Disparities in Obstructive Sleep Apnea and Its Management between a Minority-Serving Institution and a Voluntary Hospital

Racial and ethnic differences in the receipt of continuous positive airway pressure treatment for obstructive sleep apnea

OBJECTIVE

To examine the pattern of health services access and utilization that may contribute to racial/ethnic disparities in receiving continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA).

METHODS

This cross-sectional study used a national sample from the All of Us Research Program, which included over 80 % of participants from underrepresented populations in biomedical research. Study participants included adults aged 18 years and older diagnosed with OSA (N = 8518). Diagnosis of OSA and CPAP treatment were ascertained by diagnostic and procedural codes from the electronic health records. Sociodemographic characteristics and health service utilization factors were identified using self-reported survey data.

RESULTS

With this national survey, the overall diagnosed prevalence of OSA was 8.8 %, with rates of 8.12 % in non-Hispanic (NH) Black adults, 5.99 % in Hispanic adults, and 10.35 % in NH White adults. When comparing to NH White adults, Hispanic adults were less likely to receive CPAP treatment for OSA after adjusting for socioeconomic and demographic characteristics, access to and utilization of health services, and comorbidities such as obesity and having multiple chronic conditions (OR = 0.73, 95 % CI = 0.59,0.90), p < 0.01.

CONCLUSIONS

The rates of CPAP treatment among OSA patients are not consistent across racial and ethnic groups. Unequal access to health services based on residence may contribute to these differences. Interventions that target disparities in OSA diagnosis, access to treatment, and barriers in insurance coverage could potentially help reduce racial and ethnic differences in OSA diagnosis and management.

The Need for Social and Environmental Determinants of Health Research to Understand and Intervene on Racial/Ethnic Disparities in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a sleep-disordered breathing (SDB) disorder, affects at least 25 million adults in the United States and is associated with increased risk for hypertension, diabetes, and cardiovascular disease (CVD). Racial/ethnic minorities have a disproportionate burden of OSA along with the health sequelae associated with this condition. Despite supporting evidence of racial/ethnic disparities, few studies have investigated SDB including OSA among minoritized racial/ethnic groups. In this scoping review of the literature, the authors summarize current findings related to racial/ethnic disparities in OSA, identified social and environmental determinants of health, treatment inequities, and promising evidence-based interventions and conclude with future research directions.

Psychometric Assessment of Anxiety Measures in a Pilot Study of African American Patients with Obstructive Sleep Apnea

African American patient populations are disproportionately diagnosed with severe obstructive sleep apnea (OSA) compared to non-Hispanic white adults. Research suggests a link between OSA and anxiety. However, OSA and anxiety symptoms may present differently across minority groups. Research examining the reliability and validity of measures used to assess anxiety symptom severity in African American patient populations living with OSA is needed. This pilot study evaluated the reliability and validity of the Patient Reported Outcomes Measurement Information System (PROMIS) Anxiety short form and the longer State-Trait Anxiety Inventory-State (STAI-S) in a sample of African American adults recently diagnosed with OSA. In this cross-sectional pilot study, 32 African American patients newly diagnosed with OSA were recruited from an academic sleep medicine clinic in the Southeastern United States to complete survey measures. Participants completed the 6-item PROMIS Anxiety short form and 20-item STAI-S. Cronbach's alphas assessed the internal reliability of measures, and concurrent validity between measures was assessed using correlation coefficients (rs). Both PROMIS Anxiety and STAI-S showed excellent internal consistency with Cronbach's α ≥.90. The PROMIS Anxiety T-scores and STAI-S scores were positively moderately correlated with each other (rs = .68; p < .0001), indicating concurrent validity. These results illustrate that both the PROMIS Anxiety and STAI-S scales have strong internal reliability in this sample of African American adults with co-occurring OSA and prediabetes. The brief PROMIS Anxiety short-form measure is validated to the longer STAI measure in this sample. An advantage of the PROMIS Anxiety scale is that it has a lower participant burden when completing questionnaires, contributing to a more refined approach to diagnosis and management when both OSA and anxiety coexist. These findings also underscore the importance of validating psychometric measures in marginalized populations, such as African Americans, who have historically been underrepresented in psychometric research.

Demographics of Adults With Obstructive Sleep Apnea Who Undergo Nasal Surgery

Objective

To assess the demographic characteristics between adult obstructive sleep apnea (OSA) patients who did and did not undergo nasal surgery (NS).

