Financial incentive increases CPAP acceptance in patients from low socioeconomic background

Treatment of obstructive sleep apnea with a simple CPAP device

PURPOSE

CPAP is the "gold standard" treatment for obstructive sleep apnea (OSA). Current CPAP models have developed additional functions including automatic CPAP and pressure relief. However, CPAP adherence has not improved over the last three decades. Many patients in low-income countries cannot afford these CPAP devices. A novel simple CPAP device with a fixed pressure without pressure controller was developed.

METHODS

Manual CPAP pressure titration was performed in 127 patients with OSA. Six patients with a titration pressure higher than 11 cmH2O and 14 patients who could not tolerate CPAP were excluded, leaving 107 participating in the following 2 studies. In study one, 54 of 107 patients were treated by both conventional fixed CPAP and simple CPAP in random order. In the second study, another 53 patients were treated by both autoCPAP in automatic function and simple CPAP in random order. Simple CPAP was fixed at 10 cmH2O, 8 cmH2O, and 6 cmH2O for patients whose titration pressure was between 9-10, 7-8, and ≤ 6 cmH2O, respectively. Conventional fixed CPAP device was set exactly the same as manual titration pressure.

RESULTS

All patients whose manual titration pressure ≤ 10 cmH2O were effectively treated by simple CPAP (AHI 40.7 ± 2.3 events/h before vs 2.5 ± 0.3 events/h after, p < 0.001). Patients expressed similar preferences for simple CPAP, autoCPAP, and conventional fixed CPAP (p > 0.05).

CONCLUSIONS

We conclude that a novel simple CPAP is an alternative treatment for most patients with OSA, which may widen access to CPAP therapy in the developing countries because of its low cost.

Factors influencing patient delay in individuals with obstructive sleep apnoea: a study based on an integrated model

BACKGROUND

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder, yet it remains undiagnosed in a large proportion of adults.

OBJECTIVE

This study aims to investigate the status of patient delay and provider delay in OSA patients and examine related factors affecting patient delay in OSA individuals in China.

METHODS

A cross-sectional design was conducted on a sample of 309 OSA patients (aged from 18 to 76, median age of 47 years, 84.8% male) in Northeast China. Participants were required to complete the sociodemographic questionnaire, the symptom characteristics questionnaire, the help-seeking attitude scale (HSAS), the social support rating scale and the chronic disease self-efficacy scales (CDSES) to test the hypothesis. Binary logistic regression analysis was conducted to explore factors that account for the patient delay.

RESULTS

The median patient delay among OAS patients in this study was 22 months, the median provider delay was one month, and the median total delay was 26 months. As shown by multivariate analysis results, patients who have snored for over 6 years (OR = 3.377, 95%CI: 1.175-9.702) were more likely to experience prolonged patient delays. Per capita monthly family income above 3000 RMB (OR = 0.172, 95%CI: 0.052-0.571), taking up residence in cities or towns (OR = 0.484, 95%CI: 0.248-0.946), higher self-recognition of the disease (OR = 0.793, 95%CI: 0.647-0.972), higher objective support (OR = 0.825, 95%CI: 0.739-0.921) and stronger self-efficacy (OR = 0.674, 95%CI: 0.525-0.867) were significantly associated with shorter patient delays.

CONCLUSION

Patient delay is common in Chinese OSA patients. The upstream factors affecting the patient delay in individuals with OSA include income, place of residence, and objective support; midstream factors include self-recognition of the disease and self-efficacy; downstream factors include years of snoring.KEY MESSAGESDespite being a high-prevalence disease, many obstructive sleep apnoea (OSA) patients are not clearly diagnosed and treated.The factors affecting the delay in seeking medical treatment in individuals with OSA included income, place of residence, objective support, self-recognition of the disease, self-efficacy and years of snoring.Investigations into OSA patients' care-seeking behaviours can better reflect the secondary prevention of OSA, and it is crucial to pay attention to the delayed phase of patients.

Can a conditional financial incentive (CFI) reduce socio-demographic inequalities in home-based HIV testing uptake? A secondary analysis of the HITS clinical trial intervention in rural South Africa

