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Wallace DM, Grant AB, Belisova-Gyure Z, Ebben M, Bubu OM, Johnson DA, Jean-Louis G, Williams NJ. Discrimination Predicts Suboptimal Adherence to CPAP Treatment and Mediates Black-White Differences in Use. Chest 2024; 165:437-445. [PMID: 37741324 PMCID: PMC10851273 DOI: 10.1016/j.chest.2023.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 09/07/2023] [Accepted: 09/14/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Although racial and ethnic differences in CPAP adherence for OSA are widely established, no studies have examined the influence of perceived racial discrimination on CPAP usage, to our knowledge. RESEARCH QUESTION (1) Do Black adults with OSA report experiencing greater amounts of discrimination than non-Hispanic White adults? (2) Is discrimination associated with poorer CPAP adherence over time, independent of self-identified race? (3) Does discrimination mediate the relationship between self-identified Black race and CPAP usage? STUDY DESIGN AND METHODS In this prospective study, Black and non-Hispanic White adults with OSA initiating CPAP were enrolled from two sleep centers and completed questionnaires including sociodemographics, perceived discrimination, daytime sleepiness, insomnia symptoms, and depressive symptoms. Perceived discrimination was measured using the Everyday Discrimination Scale (EDS). Black and White group comparisons for baseline sociodemographic variables, sleep symptoms, and perceived discrimination were performed with Student t test or χ2/Fisher exact test, as appropriate. A linear regression model was completed with self-identified Black race and EDS total score as the primary independent variables of interest and mean daily CPAP usage at 30 and 90 days serving as the dependent outcomes. This regression modeling was repeated after adjusting for psychosocial variables known to be associated with CPAP usage. EDS total score was explored as a potential mediator of the association between self-identified Black race and mean daily CPAP adherence at 30 and 90 days. RESULTS The sample for this analysis consisted of 78 participants (31% female, 38% Black) with a mean age of 57 ± 14 years. Sixty percent of the Black adults reported they experienced racial discrimination at least a few times each year. Relative to White adults, Black adults were also more likely to indicate more than one reason for discrimination (27% vs 4%, P = .003). Adjusting for discrimination, self-identified Black race was associated with 1.4 (95% CI, -2.3 to -0.4 h; P = .006) and 1.6 (95% CI, -2.6 to -0.6 h; P = .003) fewer hours of mean daily CPAP usage at 30 and 90 days, respectively. In the fully adjusted model, a 1-unit change in the total discrimination score (more discrimination) was associated with a 0.08-h (95% CI, 0.01-0.15 h; P = .029) and 0.08-h (95% CI, 0.01-0.16 h; P = .045) change in mean daily CPAP usage at 30 and 90 days, respectively. INTERPRETATION Adults with OSA who encountered racial discrimination experienced greater decrement in CPAP usage than those who did not experience racial discrimination.
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Affiliation(s)
- Douglas M Wallace
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL; Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | | | | | - Matthew Ebben
- Weill Cornell Medicine, Center for Sleep Medicine, New York, NY
| | - Omonigho M Bubu
- Departments of Population Health and Psychiatry, NYU Grossman School of Medicine, New York, NY
| | - Dayna A Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Girardin Jean-Louis
- Psychiatry and Behavioral Sciences, Neurology, Psychology and Public Health, University of Miami Miller School of Medicine, Miami, FL
| | - Natasha J Williams
- Department of Population Health, Institute for Excellence in Health Equity, Center for Healthful Behavior Change, NYU Grossman School of Medicine, New York, NY.
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Williams NJ, Grant AB, Butler M, Ebben M, Belisova-Gyure Z, Bubu OM, Jean-Louis G, Wallace DM. The effects of social support and support types on continuous positive airway pressure use after 1month of therapy among adults with obstructive sleep apnea. Sleep Health 2024; 10:69-74. [PMID: 38007302 DOI: 10.1016/j.sleh.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND The relationship between perceived social support and continuous positive airway pressure remains understudied among individuals with obstructive sleep apnea. The aim of this prospective cohort study was to determine if baseline perceived social support and subtypes predict regular continuous positive airway pressure use after 1month of therapy. METHODS Adults with obstructive sleep apnea initiating continuous positive airway pressure therapy were recruited from sleep clinics in New York City. Demographics, medical history, and comorbidities were obtained from patient interview and review of medical records. Objective continuous positive airway pressure adherence data was collected at the first clinical follow-up. RESULTS Seventy-five participants (32% female; non-Hispanic Black 41%; mean age of 56 ± 14years) provided data. In adjusted analyses, poorer levels of overall social support, and subtypes including informational/emotional support, and positive social interactions were associated with lower continuous positive airway pressure use at 1month. Relative to patients reporting higher levels of support, participants endorsing lower levels of overall social support, positive social interaction and emotional/informational support had 1.6 hours (95% CI: 0.5,2.7, hours; p = .007), 1.3 hours (95% CI: 0.2,2.4; p = .026), and 1.2 hours (95% CI: 0.05,2.4; p = .041) lower mean daily continuous positive airway pressure use at 1month, respectively. CONCLUSION Focusing on social support overall and positive social interaction particularly, could be an effective approach to improve continuous positive airway pressure adherence in patients at risk of suboptimal adherence.