Study Design

Retrospective cohort study.

Setting

Kaiser Permanente Northern California clinical database.

Methods

Retrospective study of adult patients with ≥1 OSA diagnoses linked to clinical encounters from 2009 to 2016. Qualifying NS procedures performed on or after cohort entry through 2017 were ascertained. Demographic and clinical characteristics were compared; multivariable logistic regression examined associations of these characteristics with undergoing NS.

Results

A total of 174,821 patients had an OSA diagnosis. Among these, 3518 (2.0%) underwent NS, including septoplasty (61.9%), sinus-related (12.9%), turbinate (14.2%), and rhinoplasty (11.1%) procedures. Compared to the nonsurgery group, NS patients were more likely to be male (75.5% vs 62.1%), younger (48.2 ± 13.0 vs 54.7 ± 14.1), have lower body mass index (31.8 ± 6.4 vs 34.3 ± 8.1), and no comorbid conditions (63.1% vs 53.5%), P < .001. After adjusting for sex, age, body mass index (BMI), neighborhood deprivation, and comorbidities, black and Asian/Pacific Islander adults with OSA had 42% and 46% decreased odds of undergoing NS compared with non-Hispanic white patients (odds ratio, OR [95% confidence interval, CI]: 0.58 [0.50-0.67] and 0.54 [0.49-0.61]), while Hispanic patients had similar odds (OR [95% CI]: 1.02 [0.93-1.12]). Patients living in neighborhoods of highest deprivation had 18% lower odds of undergoing NS, compared with patients from neighborhoods corresponding to areas of lowest deprivation (adjusted odds ratio [95% CI]: 0.82 [0.75-0.91]).

Conclusion

These findings suggest that younger age, male sex, lower BMI, and higher SES may be associated with a higher likelihood of undergoing NS in OSA patients.

Association between severity of obstructive sleep apnea and its common symptoms varies by race, ethnicity, and sex

STUDY OBJECTIVES

The US Preventive Services Task Force recently released guidelines suggesting little evidence of benefit to screening asymptomatic adults for obstructive sleep apnea (OSA). Our goal was to provide important context to this statement. Specifically, we examined associations between common OSA symptoms, excessive daytime sleepiness and snoring, and OSA severity for different racial/ethnic and sex groups.

METHODS

Analyses were performed on 2 samples. One combined 2 observational studies that included full polysomnography, the Epworth Sleepiness Scale (ESS), and questions about snoring (mean [standard deviation] age 39 [15.2] years). The second sample was the Multi-Ethnic Study of Atherosclerosis study of older adults (mean [standard deviation] age 69 [9.1] years), which also included polysomnography, ESS and a question about snoring. Apnea-hypopnea index represented OSA severity. For each racial/ethnic-sex group we estimated correlations between apnea-hypopnea index and ESS and the sensitivity and specificity of excessive daytime sleepiness (ESS >10) or frequent snoring to predict moderate-to-severe OSA (apnea-hypopnea index >15 events/h).

RESULTS

A weak significant correlation between OSA severity and ESS was found only in White men in the first sample and Black men in the second sample. Screening tool characteristics for ESS and snoring were poor except for moderate specificity in some racial/ethnic-sex groups.

CONCLUSIONS

Excessive daytime sleepiness and snoring are commonly used to identify symptomatic patients. Our results suggest that the accuracy of these symptoms to identify OSA varies by race/ethnicity and sex. Therefore, focus on common symptoms as an OSA screen could systematically leave out certain patient populations who would benefit from treatment.

CITATION

Stepney D, Attarian HP, Knutson KL. Association between severity of obstructive sleep apnea and its common symptoms varies by race, ethnicity, and sex. J Clin Sleep Med. 2023;19(10):1727-1733.

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.

The Need for Social and Environmental Determinants of Health Research to Understand and Intervene on Racial/Ethnic Disparities in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a sleep-disordered breathing (SDB) disorder, affects at least 25 million adults in the United States and is associated with increased risk for hypertension, diabetes, and cardiovascular disease (CVD). Racial/ethnic minorities have a disproportionate burden of OSA along with the health sequelae associated with this condition. Despite supporting evidence of racial/ethnic disparities, few studies have investigated SDB including OSA among minoritized racial/ethnic groups. In this scoping review of the literature, the authors summarize current findings related to racial/ethnic disparities in OSA, identified social and environmental determinants of health, treatment inequities, and promising evidence-based interventions and conclude with future research directions.