In sub-Saharan Africa, home-based HIV testing interventions are designed to reach sub-populations with low access to HIV testing such as men, younger or less educated people. Combining these interventions with conditional financial incentives (CFI) has been shown to be effective to increase testing uptake. CFI are effective for one-off health behaviour change but whether they operate differentially on different socio-demographic groups is less clear. Using data from the HITS trial in South Africa, we investigated whether a CFI was able to reduce existing home-based HIV testing uptake inequalities observed by socio-demographic groups. Residents aged ≥15 years in the study area were assigned to an intervention arm (16 clusters) or a control arm (29 clusters). In the intervention arm, individuals received a food voucher (∼3.5 US dollars) if they accepted to take a home-based HIV test. Testing uptake differences were considered for socio-demographic (sex, age, education, employment status, marital status, household asset index) and geographical (urban/rural living area, distance from clinic) characteristics. Among the 37,028 residents, 24,793 (9290 men, 15,503 women) were included in the analysis. CFI increased significantly testing uptake among men (39.2% vs 25.2%, p < 0.001) and women (45.9% vs 32.0%, p < 0.001) with similar absolute increase between men and women. Uptake was higher amongst the youngest or least educated individuals, and amongst single (vs in union) or unemployed men. Absolute uptake increase was also significantly higher amongst these groups resulting in increasing socio-demographic differentials for home-based HIV testing uptake. However, because these groups are known to have less access to other public HIV testing services, CFI could reduce inequalities for HIV testing access in our specific context. Although CFI significantly increased home-based HIV testing uptake, it did not do so differentially by socio-demographic group. Future interventions using CFI should make sure that the intervention alone does not increase existing health inequities.

Self-management behavior, associated factors and its relationship with social support and health literacy in patients with obstructive sleep apnea–hypopnea syndrome

Background

The proportion of patients with obstructive sleep apnea–hypopnea syndrome (OSAHS) is increasing year by year in China, which has become a major public health problem. Self-management of OSAHS and multiple support from caregivers are key to low hospital admissions and high quality of life for patients with OSAHS. Social support and health literacy are the main promoters of self-management behavior. However, their contributions have not been adequately studied. The purpose of this study is to investigate the level of self-management among patients with OSAHS and its relationship with general demographics, social support, and health literacy.

Methods

A total of 280 patients with OSAHS treated in two Classiii Grade A hospitals in Jinzhou City, Liaoning Province from October 2020 to July 2021 were selected as the study subjects. Patients were investigated by General Characteristics Questionnaire, Social Support Rating Scale (SSRS), Health Literacy Scale for Chronic Patients (HLSCP), and OSAHS Self-management Behavior Questionnaire, and the influencing factors of self-management of patients with OSAHS were analyzed.

Results

The average score of OSAHS self-management was 74.49(SD = 8.06), SSRS and HLSCP scores were positively correlated with total scores of self-management behavior. Furthermore, we found that disease duration, SSRS, and HLSCP scores were the main predictors of self-management behavior (R² = 0.390, P < 0.001).

Conclusion

This study found that OSAHS patients with a longer duration of disease and higher SSRS or HLSCP scores also had higher levels of self-management. The factors discussed in this study may be helpful in developing individualized interventions in self-management for patients with OSAHS.

Bone mineral density alteration in obstructive sleep apnea by derived computed tomography screening

The association between obstructive sleep apnea (OSA) and bone mineral density (BMD) is poorly elucidated and has contradictory findings. Abdominal computed tomography (CT) for other indications can provide a valuable opportunity for osteoporosis screening. Thus, we retrospectively explored the association between OSA and BMD by examining abdominal CT vertebrae images for a multitude of conditions and indications. We included 315 subjects (174 with OSA and 141 without OSA) who performed at least two CT scans (under similar settings). Both groups had a similar duration between the first and second CT scans of 3.6 years. BMD decreased in those with OSA and increased age. A multivariate linear regression indicated that OSA is associated with BMD alterations after controlling for age, gender, and cardiovascular diseases. Here, we report that OSA is associated with BMD alterations. Further studies are required to untangle the complex affect of OSA on BMD and the possible clinical implications of vertebra-depressed or femoral neck fractures.

A meta‑analysis to identify factors associated with CPAP machine purchasing in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disease and related to several cardiovascular diseases. Treatment with a continuous positive airway pressure (CPAP) machine is effective. However, not all patients with OSA purchase a CPAP machine for personal use. Previous studies showed different predictors of CPAP machine purchasing in patients with OSA. The present study aimed to summarize and identify predictors of CPAP purchasing using meta-analysis. The study was conducted using factors associated with CPAP purchasing in patients with OSA. The types of studies conducted in adult patients with OSA included: Randomized controlled trials, observational studies or descriptive studies comparing factors between those who purchased CPAP and those who did not. A total of five databases, including PubMed, Central database, Scopus, CINAHL Plus and Web of Science, were searched, and the final search was performed on February 8, 2021. Predictors for CPAP purchasing were determined. There were 598 articles from five databases, which met the inclusion criteria. After duplicated article removal, 390 articles were included in the screening process. There were 12 eligible articles for full text evaluation, and of those, eight studies met the study criteria with 1,605 patients from four countries. There were 11 variables that were available for a comparison between those who purchased the CPAP machine and those who did not, and six factors were different between the two groups: Age, years of education, income, smoking, Epworth Sleepiness Scale (ESS) score and apnea hypopnea index/respiratory disturbance index (AHI/RDI). The AHI/RDI was significantly different between the two groups, with the highest mean difference of 10.40 events/h (95% CI, 4.95-15.86). Patients who purchased CPAP were older (1.11 years), had more years of education (0.93 years), smoked more (1.15 pack/year), and had both higher ESS (0.61) and AHI/RDI (10.40) than those who did not purchase CPAP. Additionally, those who purchased CPAP had a 1.47 times higher income than those who did not. In conclusion, specific personal customer and clinical factors were related to the decision of CPAP purchase in patients with OSA.

