Obstructive Sleep Apnea Care Research Articles

Craniofacial Sleep Medicine: The Important Role of Dental Providers in Detecting and Treating Sleep Disordered Breathing in Children.

Obstructive sleep apnea (OSA) is a clinical disorder within the spectrum of sleep-related breathing disorders (SRDB) which is used to describe abnormal breathing during sleep resulting in gas exchange abnormalities and/or sleep disruption. OSA is a highly prevalent disorder with associated sequelae across multiple physical domains, overlapping with other chronic diseases, affecting development in children as well as increased health care utilization. More precise and personalized approaches are required to treat the complex constellation of symptoms with its associated comorbidities since not all children are cured by surgery (removal of the adenoids and tonsils). Given that dentists manage the teeth throughout the lifespan and have an important understanding of the anatomy and physiology involved with the airway from a dental perspective, it seems reasonable that better understanding and management from their field will give the opportunity to provide better integrated and optimized outcomes for children affected by OSA. With the emergence of therapies such as mandibular advancement devices and maxillary expansion, etc., dentists can be involved in providing care for OSA along with sleep medicine doctors. Furthermore, the evolving role of myofunctional therapy may also be indicated as adjunctive therapy in the management of children with OSA. The objective of this article is to discuss the important role of dentists and the collaborative approach between dentists, allied dental professionals such as myofunctional therapists, and sleep medicine specialists for identifying and managing children with OSA. Prevention and anticipatory guidance will also be addressed.

Holistic care for obstructive sleep apnea (OSA) with an emphasis on restoring nasal breathing: A review and perspective.

Obstructive sleep apnea (OSA) is characterized by partial or complete airway blockage during sleep. Nocturnal nasal obstruction usually leads to mouth breathing while sleeping, which worsens sleep apnea by aggravating tongue base and lateral pharyngeal wall collapse. The pathogenesis of OSA is multifactorial, and the precipitating factors vary significantly among individuals. Although continuous positive airway pressure (CPAP) is considered the first-line therapy for OSA, its adherence rate remains a challenge. Oral appliances are more suitable for simple snorers or patients with mild OSA. Maxillomandibular advancement (MMA) is highly effective for treating those with mandibular retrognathia and moderate-to-severe OSA. Intrapharyngeal surgeries yield favorable outcomes in patients with large tonsils and low tongue resting position (Friedman Stage I); however, their efficacy declines with time. Each therapy has its own strength and weakness; thus, the principle of multimodality treatment should be adopted. Nasal surgery plays an indispensable role in the holistic care for OSA. In addition to alleviating nasal congestion, nasal surgery significantly reduces snoring intensity and daytime sleepiness, which improves the quality of life of patients with OSA. Although it significantly reduces the respiratory disturbance index, its effect on the apnea-hypopnea index remains controversial. A combination of nasal surgery and multilevel pharyngeal surgery may result in better prognosis. Nasal surgery can significantly reduce the therapeutic pressure and improve the CPAP compliance of patients undergoing CPAP therapy. In conclusion, multimodality treatment and holistic care for OSA should involve nasal surgery for optimizing treatment outcomes.

0759 A real world study assessing patient satisfaction in the primary care setting in relation to excessive daytime sleepiness in participants with obstructive sleep apnea

