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Cai Y, Parekh MH, Rodin J, Tangutur A, Yu JL, Keenan BT, Schwartz AR, Dedhia RC. Differences in Positive Airway Pressure Requirements in Obstructive Sleep Apnea Between Black and White Patients. Otolaryngol Head Neck Surg 2024; 171:910-918. [PMID: 38881373 DOI: 10.1002/ohn.854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/08/2024] [Accepted: 05/23/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE There are disparities between Black and White patients in the utilization of positive airway pressure (PAP) alternatives for obstructive sleep apnea (OSA). Given low utilization rates among Black patients, there is limited knowledge of PAP alternative outcomes in this group. Therapeutic PAP levels are clinically accessible measures that have been shown to predict PAP alternative outcomes. Herein, we examined differences in PAP requirements between Black and White patients in a large clinical sample. STUDY DESIGN Cross-sectional. SETTING Academic sleep center. METHODS We included OSA patients prescribed autoadjusting PAP between January 2018 and 2020 with baseline apnea-hypopnea index (AHI) ≥ 10. Mean and 90th percentile PAP levels were compared between White and Black patients who used PAP for ≥1 hour daily using linear regression controlling for age, sex, body mass index (BMI), AHI, oxygen saturation nadir, and mask type. RESULTS There were 157 Black and 234 White patients who were generally obese (BMI, 37.3 ± 8.7) with severe OSA (AHI, 36.9 ± 25.6). Black patients had a 0.68 cm higher (95% confidence interval [CI]: 0.36, 1.35) mean PAP level and 0.85 cm H2O higher (95% CI: 0.36, 1.35) 90th percentile PAP level than white patients. Although statistically significant, differences were small and not clinically meaningful. CONCLUSION Black and White OSA patients had clinically insignificant differences in PAP requirements, suggesting comparable upper airway collapsibility. Considering the predictive value of therapeutic PAP levels, our findings suggest Black and White patients may have comparable PAP alternative responses from a collapsibility standpoint. Future studies should explore reasons for low utilization of PAP alternatives among Black patients.
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Affiliation(s)
- Yi Cai
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Manan H Parekh
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julianna Rodin
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akshay Tangutur
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason L Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Brendan T Keenan
- Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan R Schwartz
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raj C Dedhia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Robbins R, Yuan Y, Johnson DA, Long DL, Molano J, Kleindorfer D, Petrov ME, Howard VJ. Sleep Apnea and Incident Stroke in a National Cohort of Black and White Adults. Neurology 2024; 102:e209171. [PMID: 38447086 PMCID: PMC11383872 DOI: 10.1212/wnl.0000000000209171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/11/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Racial/ethnic differences have been documented in the relationship between obstructive sleep apnea (OSA) and stroke incidence, yet racial differences in OSA symptoms or treatment and their relationship with stroke incidence are underexplored and may contribute to stroke disparities. We comprehensively examined OSA symptoms and their relationships to stroke incidence by race/ethnicity. METHODS Data were collected from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a population-based cohort of Black and White individuals in the United States. Participants free from a stroke diagnosis at baseline were included. Participants self-reported the following: (1) snoring; (2) daytime sleepiness; (3) provider-diagnosed sleep apnea (PDSA); and (4) treatment for PDSA using positive airway pressure (PAP). OSA risk was categorized as high or low based on the Berlin Sleep Questionnaire. Incident stroke was defined as first occurrence of stroke over an average of 12 (SD 3.9) years of follow-up. We report the relationships between snoring, OSA risk, PDSA, PAP therapy use, and incident stroke by race/ethnicity using Cox proportional hazards models after adjusting for demographic and socioeconomic factors and stroke risk factors. RESULTS Among the 22,192 participants (mean age [SD] 64.2[9.1] years), 38.1% identified as Black. Overall, snoring was not associated with incident stroke (hazard ratio [HR] 0.98, 95% CI 0.85-1.13). However, among White individuals but not Black individuals, high OSA risk and PDSA were associated with incident stroke (HR 1.22, 95% CI 1.01-1.47; HR 1.33, 95% CI 1.04-1.70, respectively). PAP therapy use among those with PDSA (compared with non-PDSA) was associated with incident stroke in White individuals (HR 1.38, 95% CI 1.05-1.80). PAP therapy use among those with PDSA (compared with those with PDSA without PAP therapy use) was associated with reduced risk of incident stroke in Black (HR 0.39, 95% CI 0.17-0.91) but not White (HR 0.63, 95% CI 0.37-1.10) individuals. DISCUSSION White individuals with high OSA risk and those with PDSA with or without PAP therapy use were at increased incident stroke risk, whereas Black individuals reporting PDSA and PAP had reduced incident stroke risk relative to those not using PAP. Future research is needed to understand the mechanisms underlying racial differences in OSA and stroke such as differences in assessment modes and treatment.
