Cost-Effectiveness of Sleep Apnea Diagnosis and Treatment in Hospitalized Persons With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To assess the cost-effectiveness of alternative approaches to diagnose and treat obstructive sleep apnea (OSA) in patients with traumatic brain injury (TBI) during inpatient rehabilitation.

SETTING

Data collected during the Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS) clinical trial (NCT03033901) on an inpatient rehabilitation TBI cohort were used in this study.

STUDY DESIGN

Decision tree analysis was used to determine the cost-effectiveness of approaches to diagnosing and treating sleep apnea. Costs were determined using 2021 Centers for Medicare and Medicaid Services reimbursement codes. Effectiveness was defined in terms of the appropriateness of treatment. Costs averted were extracted from the literature. A sensitivity analysis was performed to account for uncertainty. Analyses were performed for all severity levels of OSA and a subgroup of those with moderate to severe OSA. Six inpatient approaches using various phases of screening, testing, and treatment that conform to usual care or guideline-endorsed interventions were evaluated: (1) usual care; (2) portable diagnostic testing followed by laboratory-quality testing; (3) screening with the snoring, tiredness, observed apnea, high BP, BMI, age, neck circumference, and male gender (STOP-Bang) questionnaire; (4) Multivariable Apnea Prediction Index (MAPI) followed by portable diagnostic testing and laboratory-quality testing; (5) laboratory-quality testing for all; and (6) treatment for all patients.

MAIN MEASURES

Cost, Effectiveness, and Incremental Cost-Effectiveness Ratio (ICER).

RESULTS

Phased approaches utilizing screening and diagnostic tools were more effective in diagnosing and allocating treatment for OSA than all alternatives in patients with mild to severe and moderate to severe OSA. Usual care was more costly and less effective than all other approaches for mild to severe and moderate to severe OSA.

CONCLUSIONS

Diagnosing and treating OSA in patients with TBI is a cost-effective strategy when compared with usual care.

Positive airway pressure treatment for sleep-disordered breathing is rare during the first year after stroke: The BASIC project

OBJECTIVE/BACKGROUND

Sleep-disordered breathing (SDB) is very common after ischemic stroke, and its treatment may have a positive impact on recovery from stroke and on secondary stroke prevention. This study sought to determine the prevalence of positive airway pressure (PAP) use after stroke.

PATIENTS/METHODS

Participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Demographics and co-morbidities were ascertained from the medical record. Self-reported PAP use (present vs absent) was assessed at 3, 6, and 12 months after stroke. Fisher exact tests and t-tests were used to compare PAP users versus non-users.

RESULTS

Of 328 participants who were found to have SDB after stroke, only 20 (6.1%) indicated using PAP at any point during the 12-month follow up period. High pre-stroke sleep apnea risk based on Berlin Questionnaire score, neck circumference, and co-morbid atrial fibrillation were associated with any self-reported PAP use; race/ethnicity, insurance status and other demographic variables were not associated with PAP use.

CONCLUSIONS

Only a small proportion of individuals with ischemic stroke and SDB received treatment with PAP during the initial year after stroke among participants in this population-based cohort study in Nueces County, Texas. Closing the substantial treatment gap for SDB after stroke might improve sleepiness and neurologic recovery.

Effects of heated humidification on positive airway pressure side effects in patients with obstructive sleep apnoea: a meta-analysis

PURPOSE

An earlier study found that heated humidification reduced the side effects of positive airway pressure (PAP) in patients with obstructive sleep apnoea (OSA). However, other studies disagreed with this finding. Therefore, we evaluated the relationship between heated humidification and the side effects of PAP in patients with OSA.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six databases were searched for relevant randomised controlled trials (RCTs) performed from January 1999 to June 2021.

RESULTS

From 1012 retrieved articles, we identified 9 eligible RCTs. Compared to the control group, the heated humidification group reported improvements in dry nose (pooled standardised mean difference [SMD] =  - 0.70, 95% confidence interval [CI] =  - 0.96 to - 0.45, I² = 0%, p < 0.00001), blocked nose (SMD =  - 0.47, 95%CI - 0.69 to - 0.25, I² = 36%, p < 0.0001), runny nose (SMD =  - 0.22, 95%CI - 0.44 to 0, I² = 0%, p = 0.05), dry mouth (SMD =  - 0.62, 95%CI - 0.87 to - 0.37, I² = 0%, p < 0.00001), and dry throat (SMD =  - 0.61, 95%CI - 0.90 to - 0.33, I² = 41%, p < 0.0001), but did not enhance positive airway pressure adherence (pooled mean difference [MD] = 0.24, 95% CI - 0.10 to 0.58, I² = 0%, p = 0.17).

CONCLUSIONS

Heated humidification improved some PAP side effects in patients with OSA but did not increase PAP adherence. Additional large-scale multi-centre RCTs are needed to verify the long-term effects.

Motivational Interviewing Effects on Positive Airway Pressure Therapy (PAP) Adherence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This systematic review and meta-analysis examined Motivational Interviewing (MI) effects on positive airway pressure (PAP) adherence and related outcomes.