The association of age with continuous positive airway pressure ventilation acceptance in an outpatient cohort of patients with obstructive sleep apnea

STUDY OBJECTIVES

This study examined the association between age and continuous positive airway pressure (CPAP) acceptance in a consecutive series of patients with obstructive sleep apnea being managed in a physician-led outpatient CPAP acclimatization program in Canberra, Australia.

METHODS

We performed a retrospective consecutive case series analysis of registry data collected from patients attending the Canberra Hospital PAP Acclimatization Clinic between 2011 and 2019. Data on patient demographics, diagnostic polysomnography results, CPAP device download parameters during acclimatization, and overall CPAP acceptance at the end of acclimatization were extracted from the Clinic Registry. Analysis of variance and chi-square were used to assess for associations between patient age, CPAP acceptance, and other clinical characteristics. Univariate and stepwise multiple logistic regression was used to identify predictors of CPAP acceptance.

RESULTS

We found that 1,075 consecutive CPAP trials among 1,043 patients were eligible for inclusion. CPAP acceptance was lower in those aged > 75 years compared with those aged ≤ 75 years (odds ratio: 0.57; 95% confidence interval, 0.36-0.92; P = .02). Patients aged > 75 years had lower body mass index, had higher initial and final visit 95th percentile mask leak, and were less likely to be CPAP naïve. Using univariate regression, younger age, severe obstructive sleep apnea, obesity, shorter trial duration, more clinic visits, higher initial visit CPAP usage, and lower final visit mask leak were predictors of CPAP acceptance. In a multiple logistic regression model, younger age, severe obstructive sleep apnea, shorter trial duration, more clinic visits, higher first visit usage, and lower final visit leak predicted acceptance.

CONCLUSIONS

Older age is associated with lower CPAP acceptance. The factors contributing to this association are unclear and require further investigation.

CITATION

Han M, Wee R, Shadbolt B, Huang H-CC. The association of age with continuous positive airway pressure ventilation acceptance in an outpatient cohort of patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(1):217-224.

Positive Airway Pressure Therapy Adherence with Mask Resupply: A Propensity-Matched Analysis

There are currently few data on the impact of mask resupply on longer-term adherence to positive airway pressure (PAP) therapy. This retrospective analysis investigated the effects of mask/mask cushion resupply on the adherence to PAP versus no resupply. Deidentified patient billing data for PAP supply items were merged with telemonitoring data from Cloud-connected AirSense 10/AirCurve 10 devices via AirView^TM (ResMed). Eligible patients started PAP between 1 July 2014 and 17 June 2016, had ≥360 days of PAP device data, and achieved initial U.S. Medicare adherence criteria. Patients who received a resupply of mask systems/cushions (resupply group) were propensity-score-matched with those not receiving any mask/cushion resupply (control group). A total of 100,370 patients were included. From days 91 to 360, the mean device usage was 5.6 and 4.5 h/night in the resupply and control groups, respectively (p < 0.0001). The proportion of patients with a mean device usage ≥4 h/night was significantly higher in the resupply group versus the control group (77% vs. 59%; p < 0.0001). The therapy termination rate was significantly lower in the resupply group versus the control group (14.7% vs. 31.9%; p < 0.0001); there was a trend toward lower therapy termination rates as the number of resupplies increased. The replacement of mask interface components was associated with better longer-term adherence to PAP therapy versus no resupply.

Persistent Obstructive Sleep Apnea Burden on Family Finances and Quality of Life

OBJECTIVE

We previously found that financial concerns negatively affect the quality of life of families of children with persistent obstructive sleep apnea (OSA) after tonsillectomy. The goal is to quantify the financial impact on families of children with persistent OSA and assess contributing factors.

STUDY DESIGN

Cross-sectional survey study with comparison group.

SETTING

Upper airway center at a tertiary pediatric hospital.

METHODS

Participants included consecutive children with persistent OSA from September to October 2017. Healthy children seen in a general otolaryngology clinic served as controls. Families of both groups completed the Family Impact Questionnaire and the modified Comprehensive Score for Financial Toxicity (COST).