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Affiliation(s)
- Rebecca Robbins
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - Ya Yuan
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - Dayna A Johnson
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - D Leann Long
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - Jennifer Molano
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - Dawn Kleindorfer
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - Megan E Petrov
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
| | - Virginia J Howard
- From the Division of Sleep and Circadian Disorders (R.R.), Departments of Medicine and Neurology and Division of Sleep Medicine (R.R.), Harvard Medical School, Boston, MA; Departments of Biostatistics (Y.Y., D.L.L.) and Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Epidemiology (D.A.J.), Rollins School of Public Health, Emory University, Atlanta, GA; Department of Neurology and Rehabilitation Medicine (J.M.), University of Cincinnati, OH; Department of Neurology (D.K.), University of Michigan Medical Center, Ann Arbor; and Edson College of Nursing and Health Innovation (M.E.P.), Arizona State University, Phoenix
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Hage S, Hagan M, Bi D, Stadnik A, Lee J, Romanos S, Srinath A, Shenkar R, Lee C, Horowitz PM, Girard R, Awad IA. Impact of socioeconomics and race on clinical follow-up and trial enrollment and adherence in cerebral cavernous malformation. J Stroke Cerebrovasc Dis 2023; 32:107167. [PMID: 37146402 PMCID: PMC10201538 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES Cerebral cavernous malformation (CCM) affects more than a million Americans but advanced care for symptomatic lesions and access to research studies is largely limited to referral academic centers MATERIALS AND METHODS: A cohort of CCM patients screened for research studies at an accredited center of excellence for CCM was analyzed. Demographics, lesion location, history of hemorrhage, insurance type and area of deprivation index (ADI) were collected. Primary outcomes were clinical follow-up within a year from initial evaluation, and enrollment and adherence in clinical trials among eligible subjects RESULTS: A majority (52.8%) of CCM patients evaluated had a high socioeconomic status (SES) (ADI 1-3), and only 11.5% were African American. Patients who had a symptomatic bleed were more likely to follow-up (p=0.01), and those with brainstem lesion were more likely to enroll/adhere in a clinical trial (p=0.02). Rates of clinical follow-up were similar across different ADI groups, insurance coverage and race. Patients who were uninsured/self-paying, and African Americans were more likely to decline/drop from clinical trials (OR 2.4, 95% CI 0.46-10.20 and OR 2.2, 95% CI 0.33-10.75, respectively), but differences were not statistically significant CONCLUSIONS: Access of disadvantaged patients to center of excellence care and research remains limited despite geographic proximity to their community. Patients with lower SES and African Americans are as likely to follow-up clinically, but there were trends of differences in enrollment/adherence in clinical trials. Mitigation efforts should target systemic causes of low access to specialized care among uninsured and African American patients.
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Affiliation(s)
- Stephanie Hage
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Matthew Hagan
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Dehua Bi
- Department of Public Health Sciences, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Justine Lee
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Robert Shenkar
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Cornelia Lee
- Alliance to Cure Cavernous Malformations, Charlottesville, Virginia, USA.
| | - Peleg M Horowitz
- Neurotrauma Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Issam A Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
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Rojanapairat O, Beggs A, Zeidler M, Prasad B. Race and Socioeconomic Status: Interlinked Drivers of Sleep Health Disparities. Health Equity 2023; 7:307-311. [PMID: 37284532 PMCID: PMC10240326 DOI: 10.1089/heq.2023.0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/08/2023] Open
Abstract
The effect of race and socioeconomic status on sleep disorders has significant effects on the availability of healthcare and health outcomes. This paper examines how race and SES contribute to sleep health disparities, emphasizing the importance of understanding their impact on sleep disorders and treatment particularly in minority populations and veterans.