METHOD

Medline, CIHANL, Psych Info, Web of Science, PubMed, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials published from peer-reviewed journals in English from 1990 to 2021 that compared objective PAP adherence among adults with obstructive sleep apnea (OSA) in a MI and non-MI intervention. A random effects meta-analysis model was completed at the 1-to-2-week, and 1-, 2-, 3-, and 12-month follow-up, and risk of bias was analyzed with the Cochrane Risk of Bias Tool.

RESULTS

In 10 trials of naïve PAP users and one trial of non-naïve PAP users, 14 to 277 middle-aged adults with moderate-to-severe OSA generally engaged in a brief, individual, face-to-face, MI intervention with standard care or a control condition. Several trials of naïve PAP users demonstrated that MI increased PAP use 1-2.6 hours per night, but a similar number of trials showed comparable conditions. Secondary outcomes were mixed. Among non-naïve PAP users, MI did not significantly increase adherence or secondary outcomes. The meta-analysis of PAP-naïve participants revealed that MI had a small to moderate significant effect on PAP adherence at 1, 2, and 3 months after beginning PAP (Hedges' g = 0.38 to 0.48; 95% CI = 0.04, 0.75) compared to standard care alone.

CONCLUSIONS

Despite heterogeneity, MI moderately increased PAP adherence among PAP-naïve adults with moderate-to-severe OSA, suggesting an effective strategy for short-term (1-3 months) adherence.

Sex differences in the effectiveness and affecting factors to adherence of continuous positive airway pressure therapy

Although sex differences in clinical backgrounds of patients with obstructive sleep apnea (OSA) are well known, studies of sex differences about the influencing factors on adherence to continuous positive airway pressure (CPAP) are very sparse. Our aim was to investigate the effects of CPAP use affecting therapeutic adherence in sex differences. We retrospectively assessed demographic data, clinical characteristics, OSA-related symptoms, and effects and adherence of CPAP use in 348 patients (264 males, median age 58 years) who continued CPAP for at least 1 year. Poor adherence was defined as CPAP dropout within 1 year after starting CPAP or the average cumulative CPAP use less than four hours/night. We also studied the predictors or influencing factors of CPAP adherence by multivariate logistic regression analyses. Age was higher and the severity of OSA was lower in female patients. Although the adherence level itself was not significantly different between both sexes, influencing factors were different. OSA severity, such as apnea-hypopnea index and sleepiness, and many effects from CPAP use (respiratory difficulty, difficult adaptation to CPAP use, improved awakening, reduced nocturia, and easy adaptation to CPAP) influenced adherence only in men. Common factors of poor adherence in both sexes were lower age, insomnia by CPAP use, and improved daytime sleepiness. No other specific factors predicted poor adherence in women. We found that there were sex differences in influencing factors on CPAP adherence not only in clinical characteristics of OSA, but also in effectiveness and side effects of CPAP use.

Treatment preferences and willingness to pay in patients with obstructive sleep apnea: relevance of treatment experience

Background

Patients with obstructive sleep apnea (OSA) most commonly receive positive airway pressure therapy (PAP) as primary treatment, which is highly effective when used consistently. Little is known about the preferences for and relevance of attributes of OSA treatments, especially of non-PAP alternatives. The aim of this study was to evaluate treatment preferences and willingness to pay (WTP) among patients with and without previous experience of OSA therapies.

Methods

A discrete choice experiment and a structured survey were applied to patients presenting for overnight polysomnography at a tertiary sleep center. Medical variables were obtained from hospital case records.

Results

Over a period of 4 months, 241 subjects were enrolled and answered the questionnaire (61.8% with an existing diagnosis, 38.2% with a new diagnosis). The most preferred treatment among all patients was PAP therapy (51.1%), followed by mandibular advancement devices (18.1%), hypoglossal nerve stimulation (17.2%), and medication (13.7%). Approval for the different treatments varied by gender as well as by OSA therapy experience. The importance of attributes of OSA treatment varied too, with low rates of treatment-related side effects being equally important, independent of the preferred therapy. The most often stated monthly WTP for optimal sleep was € 50, with increasing age leading to lower WTP values.

Conclusion

Preferences for OSA therapies vary among patients and patient subgroups. PAP therapy is the most preferred treatment, though non-PAP interventions receive high approval ratings too, particularly in treatment-naïve patients. The importance of treatment attributes varies as well, depending on the choice of preferred treatment.

Treatment burden experienced by patients with obstructive sleep apnoea using continuous positive airway pressure therapy

BACKGROUND

Little is known about the treatment burden experienced by patients with obstructive sleep apnoea (OSA) who use continuous positive airway pressure (CPAP) therapy.

PARTICIPANTS

18 patients (33.3% males, mean age 59.7±11.8 years) with OSA who use CPAP therapy were interviewed.

METHODS

Patients treated with CPAP for OSA at a tertiary hospital outpatient clinic in Sydney, Australia, were invited to participate in an interview in person or via phone. Semi-structured interviews were used to explore the treatment burden associated with using CPAP. The interviews were recorded, transcribed, and analysed using NVivo 12 qualitative analysis software.