Abstract Introduction Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA), despite positive airway pressure (PAP) therapy. These analyses evaluated EDS prevalence and its relationship with satisfaction with care in participants with OSA receiving OSA care in a primary care setting. Methods US residents (aged ≥18 years, self-reported physician OSA diagnosis [1/1/2015–3/31/2020]) completed a survey in Evidation Health’s Achievement app assessing Epworth Sleepiness Scale (ESS), specialties of healthcare providers (HCPs) treating OSA, PAP usage, and satisfaction with HCPs and overall OSA care. Self-reported PAP use was categorized: nonuse, nonadherent (<4 h/night, <5 d/wk), intermediate (4–6 h/night, ≥5 d/wk), or highly-adherent (≥6 h/night, ≥5 d/wk) (PAP-adherent=intermediate+highly-adherent groups). Linear modeling assessed the relationship between PAP use and ESS score; logistic regression assessed impacts of PAP adherence and EDS on satisfaction with care. P-values are uncontrolled for multiplicity. Results Participants (N=2289) were 50.3% female; 82.5% White; 44.8±11.1 years old (mean±SD); with BMI 35.4±8.7 kg/m2; 42.5% had EDS (ESS>10). OSA was primarily managed by sleep specialists (43.5%), general practitioners (GPs) (42.5% [28.9% saw a GP only; 13.6% saw a GP and a specialist/pulmonologist]), and/or pulmonologists (18.0%). Among participants with OSA managed by a GP only (n=662), proportions (95% CI) with EDS were: PAP nonuse (49% [42.8–54.9]), nonadherent (47% [31.5–63.2]), intermediate (47% [33.4–60.8]), and highly-adherent (35% [29.3–39.9]). Linear modeling (PAP users; n=398) showed an additional h/night of PAP use was associated with lower ESS scores (estimate [SE], –0.26 [0.13]; P<0.05); logistic regression showed association between PAP adherence and higher satisfaction with HCPs (adjOR=2.26; 95% CI=1.09–4.70; P<0.05) and OSA care (adjOR=1.58; 95% CI=0.75–3.36; P>0.05). There was an association between presence of EDS and lower satisfaction with their HCPs (adjOR=0.62; 95% CI=0.39–0.99; P<0.05) and OSA care (adjOR=0.49; 95% CI=0.31–0.79; P<0.05). Conclusion In a real-world population of participants with OSA receiving OSA care from GPs, EDS was common, even among highly-adherent PAP users. ESS scores were generally lower with increasing PAP adherence. PAP adherence was associated with increased satisfaction with their HCPs; EDS was associated with lower satisfaction with HCPs and overall OSA care. Support (If Any) Jazz Pharmaceuticals

0593 Maxillomandibular Advancement Referrals and Follow-up After Drug Induced Sleep Endoscopy

Abstract Introduction Several surgical options exist for treating obstructive sleep apnea (OSA), but few correct airway obstruction at multiple levels like maxillomandibular advancement (MMA). MMA has been shown to significantly improve OSA, decrease sleepiness, and also improve quality of life. Despite the accepted success of MMA surgery, it is unclear if patients referred for MMA undergo MMA or are lost to follow-up in real world clinical care. This quality improvement study aims to determine if patients referred for MMA by ENT sleep surgeons then undergo MMA surgery by oral maxillofacial surgeons (OMFS). Methods At our academic urban hospital, all drug induced sleep endoscopy (DISE) cases performed on OSA patients by two otolaryngology sleep surgeons were reviewed over a one year period. Patients who were not recommended for MMA based on DISE findings were excluded. Retrospective chart review included VOTE classification, DISE findings, and referrals for MMA to the OMFS clinic. Other data included age, BMI, past medical history, sleep study data including AHI and oxygen nadir, and if MMA or other OSA treatments were done. Results Out of 408 DISE performed, 58 patients (14.2%) were referred to our OMFS for MMA. Patients’ demographics were: male (48; 82.8%); average age: 51; average BMI: 32.5; 39 (67.2%) with comorbidities. Sleep studies included: 32 HSATs, 22 PSGs, 4 missing. 41 patients (75.9%) had severe OSA. Average O2 nadir was 75%. On DISE, most patients had some level of obstruction at all anatomic subsites (94.8%). All patients had complete obstruction at the level of the palate or velum. 41 (70.7%) also had additional anatomic abnormalities noted including maxillary constriction, midface hypoplasia, retrognathia or micrognathia. From 58 patients recommended for MMA, 35 (60.3%) followed up in OMFS clinic and 11 (31.4%) underwent MMA surgery. Five patients (14.3%) received OATs. 11 patients (19%) had CPAP re-evaluation. 27 patients (46.6%) were lost to follow-up. Conclusion Of patients referred by ENT to OMFS following DISE, only 60% were seen at OMFS clinic and only half of these patients underwent MMA. While some received other treatments, nearly half were lost to follow-up altogether. We propose a revised workflow to improve patient education, acceptance, and coordination of OSA care and follow-up. Support (If Any)

