Centers for Medicare and Medicaid Services Positive Airway Pressure Adherence Criteria May Limit Treatment to Many Medicare Beneficiaries

A systematic review on adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in individuals with mild cognitive impairment and Alzheimer's disease dementia

Obstructive sleep apnoea (OSA) is highly prevalent in mild cognitive impairment (MCI) and Alzheimer's disease (AD). The gold standard treatment for OSA is continuous positive airway pressure (CPAP). Long-term, well-powered efficacy trials are required to understand whether CPAP could slow cognitive decline in individuals with MCI/AD, but its tolerability in this group remains uncertain. The present review investigates CPAP adherence among individuals with OSA and MCI/AD. Electronic searches were performed on 8 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Six independent studies and four secondary analyses included 278 unique participants (mean age = 72.1 years). In five of the retained studies, around half of participants (45% N = 85 MCI, 56% N = 22 AD) were adherent to CPAP, where ≥4 h use per night was considered adherent. Three of the retained studies also reported average CPAP use to range between 3.2 and 6.3 h/night. CPAP adherence in individuals with MCI and AD is low, albeit similar to the general elderly population. Reporting adherence in future studies as both average duration as well as using a binary cut-off would improve our understanding of the optimum CPAP use in dementia clinical trials and care.

CPAP resumption after a first termination and impact on all-cause mortality in France

BACKGROUND

Continuation of continuous positive airway pressure (CPAP) therapy after initial prescription has been shown to reduce all-cause mortality versus therapy termination. However, there is a lack of data on the rates and impact of resuming CPAP in patients with obstructive sleep apnoea (OSA). This analysis determined the prevalence of CPAP resumption in the year after termination, characterised determinants of CPAP resumption, and examined the impact of CPAP resumption on all-cause mortality.

METHODS

French national health insurance reimbursement system data for adults aged ≥18 years were used. CPAP prescription was identified by specific treatment codes. Patients who resumed CPAP after first therapy termination and continued to use CPAP for 1 year were matched with those who resumed CPAP then terminated therapy for a second time.

RESULTS

Out of 103 091 individuals with a first CPAP termination, 26% resumed CPAP over the next 12 months, and 65% of these were still using CPAP 1 year later. Significant predictors of CPAP continuation after resumption included male sex, hypertension and CPAP prescription by a pulmonologist. In the matched population, the risk of all-cause death was 38% lower in individuals who continued using CPAP after therapy resumption versus those who had a second therapy discontinuation (hazard ratio 0.62, 95% CI 0.48-0.79; p=0.0001).

CONCLUSION

These data suggest that individuals with OSA who fail initial therapy with CPAP should be offered a second trial with the device to ensure that effective therapy is not withheld from those who might benefit.

The effects of social support and support types on continuous positive airway pressure use after 1month of therapy among adults with obstructive sleep apnea

BACKGROUND

The relationship between perceived social support and continuous positive airway pressure remains understudied among individuals with obstructive sleep apnea. The aim of this prospective cohort study was to determine if baseline perceived social support and subtypes predict regular continuous positive airway pressure use after 1month of therapy.

METHODS

Adults with obstructive sleep apnea initiating continuous positive airway pressure therapy were recruited from sleep clinics in New York City. Demographics, medical history, and comorbidities were obtained from patient interview and review of medical records. Objective continuous positive airway pressure adherence data was collected at the first clinical follow-up.

RESULTS

Seventy-five participants (32% female; non-Hispanic Black 41%; mean age of 56 ± 14years) provided data. In adjusted analyses, poorer levels of overall social support, and subtypes including informational/emotional support, and positive social interactions were associated with lower continuous positive airway pressure use at 1month. Relative to patients reporting higher levels of support, participants endorsing lower levels of overall social support, positive social interaction and emotional/informational support had 1.6 hours (95% CI: 0.5,2.7, hours; p = .007), 1.3 hours (95% CI: 0.2,2.4; p = .026), and 1.2 hours (95% CI: 0.05,2.4; p = .041) lower mean daily continuous positive airway pressure use at 1month, respectively.