Differences in Symptoms and Severity of Obstructive Sleep Apnea between Black and White Patients

Rationale: Prior work suggests that Black patients have more severe obstructive sleep apnea (OSA) upon clinical presentation. However, the extent to which this may reflect differences in symptoms or other standard measures of OSA risk is unclear. Objectives: We assessed for racial disparities in OSA characteristics at time of initial clinical diagnosis. Methods: Data from 890 newly diagnosed patients with OSA at an urban academic sleep center were included in this analysis. All patients completed a standardized questionnaire on demographics and sleep-related symptoms and underwent laboratory polysomnography. Symptom severity at the time of evaluation was compared across race and sex. Results: Black men were underrepresented in the sleep lab, making up only 15.8% of the cohort and 31.3% of Black participants (P < 0.001). Despite this, Black men had the most severe OSA with a mean apnea hypopnea index of 52.4 ± 39.4 events/hour, compared with 39.0 ± 28.9 in White men, 33.4 ± 32.3 in Black women, and 26.2 ± 23.8 in White women (P < 0.001 for test of homogeneity). Black men also had the greatest burden of OSA symptoms with the highest mean Epworth Sleepiness Scale score (12.2 ± 5.9 versus 9.4 ± 5.2 in White men, 11.2 ± 5.9, in Black women, and 9.8 ± 5.6 in White women; P < 0.001). Compared with White men, Black men were 1.61 (95% CI [1.04-2.51]) times more likely to have witnessed apneas and 1.56 (95% CI [1.00-2.46]) times more likely to have drowsy driving at the time of OSA diagnosis. Conclusions: At the time of clinical diagnosis, Black men have greater disease severity, suggesting delay in diagnosis. Further, the greater burden of classic OSA symptoms suggests the delayed diagnosis of OSA in Black men is not due to atypical presentation. Further research is needed to identify why screening methods for OSA are not equitably implemented in the care of Black men.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluating the effect of an educational intervention on the adherence rate to sleep study: A multi-centered stratified randomized controlled trial

An appropriate diagnosis and effective treatment of sleep apnea can improve the associated quality of care and reduce morbidities. The study aims to develop and evaluate an educational intervention tailored to patients’ needs in order to increase the rate of patients’ adherence to physician's prescription for a sleep test. A multi-center, stratified, 2 parallel-arm, randomized controlled trial was conducted. The patients in the intervention group received the educational booklets on sleep apnea and sleep test which was designed based on the extracted factors through an in-depth interview with patients. All participants were contacted after two months to ask whether they completed an assessment for OSA. A total number of 1,650 individuals were screened. Finally, 104 participants were randomized to the control group (n = 50) or intervention group (n = 45) that did not differ significantly in baseline characteristics. The results of the intention to treat analysis indicate that patients in the intervention group were significantly more adherent to attend a sleep assessment for their OSA risk (30%; n = 15/50) than the patients in the control group (11.1%; n = 5/45, P <0.05). Age, history of diabetes, and the educational intervention were effective in performing the sleep test. Time limitations, Condition improvement, and high cost of diagnostic test were the most barriers, respectively. The intervention was successful in improving the adherence rate of patients to prescribed sleep test. However, the adherence rate to sleep study testing is still far from desirable and requires more complex interventions.

Adherence to prescribed overnight sleep study in patients suspected of sleep apnea: problem size and influential factors

PURPOSE

Despite the serious consequences of sleep apnea, some patients do not follow their physicians' advice to undergo a sleep study. The present study aimed to determine the rate of adherence and influencing factors in conducting a polysomnography test in patients suspected of obstructive sleep apnea.

METHODS

This qualitative and quantitative analysis was conducted between July 2017 and November 2019 on patients suspected of sleep apnea. The quantitative analysis aimed at determining the rate of adherence through a retrospective cross-sectional study. The qualitative content analysis was conducted on purposefully selected subgroup of patients suspected of obstructive sleep apnea who were referred for polysomnography. The required data were collected through the semi-structured in-depth interviews and then recorded, transcribed, and analyzed using SPSS.22 and MAXQDA10.