0760 Excessive daytime sleepiness, positive airway pressure, and patient satisfaction with multiple aspects of care in a real-world population with obstructive sleep apnea

Abstract Introduction Excessive daytime sleepiness (EDS) is common in patients with obstructive sleep apnea (OSA) and can persist despite use of positive airway pressure (PAP) therapy. These analyses assessed relationships between EDS, PAP use, and patient satisfaction across several aspects of OSA care in a real-world population with OSA. Methods US residents (aged ≥18 years, self-reported physician OSA diagnosis [1/1/2015–3/31/2020]) completed a survey in Evidation Health’s Achievement app assessing Epworth Sleepiness Scale (ESS), PAP usage, and satisfaction with care. Self-reported PAP use was categorized as nonuse, nonadherent (<4 h/night; <5 d/wk), intermediate (4–6 h/night, ≥5 d/wk), or highly adherent (≥6 h/night, ≥5 d/wk) (PAP-adherent=intermediate and highly adherent groups). Logistic regression models assessed impacts of PAP adherence and EDS on satisfaction with care across 7 domains. P-values are uncontrolled for multiplicity (nominal). Results Among all participants (N=2289; 50.3% female, 82.5% White, 44.8±11.1 years old [mean±SD], 35.4±8.7 kg/m2 body mass index [mean±SD]), 42.5% had EDS (ESS>10). PAP use was: nonuse (n=700), nonadherent (n=153), or adherent (n=1436; intermediate n=225, high n=1211). Within these subgroups, the proportions (95% CI) with EDS were: nonuse (47% [43.7–51.1]), nonadherent (52% [44.4–60.2]), intermediate (53% [46.4–59.4]), and highly adherent (36% [33.7–39.1]). Logistic regression (using data from PAP users) showed a positive association of PAP adherence with satisfaction with PAP (OR [95% CI]: 5.43 [3.73–7.90]); OSA treatment effectiveness (3.56 [2.48–5.12]); OSA symptom management (3.15 [2.17–4.57]); coordination of OSA care (2.60 [1.82–3.72]); and education from their healthcare provider on the impact of OSA on cardiovascular health (1.62 [1.13–2.35]), importance of using PAP (1.7 [1.15–2.52]), or availability of prescription drugs to treat OSA symptoms (1.55 [1.06–2.26]). The presence of EDS was associated with lower patient satisfaction in nearly all domains examined (ORs ranged from 0.44–0.62 across 6 of 7 domains). Conclusion EDS was common in this real-world population with OSA, even among participants who were highly adherent PAP users. PAP adherence was associated with higher patient satisfaction across all care domains; the presence of EDS was associated with lower patient satisfaction across 6 of 7 domains. Support (If Any) Jazz Pharmaceuticals

The impact of sleep events on weight gain following early adenotonsillectomy compared to supportive care for pediatric OSA

ObjectivesChildren with obstructive sleep apnea (OSA) who undergo adenotonsillectomy (AT) often experience post-operative weight gain, although the mechanism remains unclear. Our aim is to understand how changes in sleep events impact changes in weight in children with OSA following adenotonsillectomy compared to watchful waiting with supportive care. MethodsWe performed a secondary analysis of the Childhood adenotonsillectomy trial (CHAT) dataset in which children with OSA were randomized to undergo early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC). The primary outcome measures included changes in body mass index (BMI) percentile, apnea-hypopnea index (AHI) and arousal index (AI) during rapid eye movement (REM) sleep. The change in BMI percentile attributable to changes in AHI and AI during REM sleep was determined using causal mediation analysis. ResultsOf the 453 children with OSA randomized to eAT or WWSC, 397 children were included in the analysis. Children in the eAT arm experienced a greater increase in their weight as measured by BMI percentile, compared to children who received WWSC (WWSC 4.12 (2.70, 5.55) vs. eAT 6.62 (4.87, 8.38), Cohen's d = 0.22 (0.02, 0.42), p = 0.02). A significant proportion of the weight gain was attributable to decreases in apneic events (proportion mediated 19% (2–97%), p = 0.03) and arousals (proportion mediated 20% (5–78%), p = 0.01) during REM sleep. ConclusionA significant proportion of post-adenotonsillectomy weight gain in children with OSA is attributable to polysomnographic changes during REM sleep, potentially due to the mitigation of REM-related sleep fragmentation and subsequent reduction in metabolic expenditure.

