Obstructive sleep apnea in older adults: geographic disparities in PAP treatment and adherence

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.

Regional differences in PAP care: more questions than answers

“…They identified, in preliminary analysis, differences in 90-day adherence by HRR, with higher levels of adherence in the central Midwest and lower levels in urban northeastern and southwestern regions. In this large general population of patients with OSA, the regions with higher adherence to PAP were similar to those found by Dunietz et al 4 among Medicare beneficiaries aged ≥ 65 years. This finding suggests that health care system features, in addition to provider and patient factors, contribute to PAP adherence.…”

“…7 HRRs with lower per capita spending are in the northwestern and central United States; regions with greater expenditures cluster in the Southeast and are not associated with better health outcomes. 8 Interestingly, these HRR patterns somewhat parallel PAP adherence patterns found by Dunietz et al, 4 with greater adherence in regions with lower Medicare spending.…”

“…It is notable that per Dunietz et al, 4 the HRR in the United States with the highest proportion of PAP treatment and adherence, in the central upper Midwest, serves a predominantly white population. In addition, the patient sample in their study was 89% white, a much greater fraction than the general CMS population aged ≥ 65 years, which is 75% white.…”

“…In this issue of the Journal of Clinical Sleep Medicine, Dunietz et al 4 examined the proportions of beneficiaries with an OSA diagnosis by International Classification of Diseases, Ninth Revision codes who obtained PAP treatment and supplies using CMS claims data by geography. Dunietz et al 4 evaluated patterns of PAP treatment and adherence by state and by hospital referral regions (HRRs) or health care markets. Among Medicare beneficiaries aged ≥ 65 years with an OSA diagnostic code (from a random sample of 5% of older adults enrolled in Medicare fee-for-service), rates of PAP treatment and adherence were highest in the Midwest.…”

“…Lowest rates of adherence were observed in the southwestern, mid-Atlantic, and southeastern HRRs. 4 Regional differences in care among Medicare recipients are well documented, with a generally greater utilization of care and costs in regions with a greater density of hospital-based specialists and fewer primary care providers. 5,6 Work by the Dartmouth Atlas Project has identified overuse of care in regions with greater Medicare spending and poorer-quality care by health metrics.…”