM was found to be a promising theoretical model in explaining the intention for initiation and sustenance of PAP therapy.

Acceptance and Compliance of Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea: Local Population Survey

Objectives

Continuous positive airway pressure (CPAP) compliance of > 4 hours per night has been considered acceptable to achieve clinical improvements in patients with obstructive sleep apnea (OSA). However, the factors determining CPAP adherence are unclear. This study aims to address the issue of acceptance and adherence to CPAP treatment in the Omani population and to determine the factors affecting adherence to CPAP.

Methods

This retrospective study included adult OSA patients who underwent polysomnography between January 2008 and December 2014 (n = 3046). Demographic information, Epworth Sleepiness Scale (ESS), apnea/hypopnea index (AHI), and desaturation events were collected from the sleep laboratory records. Subjects were grouped as CPAP users and CPAP non-users. CPAP users were divided into compliers (> 4 hours/night) and non-compliers (< 4 hours/night). Student’s t-test was used to find differences in CPAP users and non-users, compliers, and gender differences in CPAP users. The association of CPAP compliers and non-compliers with age, gender, AHI, ESS, and comorbidities were assessed using the chi-square test.

Results

Out of the 90.0% patients advised CPAP treatment, 34.7% came for regular CPAP follow-up. Total CPAP compliers were 59.3% (n = 274). The CPAP users had higher age, high ESS, baseline AHI, and more oxygen desaturation events than CPAP non-users (p < 0.010). Among the CPAP users, females were significantly older than males and had more oxygen desaturation events. CPAP compliers had significantly higher baseline AHI and more oxygen desaturation events. There was no association between CPAP compliance and age, gender, AHI, ESS, or comorbidities.

Conclusions

CPAP users and compilers have severe OSA. CPAP acceptance and adherence are suboptimal and could not be predicted by age, gender, AHI, ESS, or comorbidities.

Association between adherence to continuous positive airway pressure treatment and cost among medicare enrollees

OBJECTIVE

To analyze the cost associated with sleep apnea and effects of continuous positive airway pressure (CPAP) treatment on costs among fee-for-service Medicare beneficiaries.

METHODS

Retrospective cohort design using 5% Medicare claims between 2006 and 2010. Medicare beneficiaries with and without sleep apnea diagnosis between 2007 and 2008 were identified and followed retrospectively for 2 years pre-index-date and 2 years post-index-date. We defined CPAP fill as at least one durable medical equipment claim for CPAP in 6-month period. At least three CPAP fills was defined as "full adherence," and one or two CPAP fills was "partial adherence." We used interrupted time series and generalized linear log-link models to study the association between sleep apnea, CPAP treatment, and costs. To minimize bias, we used propensity score and instrumental variables approach.

RESULTS

Sleep apnea was associated with higher costs (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.58, 1.63) compared to those without sleep apnea. Almost half of those with sleep apnea received CPAP treatment. Interrupted time series analysis indicated post level increase in mean monthly cost for full CPAP adherence group, partial CPAP adherence group and no-CPAP group. However, the increase was smallest for the full CPAP adherence group. Full CPAP adherence was associated with lower change in cost (OR = 0.92; 95% CI = 0.88, 0.97) compared to the no-CPAP group.

CONCLUSIONS

Medicare beneficiaries with sleep apnea experience increased cost. Full adherence to CPAP treatment for sleep apnea was associated with lower increase in cost. These findings emphasize the need to effectively identify and treat sleep apnea in Medicare patients.

Role of rhinomanometry in the prediction of therapeutic positive airway pressure for obstructive sleep apnea

Background

This study was conducted to evaluate the relationship between nasal resistance in different posture and optimal positive airway pressure (PAP) level. Other potential factors were also assessed for possible influence on PAP pressure.

