“…While we acknowledge that objective definitions of PAP adherence and efficacy are preferred to estimate exposure to PAP, telemonitoring data has only become available in recent years 80 . Prior studies have investigated similar PAP exposure definitions in a nationwide claims database in France 35,79 and within 5% Medicare beneficiaries samples in the U.S. [36][37][38]81 , and reported consistent results as with objective PAP adherence data 66,67 . From an epidemiologic perspective, state-wide claims databases cover a large proportion of the older adult demographic and offer a scalable approach to identify those likely to be exposed to PAP independently of vendor or telemonitoring capabilities, thus maximizing generalizability.…”
Section: Discussionmentioning
confidence: 59%
“…Studies exploring a 5% sample of randomly selected beneficiaries found that those with OSA had higher healthcare utilization when compared to matched controls 36 . Moreover, those adherent to CPAP based on Durable Medical Equipment (DME) claims were found to have reduced risk of stroke 37 and healthcare expenses among those with pre-existing CV diseases 38 . However, a major limitation is the reliance only on a sample of beneficiaries, which might represent challenges characterizing the effects of PAP on the incidence of individual CV diseases with accuracy.…”
Background: Obesity is associated with obstructive sleep apnoea (OSA) and cardiovascular risk. Positive airway pressure (PAP) is the first line treatment for OSA, but evidence on its beneficial effect on major adverse cardiovascular events (MACE) prevention is limited. Using claims data, the effects of PAP on mortality and incidence of MACE among Medicare beneficiaries with OSA were examined. Methods: A cohort of beneficiaries (>65 years) with ≥5 years of consecutive enrolment to Medicare and ≥2 distinct OSA claims was defined from multi-state, state-wide, multi-year (2011-2017) Medicare fee-for-service claims data. Evidence of PAP initiation and utilisation was based on PAP claims after OSA diagnosis. MACE was defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularisation. Doubly robust Cox proportional hazards models with inverse probability of treatment weights estimated treatment effects controlling for sociodemographic and clinical factors. Results: Among 225,132 beneficiaries with OSA (median age 74 years; 45.3% women; median follow-up 3 years), those with evidence of PAP initiation (50.1%) had significantly lower all-cause mortality (HR [95%CI]: 0.57 [0.56-0.59]) and MACE incidence risk (0.90 [0.88-0.92]). Higher quartiles of annual PAP claims were progressively associated with lower mortality (Q2: 0.80 [0.75-0.86], Q3: 0.68 [0.64-0.72], Q4: 0.65 [0.61-0.70]) and MACE incidence risk (Q2: 0.91 [0.86-0.97], Q3: 0.87 [0.82-0.91], Q4: 0.85 [0.80-0.90]). Conclusion: PAP utilisation was associated with lower all-cause mortality and MACE incidence among Medicare beneficiaries with OSA. Results might inform trials assessing the importance of OSA therapy towards minimising cardiovascular risk and mortality in older adults.