RESULTS

Quantitative part: Of 311 patients (mean age: 47.6 ± 13.1 years) referred for polysomnography, 283 patients (91%) were at a high risk of developing obstructive sleep apnea. Among those referred for polysomnography, 31% (n = 95) adhered to recommendations for a sleep study. Qualitative part: Factors affecting adherence to polysomnography were categorized as "barriers" and "triggers." Barriers included inadequate knowledge, psychological factors, cost, and the service system. Triggers included adequate knowledge and tangible experience of consequences of the illness.

CONCLUSION

The majority of patients at risk of developing obstructive sleep apnea did not follow the recommendation for polysomnography, indicating a need for systematic interventions. Among the identified barriers, knowledge and psychological factors are modifiable ones that can be addressed with the patient. We theorize that raising awareness among patients by providing additional information and eliminating concerns may help to increase the rate of adherence. Insurance coverage or subsidy to reduce the sleep study costs may also be an effective strategy to increase adherence to recommendations for polysomnography.

The Burden of Associated Comorbidities in Patients with Obstructive Sleep Apnea-Regional Differences in Two Central-Eastern European Sleep Centers

Background: Obstructive sleep apnea (OSA) is usually associated with cardiovascular and cerebrovascular disease, metabolic syndrome and depression. Data on relevant OSA-associated comorbidities in Central–European populations are scarce. The aim of this study was to compare the prevalence of comorbidities in two OSA cohorts from Hungary and Romania. Methods: Data from 588 (282 from Hungary, 306 from Romania) untreated patients with OSA were retrospectively analyzed. The prevalence rates of hypertension, diabetes, dyslipidemia, allergic rhinitis, asthma, chronic obstructive pulmonary disease (COPD), osteoporosis, cerebrovascular and cardiovascular disease, arrhythmia and depression were compared between the two populations following adjustment for demographics, body mass index, smoking history, comorbidities and sleep parameters. Results: The prevalence rates of hypertension, arrhythmia, cerebrovascular and cardiovascular disease, diabetes and COPD in the whole study population were directly related to the severity of OSA. We found an inverse correlation between the prevalence of osteoporosis and OSA severity (all p < 0.05). Following adjustment, the prevalence of dyslipidemia was higher in the Hungarian cohort, whilst the prevalence of asthma, cardiovascular and cerebrovascular diseases was higher in the Romanian cohort (all p < 0.05). Conclusions: There was no difference in the prevalence rate of most comorbidities in patients with OSA from the two cohorts, except for dyslipidemia, asthma, cardiovascular and cerebrovascular disease.

Risk of obstructive sleep apnea in patients with bipolar disorder: A nationwide population-based cohort study in Taiwan

AIM

Previous studies have found a high prevalence of risk factors for obstructive sleep apnea (OSA) in patients with bipolar disorder (BD). This study aimed to determine whether BD patients are associated with an increased risk of incident OSA.

METHODS

Using the National Health Insurance Research Database of Taiwan, 3650 BD patients and 18 250 non-BD controls matched by sex and age were enrolled between 2000 and 2010 and followed until the end of 2013. Patients who developed OSA confirmed by a polysomnographic examination during the follow-up period were identified. Cox regression analysis was performed to examine the risk of OSA between BD patients and comparative controls.

RESULTS

BD patients were prone to developing OSA in the crude analysis (hazard ratio [HR]: 1.63, 95% confidence interval [CI]: 1.07-2.49). After adjusting for demographics and comorbidities, the HR declined and was only marginally significant (HR: 1.54, 95%CI: 0.99-2.37). The stratification analysis by sex revealed that the risk trend with BD and subsequent OSA was mainly contributed by male BD patients (HR: 1.72, 95%CI: 1.02-2.91) and female BD patients weakened the overall association. Additionally, this study found that older age, higher income, living in urbanized areas, and some metabolic comorbidities were potential risk factors for developing OSA.

CONCLUSION

This study shows that male BD patients are associated with an increased risk of OSA, which has direct implications for the development of targeted prevention interventions or the implementation of a screening algorithm for OSA to reduce its negative health impact.