CONCLUSION

Focusing on social support overall and positive social interaction particularly, could be an effective approach to improve continuous positive airway pressure adherence in patients at risk of suboptimal adherence.

Fifteen Patients Who Can Be Helped by Medicare: Insurance Policy Changes in the Coverage of CPAP Therapy for Obstructive Sleep Apnea

Insurance coverage policies define the diagnostic criteria and adherence requirements for patients to qualify for initial and ongoing therapy with continuous positive airway pressure (CPAP) treatment, the most complete therapy for obstructive sleep apnea. Unfortunately, a number of patients who use CPAP and benefit from treatment fail to meet these requirements. We present 15 patients who fail to meet Centers for Medicare and Medicaid Services' (CMS) criteria, highlighting policies that do not support patient care. Finally, we review expert panel recommendations to improve CMS policies, and we suggest ways that physicians can better support CPAP access within the current regulatory restrictions.

Telehealth Technology Application in Enhancing Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea Patients: A Review of Current Evidence

Obstructive sleep apnea (OSA) is a common type of sleep-disordered breathing associated with multiple comorbidities. Continuous positive airway pressure (CPAP) is the first choice for moderate-severe OSA but poor compliance brings a great challenge to its effectiveness. Telehealth interventions ease the follow-up process and allow healthcare facilities to provide consistent care. Fifth-generation wireless transmission technology has also greatly rationalized the wide use of telemedicine. Herein, we review the efficacy of the telehealth system in enhancing CPAP adherence. We recommend applying telemonitoring in clinical practice and advocate the development of a biopsychosocial telemedicine model with the integration of several interventions. Big databases and promising artificial intelligent technologies make clinical decision support systems and predictive models based on these databases possible.

PAP therapy and readmission rates after in-hospital laboratory titration polysomnography in patients with hypoventilation

STUDY OBJECTIVES

Hypoventilation associated with sleep disordered breathing in inpatients is associated with higher risk of morbidity, hospitalizations and death. In-hospital titration polysomnography qualifies patients for positive airway pressure (PAP) therapy and optimizes settings, but impact is unknown. This study describes a process for in-hospital sleep testing and evaluates subsequent PAP adherence and readmission.

METHODS

A retrospective cohort of patients with hypoventilation and in-hospital titration polysomnography with available PAP data were analyzed to determine whether PAP adherence was associated with 90-day readmission. Absolute differences were obtained using logistic regression models. Models were adjusted for body mass index, age and Elixhauser Index. PAP adherence and nonadherence were defined as ≥ 4 and < 4 hours daily average use prior to readmission or first 90-days post-discharge.

RESULTS

81 patients, 50.6% male, age (mean ± SD) 61.1 ± 13.5 years were included. Comorbid sleep disorders included 91.4% with OSA and 23.5% with central sleep apnea. 28/52 (53.8%) nonadherent and 6/29 (20.7%) adherent patients had 90-day readmissions. 11 (13.6%) patients (all nonadherent) were readmitted within 2 weeks of discharge. Adjusted model showed a 35.6% (95% CI 15.9%-55.2%) reduction in 90-day readmission in adherent group compared to nonadherent (p=0.004). Similar reductions in readmission were found with adherence ≥ 50% and ≥ 70% days ≥ 4 hours. Male sex, treatment with iVAPS, and highest CO₂ ≥ 60 mmHg on polysomnography were associated with largest differences in readmission rates between adherent and nonadherent patients.

CONCLUSIONS

Adherence to optimized PAP therapy after in-hospital titration polysomnography in patients with hypoventilation may decrease readmissions.

