Referral Patterns and Positive Airway Pressure Adherence upon Diagnosis of Obstructive Sleep Apnea

Abstract

To our knowledge, this is the first study to define the subsequent management of patients who have failed or refused PAP. Despite the known sequelae of OSA, clinicians are not treating a significant percentage of patients with diagnosed OSA. Those who fail to tolerate PAP therapy are unlikely to be referred for additional treatment. Therapies other than PAP may be warranted in this population.

Impact of an oral appliance on obstructive sleep apnea severity, quality of life, and biomarkers

“…It is not uncommon to see patients, even those with severe obstructive sleep apnea syndrome and symptoms, who reject any treatment for various reasons, including low disease severity perception, the opinion that being connected to a medical device is unacceptable, self‐esteem in terms of their relationship with a partner, patient impression that sleepiness is due to overwork, early awakening or shift work, invasive nature of the treatment (surgery), and the economic cost of OAs. In a recent publication, nearly half (46%) of all patients with diagnosed OSA were not being actively treated for this condition. The groups were matched by age, sex, body mass index (BMI), and AHI.…”

Untreated Sleep Apnea: An Analysis of Administrative Data to Identify Risk Factors for Early Nonadherence

“…Prior studies have shown that perceived benefit of therapy, 20,45,46 perceived self-efficacy, 20,47 patient education, 48 and structure in the home 46 are important predictors of discontinuation of PAP therapy. Another limitation is that the nonadherence rate measured in this study is limited to patients whose provider prescribed and submitted sleep preauthorization; the patients whose providers did not order a test or therapy knowing that the patient would not use PAP 20,22 were not included, so missed opportunities for OSA treatment benefit may have been underestimated. An additional limitation is that the study assumes that testing and treatment are appropriate after it is prescribed by the practitioner and preauthorized by the sleep management program; it does not take into account shared decision-making processes (or lack thereof) with the patient, particularly in more mild cases of OSA, or other valid reasons for patients not to proceed with testing and treatment.…”

“…Among those in whom OSA has been diagnosed, 46% to 55% either refuse PAP therapy outright or do not adhere to treatment. 21,22 In late 2013, an internal report within a large commercial health insurer revealed a substantial gap between the number of preauthorizations for sleep services (sleep apnea testing and PAP treatment initiation) and the actual number of services for which a billing claim was submitted. That is, patients did not undergo diagnostic testing or initiate treatment even though the service had been prescribed by a physician and approved by the insurer as clinically appropriate.…”

“…Prior research exploring reasons for patient nonadherence to PAP therapy has largely focused on barriers to persistence with long-term therapy among patients who initiated treatment but subsequently discontinued. These prior studies assessed patient-equipment interaction barriers, behavior-related issues, [21][22][23][24] and many other factors affecting continuation of longterm therapy. However, the mismatch between approved and performed diagnostic testing and the noninitiation of approved PAP therapy have not been addressed in the literature.…”

A New Metric for Precision Medicine: PAP and Hypoglossal Neurostimulation

“…For many patients, a diagnosis of obstructive sleep apnea (OSA) results in a single treatment option of positive airway pressure (PAP) therapy, but PAP is not always accepted and long-term adherence to PAP is not achieved by a substantial percentage of patients. 1 The PAP-or-none approach has been gradually replaced by personalized treatment that includes oral appliances, modern upper airway surgery, positioning devices, weight loss, and-most recently-implantable hypoglossal neurostimulation (HGNS). To help match treatment modalities to patients, various phenotypes and endotypes such as loop gain, arousal threshold and anatomic burden have been identified but application of these measures is hampered by methodological complexity.…”