RESULTS

Four categories of OSA-specific treatment burden were identified: healthcare tasks, consequences of healthcare tasks, exacerbating and alleviating factors of treatment burden. Participants reported a significant burden associated with using CPAP, independently of how frequently they used their device. Common sources of their treatment burden included attending healthcare appointments, the financial cost of treatment, lifestyle changes, treatment-related side effects and general discomfort.

CONCLUSIONS

This study demonstrated that there is a significant treatment burden associated with the use of CPAP, and that treatment non-adherence is not the only consequence of treatment burden. Other consequences include relationship burden, stigma and financial burden. It is important for physicians to identify other negative impacts of treatment burden in order to optimise the patient experience.

Tendon-like tether formation for tongue-base advancement in an ovine model using a novel implant device intended for the surgical management of obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a serious debilitating condition with significant morbidity and mortality affecting almost one billion adults globally. The current gold standard in the non-surgical management of airway collapse is continuous positive airway pressure (CPAP). However, non-compliance leads to a high abandon rate (27-46%). While there are multiple sites of airway obstruction during sleep, the tongue base is recognized as the key player in the pathogenesis of OSA. Poor outcomes of current tongue suspension devices are due to fracture, slippage or migration of devices. Three tongue tethering device groups, namely a polydioxanone/polyurethane combination (PDO + PU) treatment group, a PDO analytical control group, and a polypropylene (PP) descriptive control group, were implanted into 22 sheep (75-85 kg) in a two-phased study. After implant times of 8, 16, and 32 weeks, sheep were serially euthanized to allow for explantation of their tongues and chins. The PDO + PU devices remodeled during the 32-week implant period into a hybrid biological tendon-like tether through the process of gradual degradation of the PDO and collagen deposition as shown by electrophoresis, histology and mechanical testing. The control PDO device degraded completely after 32 weeks and the PP devices remained intact. The hybrid biological tendon-like tether exhibited a break-strength of 60 N, thus exceeding the maximum force to overcome upper airway collapse.

A survey of positive airway pressure therapy preparedness and outcomes following Hurricane Irma in patients with obstructive sleep apnea

STUDY OBJECTIVES

Clinical benefit from positive pressure therapy is dependent on treatment adherence. Extreme weather events, such as floods, hurricanes, and tornadoes, can contribute to nonadherence by electricity loss and mandatory evacuation. We aimed to evaluate the concerns and behaviors of regular positive airway pressure users surrounding the extreme weather event Hurricane Irma.

METHODS

A questionnaire on positive pressure concerns surrounding Hurricane Irma was completed by 117 patients with pre-hurricane objectively confirmed treatment adherence as defined by Medicare. Responses were tabulated to identify concerns and behavior in preparation for and after Hurricane Irma. Cloud-based monitoring, available on 50 (43%) cases, was used to determine the effect of self-reported electricity loss on treatment adherence before and after the storm. Quantitative use data pre- and post-Hurricane Irma was compared by t test with P < .05 considered statistically significant.

RESULTS

Post-hurricane 78 (67%) patients were unable to use treatment with mean duration of 4.3 days. Of these, snoring, choking, and sleepiness were reported in 64%, 19%, and 42%, respectively. Loss of electricity was identified as the cause of missed treatment in 71 patients. In those with cloud monitoring, mean 14-day pre- and post-hurricane use differed by 8 minutes (P =.056). Cloud-monitored cases with loss of electricity had a decline in mean use of 33 minutes for the first 7 days post-hurricane. There was a trend towards increased use post-hurricane in those that retained electricity. Many patients expressed dissatisfaction with the availability of preparedness guidelines.

CONCLUSIONS

Although common, loss of electricity was not the sole disruptor of positive pressure use after extreme weather events. Regular users of positive airway pressure experience both disruption in patterns of use and concerns regarding preparedness for extreme weather events.

Cost-Benefit Analysis From the Payor's Perspective for Screening and Diagnosing Obstructive Sleep Apnea During Inpatient Rehabilitation for Moderate to Severe TBI

OBJECTIVE

To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective.

DESIGN

A cost-benefit analysis of phased approaches to sleep apnea diagnosis.

SETTING

Six TBI Model System Inpatient Rehabilitation Centers.

PARTICIPANTS

Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5).

INTERVENTION

Not applicable.

MAIN OUTCOME

Cost benefit.

RESULTS

At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness.

CONCLUSIONS

The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.

Clinical side effects of continuous positive airway pressure in patients with obstructive sleep apnoea

CPAP is considered the gold standard treatment in OSA and is highly efficacious in controlling OSA symptoms. However, treatment effectiveness is limited because of many factors including low adherence due to side effects. This review highlights the range of side effects associated with CPAP therapy in patients with OSA. This information is important for the initiation of patients onto CPAP as well as their continued care while on treatment, given the increase in non-medically supervised CPAP care models in use globally.

Incidence and predictors of adherence to sleep apnea treatment in rehabilitation inpatients with acquired brain injury

OBJECTIVE

The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI).