Positive Airway Pressure Therapy for Pediatric Obstructive Sleep Apnea

Pediatric obstructive sleep apnea syndrome (OSAS) is a disorder of breathing during sleep, characterized by intermittent or prolonged upper airway obstruction that can disrupt normal ventilation and/or sleep patterns. It can affect an estimated 2–4% of children worldwide. Untreated OSAS can have far reaching consequences on a child’s health, including low mood and concentration as well as metabolic derangements and pulmonary vascular disease. Most children are treated with surgical intervention (e.g., first-line therapy, adenotonsillectomy); however, for those for whom surgery is not indicated or desired, or for those with postoperative residual OSAS, positive airway pressure (PAP) therapy is often employed. PAP therapy can be used to relieve upper airway obstruction as well as aid in ventilation. PAP therapy is effective in treatment of OSAS in children and adults, although with pediatric patients, additional considerations and limitations exist. Active management and care for various considerations important to pediatric patients with OSAS can allow PAP to be an effective and safe therapy in this population.

Neighborhoods with Greater Prevalence of Minority Residents Have Lower Continuous Positive Airway Pressure Adherence

Rationale: Limited data suggest racial disparities in continuous positive airway pressure (CPAP) adherence exist.Objectives: To assess whether CPAP adherence varies by neighborhood racial composition at a national scale.Methods: Telemonitoring data from a CPAP manufacturer database were used to assess adherence in adult patients initiating CPAP therapy between November 2015 and October 2018. Mapping ZIP code to ZIP code tabulation areas, age- and sex-adjusted CPAP adherence data at a neighborhood level was computed as a function of neighborhood racial composition. Secondary analyses adjusted for neighborhood education and poverty.Measurements and Main Results: Among 787,236 patients living in 26,180 ZIP code tabulation areas, the prevalence of CPAP adherence was 1.3% (95% confidence interval [CI], 1.0-1.6%) lower in neighborhoods with high (⩾25%) versus low (<1%) percentages of Black residents and 1.2% (95% CI, 0.9-1.5%) lower in neighborhoods with high versus low percentages of Hispanic residents (P < 0.001 for both), even after adjusting for neighborhood differences in poverty and education. Mean CPAP usage was similar across neighborhoods for the first 2 days, but by 90 days, differences in CPAP usage increased to 22 minutes (95% CI, 18-27 min) between neighborhoods with high versus low percentages of Black residents and 22 minutes (95% CI 17-27 min) between neighborhoods with high versus low percentages of Hispanic residents (P < 0.001 for both).Conclusions: CPAP adherence is lower in neighborhoods with greater proportions of Black and Hispanic residents, independent of education or poverty. These differences lead to a lower likelihood of meeting insurance coverage requirements for CPAP therapy, potentially exacerbating sleep health disparities.

Optimal Noninvasive Medicare Access Promotion: Patients with Obstructive Sleep Apnea A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society

This document summarizes the work of the CPAP and Bilevel PAP Therapy for Obstructive Sleep Apnea (OSA) Technical Expert Panel working group. For PAP therapy, the most pressing current coverage barriers identified were: an insufficient symptom list describing all potential symptoms in patients with mild OSA; the 4 hours/night of PAP usage requirement to keep the device; the additional sleep studies requirement to re-qualify for PAP or supplemental oxygen; the inability to use telehealth visits for followup visits. Critical evidence support changes to current policies and include: symptom list inadequate to cover all scenarios based on updated clinical practice guidelines; published evidence that 2 hours/night of PAP use can result in benefit to quality of life and other metrics; the costs of another sleep study not justified for all non-adherent patients or for supplemental oxygen due to other types of assessment currently available; and the remarkable success and acceptance of telehealth visits. In order to achieve optimal access for patients on PAP therapy, we make the following key suggestions: removing symptom criteria for mild OSA; reduce continued coverage criteria to > 2 hours/night; eliminate the need for a sleep study to re-qualify if non-adherent or for new CMS beneficiaries already on and adherent to PAP therapy; allow telehealth visits for documenting benefit and adherence; and allow PAP reports and domiciliary oximetry to qualify for supplemental oxygen with PAP if needed. This paper shares our best vision for bringing the right device to the right patient at the right time.

Effect of cloud-based sleep coaches on positive airway pressure adherence

STUDY OBJECTIVES

Decreased early positive airway pressure (PAP) adherence is predictive of poor long-term adherence. We hypothesized that cloud-based sleep coaches (CBSC) providing protocol-driven live telephone contact with patients starting treatment would improve early adherence.