Adherence to positive airway pressure treatment among minority populations in the US: A scoping review

Minority individuals in the United States (US) have an increased prevalence of obstructive sleep apnea (OSA) compared to their white/Caucasian counterparts. In general, adherence to positive airway pressure (PAP) therapy is poor and some studies suggest that PAP use among minority individuals is inferior to that of whites. However, there has not been a review of the evidence that addresses racial-ethnic disparities for PAP adherence in the treatment of OSA, and no review has systematically examined the contributing factors to poor adherence among minority individuals compared to whites. We searched the literature for studies published between January 1990 to July 2016 that included objective PAP use comparisons between adult US minority individuals and whites. Twenty-two studies met the inclusion criteria. All studies compared the PAP adherence of blacks to whites. Seven studies compared the PAP adherence of additional minority groups to that of whites. Sixteen of the 22 studies (73%) showed worse PAP adherence in blacks compared to whites. Four studies found equivalent PAP use in US Hispanics compared to whites. Little is known about the PAP adherence of other US minority groups. We present a framework and research agenda for understanding PAP use barriers among US minority individuals.

Legal and Regulatory Aspects of Sleep Disorders

Sleep disorders may interact with the law, making awareness important. Insufficient sleep and obstructive sleep apnea (OSA) are prevalent and associated with excessive sleepiness. Patients with excessive sleepiness may have civil or criminal liability if they fall asleep and cause a motor vehicle accident. Awareness of screening and treatment of OSA is increasing in certain industries. Parasomnia associated sleep-related violence represents a challenge to clinicians, who may be called on to consider parasomnia as a contributing, mitigating, or exculpatory factor in criminal proceedings. Improving access to sleep medicine care is an important aspect in reducing the consequences of sleep disorders.

Continuous Positive Airway Pressure Device Time to Procurement in a Disadvantaged Population

Introduction. The management of obstructive sleep apnea (OSA) in patients who cannot afford a continuous positive airway pressure (CPAP) device is challenging. In this study we compare time to CPAP procurement in three groups of patients diagnosed with OSA: uninsured subsidized by a humanitarian grant (Group 1), uninsured unsubsidized (Group 2), and those with Medicare or Medicaid (Group 3). We evaluate follow-up and adherence in Group 1. We hypothesize that additional factors, rather than just the ability to obtain CPAP, may uniquely affect follow-up and adherence in uninsured patients. Methods. 30 patients were in Groups 1 and 2, respectively. 12 patients were in Group 3. Time of CPAP procurement from OSA diagnosis to CPAP initiation was assessed in all groups. CPAP adherence data was collected for Group 1 patients at 1, 3, 6, and 9 months. Results. There were no significant differences between groups in gender, age, body mass index, or apnea hypopnea index. The mean time to procurement in Group 1 was shorter compared to Group 2 but not significant. Compared to both Group 1 and Group 2, Group 3 patients had significantly shorter times to device procurement. Conclusion. Time to procurement of CPAP was significantly shorter in those with Medicaid/Medicare insurance compared to the uninsured.

The economic impact of obstructive sleep apnea

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) has a substantial economic impact on healthcare systems. We reviewed parameters affecting healthcare costs (race, low education, and socioeconomic status) on OSA comorbidity, and costs and the effect of OSA treatment on medical costs.

RECENT FINDINGS

OSA is associated with increased cardiovascular disease (CVD) morbidity and substantially increased medical costs. Risk for OSA and resulting CVD are associated with obesity, tobacco smoking, black race, and low socioeconomic status; all these are associated with poor continuous positive airway pressure (CPAP) adherence. Healthcare costs are not normally distributed, that is, the costliest and the sickest upper third of patients consume 65-82% of all medical costs. Only a limited number of studies have explored the effect of CPAP on medical costs.

SUMMARY

Costs of untreated OSA may double the medical expenses mainly because of CVD. Identifying the costliest, sickest upper third of OSA patients will reduce expenses to healthcare systems. Studies exploring the effect of CPAP on medical costs are essential. In addition, tailoring intervention programs to reduce barriers to adherence have the potential to improve CPAP treatment, specially in at-risk populations that are sicker and consume more healthcare costs.

Financial incentive increases CPAP acceptance in patients from low socioeconomic background

Objective

We explored whether financial incentives have a role in patients′ decisions to accept (purchase) a continuous positive airway pressure (CPAP) device in a healthcare system that requires cost sharing.

Design

Longitudinal interventional study.