METHODS

A 2012-2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed.

RESULTS

ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (β = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023).

CONCLUSIONS

In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.

Untreated Sleep Apnea: An Analysis of Administrative Data to Identify Risk Factors for Early Nonadherence

STUDY OBJECTIVES

Discontinuation of positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) is widely reported, but research has not adequately addressed nonadherence with diagnostic testing for sleep disorders and initiation of PAP. This study sought to identify drivers of nonadherence with diagnostic sleep testing and PAP treatment initiation among patients preauthorized for these services.

METHODS

This observational cohort study used preauthorization records from a sleep management program and administrative medical claims from a large commercial health insurer. Participants included adults preauthorized for sleep testing and a subset in whom OSA was diagnosed and who were preauthorized for PAP treatment. Outcome measures were nonadherence with diagnostic sleep testing and PAP treatment initiation, identified as lack of a claim for a preauthorized service within 3 months of preauthorization of that service. Risk factors for nonadherence included patient demographics, prescribing factors, signs and symptoms of OSA, comorbidities, and prior health service utilization.

RESULTS

Of 51,749 patients preauthorized for diagnostic testing, 23.5% did not undergo testing. Among 19,968 patients preauthorized for PAP treatment, 11.1% did not initiate treatment. Testing and treatment ordered by primary care providers, residence outside the Midwest region, and two or fewer office visits within 6 months before preauthorization were strong predictors of nonadherence. Apnea-hypopnea index score < 30 events/h was also a strong predictor of nonadherence with treatment initiation.

CONCLUSIONS

This study adds to existing knowledge about risk factors for nonadherence with sleep testing and treatment initiation following preauthorization. Health plans and providers should develop strategies to better engage patients with higher risk of nonadherence.

Prevalence, Associated Clinical Features, and Impact on Continuous Positive Airway Pressure Use of a Low Respiratory Arousal Threshold Among Male United States Veterans With Obstructive Sleep Apnea

STUDY OBJECTIVES

Determine the prevalence of, and clinical features associated with, a low respiratory arousal threshold (ArTH) among patients with obstructive sleep apnea (OSA), and to assess whether a low ArTH is associated with reduced long-term CPAP use.

METHODS

Cross-sectional and longitudinal analyses were performed in an observational study conducted among 940 male Veterans with OSA. Data for clinical characteristics, polysomnography characteristics, and long-term (5 ± 2 years) CPAP use were obtained from clinical records. Logistic regression was used to assess the associations between low ArTH and clinical features, including regular CPAP use.

RESULTS

A low ArTH was observed in 38% of participants overall, and was more common among nonobese (body mass index < 30 kg/m²) patients (55%). In adjusted analyses, increasing body mass index (per 5 kg/m²) and antihypertensive medication use were negatively associated with low ArTH, with odds ratio (OR) (95% confidence interval [CI]) of 0.77 (0.69, 0.87) and 0.69 (0.49, 0.98), respectively. Conversely, increasing age (per 10 years) and antidepressant use-OR (95% CI) 1.15 (1.01,1.31) and 1.54 (1.14,1.98), respectively-were positively associated with low ArTH. Nonobese patients with low ArTH were less likely to be regular CPAP users-OR (95% CI) 0.38 (0.20, 0.72)-in an adjusted model.

CONCLUSIONS

Low ArTH is a common trait among Veterans with OSA and is more frequent among those who are older and nonobese and those taking antidepressants, but is less frequent among patients taking antihypertensive medications. A marked reduction of long-term CPAP use in nonobese patients with low ArTH highlights the importance of understanding a patient's physiologic phenotype for OSA management, and suggests potential targets to improve CPAP adherence.

COMMENTARY

A commentary on this article appears in this issue on page 713.

CPAP Adherence Predictors in a Randomized Trial of Moderate-to-Severe OSA Enriched With Women and Minorities

BACKGROUND

Suboptimal CPAP adherence in OSA clinical trials involving predominantly white men limits interpretability and generalizability. We examined predictors of CPAP adherence in a clinical trial enriched with minorities.

METHODS

The Sleep Apnea Stress Study-a randomized, double-blind, sham-controlled trial of patients with moderate-to-severe OSA-included participants with complete 8-week adherence data (n = 138). Overnight 14-channel polysomnography, anthropometry, socioeconomic status, mood questionnaires, and week 1 CPAP adherence were analyzed via adjusted linear models relative to CPAP adherence (average minutes per night usage).

RESULTS

Overall, age was 51 ± 12 years, 55% of the patients were male, 55% were white, BMI was 36.7 ± 7.7 kg/m², and median apnea-hypopnea index was 20 (interquartile range, 13-37). In univariate analyses adherence increased with randomization to active CPAP (81 min; 95% CI, 30-132), increasing age (35 min/decade; 95% CI, 13-57), white race (78 min, 95% CI, 26-129), and per hour of week 1 adherence (41 min, 95% CI, 32-51). Active CPAP (48 min, 95% CI, 6-91), increasing age (27 min/decade, 95% CI, 10-44), and higher 1-week adherence (36 min/h, 95% CI, 27-46) were significantly associated with improved adherence in multivariable analyses. Subgroup analyses showed stronger associations of adherence with treatment arm in whites and increasing age in minorities. Increasing age and white race were more strongly associated with adherence in women.