RESULTS

Families of the 50 patients (25 study and 25 control) completed the surveys: the mean age was 6.4 years (95% CI, 5.0-7.8), and 19 (38%) were female. There were no differences in age, sex, race, or insurance status between groups (P > .05). The mean apnea-hypopnea index for the study group was 7.9 events/h (range, 5.5-10.3), and 40% (10/25) had Down syndrome. Positive airway pressure and/or oxygen were used by 72% (18/25). The Comprehensive Score for Financial Toxicity for study patients (21.9; 95% CI, 14.8-26.0) was significantly lower than for controls (30.2; 95% CI, 26.6-30.8; P = .003), reflecting elevated financial toxicity. Study families reported greater financial impact on the Family Impact Questionnaire (8.4; 95% CI, 6.1-10.7) versus controls (3.6; 95% CI, 1.8-5.4; P = .002); concerns regarding missed days of work and school were common (30.7%).

CONCLUSION

Families of children with persistent OSA reported a high financial burden related to their children's disease and were more likely to report financial toxicity than families of controls. Concern regarding missed work and school associated with appointments and treatment was a significant factor.

Characteristics of Obstructive Sleep Apnea Patients With Hypertension and Factors Associated With Autotitration Acceptance

In order to explore the characteristics and treatment status of obstructive sleep apnea (OSA) patients with hypertension, a retrospective study was conducted on 306 patients admitted from October 2018 to December 2019. According to the apnea hypopnea index (AHI), OSA patients with hypertension were divided into three groups. 69 cases were mild OSA (5 ≤ AHI < 15), 86 cases were moderate (15 ≤ AHI < 30), and 151 cases were severe (AHI ≥ 30). Compared with patients in the mild and moderate groups, the severe group had more male patients, with higher body mass index (BMI) and non-rapid eye movement stage 1 accounted for total sleep time (N1%), and lower non-rapid eye movement stage 2 accounted for total sleep time (N2%), average and minimum blood oxygen. Among all the patients, those who underwent the titration test accounted for 20.6% (63/306). Multivariate analysis showed that sleep efficiency (p < 0.001) and AHI (p < 0.001) were independent factors for patients to accept titration test. OSA patients with hypertension had a low acceptance of titration therapy. These people with higher sleep efficiency and AHI were more likely to receive autotitration.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

Cost-effectiveness of continuous positive airway pressure therapy for obstructive sleep apnea: health care system and societal perspectives

Study Objectives

To determine cost-effectiveness of continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA) in Australia for 2017–2018 to facilitate public health decision-making.

Methods

Analysis was undertaken of direct per-person costs of CPAP therapy (according to 5-year care pathways), health system and other costs of OSA and its comorbidities averted by CPAP treatment (5-year adherence rate 56.7%) and incremental benefit of therapy (in terms of disability-adjusted life years [DALYs] averted) to determine cost-effectiveness of CPAP. This was expressed as the incremental cost-effectiveness ratio (= dollars per DALY averted). Direct costs of CPAP were estimated from government reimbursements for services and advertised equipment costs. Costs averted were calculated from both the health care system perspective (health system costs only) and societal perspective (health system plus other financial costs including informal care, productivity losses, nonmedical accident costs, deadweight taxation and welfare losses). These estimates of costs (expressed in US dollars) and DALYs averted were based on our recent analyses of costs of untreated OSA.

Results

From the health care system perspective, estimated cost of CPAP therapy to treat OSA was $12 495 per DALY averted while from a societal perspective the effect was dominant (−$10 688 per DALY averted) meaning it costs more not to treat the problem than to treat it.

Conclusions

These estimates suggest substantial community investment in measures to more systematically identify and treat OSA is justified. Apart from potential health and well-being benefits, it is financially prudent to do so.

Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis

BACKGROUND

In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta₂-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government.

METHODS

We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure.

RESULTS

Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person.

CONCLUSIONS

Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.

Impact of purchasing the CPAP device on acceptance and long-term adherence: a Belgian model

RATIONALE

In Belgium, patients with moderate to severe OSA (AHI > 20) who show less than 30 micro-arousals per hour slept (MAI) cannot benefit from CPAP refund by the social security (SS).

OBJECTIVES

To assess the influence of reimbursement on CPAP acceptance, and long-term adherence.

METHODS

OSA patients (AHI > 20) were included regardless of MAI. All patients were offered a CPAP trial of 3-5 days for habituation. Two groups were defined and compared: «Out of pocket money» patients (OOP) with MAI < 30 that were invited to purchase their device and «reimbursed group» that were offered a CPAP reimbursed by the social security.