Methods

Forty- three patients diagnosed with obstructive sleep apnea (OSA) were prospectively recruited in this study. Nasal resistance was assessed by active anterior rhinomanometry in a seated position and then in a supine position at pressures of 75, 150, and 300 pascal. The factors correlating with PAP pressure were analyzed, including nasal resistance and patients’ clinical data.

Results

Univariate analysis revealed that PAP pressure was correlated to nasal resistance in the supine position at 75 and 150 pascal (SupineNR75 and SupineNR150) (P = 0.019 and P = 0.004 in Spearman’s correlation coefficient analysis), but not correlated to nasal resistance in the seated position at different pressures or in the supine position at 300 pascal. The multiple linear regression analysis revealed that both SupineNR150 and body mass index (BMI) significantly predicted PAP pressure (β = 0.308, p = 0.044; β = 0.727, p = 0.006). The final PAP pressure predictive model was:

PAP pressure = 0.29 BMI + 2.65 SupineNR150 + 2.11.

Conclusions

Nasal resistance in the supine position measured at 150 pascal may provide valuable information regarding optimal PAP pressure. Rhinomanometry should be included in the treatment algorithm of OSA patients when PAP therapy is considered.

The specific branches leading to the genioglossus muscle: three-dimensional localisation using skin reference points

INTRODUCTION

Supra-selective stimulation of the branches destined for the horizontal part of genioglossus muscle (GGh) could be a target of choice in the treatment of mild-to-severe obstructive sleep apnea syndrome. The main aim of our study was to assess a percutaneous method for the three-dimensional localisation of the terminal branches destined to GGh.

MATERIALS AND METHODS

Twenty cadaveric hypoglossal nerves were dissected and included in the injection protocol. The distance between the posterior edge of the mandibular symphysis and the hyoid bone on the sagittal midline as the approximated distance of the geniohyoid muscle (dGH) was measured before any dissection. Methylene blue mixed with a thickening agent, was injected. The injection point was defined in relation to dGH, in an orthonormal coordinate system. For each dissection, we recorded the theoretical and the real (X, Y, Z) coordinates of GGh motor points and measured their distance to each other.

RESULTS

X was accurately estimated. Y and Z were overestimated by + 5.34 ± 5.21 mm ([Formula: see text]) and + 4.79 ± 3.99 mm ([Formula: see text]) on average, respectively. We found a more significant difference between the theoretical and real Y and Z coordinates in the subgroup BMI < 25 kg/m² (8.6 ± 4.5 mm and 6.9 ± 2.5 mm, respectively, p = 0.0009), and of Z in subgroup with dGH ≥ 50 mm (6.89 ± 3.26 mm, p = 0.0494).

CONCLUSIONS

X can be estimated accurately using the relationship [Formula: see text]. Y seems to be related to BMI and Z may be estimated with the relationship [Formula: see text]. This three-dimensional localisation could be very helpful to facilitate placement of cuff electrodes to manage refractory sleep apnea.

The Veterans Affairs Continuous Positive Airway Pressure Use and Diabetic Retinopathy Study

SIGNIFICANCE

Obstructive sleep apnea has been linked to the development and progression of diabetic retinopathy. In this study, diabetic patients compliant with continuous positive airway pressure therapy (CPAP) for sleep apnea were less likely to have retinopathy, emphasizing the benefits and potential therapeutic role of CPAP in individuals with both conditions.

PURPOSE

The aim of this study was to compare the prevalence of diabetic retinopathy in type 2 diabetic patients with obstructive sleep apnea who were compliant with CPAP therapy with those who were not compliant with CPAP therapy.

METHODS

A retrospective cross-sectional review of type 2 diabetic patients using CPAP for obstructive sleep apnea was conducted. The prevalence of retinopathy was identified, and groups with and without retinopathy were compared using univariate analyses and multivariate logistic regression.

RESULTS

The prevalence of retinopathy was 19.6% (n = 321). Retinopathy was significantly less prevalent in those compliant with CPAP (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.94; P = .04). The relationship remained statistically significant when adjusting for other factors known to impact the course of diabetic eye disease.