CONCLUSIONS

In this trial with near-even sex distribution and high ethnic minority representation, we identified CPAP assignment, increasing age, and early adherence to be associated with improved adherence in addition to sex-specific and race-specific adherence differences. These results can inform targeted clinical trial adherence optimization strategies.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00607893; URL: www.clinicaltrials.gov.

Barriers to acceptance and adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea: a report from Kermanshah province, western Iran

PURPOSE

Continuous positive airway pressure (CPAP) is the gold standard treatment for obstructive sleep apnea (OSA). CPAP acceptance and adherence are critical issues for optimal treatment outcome. Identifying barriers to acceptance and adherence can improve intervention development and outcomes. This study aimed to investigate the barriers to CPAP acceptance/adherence in patients with OSA in western Iran.

PATIENTS AND METHODS

Patients with OSA, who had been prescribed CPAP by the Sleep Disorders Research Center of Kermanshah University of Medical Sciences, were recruited. They were interviewed via telephone regarding acceptance (ie, CPAP use during the first 2 weeks) and adherence (ie, CPAP use 4 h/d for 70% of the nights per week). Barriers to acceptance and adherence were solicited.

RESULTS

Out of a possible sample of 101, 97 patients (79 male) were reached and included in the study. They had a mean age of 48.76 years (SD =12.04) and mean apnea/hypopnea index score of 36.06 (SD =1.87). Patients were categorized into the following acceptance/adherence groups: nonacceptance (CPAP not purchased; 72.2%), poor adherence (5.2%), and adherent (22.7%). Inability to afford a CPAP device, perception of symptom reduction/no need for treatment, and dissatisfaction with treatment were among the most common reasons for nonacceptance and poor adherence.

CONCLUSION

CPAP acceptance and adherence in western Iran are low. Approximately 70% of the patients did not accept CPAP treatment (due to not obtaining the device) and 5% did not adhere. To improve acceptance/adherence, increased access (ie, reduced cost or increased insurance coverage) and enhanced education about the benefits of the treatment are recommended. Treatment monitoring via regular follow-ups may also prove beneficial.

A Randomized Crossover Trial of a Pressure Relief Technology (SensAwake™) in Continuous Positive Airway Pressure to Treat Obstructive Sleep Apnea

Objectives/Background

Improving adherence to CPAP devices is crucial to reduce the long-term morbidity associated with OSA. SensAwake is a unique pressure relief technology that aims to promptly reduce the pressure upon sensing irregular respiration indicative of wakefulness. The purpose of this study was to compare adherence and sleep-quality outcomes in patients treated by CPAP with and without SensAwake technology.

Methods

Participants with moderate-to-severe OSA were randomized to use CPAP devices with or without SensAwake (4 weeks) before crossing over.

Results

Sixty-five patients completed both arms of the trial. There were no statistically significant differences in CPAP adherence with or without SensAwake over the study period (SensAwake ON 272.67 ± 17.06 versus SensAwake OFF 289.09 ± 15.24; p = 0.180). SensAwake reported a significantly lower system leak, 90th percentile leak, and time spent with excessive (>60 L/min) leak. Subgroup analysis suggested a trend towards improved adherence in patients with moderate-to-severe insomnia when using SensAwake.

Conclusions

Using SensAwake incurred benefit in terms of reduced leaks; however, SensAwake did not improve CPAP adherence or objective sleep quality. Further studies should investigate the accuracy of observed trends towards increased adherence using SensAwake among patients with OSA and insomnia.

Determinants for adherence to continuous positive airway pressure therapy in obstructive sleep apnea

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is an efficacious treatment for patients diagnosed with obstructive sleep apnea (OSA). However, there are only few data on long-term adherence. The aim of this study is to quantify the extent of non-adherence and describe the clinical characteristics.

METHODS

A retrospective study including 695 patients with newly diagnosed OSA and prescribed CPAP therapy within an inclusion period of 14 months. All patients were offered free of charge individually adjusted CPAP therapy. Data on comorbidity, medication, BMI and Epworth Sleepiness Score (ESS) were obtained by questionnaires and consultation with an otorhinolaryngeal specialist.

RESULTS

The median follow-up time after initiating CPAP therapy was 3.0 (range 2.4-3.6) years. An adherence rate of 89% was found for severe OSA, 71% for moderate OSA and 55% for mild OSA. 18% initiated humidification. Patients adherent to CPAP had a significantly higher Body Mass Index (BMI), Apnea Hypopnea Index (AHI), Oxygen Desaturation Index (ODI) and ESS compared to non-adherent patients. Furthermore, adherence was associated with a higher frequency of observed interrupted breathing, a less frequent use of hypnotic drugs, fewer smokers, and they were more often offered humidification. Age, gender and comorbidity were not significantly associated with adherence. In a Cox model only AHI (Hazard Ratio (HR) 0.963, p < 0.001), ESS (HR 0.939, p = 0.001) and smoking (HR 1.576, p = 0.022) were independently associated with CPAP non-adherence.