Assessment, referral and management of obstructive sleep apnea by Australian general practitioners: a qualitative analysis

BackgroundThe high and increasing demand for obstructive sleep apnea (OSA) care has exceeded the capacity of specialist sleep services prompting consideration of whether general practitioners could have an enhanced role in service delivery. However, little is known about the current involvement, experiences and attitudes of Australian general practitioners towards OSA. The purpose of this study was to provide an in-depth analysis of Australian general practitioners’ experiences and opinions regarding their care of patients with OSA to inform the design and implementation of new general practice models of care.MethodsPurposive sampling was used to recruit participants with maximum variation in age, experience and location. Semi-structured interviews were conducted and were analysed using Thematic Analysis.ResultsThree major themes were identified: (1) General practitioners are important in recognising symptoms of OSA and facilitating a diagnosis by others; (2) Inequities in access to the assessment and management of OSA; and (3) General practitioners currently have a limited role in the management of OSA.ConclusionsWhen consulting with patients with symptoms of OSA, general practitioners see their primary responsibility as providing a referral for diagnosis by others. General practitioners working with patients in areas of greater need, such as rural/remote areas and those of socio-economic disadvantage, demonstrated interest in being more involved in OSA management. Inequities in access to assessment and management are potential drivers for change in future models of care for OSA in general practice.

A REAL-WORLD STUDY ASSESSING THE RELATIONSHIP BETWEEN POSITIVE AIRWAY PRESSURE TREATMENT, EXCESSIVE DAYTIME SLEEPINESS, AND PATIENT SATISFACTION IN OSA