RESULTS

812 patients were found: 59 in the OOP group, mostly females, sleepier and using more hypnotics. Out of the reimbursed group, 183 patients were matched to the OOP patients on the grounds of age, AHI and BMI. 90% of OOP and 94% of reimbursed patients (p 0.379) accepted a CPAP trial; 74% of OOP and 90% of reimbursed patients acquired a CPAP device (p 0.005) thereafter, whereas 82% and, respectively, 84% of those (p 0.254) were still on CPAP after a mean follow-up of 711 and 604 days with a mean ± SD daily compliance of 5.3 ± 3 and 6.1 ± 2 h, respectively (p 0.159). Only fatigue scale seems to influence the purchase of CPAP by OOP patients.

CONCLUSION

CPAP reimbursement influences the purchase of CPAP but once the device becomes available there is no difference with reimbursed patients in long-term adherence.

Barriers to CPAP Use in India: An Exploratory Study

STUDY OBJECTIVES

To investigate adherence to continuous positive airway pressure (CPAP) therapy and identify barriers to CPAP use among patients with obstructive sleep apnea (OSA) in India.

METHODS

A self-devised semistructured questionnaire (which collected patients' demographic information, socioeconomic position, and information about disease status, symptoms, and complications) was administered to consecutive patients with moderate to severe OSA from June 2015 to August 2016. Patients were grouped according to CPAP device buying behavior (buyers versus nonbuyers) and CPAP compliance behavior (compliant versus noncompliant).

RESULTS

Out of 187 patients with moderate-severe OSA, 79 patients were enrolled for this study. The overall adherence rate (usage > 4 hours per night on > 70% nights) was 30.3%. Among the patients in the buyer group, adherence was 82.7%. Fifty patients did not buy a CPAP device; 30 of these 50 patients (60%) said financial constraints were the most important reason for not buying a CPAP device. Patients without financial constraints had higher chances-odds ratio (95% confidence interval) = 4.85 (1.6-16.1)-of buying a CPAP device than patients with financial constraints. Patients with more severe disease (ie, lower nadir oxygen saturation during sleep, higher apnea-hypopnea index, or presence of obesity hypoventilation syndrome) were more likely to buy and use a CPAP device.

CONCLUSIONS

The main cause of nonuse of CPAP in India is the inability to buy a CPAP device. In patients who are able to buy a CPAP device, adherence was significantly higher (82.7%) compared to adherence in the study's overall population (30.3%). Furthermore, patients with more severe OSA were more likely to buy a device and adhere to CPAP. Patients' behaviors and attitudes are also important barriers in using CPAP. There needs to be increased awareness of the benefits of CPAP therapy among patients.

Impact of Obstructive Sleep Apnea and Its Treatments on Partners: A Literature Review

STUDY OBJECTIVES

Many adults sleep with a significant other; thus, sleep disorder symptoms and treatments of one partner are likely to impact the other partner's health. A literature review was conducted to examine the impact of obstructive sleep apnea (OSA) and OSA treatments on partner-assessed sleep and daytime functioning and partner involvement in OSA treatment.

METHODS

MEDLINE, EMBASE, and CINAHL searches yielded 38 pertinent quantitative and qualitative studies that described sleep and/or daytime functioning assessed in partners of patients with untreated OSA, sleep and/or daytime functioning assessed in partners who were referred for OSA treatment, including continuous positive airway pressure (CPAP) therapy, oral appliance (OA), or surgery, and/or associations between partner involvement and OSA treatment use.

RESULTS

The majority of studies found untreated OSA to have a negative impact on partners' objective and subjective sleep and daytime functioning, in particular mood, quality of life, and relationship quality. Improvements in partner-assessed sleep quality were reported for CPAP, OA, and surgery. Conflicting results were reported for partners' mood, quality of life, daytime sleepiness, and relationship quality. Perceived partner support was associated with greater CPAP use.

CONCLUSIONS

Symptoms associated with OSA can negatively impact partners' sleep and daytime functioning. Treatment of OSA with CPAP, OA, or surgery can have health benefits for not only patients but also partners. Collaborative partner involvement may be a useful strategy for interventions promoting CPAP adherence.

Acceptance and Adherence to Continuous Positive Airway Pressure Therapy in patients with Obstructive Sleep Apnea (OSA) in a Southeast Asian privately funded healthcare system

BACKGROUND

There is limited data on long term Continuous Positive Airway Pressure (CPAP) adherence in Southeast Asian countries. This is a prospective study on CPAP adherence among Obstructive sleep apnea (OSA) patients in a Southeast Asian privately funded healthcare system.

METHODS

Patients with moderate-severe OSA who had been initiated on CPAP at least one year previously were contacted for a scripted telephone interview to assess compliance and factors associated with CPAP adherence.

