Positive airway pressure (PAP) usage and health care resource utilization have a dose-response relationship: health care utilization decreases with increasing PAP use of up to 8 hours per night, according to study findings published in the Annals of the American Thoracic Society.
The effectiveness of positive airway pressure, the first-line treatment for OSA, is dependent upon the patient’s adherence to treatment. Investigators sought to examine the dose-response relationship between PAP usage and health care resource utilization in patients with OSA, and to determine the minimum device usage necessary for benefit. The primary endpoint was the number of all-cause hospitalizations and emergency room (ER) visits within 3, 12, and 24 months following PAP initiation; the primary predictor of interest was average hours per night of PAP use.
Investigators conducted a review of de-identified administrative medical/pharmacy claims data from more than 100 US health plans as well as individual patient PAP usage data collected from cloud-connected devices. The study included adults newly diagnosed with OSA (ie, within 60 days of a sleep test) between June 2014 and April 2018. All participants had claims data for at least 1 year before and 2 years after receiving PAP therapy using an AirSense 10 device (manufactured by ResMed Corp., which sponsored the current study). The number of all-cause hospitalizations and ER visits across 3, 12, and 24 months following PAP initiation formed the basis for assessing health care resource utilization.
A total of 179,188 patients were included in the final analysis (average age, 52.5 years; 40.5% women; 51.5% obese). Participants’ most common comorbidities included hypertension (57.2%), type 2 diabetes (22.6%), and depression (15.7%). The researchers calculated health care utilization in the year before PAP initiation as the mean number of hospitalizations (0.11 per patient) and mean number of ER visits (0.53 per patient). Notably, resource utilization in the year prior to PAP use was a major significant predictor of increased events after PAP initiation. Other significant predictors of hospitalizations and ER visits were female sex, Medicaid insurance, older age, and presence of comorbidities.
Investigators found that the proportion of patients with less than 1 hour per night PAP usage increased as follow-up time increased. Usage of 3 to 7 hours per night was most common across all follow-up time periods. The researchers found that not more than 5% of patients in any follow-up time period had at least 8 hours/night usage.
The researchers identified a dose-response relationship between daily PAP usage and health care utilization, with health care utilization decreasing with increasing nightly PAP usage up to 8 hours/night, across all follow-up time periods. Notably, patients who used PAP for 8 or more hours per night had an increase in event rates, though below the event rate for those with less than 1 hour/night PAP usage. At least 1 to 3 hours usage/night was required for benefit.
Increased PAP usage (ie, usage levels above 1 hour and less than 8 hours per night) correlated with a significantly decreased rate of hospitalizations and ER visits across all follow-up time periods (all P <.0001). Hospitalizations were decreased by an additional 5% to 10% and ER visits were decreased by an additional 5% to 7% with each additional hour/night of PAP usage.
After risk-adjustment, minimum hours of PAP usage to derive significant benefit was 3 to 4 hours/night for all outcomes and time periods. There was also a statistically significant relationship between increased PAP usage and decreased 12-month health care utilization after adjusting for medication adherence.
Review limitations include a lack of information on underlying disease severity; lack of a control group; and the lack of Medicare fee-for-service study participants.
“These data provide compelling evidence for a dose-response relationship between
positive airway pressure usage and healthcare utilization, with benefits seen even when usage is as low as 1-2 h/night,” the study authors concluded. “These data could help inform evidence-based guidelines for PAP usage and reimbursement until more definitive data are available.”
Disclosure: This research was supported by ResMed, which was also involved in the design and implementation of the study. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Malhotra A, Sterling KL, Cistulli PA, et al.; medXcloud group. Dose-response relationship between obstructive sleep apnea therapy adherence and healthcare utilization. Ann Am Thorac Soc. Published online February 3, 2023. doi:10.1513/AnnalsATS.202208-738OC