TOPIC: Sleep Disorders TYPE: Original Investigations PURPOSE: Excessive daytime sleepiness (EDS) persists in some positive airway pressure (PAP)-treated patients with obstructive sleep apnea (OSA). This study examined prevalence and severity of EDS in a real-world population with OSA to understand how EDS, PAP adherence, and patient satisfaction with care relate. METHODS: US residents (aged ≥18 years, self-reported diagnosis of OSA [from 1/1/2015 to 3/31/2020]) completed a survey in Evidation Health’s Achievement app assessing the Epworth Sleepiness Scale (ESS), PAP usage, and satisfaction with healthcare providers (HCPs) and overall OSA care. Patients were categorized by self-reported PAP use (nonuse [no PAP use], nonadherent [<4 h/night or <5 d/wk], intermediate [4-6 h/night, ≥5 d/wk], or highly adherent [≥6 h/night, ≥5 d/wk]; PAP-adherent refers to the intermediate and highly adherent groups). ESS >10 defined EDS. A linear model assessed relationship between PAP use and ESS score; a logistic regression model assessed the impact of PAP use and EDS on satisfaction with HCPs and overall OSA care. P-values are uncontrolled for multiplicity (nominal). RESULTS: In total, 2289 participants completed the survey (50.3% female; 82.5% White; mean±standard deviation [SD] age, 44.8±11.1 years; body mass index, 35.4±8.7 kg/m2). PAP use was: nonuse (n=700), nonadherent (n=153), or adherent (n=1436; intermediate n=225, high n=1211). Overall, 42.5% had EDS (ESS>10); mean (95% confidence interval [CI]) ESS scores were 14.1 (13.9, 14.3) in those with EDS and 6.7 (6.5, 6.8) in those without. The proportion (95% CI) with EDS per group were: nonuse (47% [43.7, 51.1]), nonadherent (52% [44.4, 60.2]), intermediate (53% [46.4, 59.4]), and highly adherent (36% [33.7, 39.1]). In a linear model (PAP users; n=1589), an additional h/night of PAP use was associated with lower ESS scores (β=–0.28; 95% CI=–0.40, –0.16; P<0.001). Overall, 72% were satisfied with HCPs and 65% with OSA care. Logistic regression (PAP users; n=1589) identified a positive association between PAP adherence (nonadherence=0, adherence=1) and satisfaction with HCPs (adjusted odds ratio [adjOR]=2.37; 95% CI=1.64, 3.43; P<0.001) and satisfaction with overall OSA care (adjOR=2.91; 95% CI=2.03, 4.17; P<0.001). EDS was associated with lower satisfaction with HCPs (adjOR=0.62; 95% CI=0.48, 0.80; P<0.001) and overall OSA care (adjOR=0.50; 95% CI=0.39, 0.64; P<0.001). CONCLUSIONS: In this real-world study, ESS scores decreased as PAP use increased, but EDS remained highly prevalent even among highly adherent patients. Adherence was associated with greater patient satisfaction with HCPs and overall care, whereas persistent EDS was associated with lower patient satisfaction with HCPs and overall OSA care. CLINICAL IMPLICATIONS: Strategies to improve patient satisfaction with OSA care should focus equally on PAP adherence and monitoring and resolution of residual EDS. DISCLOSURES: Employee relationship with Jazz Pharmaceuticals Please note: 2018-present Added 04/30/2021 by James Doherty, source=Web Response, value=Salary Consultant relationship with Evidation Health Please note: 08/2020-Present Added 05/03/2021 by Levon Eldemir, source=Web Response, value=Consulting fee Consultant relationship with Jazz Pharmaceuticals Please note: 08/2020 - Present Added 04/30/2021 by Benjamin Fox, source=Web Response, value=Consulting fee Employee relationship with Jazz Pharmaceuticals Please note: 2014 - current Added 04/13/2021 by Danielle Hyman, source=Web Response, value=Salary Stock Holder relationship with Jazz Pharmaceuticals Please note: 2014 - current Added 04/13/2021 by Danielle Hyman, source=Web Response, value=Ownership interest No relevant relationships by Nell Marshall, source=Web Response Employee relationship with Jazz Pharmaceuticals Please note: May 2018 to Present Added 05/05/2021 by Susan Morris, source=Web Response, value=Salary Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Salary Removed 04/13/2021 by Gregory Parks, source=Web Response Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Salary Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Ownership interest Employee relationship with Jazz Pharmaceuticals Please note: current Added 04/26/2021 by Gregory Parks, source=Web Response, value=Salary Employee relationship with Jazz Pharmaceuticals Please note: current Added 04/26/2021 by Gregory Parks, source=Web Response, value=stock options Consultant relationship with Jazz Pharmaceuticals, Inc. 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Primary versus Specialist Care for Obstructive Sleep Apnea: A Systematic Review and Individual-Participant Data-Level Meta-Analysis.

Rationale: Primary care clinicians may be well placed to play a greater role in obstructive sleep apnea (OSA) management. Objectives: To evaluate the outcomes and cost-effectiveness of sleep apnea management in primary versus specialist care, using an individual-participant data meta-analysis to determine whether age, sex, severity of OSA, and daytime sleepiness impacted outcomes. Methods: Data sources were the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP, Scopus, ProQuest, U.S. National Institutes of Health Ongoing Trials Register, and ISRCTN registry (inception until 09-25-2019). Hand searching was undertaken. Two authors independently assessed articles and included trials that randomized adults with a suspected diagnosis of sleep apnea to primary versus specialist management within the same study and reported daytime sleepiness using the Epworth Sleepiness Scale (range 0-24; >10 indicates pathological sleepiness; minimum clinically important difference 2 units) at baseline and follow-up. Results: The primary analysis combined data from 970 (100%) participants (four trials). Risk of bias was assessed (Cochrane Tool). One-stage intention-to-treat analysis showed a slightly smaller decrease in daytime sleepiness (0.8; 0.2 to 1.4), but greater reduction in diastolic blood pressure in primary care (-1.9; -3.2 to -0.6 mm Hg), with similar findings in the per-protocol analysis. Primary care-based within-trial healthcare system costs per participant were lower (-$448.51 U.S.), and quality-adjusted life years and daytime sleepiness improvements were less expensive. Similar primary outcome results were obtained for subgroups in both management settings. Conclusions: Similar outcomes in primary care at a lower cost provide strong support for implementation of primary care-based management of sleep apnea.