RESULTS

Of 135 consecutive patients diagnosed to have moderate to severe OSA, 78 (57.8%) were initiated on CPAP treatment while 57 (42.2%) rejected CPAP upfront. 41 (52.6%) who initiated CPAP remained adherent at one year. OSA severity (AHI, ODI) and symptomatic improvement after CPAP were associated with better adherence. Presence of machine related side effects was associated with lower adherence. Inconvenience, cost and poor disease perception were reported as major barriers to uptake of CPAP therapy.

CONCLUSIONS

In this Southeast Asian privately funded healthcare system, almost half of all patients with significant OSA rejected CPAP treatment upfront, but adherence among those who started CPAP is comparable to other reports. Challenges with CPAP acceptance as well as CPAP adherence need to be addressed to improve outcomes.

The Effect of Patient Neighborhood Income Level on the Purchase of Continuous Positive Airway Pressure Treatment among Patients with Sleep Apnea

RATIONALE

The cost of continuous positive airway pressure (CPAP) treatment for patients with low socioeconomic status may be an important barrier to successful treatment of obstructive sleep apnea under a copayment health care system.

OBJECTIVES

We evaluated an association between patient neighborhood income level and the purchase of a CPAP device under a cost-sharing health care insurance system.

METHODS

All adults who underwent a first diagnostic sleep study at St. Michael's Hospital (Toronto, ON, Canada) between 2004 and 2010 were included. Severity of obstructive sleep apnea was determined by the apnea-hypopnea index (AHI) and level of daytime sleepiness (by the Epworth Sleepiness Scale). Patient data were linked to provincial health administrative data from 1991 to 2013 to determine the purchase of CPAP equipment, comorbidities, neighborhood income, and rural status at baseline. Neighborhood income was categorized into quintiles, ranked from poorest (Q1) to wealthiest (Q5). Assuming that the majority of participants with severe obstructive sleep apnea (AHI > 30 events/h) and excessive daytime sleepiness (Epworth Sleepiness Scale ≥ 10) would have been strongly recommended CPAP, we evaluated the association between patient neighborhood income and purchase of a CPAP device in this group via multivariable Cox regressions.

MEASUREMENTS AND MAIN RESULTS

Of the 695 participants with severe obstructive sleep apnea and excessive daytime sleepiness, 400 (58%) purchased a CPAP device. Patients who accepted CPAP were more likely to live in a higher-income neighborhood. Cumulative incidence of CPAP acceptance at 6 months was 43% for individuals in a low-income neighborhood (Q1) and 52% in combined higher-income neighborhoods (Q2-5) (P = 0.05). Controlling for sex and age, living in higher-income neighborhoods was associated with a 27% increased chance of accepting CPAP compared with the lowest-income neighborhood (hazard ratio Q2-5 vs. Q1, 1.27; 95% confidence interval, 0.98-1.64; P = 0.07).

CONCLUSIONS

Living in an unfavorable neighborhood is not an obstacle to CPAP treatment among symptomatic patients with severe obstructive sleep apnea under a copayment health care system. However, a potential 27% improvement in CPAP acceptance associated with higher neighborhood income is not inconsequential. Also, the overall CPAP acceptance rate was relatively low, suggesting that obstacles other than finances are primarily responsible.

Factors predicting CPAP adherence in obstructive sleep apnea syndrome

PURPOSE

Obstructive sleep apnea (OSA) is associated with a range of neurocognitive and cardiovascular complications, leading to a compromised quality of life. Continuous positive airway pressure (CPAP) is the gold standard therapeutic intervention for this disorder, yet patient compliance remains essential to its success. This study aimed at identifying the determinants of short-term and long-term CPAP adherence in a group of Lebanese patients.

METHODS

This cross-sectional study, conducted at the Sleep Center of Hôtel-Dieu de France hospital in Lebanon, included patients diagnosed with OSA and treated with CPAP for at least one night between June 2008 and January 2015. Adherence was assessed based on patients' self-report.

RESULTS

The study enrolled 138 patients. Adherence rate was 70.3 % at 6 months and around 50 % after 5 years. Cox models showed that use of nasal masks (HR 0.48, p = 0.048) and higher oxygen desaturation index at baseline (HR 0.98 p = 0.048) were associated with a better short-term CPAP adherence. Patients who bought their devices (HR 0.18, p < 0.001), those who were frequently contacted by the CPAP provider (HR 0.85, p 0.024), and those who reported improvement on treatment (HR 0.36, p < 0.001) were significantly more likely to remain adherent on the long term. Conversely, individuals on a diet plan tended to interrupt the treatment earlier (HR 4.85, p 0.039).

CONCLUSION

The present findings should be further explored in order to tailor interventions to the specific needs of different patient profiles and secure an improved CPAP adherence.