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Affiliation(s)
- Oragun Rojanapairat
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Abigail Beggs
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare, Los Angeles, California, USA
| | - Michelle Zeidler
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare, Los Angeles, California, USA
| | - Bharati Prasad
- Department of Medicine, Jesse Brown VA Medical Center and the University of Illinois at Chicago, Chicago, Illinois, USA
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5
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Berg KA, Marbury M, Whaley MA, Perzynski AT, Patel SR, Thornton JD. Experiences with Continuous Positive Airway Pressure Among African American Patients and their Bed Partners. Behav Sleep Med 2023; 21:242-253. [PMID: 35583497 PMCID: PMC9672138 DOI: 10.1080/15402002.2022.2075365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
RATIONALE Despite having a higher prevalence and severity of obstructive sleep apnea (OSA), African Americans have lower adherence to continuous positive airway pressure (CPAP) compared to other groups. Information regarding challenges faced by African Americans prescribed CPAP are lacking. OBJECTIVES To determine the barriers and facilitators to optimal management of OSA with CPAP among African Americans and to understand the role bed partners may play. METHODS We conducted semi-structured in-depth interviews via video conferencing with African American patients of an urban safety-net health care system with OSA prescribed CPAP and their bed partners. Recruitment continued until theoretical saturation was achieved. Verbatim transcripts were analyzed using the principles of thematic analysis. RESULTS 15 patients (12 women) diagnosed with OSA and prescribed CPAP a mean 2.6 years prior along with 15 bed partners (3 women) were individually interviewed. Four themes emerged regarding impediments to CPAP use: 1) inadequate education and support, 2) CPAP maintenance and hygiene, 3) inconvenient design of CPAP interfaces, and 4) impediment to intimacy. Four themes emerged as facilitators to CPAP use: 1) provider and technical support, 2) properly fitted CPAP masks, 3) active support from partner and family, and 4) experiencing positive results from CPAP. CONCLUSIONS African American patients with OSA and their bed partners identified several unique barriers and facilitators to CPAP use. Active involvement by bed partners was considered by both patients and partners as helpful in improving CPAP adherence. Interventions to improve OSA outcomes in this population should focus on patients and their bed partners.
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Affiliation(s)
- Kristen A. Berg
- Center for Health Care Research and Policy, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
- Population Health Research Institute, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
| | - Marquisha Marbury
- Population Health Research Institute, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
- Center for Reducing Health Disparities, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
| | - Morgan A. Whaley
- Population Health Research Institute, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
- Center for Reducing Health Disparities, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
| | - Adam T. Perzynski
- Center for Health Care Research and Policy, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
- Population Health Research Institute, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
| | - Sanjay R. Patel
- Center for Sleep and Cardiovascular Outcomes Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - J. Daryl Thornton
- Population Health Research Institute, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
- Center for Reducing Health Disparities, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
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May AM, Patel SR, Yamauchi M, Verma TK, Weaver TE, Chai-Coetzer CL, Thornton JD, Ewart G, Showers T, Ayas NT, Parthasarathy S, Mehra R, Billings ME. Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement. Am J Respir Crit Care Med 2023; 207:244-254. [PMID: 36722719 PMCID: PMC9896653 DOI: 10.1164/rccm.202210-1846st] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.
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Obstructive Sleep Apnea in African Americans: A Literature Review. CURRENT PULMONOLOGY REPORTS 2023. [DOI: 10.1007/s13665-023-00300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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May AM, Billings ME. Racial Differences in Positive Airway Pressure Adherence in the Treatment of Sleep Apnea. Sleep Med Clin 2022; 17:543-550. [PMID: 36333073 PMCID: PMC10260288 DOI: 10.1016/j.jsmc.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although data are limited, studies suggest on average lower positive airway pressure use in Black, indigenous, and people of color (BIPOC) compared with Whites in most but not all studies. Most of these observational studies are certainly limited by confounding by socioeconomic status and other unmeasured factors that likely contribute to differences. The etiology of these observed disparities is likely multifactorial, due in part to financial limitations, differences in sleep opportunity, poor sleep quality due to environmental disruptions, and so forth. These disparities in sleep health are likely related to chronic inequities, including experiences of racism, neighborhood features, structural, and contextual factors. Dedicated studies focusing on understanding adherence in BIPOC are lacking. Further research is needed to understand determinants of PAP use in BIPOC subjects and identify feasible interventions to improve sleep health and reduce sleep apnea treatment disparities.