Patients

The group receiving financial incentive (n = 137, 50.8±10.6 years, apnea/hypopnea index (AHI) 38.7±19.9 events/hr) and the control group (n = 121, 50.9±10.3 years, AHI 39.9±22) underwent attendant titration and a two-week adaptation to CPAP. Patients in the control group had a co-payment of $330–660; the financial incentive group paid a subsidized price of $55.

Results

CPAP acceptance was 43% greater (p = 0.02) in the financial incentive group. CPAP acceptance among the low socioeconomic strata (n = 113) (adjusting for age, gender, BMI, tobacco smoking) was enhanced by financial incentive (OR, 95% CI) (3.43, 1.09–10.85), age (1.1, 1.03–1.17), AHI (>30 vs. <30) (4.87, 1.56–15.2), and by family/friends who had positive experience with CPAP (4.29, 1.05–17.51). Among average/high-income patients (n = 145) CPAP acceptance was affected by AHI (>30 vs. <30) (3.16, 1.14–8.75), living with a partner (8.82, 1.03–75.8) but not by the financial incentive. At one-year follow-up CPAP adherence was similar in the financial incentive and control groups, 35% and 39%, respectively (p = 0.82). Adherence rate was sensitive to education (+yr) (1.28, 1.06–1.55) and AHI (>30 vs. <30) (5.25, 1.34–18.5).

Conclusions

Minimizing cost sharing reduces a barrier for CPAP acceptance among low socioeconomic status patients. Thus, financial incentive should be applied as a policy to encourage CPAP treatment, especially among low socioeconomic strata patients.

Race and residential socioeconomics as predictors of CPAP adherence

STUDY OBJECTIVES

There are few established predictors of CPAP adherence; poor adherence limits its effectiveness. We investigated whether race, education level, and residential economic status predict CPAP adherence in participants enrolled in a trial with standard access to treatment.

DESIGN

A multi-center randomized trial of home vs. lab-based evaluation and treatment of OSA assessing adherence to CPAP at 1 and 3 months.

SETTING

Seven AASM-accredited sleep centers in 5 U.S. cities.

PARTICIPANTS

Subjects with moderate to severe OSA (AHI ≥ 15 and Epworth Sleepiness Scale score > 12) who completed follow-up at 1 and/or 3 months (n = 135).

MEASUREMENTS AND RESULTS

Subjects' demographic data were collected upon enrollment; CPAP use at 1 and 3 months was assessed at clinic follow-up. In unadjusted analyses, CPAP adherence (average minutes per night of CPAP use) at 3 months was lower in black subjects and in subjects from lower socioeconomic status ZIP codes. In adjusted analyses using multivariate linear regression, black race was predictive of CPAP adherence at one month (P = 0.03). At 3 months, black race was predictive in analyses only when ZIP code SES was not adjusted for.

CONCLUSION

Black race and lower socioeconomic residential areas are associated with poorer adherence to CPAP in subjects with standardized access to care and treatment. Disparities remain despite provision of standardized care in a clinical trial setting. Future research is needed to identify barriers to adherence and to develop interventions tailored to improve CPAP adherence in at risk populations. Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP) CLINICAL TRIAL INFORMATION: NIH CLINICAL TRIALS REGISTRY NUMBER: NCT00642486. URL: http://clinicaltrials.gov/show/NCT00642486.

Predictors of continuous positive airway pressure use during the first week of treatment

This study aimed to identify pre-treatment and immediate early treatment factors predicting continuous positive airway pressure (CPAP) use during the first week of therapy, when the pattern of non-adherence is established. Four domains of potential predictors were examined: pre-treatment demographic and clinical factors, patients' perceived self-efficacy, treatment delivery (mask leak and bothering side effects) and immediate disease reduction (residual respiratory events and flow limitation). The Autoset™ Clinical System objectively documented daily CPAP use, mask leak, residual respiratory events and flow limitation. Ninety-one CPAP-naive patients with newly diagnosed obstructive sleep apnea were followed for 1week after treatment initiation. Mean CPAP daily use during the first week was 3.4±2.7h, with significantly lower use observed in black than non-black participants (2.7 versus 4.4h, respectively, P=0.002). Less intimacy with partners caused by CPAP was the only treatment side effect correlated with CPAP use (r=-0.300, P=0.025). Reduced CPAP use during the first week was associated simultaneously with being black, higher residual apnea-hypopnea index and the treatment side effect of less intimacy with partners. The three factors together accounted for 25.4% of the variance in the CPAP use (R(2) =0.254, P<0.01). These data suggest the need to assess the impact of CPAP on intimacy and troubleshooting aspects of the treatment that interfere with sexual relationships. Assessing the presence of residual respiratory events may be important in promoting CPAP adherence. The association of race and CPAP use needs to be explored further by including more socioeconomic information.

