Adherence to sleep apnea treatment reduces health care use, costs in heart failure
Positive airway pressure-adherent patients with heart failure with preserved ejection fraction and obstructive sleep apnea had fewer health care visits, including ED and hospital visits, than nonadherent patients, according to a new industry-funded study.
Treating obstructive sleep apnea (OSA) in patients with heart failure with preserved ejection fraction (HFpEF) with positive airway pressure (PAP) therapy was associated with a reduction in health care resource use, a study found.
Researchers reviewed insurance claims data linked with PAP usage data recorded by devices manufactured by the study sponsor. One-year PAP adherence was based on a Medicare definition of at least four hours per night on 70% of the nights during 30 consecutive days in the first 90 days of therapy. Patients were classified as adherent (met criteria for four consecutive quarters within the first year), nonadherent (did not meet criteria in any of the four quarters), and intermediate adherent (met criteria in at least one but no more than three quarters). Results were published July 8 by the Journal of the American Heart Association.
The study cohort included 4,237 patients: 40% adherent, 30% intermediate adherent, and 30% nonadherent. Overall, 64.1% met criteria within the first 90 days of therapy. On average, adherent patients used the device on 6.6 days per week for 7.2 hours per use day. Patients with intermediate adherence used PAP an average of 3.8 days per week for 5.4 hours per use day, and nonadherent patients used PAP on 0.9 days per week for 2.9 hours per use day.
Significant predictors of adherence to PAP included age older than 55 years and comorbidities of cancer or morbid obesity. Significant predictors of not adhering to PAP included female sex, Medicaid or Medicare Advantage insurance compared with commercial insurance, comorbidities of hypertension or type 2 diabetes, and at least one ED visit in the year before therapy.
In the year before starting PAP, 61% of patients had an ED visit and 48% a hospitalization; after a year, those rates were 48% and 26%, respectively. Researchers propensity-score matched 963 adherent and 963 nonadherent patients and found that PAP-adherent patients had a 57% decrease in hospitalizations and a 36% decrease in ED visits versus the year before starting PAP. Total health care costs were lower in adherent patients than nonadherent patients ($12,732 vs. $15,610; P<0.001). Outcomes for intermediately adherent patients were most like those for nonadherent patients.
Numbers needed to treat (moving from nonadherent to adherent) were 0.8 to avoid a hospitalization or ED visit, 1.1 to avoid an ED visit, and 3.3 to avoid a hospitalization (P<0.001 for all). The number needed to treat to avoid a cardiovascular hospitalization was 14.9 (P<0.001).
The study authors said that the results emphasize the value of managing concomitant OSA in patients with HFpEF and the need for strategies to enhance PAP adherence in this population.
“The results of this study showed improved outcomes in patients with OSA and HFpEF who were adherent to PAP therapy during the first year after treatment initiation, with an overall reduction in health care resource use,” they wrote. “This highlights the importance of diagnosing and treating coexistent OSA in patients with HFpEF and gives credibility to the notion that OSA may have a causal role in the progression of HFpEF.”
An accompanying editorial praised the study as “the largest evaluation of the effect of CPAP therapy on HFpEF readmission and economic analysis yet to date” but called for more research “evaluating actual patients with consideration of different levels of adherence to CPAP” to confirm the results.