Incremental health care utilization and expenditures for sleep disorders in the United States.

To determine the incremental increases in health care utilization and expenditures associated with sleep disorders. Adults with a diagnosis of a sleep disorder (International Classification of Diseases, 10th Revision, code G47.x) within the medical conditions file of the 2018 Medical Expenditure Panel Survey medical conditions file were identified. This dataset was then linked to the consolidated expenditures file and comparisons in health care utilization and expenditures were made between those with and without sleep disorders. Multivariate analyses, adjusted for demographics and comorbidities, were conducted for these comparisons. Overall, 5.6% ± 0.2% of the study population had been diagnosed with a sleep disorder, representing approximately 13.6 ± 0.6 million adults in the United States. Those with sleep disorders were more likely to be non-Hispanic, White, and female, with a higher proportion with public insurance and higher Charlson Comorbidity Scores. Adults with sleep disorders were found to have increased utilization of office visits (16.3 ± 0.8 vs 8.7 ± 0.3, P < .001), emergency room visits (0.52 ± 0.03 vs 0.37 ± 0.02, P < .001), and prescriptions (39.7 ± 1.2 vs 21.9 ± 0.4, P < .001) vs those without sleep disorders. The additional incremental health care expenses for those with sleep disorders were increased in all examined measures: total health care expense ($6,975 ± $800, P < .001), total office-based expenditures ($1,694 ± $277, P < .001), total prescription expenditures ($2,574 ± $364, P < .001), and total self-expenditures for prescriptions ($195 ± $32, P < .001). Sleep disorders are associated with significantly higher rates of health care utilization and expenditures. By using the conservative prevalence estimate found in this study, the overall incremental health care costs of sleep disorders in the United States represents approximately $94.9 billion. Huyett P, Bhattacharyya N. Incremental health care utilization and expenditures for sleep disorders in the United States. J Clin Sleep Med. 2021;17(10):1981-1986.

723 Sleep Apnea Care During the COVID-19 Pandemic: Perspectives on the Transition to Telemedicine from Clinicians and Patients

IntroductionCovid-19-related public health control measures have necessitated a rapid transition in healthcare delivery. We qualitatively explored clinicians’ and patients’ experiences of the pandemic’s impact on the delivery and receipt of obstructive sleep apnea (OSA) care.MethodsBetween September and December 2020, we conducted ten 90-minute virtual focus groups with sleep clinicians (n=19) and English and Spanish-speaking patients with OSA (n= 30) recruited through an urban academic sleep clinic, national organizations, social media, and snowball sampling. An interdisciplinary team conducted a rapid qualitative analysis that included prefigured and emergent domains. The team developed a comprehensive analytic matrix, identifying key themes within and between groups and triangulating them across participant types.ResultsClinicians and patients across all groups confirmed a rapid shift to the adoption of telemedicine. Clinicians reported telemedicine enhanced evaluations by enabling direct observation of the home environment, providing opportunities to guide patients on medical equipment used in the home, and cultivating meaningful social connections for patients. Perceived benefits varied across patient subgroups (age, language, technological self-efficacy). The majority of clinicians reported that telemedicine’s initial uptake resulted in delays in care and revenue loss, but sustained use was thought to be feasible over time. Patients reported delays in care related to the pandemic’s disruption on healthcare and their personal safety concerns. Additionally, telemedicine’s adoption directly altered other elements of care, including the delivery of patient education materials and loss of tacit information gained during the in-person visit. All groups reported adequate mask fitting as a central challenge for patients using positive airway pressure therapy. Spanish-speaking patients noted concerns of increased difficulty accessing care and navigating the OSA care system due to limited English proficiency, in addition to the limited availability of OSA resources in Spanish.ConclusionDuring the Covid-19 pandemic, the rapid adoption of telemedicine largely facilitated OSA care but altered patient-clinician interactions, delivery of patient education materials, and mask fitting success. Given that telemedicine will likely be sustained post-pandemic, there are needs for targeted efforts aimed at addressing disparities in telemedicine, enhancing practitioner telepresence and education, and new approaches for mask fitting to ensure successful OSA care.Support (if any)Patient-Centered Outcomes Research Institute EADI-16493

Impact of the sleep apnea management group clinic on positive airway pressure adherence.