“…While we acknowledge that objective definitions of PAP adherence and efficacy are preferred to estimate exposure to PAP, telemonitoring data has only become available in recent years 80 . Prior studies have investigated similar PAP exposure definitions in a nationwide claims database in France 35,79 and within 5% Medicare beneficiaries samples in the U.S. [36][37][38]81 , and reported consistent results as with objective PAP adherence data 66,67 . From an epidemiologic perspective, state-wide claims databases cover a large proportion of the older adult demographic and offer a scalable approach to identify those likely to be exposed to PAP independently of vendor or telemonitoring capabilities, thus maximizing generalizability.…”
Section: Discussionmentioning
confidence: 59%
“…Studies exploring a 5% sample of randomly selected beneficiaries found that those with OSA had higher healthcare utilization when compared to matched controls 36 . Moreover, those adherent to CPAP based on Durable Medical Equipment (DME) claims were found to have reduced risk of stroke 37 and healthcare expenses among those with pre-existing CV diseases 38 . However, a major limitation is the reliance only on a sample of beneficiaries, which might represent challenges characterizing the effects of PAP on the incidence of individual CV diseases with accuracy.…”
Background: Obesity is associated with obstructive sleep apnoea (OSA) and cardiovascular risk. Positive airway pressure (PAP) is the first line treatment for OSA, but evidence on its beneficial effect on major adverse cardiovascular events (MACE) prevention is limited. Using claims data, the effects of PAP on mortality and incidence of MACE among Medicare beneficiaries with OSA were examined. Methods: A cohort of beneficiaries (>65 years) with ≥5 years of consecutive enrolment to Medicare and ≥2 distinct OSA claims was defined from multi-state, state-wide, multi-year (2011-2017) Medicare fee-for-service claims data. Evidence of PAP initiation and utilisation was based on PAP claims after OSA diagnosis. MACE was defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularisation. Doubly robust Cox proportional hazards models with inverse probability of treatment weights estimated treatment effects controlling for sociodemographic and clinical factors. Results: Among 225,132 beneficiaries with OSA (median age 74 years; 45.3% women; median follow-up 3 years), those with evidence of PAP initiation (50.1%) had significantly lower all-cause mortality (HR [95%CI]: 0.57 [0.56-0.59]) and MACE incidence risk (0.90 [0.88-0.92]). Higher quartiles of annual PAP claims were progressively associated with lower mortality (Q2: 0.80 [0.75-0.86], Q3: 0.68 [0.64-0.72], Q4: 0.65 [0.61-0.70]) and MACE incidence risk (Q2: 0.91 [0.86-0.97], Q3: 0.87 [0.82-0.91], Q4: 0.85 [0.80-0.90]). Conclusion: PAP utilisation was associated with lower all-cause mortality and MACE incidence among Medicare beneficiaries with OSA. Results might inform trials assessing the importance of OSA therapy towards minimising cardiovascular risk and mortality in older adults.
“…Similarly, a recent meta-analysis including 13 studies (nine RCTs and four observational studies) reported an efficacy of CPAP treatment in reducing the risk of stroke in patients with good adherence and patients with moderate to severe OSA [71 •]. This data was further confirmed by a retrospective cohort study conducted on 5757 Medicare beneficiaries aged ≥ 65 years that revealed that CPAP adherence was associated with a 2% reduction in risk of stroke for each month [72].…”
Section: Treatment Of Sleep Apnea In Stroke Patientsmentioning
Purpose of Review
To elucidate the interconnection between sleep and stroke.
Recent Findings
Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients.
Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke.
Summary
Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.
“…Patients diagnosed as having OSA (per ICD-10 diagnosis codes) in the 12 months after the identified PSG or HSAT were matched to a DME claims file (∼5% of sampled patients), representative of January 1, 2017, through December 31, 2018, to determine presence of CPAP claims (eg, CPAP device, supplies) using the Healthcare Common Procedure Coding System, similar to our previous work. 19 , 20 , 29 All codes used are reported in the Supplemental Table , available online at http://www.mayoclinicproceedings.org ). Figure 1 Flow diagram of participant selection.…”
Section: Methodsmentioning
confidence: 99%
“…Continuous positive airway pressure (CPAP), considered the gold standard treatment for OSA, prevents nocturnal hypoxemia and provides beneficial effects on various cardiometabolic outcomes, including blood pressure, 16 insulin sensitivity, 17 inflammation, 18 oxidative stress, 18 and vascular health. 18 In addition, we recently reported that older adults who adhere to CPAP treatment have reduced cardiovascular 19 and stroke 20 risk, which translates into reduced inpatient health care use among Medicare beneficiaries with comorbid OSA and CVD 21 and overall positive economic benefits among patients with OSA. 22 However, to date, there have been no studies investigating the impact of CPAP adherence on health care costs among patients with high-cost comorbidities (eg, combined OSA and CVD).…”
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