Socioeconomic Inequities in Adherence to Positive Airway Pressure Therapy in Population-Level Analysis

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.

Disparities in Sleep Health and Potential Intervention Models

“…42 Once initiated on therapy, African-Americans and low SES groups have lower adherence with treatment. 43 The causes of this disparity are unclear, but potential reasons include poorer sleep health in general (shorter sleep duration, 44 more irregular patterns) that makes adherence more difficult and reduced quality of interactions with the health system because of implicit biases and medical mistrust. 45 The high-prevalence and yet underrecognized aspects of sleep apnea create a need for innovative models of care that embrace new technologies and leverage the realignment of traditional provider roles in an attempt to mitigate sleep health disparities in nonwhite and low SES populations.…”

Sleep Apnea and Fetal Growth Restriction (SAFER) study: protocol for a pragmatic randomised clinical trial of positive airway pressure as an antenatal therapy for fetal growth restriction in maternal obstructive sleep apnoea

“…Estimates of fetal weight were all based on the Hadlock formula using the standard biometric parameters (biparietal diameter, head circumference, abdominal circumference, femur length) [52,53]. 50 51 However, when converting fetal weight to a calculated percentile, this must reference a 'population or customized standard'. 52 As this is a pragmatic multicentre study, each study centre defines FGR and SGA by the population or customised standard used in their routine care (see table 1).…”

“…51 54 Adherence is generally higher for aPAP devices, as used in this study, when compared with CPAP devices. 51 Two recent large national database studies reported conflicting results regarding gender effects on PAP adherence-either lower in men 51 or lower in women, 54 although it is not known whether any of these women were pregnant in those studies. It is possible that pregnant women concerned about potentially optimising fetal and maternal outcomes would be more adherent to PAP.…”

The Legacy of Racial and Ethnic Segregation on Health: The Story of Continuous Positive Airway Pressure Use

“…PAP users living in the lowest median household income ZIP codes had significantly lower proportion reaching CMS criteria for PAP adherence than those living in the highest, at 40% vs. 47%, respectively. (11) Non-white communities are also more commonly affected by physical environmental features that are deleterious to sleep. Residents more frequently report insufficient sleep, delayed sleep onset, and poor sleep quality (3,12).…”