Influence of marital status and employment status on long-term adherence with continuous positive airway pressure in sleep apnea patients

Background

Long-term adherence is a major issue in patients receiving home continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea-hypopnea syndrome (OSAHS). In a multicenter prospective cohort (the Institut de Recherche en Santé Respiratoire des Pays de la Loire [IRSR] sleep cohort) of consecutive OSAHS patients in whom CPAP had been prescribed for at least 90 days, we studied the impact on long-term treatment adherence of socioeconomic factors, patients and disease characteristics prior to CPAP initiation.

Methods and Principal Findings

Among 1,141 patients in whom CPAP had been prescribed for an average of 504±251 days (range: 91 to 1035), 674 (59%) were adherent with a mean daily use of CPAP≥4 h (mean: 6.42±1.35 h). Stepwise regression analysis identified 4 independent factors of CPAP adherence including apnea-hypopnea index (AHI) (OR: 1.549, 95%CI 1.163 to 2.062 for AHI≥30 vs. AHI<30; p = 0.003), body mass index (BMI) (OR: 1.786, 95%CI 1.131 to 2.822 for BMI≥25 and <30 kg/m², p = 0.01; OR: 1.768, 95%CI 1.145–2.731 for BMI≥30 kg/m², p = 0.01 vs. BMI<25 kg/m²), employment status (OR: 1.414, 95%CI 1.097–1.821 for retired vs. employed; p = 0.007) and marital status (OR: 1.482, 95%CI 1.088–2.019 for married or living as a couple vs. living alone; p = 0.01). Age, gender, Epworth sleepiness scale, depressive syndrome, associated cardiovascular morbidities, educational attainment and occupation category did not influence CPAP adherence.

Conclusions

Marital status and employment status are independent factors of CPAP adherence in addition to BMI and disease severity. Patients living alone and/or working patients are at greater risk of non-adherence, whereas adherence is higher in married and retired patients. These findings suggest that the social context of daily life should be taken into account in risk screening for CPAP non-adherence. Future interventional studies targeting at-risk patients should be designed to address social motivating factors and work-related barriers to CPAP adherence.

Low Socioeconomic Status Is a Risk Factor for Cardiovascular Disease Among Adult Obstructive Sleep Apnea Syndrome Patients Requiring Treatment

STUDY OBJECTIVE

To evaluate the possible role of low socioeconomic status (SES) as a risk factor for cardiovascular disease (CVD) among obstructive sleep apnea syndrome (OSAS) patients requiring treatment.

DESIGN

Polysomnographic and demographic characteristics and associated morbidity were measured in 686 prospectively recruited adult OSAS patients from two regions in Israel.

SETTING

Two university-affiliated sleep laboratories.

MEASUREMENTS AND RESULTS

The multiple logistic regression (after adjusting for gender, body mass index [BMI], and smoking) revealed that the following are independent determinants for CVD in OSAS patients requiring treatment: each decrease in income level category (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7), age > or = 1 year (OR, 1.07; 95% CI, 1.04 to 1.1), hypertension (OR, 2.0; 95% CI, 1.3 to 3.1), and hyperlipidemia (OR, 3.7; 95% CI, 2.4 to 5.8); area under the receiver operating characteristic (ROC) = 81.9%. The multivariate determinants describing the low-SES OSAS patients included: minorities and immigrants combined (OR, 6.0; 95% CI, 2.9 to 12), female gender (OR, 2.4; 95% CI, 1.6 to 3.9), increased BMI (OR, 1.9; 95% CI, 1.3 to 2.9), unmarried status (OR, 1.9; 95% CI, 1.2 to 3.1), and years of education (> or = 1 year) [OR, 0.8; 95% CI, 0.7 to 0.8]; area under the ROC = 78.1%.

CONCLUSION

In addition to the already known traditional risk factors, low SES was found to be a novel independent risk factor for CVD among adult OSAS patients requiring treatment.