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Affiliation(s)
- Anna M May
- Research Section and Sleep Section, VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Martha E Billings
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington School of Medicine, UW Medicine Sleep Center, Harborview Medical Center, Box 359803, 325 Ninth Avenue, Seattle, WA 98104, USA
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Goosmann M, Williams AM, Springer K, Yaremchuk KL. The Impact of Marital Status and Race in Obstructive Sleep Apnea. EAR, NOSE & THROAT JOURNAL 2022:1455613221120068. [PMID: 35968832 DOI: 10.1177/01455613221120068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVES To examine the difference in survival of obstructive sleep apnea (OSA) based on marital status and race. METHODS A single academic institution with data collection from 2005 to 2015. Patients with a diagnosis of OSA based on polysomnogram were abstracted from electronic medical records. Patients were classified as "married" or "unmarried." Race was self-reported as White, Black, Asian American, Hispanic/Latinx, Middle Eastern descent, or unrecorded and gathered from the electronic medical record. RESULTS There were 6200 adults included. Of these, married patients composed 62.7% (n = 3890) of the patients. Patients were 51.3% White (n = 3182), 39.8% (n = 2467) were Black, and 8.9% (n = 551) were other/unrecorded. Married patients had better survival probabilities (p < .0001). Unmarried patients had 2.72 times the risk of death than those who were married (95% CI 1.78-4.20) when examining OSA survival. When examining survival of those on continuous positive airway pressure (CPAP) between married and unmarried patients, those who were unmarried had 2.00 (95% CI 1.58-2.54) times the risk of death than those who were married. Married Black patients demonstrated the best survival probabilities, followed by married White patients (p < .0001). Married patients had lower mean sleep efficiency than those that were unmarried (76.2% and 77.2%, respectively; p = .019). CONCLUSION Married patients with OSA had increased survival compared to their single counterparts. Married Black patients had the highest survival.
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Affiliation(s)
- Madeline Goosmann
- Department of Otolaryngology - Head & Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Amy M Williams
- Department of Otolaryngology - Head & Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Kylie Springer
- Department of Otolaryngology - Head & Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Kathleen L Yaremchuk
- Department of Otolaryngology - Head & Neck Surgery, Henry Ford Health System, Detroit, MI, USA
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Shaukat R, Gamal Y, Ali A, Mohamed S. Adherence to Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea. Cureus 2022; 14:e25946. [PMID: 35855223 PMCID: PMC9286015 DOI: 10.7759/cureus.25946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/27/2022] Open
Abstract
Adherence to either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy in patients with obstructive sleep apnea syndrome (OSAS) represents a real challenge to sleep medicine physicians. Many risk factors/predictors for nonadherence exist, and usually, it is multifactorial. Long-term nonadherence with CPAP therapy has been associated with the use of CPAP for <4 hours/night during early treatment, moderate to severe obstructive sleep apnea (OSA), poor self-efficacy, and unsupportive bed partner. The American Academy of Sleep Medicine (AASM) recommends follow-up of patients with OSA within the first two weeks of CPAP use to optimize adherence. Measures to improve adherence to positive airway pressure (PAP) therapy go through an integrated approach that involves behavioral therapy and prompt management of side effects. Pharmacologic therapy in the form of a sedative-hypnotic sleep aid has a minor role in managing nonadherence to CPAP based on the greater risk of side effects. This article will briefly discuss the risk factors and management of nonadherence to PAP therapy in patients with OSAS.