CONCLUSIONS

The severity of OSA, subjective daytime sleepiness and smoking status are independently related to adherence to CPAP therapy.

Ambivalent Adherence and Nonadherence to Continuous Positive Airway Pressure Devices: A Qualitative Study

STUDY OBJECTIVES

Continuous positive airway pressure (CPAP) therapy is considered the front-line treatment for moderate-severe obstructive sleep apnea (OSA). However, nonuse rates are very high, such that adherence to CPAP has become a major concern. Although the literature on CPAP use is vast, further research is required to understand patients' experiences of CPAP use and nonuse. This is the goal of this study.

METHODS

This study draws on in-depth interviews with 61 Jewish-Israeli patients with OSA who received a recommendation to use a CPAP device. The sample includes both patients who started using CPAP devices as well as patients who rejected this course of treatment. It follows principles of constructivist-grounded theory in both sampling and analysis.

RESULTS

The study shows that regardless of patients' status of adherence, their attitudes toward CPAP devices are characterized by ambivalence. Users of CPAP expressed ambivalent adherence, pondering whether they should stop using the device; and patients who rejected the CPAP expressed ambivalent nonadherence, wondering whether they should give the CPAP another chance. This study identifies the experiences involved in using, as well as not using, CPAP devices that produce patients' ambivalence.

CONCLUSIONS

Both adherence and nonadherence to CPAP are dynamic processes that are characterized by patients' ambivalence and contingent upon diverse factors. These findings have practical implications as they suggest that all patients, regardless of their initial adherence status, would benefit from a close follow-up.

Insomnia complaints in lean patients with obstructive sleep apnea negatively affect positive airway pressure treatment adherence

The objective of this study was to evaluate the determinants of long-term adherence to positive airway pressure treatment among patients with obstructive sleep apnea, with special emphasis on patients who stop positive airway pressure treatment within 1 year. This is a prospective long-term follow-up of subjects in the Icelandic Sleep Apnea Cohort who were diagnosed with obstructive sleep apnea between 2005 and 2009, and started on positive airway pressure treatment. In October 2014, positive airway pressure adherence was obtained by systematically evaluating available clinical files (n = 796; 644 males, 152 females) with moderate to severe obstructive sleep apnea (apnea-hypopnea index ≥15 events per h). The mean follow-up time was 6.7 ± 1.2 years. In total, 123 subjects (15.5%) returned their positive airway pressure device within the first year, 170 (21.4%) returned it later and 503 (63.2%) were still using positive airway pressure. The quitters within the first year had lower body mass index, milder obstructive sleep apnea, less sleepiness, and more often had symptoms of initial and late insomnia compared with long-term positive airway pressure users at baseline. Both initial and late insomnia were after adjustment still significantly associated with being an early quitter among subjects with body mass index <30 kg m^-2 , but not among those with body mass index ≥30 kg m^-2 . The prevalence of early quitters decreased significantly during the study period (2005-2009). Almost two-thirds of patients with moderate to severe obstructive sleep apnea are positive airway pressure users after 7 years. Obesity level, obstructive sleep apnea severity and daytime sleepiness are important determinants of long-term adherence. Symptoms of initial and late insomnia are associated with early quitting on positive airway pressure among non-obese subjects.

Adherence to Positive Airway Pressure Therapy in Hospitalized Patients with Decompensated Heart Failure and Sleep-Disordered Breathing

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) has been implicated as a risk factor for the development of several adverse cardiovascular outcomes, but can be mitigated with positive airway pressure therapy (PAP). The nonadherence of patients with SDB on PAP in the outpatient setting ranges from 29% to 84%. However, adherence of PAP in patients with congestive heart failure (CHF) admitted for decompensated CHF and in whom SDB has been diagnosed in the hospital setting is not known. We hypothesized that despite a diagnosis in the hospital, the compliance of these patients with PAP therapy would not be different from the well-established adherence in patients with a diagnosis and treatment in the outpatient setting.

METHODS

The study was a retrospective analysis of patients admitted to an academic tertiary care hospital between March 2013 and February 2014. Patients presenting with decompensated CHF were screened and high-risk patients were started on PAP empirically and advised to undergo a postdischarge polysomnogram. Compliance of the patients with PAP was tracked for over 12 mo. Data from a similar outpatient group who underwent polysomnography during the study period were also reviewed.

RESULTS

Ninety-one patients underwent polysomnograhy postdischarge. Of the 91 patients, 81 patients agreed to PAP therapy. One patient was excluded as data were missing. The adherence at 3, 6, and 12 mo was 52%, 37%, and 27%, which was not significantly different than an outpatient control group. There was a trend for those with CHF plus SDB and compliant with PAP to have a higher probability of survival compared to those who were noncompliant (p = 0.07).

