Abstract
(a) Background: In patients with sleep apnea, poor adherence to positive airway pressure (PAP) therapy has been associated with mortality. Regional studies have suggested that lower socioeconomic status is associated with worse PAP adherence but population-level data is lacking. (b) Methods: De-identified data from a nationally representative database of PAP devices was geo-linked to sociodemographic information. (c) Results: In 170,641 patients, those in the lowest quartile of median household income had lower PAP adherence (4.1 + 2.6 hrs/night; 39.6% adherent by Medicare criteria) than those in neighborhoods with highest quartile median household income (4.5 + 2.5 hrs/night; 47% adherent by Medicare criteria; p < 0.0001). In multivariate regression, individuals in neighborhoods with the highest income quartile were more adherent to PAP therapy than those in the lowest income quartile after adjusting for various confounders (adjusted Odds Ratio (adjOR) 1.18; 95% confidence interval (CI) 1.14, 1.21; p < 0.0001). Over the past decade, PAP adherence improved over time (adjOR 1.96; 95%CI 1.94, 2.01), but health inequities in PAP adherence remained even after the Affordable Care Act was passed. (d) Conclusion: In a nationally representative population, disparities in PAP adherence persist despite Medicaid expansion. Interventions aimed at promoting health equity in sleep apnea need to be undertaken.
Highlights
Obstructive sleep apnea (OSA) is a prevalent condition that is most frequently treated with positive airway pressure (PAP) therapy [1,2]
Non-adherence to PAP therapy has been noted in a high proportion of adults with OSA (46–83%) [3,4,5], and such poor adherence is associated with increased risk for fatal and non-fatal cardiovascular events [6,7]
The adherence data within the database contained the individual-level five-digit ZIP code data which was mapped to the U.S Census collected at the ZIP Code Tabulation Areas (ZCTA) (Figure 1)
Summary
Obstructive sleep apnea (OSA) is a prevalent condition that is most frequently treated with positive airway pressure (PAP) therapy [1,2]. Similar findings were observed in the analysis of Canadian health administrative data where individuals living in higher income neighborhoods had a 27% greater chance of accepting PAP therapy when compared to the lowest income neighborhood [9]. A better understanding of health inequities pertaining to PAP adherence in patients with sleep apnea at a national-level would better prepare us to consider such data for adjustment of performance of practices with baseline differences in the proportion of individuals with socioeconomic disadvantage. It is pertinent to note here that the Affordable Care Act (ACA) reduced Medicare payments to hospitals that had a greater DSH index and such a policy could potentially negate the benefits of broadening health insurance coverage to the lower SES populations through Medicaid expansion [21]. We proposed to explore the effect of ACA over the 17 years of data that was available in our database
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