METHODS

At PAP set-up patients were randomized to: (1) standard care (SC) including respiratory therapist PAP setup, wireless adherence monitoring, and elective use of a mobile adherence feedback application (PAPapp); or (2) SC+CBSC. Primary 3-month endpoints were adherence (all nights, nights used, % of nights ≥ 4 hours use, and % participants with ≥ 4 hours use on ≥ 70% of nights [% ≥ 4 ≥ 70%]) and secondary endpoints were change in Epworth sleepiness scale (ESS) and satisfaction with treatment and PAPapp use.

RESULTS

Two hundred fifty participants were randomized (SC 126, SC+CBSC 124). Characteristics SC versus SC+CBSC (mean ± SD) for age (55.2 ± 13.4 versus 54.9 ± 11.5 years), diagnostic apnea-hypopnea index (36.7 ± 21.1 versus 36.6 ± 20.6 events/h), and ESS (10.8 ± 6.1 versus 11.2 ± 6.0) did not differ. At 3 months, the % of days with ≥ 4 hours of PAP use (SC: 48.1 ± 36.8% versus SC+CBSC: 57.9 ± 35.4%, P = 0.032), use all nights (SC:3.7 ± 2.7 hours versus SC + CBSC: 4.4 ± 2.6 hours, P=0.027), and PAPapp use satisfaction were greater with SC+CBSC (intention to treat analysis). The [% ≥ 4 ≥ 70%] did not differ between groups in the intention to treat analysis but was higher in those completing CBSC interventions. The ESS improvement and patient satisfaction did not differ between groups.

CONCLUSIONS

The CBSC system improved PAP adherence at 3 months.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: ThErapy Adherence Management in Veterans; Identifier: NCT03243487; URL: https://clinicaltrials.gov/ct2/show/NCT03243487.

Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use.

METHODS

125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected.

RESULTS

Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05).

CONCLUSIONS

An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA.

TRIAL REGISTRATION

ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.

The impact of national health insurance on the compliance of positive airway pressure therapy in patients with obstructive sleep apnea

Objectives

Compliance with positive airway pressure (PAP) in patients with obstructive sleep apnea (OSA) directly affects its treatment efficacy. Since July 2018, polysomnography and PAP therapy have been covered by the national health insurance (NHI), which has reduced the price barrier and promoted PAP therapy in Korea. This study aimed to compare changes in PAP compliance before and after NHI implementation.

Methods

This study is a retrospective analysis in a tertiary hospital setting in Korea. From 2011 to 2019, patients with OSA (apnea-hypopnea index≥5) treated using a PAP device for ≥ 1 month were included. They were allocated to the pre-insurance (PI) (having started PAP before July 2018) and NHI groups (having received a PAP reimbursement by the NHI service). We collected and analyzed medical records and PAP use information for between-group comparisons of compliance. We defined compliance as (A) percentage of usage days, (B) percentage of days with usage for ≥ 4 night hours, and (C) average daily usage hours.

Results

We included 146 and 100 patients in the PI and NHI groups, respectively. Automatic positive airway pressure (APAP) mode and NHI were independent predictors of compliance B at the 3- and 9-month follow-up points. The NHI group showed significantly higher compliance A at 3, but not 9 months. For compliance B, the NHI group showed significantly higher compliance than the PI group at 1 month and 3 months, but not at 9 months. Compared with the PI group, the NHI group showed significantly higher compliance C only at 3 months.

Conclusion

The NHI has positively affected PAP therapy in patients with OSA. Insurance policy may affect compliance within the first 3 months.

Measuring Visceral Adipose Tissue Metabolic Activity in Sleep Apnea Utilizing Hybrid 18F-FDG PET/MRI: A Pilot Study

PURPOSE

Visceral adipose tissue (VAT) is proinflammatory and is associated with cardiovascular (CV) disease. We investigated the relationship between obstructive sleep apnea (OSA) and visceral adipose tissue (VAT) metabolic activity in a pilot group of patients using positron-emission tomography/magnetic resonance imaging (PET/MRI) with ¹⁸F-fluorodeoxyglucose (FDG) tracer as a novel marker of adipose tissue inflammation.