BackgroundPositive airway pressure (PAP) adherence is critical for managing obstructive sleep apnea (OSA). We postulate that group-based Sleep Apnea Management (SAM) clinic, which harnesses the benefits of providing mutual support as well as facilitates access to system-based resources and education, will confer improvements in PAP adherence.MethodsData from SAM clinic attendees from January 2017 to June 2018 were retrospectively analyzed. Adherence data at SAM baseline visit and 1-3 months follow-up were collected. Average PAP usage from all-days and days used were analyzed along with demographics, co-morbidities, and Epworth Sleepiness Scale. Adherence was defined as >4 hours a night for ≥70% of nights over a 30-day period. Key structural elements of the SAM group clinic model were co-presence of the OSA care team members and peer group support. Key efficiency elements were group education and the prompt-to-patient multidisciplinary troubleshooting adherence barriers.ResultsOf 110 SAM clinic attendees, average age was 60.9±12.7 years, 53% were men, and 46% Caucasian. At baseline, the mean for average-all-days usage was 4.2 hours, mean average-days-used usage was 5.2 hours, and mean percentage-of-days usage ≥4 hours was 57%. At follow-up, the mean average-all-days usage increased 1.2 hours (p<0.001), mean average-days-used usage increased 0.8 hours (p<0.001), and the mean percentage-of-days with usage ≥4 hours increased 16% (p<0.001). At baseline, 46% of patients met criteria for adherence, which increased to 66% at follow-up.ConclusionIn this study, after the SAM clinic, all PAP adherence parameters improved significantly. This observational study serves as a proof of concept study for future trials pertaining to group clinic in managing PAP adherence in OSA.

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

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. 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. 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. 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.

Strategies to improve patient care for obstructive sleep apnea: a report from the American Academy of Sleep Medicine Sleep-Disordered Breathing Collaboration Summit.

In Chicago, Illinois, on Saturday, November 10, 2018, the American Academy of Sleep Medicine hosted 35 representatives from 14 medical societies, nurse practitioner associations and patient advocacy groups for a one-day Sleep-Disordered Breathing Collaboration Summit to discuss strategies to improve the diagnosis and treatment of obstructive sleep apnea. This report provides a brief synopsis of the meeting, identifies current challenges, and highlights potential opportunities for ongoing collaboration.

Surgical Algorithm for Obstructive Sleep Apnea: An Update.

Sleep surgery is part of a continuum of care for obstructive sleep apnea (OSA) that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as positive airway pressure or oral appliance therapy. The updated surgical algorithm in this review adds precision in three areas: patient selection, identification of previously unaddressed anatomic phenotypes with associated treatment modality, and improved techniques of previously established procedures. While the original Riley and Powell phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.