CONCLUSIONS

Adherence of patients to PAP therapy in whom a SDB diagnosis is made during acute hospitalization for heart failure is comparable to patients in the ambulatory setting. Adherence in first 3 mo is a predictive marker for improved survival trend.

Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure

BACKGROUND

Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease.

OBJECTIVES

(1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH.

TOMADO

A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY.

META-ANALYSIS

A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)].

LONG-TERM COST-EFFECTIVENESS

An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2.

CONCLUSIONS

Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates.

TRIAL REGISTRATION

This trial is registered as ISRCTN02309506.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.

Assessing and predicting the likelihood of interventions during routine annual follow-up visits for management of obstructive sleep

STUDY OBJECTIVES

Patients with obstructive sleep apnea (OSA) on established positive airway pressure (PAP) treatment are often advised routine annual follow-up visits to assess ongoing effectiveness and address problems associated with therapy. This study evaluates the clinical utility of annual face-to-face follow-up visits.

DESIGN

We performed a retrospective chart review of OSA patients on PAP who had completed a routine annual follow-up visit. Demographics, polysomnography, PAP compliance, Epworth Sleepiness Scale (ESS), subjective complaints (efficacy and interface issues, equipment malfunction, prescription renewal), objective findings (efficacy or leak issues, equipment problems), and visit-specific interventions were recorded. We determined relationships between patient provided information and likelihood of therapeutic versus administrative interventions.

SETTING

Academic sleep center.

MEASUREMENTS AND RESULTS

Among 716 patients who met study criteria, we abstracted data on 180 randomly selected patients. On multivariate analyses, only subjective complaints or objective findings by providers were associated with a therapeutic intervention (p < 0.0001). Though most patients (55 of 63 patients, 87.3%) who required therapeutic interventions had objective findings, without subjective complaints, the odds of such findings were only 0.12 (95% CI = 0.06-0.24, p < 0.0001). Without subjective complaints, the likelihood of a therapeutic intervention was 0.07 (95% CI = 0.03-0.15, p < 0.001).

CONCLUSION

Our data suggests that in the absence of a subjective complaint, an annual follow-up is more likely to require administrative rather than face-to-face clinical intervention. Designing a clinic model to account for this might reduce resource utilization. However, the value and optimal timing of "routine" annual follow-up visits requires further evaluation.

Breaking through limbo: experiences of adults living with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a potentially devastating condition that diminishes quality of life and leads to serious consequences without treatment. Diagnosis often is delayed and, once diagnosed, adherence to prescribed therapy tends to be a major barrier to management. This grounded theory study was focused on the experiences of a diverse group of 82 adults who were at various points in the process of obtaining a diagnosis and living with OSA. Participants described being in "limbo" and needing to break through that limbo to be successful at managing their OSA. Results provide new insights into the experience of living with OSA that can be beneficial in promoting treatment and shaping effective management of the condition.

What is known about the experiences of using CPAP for OSA from the users' perspective? A systematic integrative literature review

Economic, social and personal costs of untreated obstructive sleep apnoea (OSA) are high. Continuous positive airway pressure (CPAP) is recommended and cost effective. Increasing OSA prevalence may accompany predicted globally increasing obesity.

OBJECTIVE

To synthesise international evidence regarding personal experiences using CPAP for OSA.

METHODS

A systematic integrative literature review was conducted and quality assessment criteria applied.

RESULTS

22, of 538, identified papers met inclusion criteria. Thematic analysis identified three themes: 1) users' beliefs about CPAP influence users' experiences of CPAP; 2) CPAP users are primed to reflect negatively on experiences of CPAP; and 3) spouse and family influence users' experiences of CPAP. Personality and attitude impact expectations about CPAP prior to use, whilst engagement of spouse and family also influence experiences. Analysis highlighted that users' reporting of CPAP experiences is constrained by investigator defined assessment methods. Overall, research relating to experiences using CPAP is limited.

CONCLUSION

Users' perspectives of CPAP are constrained by researchers' concern with non-compliance. Typically experiences are not defined by the user, but from an 'expert' healthcare perspective, using words which frame CPAP as problematic. Family and social support is a significant, but neglected area of experiencing CPAP warranting further investigation. More information from users is required to determine how CPAP can be managed successfully.

Airway Mechanosensor Behavior during Application of Positive End-Expiratory Pressure

