Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement

Abstract

Background Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions Modifications to the current policies for PAP insurance coverage could improve health disparities.

Positive Airway Pressure Therapy Predicts Lower Mortality and Major Adverse Cardiovascular Events Incidence in Medicare Beneficiaries with Obstructive Sleep Apnoea

“…Yet, our results demonstrate that those with low-income subsidy and dual Medicare/Medicaid eligibility have greater benefit of PAP against MACE. These results highlight opportunities to implement care programs designed to minimize health disparities, as recently proposed 75 . Our study also identified stronger effects of PAP initiation among those with comorbid conditions, particularly obesity and atrial fibrillation (for both mortality and MACE), as well as COPD, type 2 diabetes, and those with more comorbidities according to the CCI.…”

Performance of Claims-Based Algorithms for Adherence to Positive Airway Pressure Therapy in Commercially Insured Patients With OSA

“…In addition to different coverage policies, different patient populations can also impact performance of PAP adherence algorithms. Because adherence can impact access to care, this is an especially important consideration from a health equity perspective, 25 particularly because improvement in some outcomes may be seen with lower levels of PAP use. 26 For example, studies have demonstrated an association between lower socioeconomic status and reduced PAP adherence.…”

Investigating associations between social determinants, self-efficacy measurement of sleep apnea and CPAP adherence: the SEMSA study

“…OSA health literacy has been found to be lower in individuals with lower educational attainment and socioeconomic status ( 36 ). Socioeconomic disparities were acknowledged as contributing to sleep health disparities and CPAP adherence in a recent American Thoracic Society consensus document ( 37 ).…”