0357 CPAP Adherence is Lower in Minority Neighborhoods

Abstract Introduction The effectiveness of continuous positive airway pressure (CPAP) in treating obstructive sleep apnea (OSA) is limited by adherence. Small, single-center studies have reported CPAP adherence is lower in racial minorities suggesting disparities in OSA care. We used nationally representative data to assess racial differences in CPAP adherence at a neighborhood level. Methods Telemonitoring data were obtained from a therapy database maintained by a CPAP manufacturer. Usage over the first 90 days in patients initiated on CPAP between 11/01/2015 and 10/31/2018 who had at least one usage session, age 18-90 years, and valid U.S. zip code were mapped to a zip code tabulation area (ZCTA). Age- and sex-adjusted CPAP usage was calculated for each ZCTA with greater than 10 CPAP users. Ecologic analyses were performed to model the association of the proportion of blacks and Hispanics in each ZCTA (obtained from the 2013-2017 American Community Survey) on CPAP usage controlling for proportion of adults with bachelor’s degree and proportion of adults with household income below the poverty line. Results Our analysis included 13,118 ZCTAs averaging data over 737,274 patients. In adjusted analyses, each 10% increase in the proportion of blacks and Hispanics was associated with a 0.12 (95% CI 0.11-0.12) hour and 0.14 (95% CI 0.14-0.15) hour decrease in nightly CPAP use, respectively. Mean usage in ZCTAs with &amp;lt;1%, 1-2.5%, 2.5-10%, 10-25%, and 25-100% blacks were 4.96, 4.81, 4.67, 4.56, and 4.14 hours respectively (p&amp;lt;0.001). Mean usage in ZCTAs with &amp;lt;1%, 1-2.5%, 2.5-10%, 10-25%, and 25-100% Hispanics were 4.87, 4.86, 4.75, 4.50, and 4.10 hours respectively (p&amp;lt;0.001). Conclusion CPAP adherence is lower in neighborhoods with higher proportions of black and Hispanic residents independent of differences in education or poverty. These differences lead to lower likelihood of meeting insurance coverage requirements for CPAP therapy, potentially exacerbating sleep health disparities. Support Philips Respironics, NIH R25HL130600 and K24HL127307.

0624 Voice of the Patient: A Patient-Centered Exploration of Factors Influencing Obstructive Sleep Apnea Care

Abstract Introduction Despite widely available efficacious treatments for obstructive sleep apnea (OSA), patients commonly report frustration in accessing and adhering to treatments. Sparse research has explored factors influencing OSA care from the patient perspective, which may limit provision of patient-centered care: care responsive to patient preferences, needs, and values. To this end, we conducted qualitative research to identify factors, voiced by patients, that influence OSA treatment initiation and adherence. Methods We performed semi-structured interviews with 15 patients previously diagnosed with OSA from Boston, MA and a national patient portal (MyApnea.Org). Patients were asked about barriers and facilitators to their diagnosis and treatment as well as about their preferences and values that informed their treatment decisions. Interviews were audio-recorded and transcribed. A qualitative content analysis was performed to identify themes. After developing a codebook, interviews were coded. Codes were then audited and finalized by study team consensus. Results Our sample was aged 25-74 years; 71% identified as female. Among participants, 57.1% identified as White, 14.3% Black, 14.3% Asian, and 14.3% Other. Major themes were broadly classified as (1) facilitators (provision of useful information on treatment options, participation in shared decision-making, continued clinician support); (2) barriers (inconvenience of treatment, difficulty of habit formation, treatment side effects, competing comorbid conditions); (3) motivators (value of improving chronic health, family support, positive treatment effects); (4) contextual factors (insufficient knowledge/awareness of OSA, navigating healthcare systems, access to informational resources). Awareness of OSA symptoms and treatments, and ongoing support were cited as the most common factors influencing the patient experience. Conclusion This formative research highlights that diverse factors impact the OSA evaluation and treatment patient experience. Further research should test interventions that promote effective patient-centered care for OSA, such as shared decision-making tools. Support Brigham and Women’s Hospital Research Institute Patient-Centered Comparative Effectiveness Research Center Grant

Impact of a nurse-led limited risk factor modification program on arrhythmia outcomes in patients with atrial fibrillation undergoing catheter ablation.

We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF). We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation. Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM. Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m2 ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS). Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.

Transition to Adult Care for Obstructive Sleep Apnea.

Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include risk factors, such as obesity, male sex, and aging. More recently, there has been a precipitous increase in the prevalence of obstructive sleep apnea in youth. Drivers of this phenomenon include both increasing obesity and the survival of children with complex medical conditions into adulthood. Appropriate treatment and long-term management of obstructive sleep apnea is critical to ensure that these youth maintain well-being unfettered by secondary comorbidities. To this end, patient engagement and seamless transition of care from pediatric to adult health care systems is of paramount importance. To date, this is an unacknowledged and unmet need in most sleep programs. This article highlights the need for guideline-driven sleep disorder transition processes and illustrates the authors’ experience with the development of a program for sleep apnea.

Multidisciplinary care for obstructive sleep apnea in the age of “personalized” sleep medicine

Multidisciplinary care for obstructive sleep apnea in the age of “personalized” sleep medicine