Characteristics and Trends in Hypnotics Consumption in the Largest Health Care System in Israel

Objectives. To quantify and characterize hypnotics consumption habits among adult patients insured by Clalit Health Services (CHS), the largest health care provider in Israel, in 2000 and 2010. Methods. A retrospective analysis of CHS computerized pharmacy records. Data were collected for all patients over the age of 18 years who were prescribed hypnotics in 2000 and in 2010. Results. Sleep medications were consumed by 8.7% of the adult CHS population in 2000 and by 9.6% in 2010. About one-quarter of consumers were treated for more than 6 months in both years. Multiple sleeping drugs were consumed more often in 2010 (45.2%) than a decade before (22%). While in 2000 benzodiazepines accounted for 84.5% of hypnotics, in 2010 this was reduced to 73.7% (p < 0.05). Of all patients treated for longer than 6 months only 11% in 2000 and 9% in 2010 required a dose escalation suggesting the absence of tolerance. Conclusions. Nine percent of the Israeli population consumes hypnotics. There is a major increase in prescription of combination of medications between 2000 and 2010, with an increase in Z class medications use and reduction in benzodiazepines. Most patients chronically treated did not escalate dosage, suggesting the absence of tolerance.

Pre- and in-therapy predictive score models of adult OSAS patients with poor adherence pattern on nCPAP therapy

OBJECTIVES

To identify patterns of adherence to nasal continuous positive airway pressure (nCPAP) use in the first 3 months of therapy among newly diagnosed adult patients with obstructive sleep apnea/hypopnea syndrome (OSAS) and their predictors. To develop pretherapy and in-therapy scores to predict adherence pattern.

METHODS

Newly diagnosed adult OSAS patients were consecutively recruited from March to August 2013. Baseline clinical information and measures such as Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Zung's Self-Rating Depression Scale (SDS), and The Pittsburgh Sleep Quality Index (PSQI) at baseline and at the end of 3rd-week therapy were collected. Twelve weeks' adherence data were collected from the nCPAP memory card, and K-means cluster analysis was used to explore adherence patterns. Predictive scores were developed from the coefficients of cumulative logit models of adherence patterns using variables available at baseline and after 3 weeks of therapy. Performance of the score was validated using 500 bootstrap resamples.

RESULTS

Seventy six patients completed a 12-week follow-up. Three patterns were revealed. Patients were identified as developing an adherence pattern that was poor (n=14, mean ± SD, 2.3±0.9 hours per night), moderate (n=19, 5.3±0.6 hours per night), or good (n=43, 6.8±0.3 hours per night). Cumulative logit regression models (good → moderate → poor) revealed independent baseline predictors to be ESS (per unit increase) (OR [95% CI], 0.763 [0.651, 0.893]), SDS (1.461 [1.238, 1.724]), and PSQI (2.261 [1.427, 3.584]); and 3-week therapy predictors to be ESS (0.554 [0.331, 0.926]), PSQI (2.548 [1.454, 4.465]), and the changes (3rd week-baseline data) in ESS (0.459 [0.243, 0.868]), FSS (3.556 [1.788, 7.070]), and PSQI (2.937 [1.273, 6.773]). Two predictive score formulas for poor adherence were developed. The area under the curve (AUC) of the receiver operating characteristics (ROC) curves for baseline and 3-week formulas were 0.989 and 0.999, respectively. Bootstrap analysis indicated positive predictive values of baseline and 3-week predictive scores in our patient population of 0.82 (95% CI [0.82, 0.83]) and 0.94 (95% CI [0.93, 0.94]), respectively.

CONCLUSION

A high level of prediction of poor adherence pattern is possible both before and at the first 3 weeks of therapy. The predictive scores should be further evaluated for external validity.

Comparison of cardiovascular co-morbidities and CPAP use in patients with positional and non-positional mild obstructive sleep apnea

BACKGROUND

This retrospective cohort study aimed to determine if there are differences in cardiovascular co-morbidities, blood pressure (BP) and continuous positive airway pressure (CPAP) use between patients with positional-dependent and nonpositional-dependent obstructive sleep apnea (OSA).

METHODS

Patients who were referred for overnight polysomnography for suspected OSA between 2007 and 2011 were screened. A total of 371 patients with OSA were included for analysis and divided into six groups according to positional-dependency and severity of OSA: positional mild (n = 52), positional moderate (n = 29), positional severe (n = 24), non-positional mild (n = 18), non-positional moderate (n = 70) and non-positional severe group (n = 178). The six groups were compared for anthropometric and polysomnographic variables, presence of cardiovascular co-morbidities, morning and evening BP and the changes between evening and morning BP, and CPAP device usage patterns.