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Affiliation(s)
- Natasha J Williams
- NYU Grossman School of Medicine, Institute for Excellence in Health Equity, Department of Population Health, New York, New York, USA.
| | - Andrea Barnes Grant
- VA: Department of Veterans Affairs: New York Harbor HealthCare System, Brooklyn Campus, Brooklyn, New York, USA
| | - Mark Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Matthew Ebben
- Weill Cornell Medicine, Center for Sleep Medicine, New York, New York, USA
| | - Zuzana Belisova-Gyure
- VA: Department of Veterans Affairs: New York Harbor HealthCare System, New York Campus, New York, New York, USA
| | - Omonigho M Bubu
- NYU Grossman School of Medicine, Department of Psychiatry, New York, New York, USA
| | - Girardin Jean-Louis
- NYU Grossman School of Medicine, Department of Psychiatry, New York, New York, USA
| | - Douglas M Wallace
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA; Psychiatry and Behavioral Sciences, Neurology, Psychology and Public Health, University of Miami Miller School of Medicine, Miami, Florida, USA
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Pack AI, Magalang UJ, Singh B, Kuna ST, Keenan BT, Maislin G. To RCT or not to RCT? Depends on the question. A response to McEvoy et al. Sleep 2021; 44:6161202. [PMID: 33693855 DOI: 10.1093/sleep/zsab042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Allan I Pack
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ulysses J Magalang
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bhajan Singh
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Samuel T Kuna
- Sleep Medicine Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Biostatistics Core, Division of Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Greg Maislin
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Biostatistics Core, Division of Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Pack AI, Magalang UJ, Singh B, Kuna ST, Keenan BT, Maislin G. Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias. Sleep 2021; 44:5963957. [PMID: 33165616 DOI: 10.1093/sleep/zsaa229] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/28/2020] [Indexed: 12/11/2022] Open
Abstract
Three recent randomized control trials (RCTs) found that treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) did not reduce rates of future cardiovascular events. This article discusses the biases in these RCTs that may explain their negative results, and how to overcome these biases in future studies. First, sample selection bias affected each RCT. The subjects recruited were not patients typically presenting for treatment of OSA. In particular, subjects with excessive sleepiness were excluded due to ethical concerns. As recent data indicate that the excessively sleepy OSA subtype has increased cardiovascular risk, subjects most likely to benefit from treatment were excluded. Second, RCTs had low adherence to therapy. Reported adherence is lower than found clinically, suggesting it is in part related to selection bias. Each RCT showed a CPAP benefit consistent with epidemiological studies when restricting to adherent patients, but was underpowered. Future studies need to include sleepy individuals and maximize adherence. Since it is unethical and impractical to randomize very sleepy subjects to no therapy, alternative designs are required. Observational designs using propensity scores, which are accepted by FDA for studies of medical devices, provide an opportunity. The design needs to ensure covariate balance, including measures assessing healthy user and healthy adherer biases, between regular users of CPAP and non-users. Sensitivity analyses can evaluate the robustness of results to unmeasured confounding, thereby improving confidence in conclusions. Thus, these designs can robustly assess the cardiovascular benefit of CPAP in real-world patients, overcoming biases in RCTs.
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Affiliation(s)
- Allan I Pack
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ulysses J Magalang
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bhajan Singh
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Samuel T Kuna
- Sleep Medicine Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Brendan T Keenan
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Biostatistics Core, Division of Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Greg Maislin
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Biostatistics Core, Division of Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Watach AJ, Hwang D, Sawyer AM. Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Patient Prefer Adherence 2021; 15:1557-1570. [PMID: 34285474 PMCID: PMC8286071 DOI: 10.2147/ppa.s264927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/23/2021] [Indexed: 12/12/2022] Open
Abstract
Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.
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Affiliation(s)
- Alexa J Watach
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Correspondence: Alexa J Watach University of Pennsylvania, School of Nursing, Claire Fagin Hall, Rm 349, 418 Curie Blvd, Philadelphia, PA, 19104, USATel +1-717-599-9908 Email
| | - Dennis Hwang
- Kaiser Permanente Southern California, Sleep Medicine and Department of Research and Evaluation, Fontana, CA, USA
| | - Amy M Sawyer
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
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