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Borker PV, Carmona E, Essien UR, Saeed GJ, Nouraie SM, Bakker JP, Stitt CJ, Aloia MS, Patel SR. Neighborhoods with Greater Prevalence of Minority Residents Have Lower Continuous Positive Airway Pressure Adherence. Am J Respir Crit Care Med 2021; 204:339-346. [PMID: 33689593 DOI: 10.1164/rccm.202009-3685oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Priya V Borker
- Center for Sleep and Cardiovascular Outcomes Research.,Division of Pulmonary Allergy and Critical Care Medicine
| | - Emely Carmona
- Center for Sleep and Cardiovascular Outcomes Research
| | - Utibe R Essien
- Center for Health Equity and Promotion, and.,Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | | | | | | | | | | | - Sanjay R Patel
- Center for Sleep and Cardiovascular Outcomes Research.,Division of Pulmonary Allergy and Critical Care Medicine
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12
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Billings ME, Thornton JD. The Legacy of Racial and Ethnic Segregation on Health: The Story of Continuous Positive Airway Pressure Use. Am J Respir Crit Care Med 2021; 204:252-254. [PMID: 33844933 PMCID: PMC8513586 DOI: 10.1164/rccm.202103-0649ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Martha E Billings
- Division of Pulmonary, Critical Care and Sleep Medicine University of Washington School of Medicine Seattle, Washington
| | - J Daryl Thornton
- Center for Reducing Health Disparities and.,Division of Pulmonary, Critical Care, and Sleep Medicine MetroHealth Campus of Case Western Reserve University Cleveland, Ohio
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13
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Billings ME. Regional differences in PAP care: more questions than answers. J Clin Sleep Med 2021; 17:363-364. [PMID: 33416049 DOI: 10.5664/jcsm.9106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Martha E Billings
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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14
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Dunietz GL, Yu Y, Levine RS, Conceicao AS, Burke JF, Chervin RD, Braley TJ. Obstructive sleep apnea in older adults: geographic disparities in PAP treatment and adherence. J Clin Sleep Med 2021; 17:421-427. [PMID: 33094720 DOI: 10.5664/jcsm.8914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is prevalent among older adults. Although treatment with positive airway pressure (PAP) lowers subsequent morbidity, PAP adherence is inconsistent. Socioeconomic disparities have been observed in OSA treatment, but regional differences in OSA care are unknown. This study examined geographic variations in PAP treatment and adherence among older Americans. METHODS This study utilized a representative 5% sample of all Medicare fee-for-service beneficiaries aged 65+ years. An OSA diagnosis, treatment, and PAP adherence were confirmed with International Classification of Diseases, Ninth Revision, HCPCS (Health Care Common Procedure Coding System) codes, and ≥2 HCPCS claims for PAP supplies respectively. Descriptive statistics were used to examine proportions of Medicare beneficiaries who obtained and adhered to PAP. Maps described the proportion of treated and adherent beneficiaries by state and hospital referral region. RESULTS For state-level data, PAP treatment and adherence proportions among beneficiaries with an OSA diagnosis ranged between 54-87% and 59-81%, respectively. Proportions of treated patients were higher in Midwest states (>80%), in comparison to Northwest, Northeast, and Southern states (<73%). Southern states and California had lowest proportions of PAP adherence (<70%). Within-state variability in treatment patterns were apparent along the East and West coasts. Correlations of PAP treatment and adherence proportions were low in Washington, DC, New York, and New Jersey. Discordant treatment and adherence proportions were observed in Alabama and Mississippi. CONCLUSIONS Significant state-level and regional disparities of PAP treatment and adherence among Medicare beneficiaries with OSA suggest gaps in delivery of OSA care for older Americans.
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Affiliation(s)
- Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Yue Yu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Rivkah S Levine
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Alan S Conceicao
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Ronald D Chervin
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Tiffany J Braley
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
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15
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Martin JL, Carlson G, Kelly M, Fung CH, Song Y, Mitchell MN, Zeidler MR, Josephson KR, Badr MS, Zhu R, Alessi CA, Washington DL, Yano EM. Sleep apnea in women veterans: results of a national survey of VA health care users. J Clin Sleep Med 2021; 17:555-565. [PMID: 33124975 PMCID: PMC7927345 DOI: 10.5664/jcsm.8956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population. METHODS A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities. RESULTS Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy. CONCLUSIONS Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.
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Affiliation(s)
- Jennifer L. Martin
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Gwendolyn Carlson
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Monica Kelly
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Constance H. Fung
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yeonsu Song
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael N. Mitchell
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michelle R. Zeidler
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Karen R. Josephson
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - M. Safwan Badr
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Ruoyan Zhu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Cathy A. Alessi
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Donna L. Washington
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M. Yano
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, California
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