RESULTS

Demographic and anthropometric variables showed non-positional severe OSA had poor sleep quality and higher morning blood pressures. Positional mild OSA had the lowest cardiovascular co-morbidities. Overall CPAP acceptance was 45.6%. Mild OSA patients had the lowest CPAP acceptance rate (10%), followed by moderate group (37.37%) and severe group (61.88%, P < 0.001). However, the significant difference in CPAP acceptance across OSA severity disappeared when the data was stratified by positional dependency.

CONCLUSIONS

This study found that positional mild OSA had less cardiovascular co-morbidities compared with subjects with positional severe OSA. Independent of posture, CPAP acceptance in patients with mild OSA was low, but CPAP compliance was similar in CPAP acceptors regardless of posture dependency of OSA. Since there are increasing evidences of greater cardiovascular risk for untreated mild OSA, improving CPAP acceptance among mild OSA patients may be clinically important regardless of posture dependency.

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.

Automatic detection of whole night snoring events using non-contact microphone

Objective

Although awareness of sleep disorders is increasing, limited information is available on whole night detection of snoring. Our study aimed to develop and validate a robust, high performance, and sensitive whole-night snore detector based on non-contact technology.

Design

Sounds during polysomnography (PSG) were recorded using a directional condenser microphone placed 1 m above the bed. An AdaBoost classifier was trained and validated on manually labeled snoring and non-snoring acoustic events.

Patients

Sixty-seven subjects (age 52.5±13.5 years, BMI 30.8±4.7 kg/m², m/f 40/27) referred for PSG for obstructive sleep apnea diagnoses were prospectively and consecutively recruited. Twenty-five subjects were used for the design study; the validation study was blindly performed on the remaining forty-two subjects.

Measurements and Results

To train the proposed sound detector, >76,600 acoustic episodes collected in the design study were manually classified by three scorers into snore and non-snore episodes (e.g., bedding noise, coughing, environmental). A feature selection process was applied to select the most discriminative features extracted from time and spectral domains. The average snore/non-snore detection rate (accuracy) for the design group was 98.4% based on a ten-fold cross-validation technique. When tested on the validation group, the average detection rate was 98.2% with sensitivity of 98.0% (snore as a snore) and specificity of 98.3% (noise as noise).

Conclusions

Audio-based features extracted from time and spectral domains can accurately discriminate between snore and non-snore acoustic events. This audio analysis approach enables detection and analysis of snoring sounds from a full night in order to produce quantified measures for objective follow-up of patients.

Management of obstructive sleep apnea in the indigent population: a deviation of standard of care?

Comprehensive management of patients with obstructive sleep apnea (OSA) typically is managed best via a multidisciplinary approach, involving otolaryngologists, sleep psychologists/psychiatrists, pulmonologists, neurologists, oral surgeons, and sleep trained dentists. By utilizing these resources, one could fashion a treatment individualized to the patient, giving rise to the holistic phrase of "personalized medicine." Unfortunately, in situations and environments with limited resources, the treatment options in an otolaryngologist's armamentarium are restricted--typically to continuous positive airway pressure (CPAP) versus sleep surgery. However, a recent patient encounter highlighted here shows how a hospital's reimbursement policy effectively dictated a patient's medical management to sleep surgery. This occurred although the current gold standard for the initial treatment of OSA is CPAP. Changing the course of medical/surgical management by selectively restricting funding is a cause of concern, especially when it promotes patients to choose a treatment option that is not considered the current standard of care.

The SomnuSeal Oral Mask Is Reasonably Tolerated by Otherwise CPAP Noncompliant Patients with OSA

Compliance with CPAP is the major limiting factor in treating patients with OSA. The novel SomnuSeal mask is an oral self-adaptable mask located between the teeth and the lips ensuring that there are no air leaks or skin abrasions. Fifty patients with AHI > 20, who failed previous CPAP trials, were asked to sleep with the mask for one month. In all patients, the mask was connected to an AutoPAP machine with a heated humidifier. Efficacy, convenience, and compliance (average usage for 4 or more hours per night) were monitored. Fifty patients (41 m and 9 f, mean age 57 ± 12 years, BMI 33.6 ± 4.9 kg/m(2), and AHI 47 ± 23/h) participated. Eleven were classified as compliant (average mask usage of 26 nights, 4.7 hours per night), five were only partially compliant (average usage of 13 nights, 2.9 hours per night), and 34 could not comply with it. In all patients who slept with it, the efficacy (assessed by residual AHI derived from the CPAP device) was good with an AHI of less than 8/hour. Interestingly, the required optimal pressure decreased from an average of 9.3 cmH2O to 4.6 cmH2O. The SomnuSeal oral interface is effective and may result in converting noncompliant untreated patients with OSA into well-treated ones.