<b><i>Background:</i></b> Positive end-expiratory pressure (PEEP) is commonly used in clinical settings. It is expected to affect the input from slowly adapting pulmonary stretch receptors (SARs), leading to altered cardiopulmonary functions. However, we know little about how SARs behave during PEEP application. <b><i>Objectives:</i></b> Our study aimed to characterize the behavior of SARs during PEEP application. <b><i>Methods:</i></b> We recorded single-unit activities from 18 SARs in the cervical vagus nerve and examined their response to an increase of PEEP from 3 to 10 cm H₂O for 20 min in anesthetized, open-chest and mechanically ventilated rabbits. <b><i>Results:</i></b> The mean activity of the units increased immediately from 35.7 to 80.5 impulses per second at the fifth breath after increasing PEEP (n = 14, p < 0.001) and then gradually returned to 56.5 impulses per second at the end of 20 min of PEEP application (p < 0.001). In the meantime, peak airway pressure increased from 9.3 to 32.7 cm H₂O, and then gradually returned to 29.4 cm H₂O (n = 18; p < 0.05) after 20 min. The remaining four units ceased firing at 34.7 s (range 10-56 s) after their initial increased activity upon 10 cm H₂O PEEP application. The unit activity resumed as the PEEP was returned to 3 cm H₂O. <b><i>Conclusions:</i></b> High PEEP stimulates SARs and SAR activity gradually returns towards the baseline via multiple mechanisms including receptor deactivation, neural habituation and mechanical adaptation. Understanding of the sensory inputs during PEEP application will assist in developing better strategies of mechanical ventilation.

The clinical efficiency of positive airway pressure treatment

OBJECTIVES

The aim of this study was to evaluate the clinical efficiency and compliance of positive airway pressure (PAP) treatment.

MATERIALS AND METHODS

This study was conducted on moderate-severe obstructive sleep apnea syndrome (OSAS) patients who admitted to Ankara Numune Hospital Sleep Center between 2008 and 2012. Seventy-five patients with moderate-severe OSAS who were using PAP treatment regularly were enrolled in the study. Patient's usage data, Epworth sleepiness scale (ESS) scores, and the differences in complaints of OSAS were recorded.

RESULTS

The overall complaints were improved when compared to pretreatment period. Particularly there was improvement in apnea, snoring, excessive daytime sleepiness, fatigue, and sleep quality.

CONCLUSION

PAP is effective in reducing symptoms in people with moderate and severe OSAS. To inform the patients with details and the creation of strategies for close followup are necessary for improving the compliance of the patients.

TRIAL REGISTRATION NUMBER

ACTRN12613000373774.

Elevated levels of endothelial cell-derived microparticles following short-term withdrawal of continuous positive airway pressure in patients with obstructive sleep apnea: data from a randomized controlled trial

BACKGROUND

Obstructive sleep apnea has been associated with impaired endothelial function; however, the mechanisms underlying this association are not completely understood. Cell-derived microparticles may provide a link between obstructive sleep apnea and endothelial dysfunction.

OBJECTIVES

This randomized controlled trial aimed to examine the effect of a 2-week withdrawal of continuous positive airway pressure (CPAP) therapy on levels of circulating microparticles.

METHODS

Forty-one obstructive sleep apnea patients established on CPAP treatment were randomized to either CPAP withdrawal (subtherapeutic CPAP) or continuing therapeutic CPAP, for 2 weeks. Polysomnography was performed and circulating levels of microparticles were analyzed by flow cytometry at baseline and 2 weeks.

RESULTS

CPAP withdrawal led to a recurrence of obstructive sleep apnea. Levels of CD62E+ endothelium-derived microparticles increased significantly in the CPAP withdrawal group compared to the continuing therapeutic CPAP group (median difference in change +32.4 per µl; 95% CI +7.3 to +64.1 per µl, p = 0.010). CPAP withdrawal was not associated with a statistically significant increase in granulocyte, leukocyte, and platelet-derived microparticles when compared with therapeutic CPAP.

CONCLUSIONS

Short-term withdrawal of CPAP therapy leads to a significant increase in endothelium-derived microparticles, suggesting that microparticle formation may be causally linked to obstructive sleep apnea and may promote endothelial activation.

Feasibility of noninvasive single-channel automated differentiation of obstructive and central hypopneas with nasal airflow

BACKGROUND

The identification of obstructive and central hypopneas is considered challenging in clinical practice. Presently, obstructive and central hypopneas are usually not differentiated or scores lack reliability due to the technical limitations of standard polysomnography. Esophageal pressure measurement is the gold-standard for identifying these events but its invasiveness deters its usage in daily practice.

OBJECTIVES

To determine the feasibility and efficacy of an automatic noninvasive analysis method for the differentiation of obstructive and central hypopneas based solely on a single-channel nasal airflow signal. The obtained results are compared with gold-standard esophageal pressure scores.

METHODS

A total of 41 patients underwent full night polysomnography with systematic esophageal pressure recording. Two experts in sleep medicine independently differentiated hypopneas with the gold-standard esophageal pressure signal. Features were automatically extracted from the nasal airflow signal of each annotated hypopnea to train and test the automatic analysis method. Interscorer agreement between automatic and visual scorers was measured with Cohen's kappa statistic (ĸ).

RESULTS

A total of 1,237 hypopneas were visually differentiated. The automatic analysis achieved an interscorer agreement of ĸ = 0.37 and an accuracy of 69% for scorer A, ĸ = 0.40 and 70% for scorer B and ĸ = 0.41 and 71% for the agreed scores of scorers A and B.

CONCLUSIONS

The promising results obtained in this pilot study demonstrate the feasibility of noninvasive single-channel hypopnea differentiation. Further development of this method may help improving initial diagnosis with home screening devices and offering a means of therapy selection and/or control.