PATIENTS AND METHODS

We analyzed patients from an ongoing study, recruiting those with newly diagnosed, untreated OSA (Respiratory Disturbance Index [RDI] ≥ 5), using home sleep apnea testing (WatchPAT-200 Central-Plus). PET/MRI scans were acquired before continuous positive airway pressure (CPAP)-initiation, and after 3 months of CPAP therapy. Adipose tissue metabolic activity (¹⁸F-FDG-uptake) was measured using standardized uptake values (SUV) within the adipose tissue depots. The primary outcome was VAT SUVmean, and secondary outcomes included VAT volume, and subcutaneous adipose tissue (SAT) volume/SUVmean. Reproducibility and reliability of outcome measures were analyzed using intraclass correlation coefficients (ICC). Multivariable linear regression was used to evaluate the association between OSA and primary/secondary outcomes.

RESULTS

Our analytical sample (n = 16) was 81% male (mean age 47 ± 15 years, mean BMI of 29.9 ± 4.8kg/m²). About 56% had moderate to severe OSA (mean RDI 23 ± 6 events/hour), and 50% were adherent to CPAP. We demonstrated excellent inter/intra-rater reliability and reproducibility for the primary and secondary outcomes. Patients with moderate-to-severe OSA had a higher VAT SUV mean compared to those with mild OSA (0.795 ± 0.154 vs 0.602 ± 0.19, p = 0.04). OSA severity was positively associated with VAT SUVmean (primary outcome), adjusted for age and BMI (B [SE] = 0.013 ± 0.005, p = 0.03). Change in VAT volume was inversely correlated with CPAP adherence in unadjusted analysis (B [SE] = -48.4 ± 18.7, p = 0.02).

CONCLUSION

Derangements in VAT metabolic activity are implicated in adverse cardiometabolic outcomes and may be one of the key drivers of CV risk in OSA. Our results are hypothesis-generating, and suggest that VAT should be investigated in future studies using multi-modal imaging to understand its role as a potential mediator of adverse cardiometabolic risk in OSA.

Association of Positive Airway Pressure Use With Acute Care Utilization and Costs

STUDY OBJECTIVES

The current value-based medical climate has led to scrutiny of all medical costs. Given the relationship between obstructive sleep apnea (OSA) and many significant comorbid medical conditions, treating patients with OSA via positive airway pressure (PAP) therapy might reduce health care expenditures. Our goal was to determine the relationship between PAP use and acute care utilization and costs.

METHODS

This was a retrospective cohort study of adult patients who initiated PAP therapy after a diagnosis of moderate-severe OSA at a large integrated health system during 2014-2016.

RESULTS

The study consisted of 1,098 patients, of which 60% were on PAP > 4 h/night for ≥ 70% of the nights. The average h/night were 5.3 (standard deviation 2.4). Increasing PAP usage was associated with reduced inpatient (rate ratio [RR] 0.92, 95% confidence interval [CI] 0.86-0.98) and overall acute care visits (RR 0.96, 95% CI 0.92-0.99). The linear relationships were supported by the threshold effects identified in the categorical adherence measures. No linear association was identified with emergency department visits and inpatient stays. However, lower number of emergency department visits (RR 0.78, 95% CI 0.62-0.98) and inpatient stays (RR 0.56, 95% CI 0.35-0.91) were observed among adherent (> 4 h/night for ≥ 70% of the nights) patients.

CONCLUSIONS

PAP usage was linearly associated with reduced number of inpatient and overall acute care visits, and lower likelihood of having positive costs from these visits. PAP usage was also associated with less emergency department visits and inpatient stays when comparing adherent patients to less adherent patients.

CITATION

Kirsch DB, Yang H, Maslow AL, Stolzenbach M, McCall A. Association of positive airway pressure use with acute care utilization and costs. J Clin Sleep Med. 2019;15(9):1243-1250.