CONCLUSIONS

Increased CPAP compliance may mitigate the risk of developing diabetic retinopathy in type 2 diabetic patients with obstructive sleep apnea.

Obstructive Sleep Apnea: The Role of Gender in Prevalence, Symptoms, and Treatment Success

The purpose of this article is to provide an overview of known similarities and differences between genders relative to presenting symptoms, demographics, and severity of obstructive sleep apnea. There is a relationship of risk of disease occurrence relative to stages of reproductive life of a woman, indicating that chronologic age might not be as important as timing of pregnancy and menopausal transition. The current understanding of gender differences in treatment success and compliance with oral appliance therapy is limited and requires further investigation.

Adherence to Continuous Positive Airway Pressure in patients with Obstructive Sleep Apnoea. A ten year real life study

OBJECTIVE

To assess the predictive factors at 12 month and 10 year adherence to Continuous Positive Airway Pressure (CPAP) in patients with Obstructive Sleep Apnoea (OSA).

METHODS

Retrospective data analysis of patients starting CPAP between 2006 and 2009. After 12 months (T1) from start and during a 10 year follow up the following data were recorded: Body Mass Index (BMI), Time of night use, Epworth Sleepiness Scale (ESS) score.

RESULTS

Out of 315 patients, 147 fulfilled inclusion criteria and were evaluated. According to CPAP nighttime use during the first year, patients were divided into two groups: those using the device less < 4.5 h (Poor Adherence (PA): 61 patients), and those using ≥4.5 h: (Good Adherence (GA): 86 patients). Patients of PA group were significantly younger, had greater BMI and required more unscheduled visits during the first year. After 12 months, there were 11 (7.5%) dropouts, all in PA group. Patients using the nasal mask showed a greater prevalence among GA as compared to those using the oro-nasal mask (76.5% vs 57.8% respectively, p = 0.04). After 10 years 83 out of 147 (56.4%) patients were still under CPAP, 51 (59.3% of GA) and 32 (52.4% of PA group) respectively. Dropouts were significantly more frequent during the first 5 years (p = 0.04).

CONCLUSION

Ten years after prescription the majority of patients with OSA undergoing periodical controls, still perform CPAP independent of their adherence to therapy after one year of use. Use of nasal mask may be associate to better adherence.

Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for obstructive sleep apnea syndrome (OSAS). However, poor adherence is a limiting factor, and a significant proportion of patients are unable to tolerate CPAP. The aim of this study was to determine predictors of long-term non-compliance with CPAP.

METHODS

CPAP treatment was prescribed to all consecutive patients with moderate or severe OSAS (AHI ≥15 events/h) (n = 295) who underwent a full-night CPAP titration study at home between February 1, 2002 and December 1, 2016. Adherence was defined as CPAP use for at least 4 h per night and five days per week. Subjects had periodical follow-up visits including clinical and biochemical evaluation and assessment of adherence to CPAP.

RESULTS

Median follow-up observation was 74.8 (24.2/110.9) months. The percentage of OSAS patients adhering to CPAP was 41.4% (42.3% in males and 37.0% in females), and prevalence was significantly higher in severe OSAS than in moderate (51.8% vs. 22.1%; p < 0.001; respectively). At multivariate analysis, lower severity of OSAS (HR = 0.66; CI 95 0.46-0.94) p < 0.023), cigarette smoking (HR = 1.72; CI 95 1.13-2.61); p = 0.011), and previous cardiovascular events (HR = 1.95; CI 95 1.03-3.70; p = 0.04) were the only independent predictors of long-term non-adherence to CPAP after controlling for age, gender, and metabolic syndrome.

CONCLUSIONS

In our cohort of patients with moderate/severe OSAS who were prescribed CPAP therapy, long-term compliance to treatment was present in less than half of the patients. Adherence was positively associated with OSAS severity and negatively associated with cigarette smoking and previous cardiovascular events at baseline.