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CPAP adherence linked to reduced readmissions

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Cost-effectiveness of CPAP adherence

The comorbidities associated with obstructive sleep apnea (OSA), such as heart failure, coronary artery disease, diabetes, and stroke, can be detrimental to patients’ care and commonly lead to hospitalization. Not only are these diseases interfering with successful treatment, but financial penalties linked to 30-day readmissions have economic implications for hospitals as well. Increasing CPAP adherence, therefore, may be a low-cost tool to improve hospital outcomes. Dr. Truong and her colleagues find compelling data showing the association of CPAP adherence and reduced 30-day readmissions. However, more work is needed before we can fully back the idea that CPAP adherence will prevent readmissions. While many studies have shown associations between OSA and cardiovascular events, there are no large, randomized trials that show the cardiovascular benefit of CPAP. The current theory is that patients who are adherent to CPAP are more likely to be healthier individuals, which makes them less likely to exhibit the comorbidities that would cause readmissions. A large randomized trial is the next logical step, and with OSA costs estimated at $2,000 annually per patient, it is a step worth pursuing.

Lucas M. Donovan, MD, is a pulmonologist at the University of Washington, Seattle. Martha E. Billings, MD, is an assistant professor in the division of pulmonary and critical care medicine at the University of Washington, Seattle. They reported no conflicts of interest.



Hospitalized patients with obstructive sleep apnea (OSA) who were nonadherent to continuous positive airway pressure (CPAP) treatment were more than three times as likely to be readmitted for complications, according to a study.

Since preventable causes of readmission like congestive heart failure, obstructive lung disease, and diabetes are connected to OSA, boosting adherence rates to sleep apnea treatment could be an effective way to mitigate these risks.

“Nonadherence to CPAP has been associated with increased chronic obstructive pulmonary disease (COPD) exacerbations, worsened insulin resistance, psychiatric illnesses, and lower urinary tract symptoms,” wrote Kimberly K. Truong, MD, MPH, an internist at the University of California, Irvine, and her fellow investigators in a study published in the Journal of Clinical Sleep Medicine. That OSA is not only common and linked with other help problems but also can be treated readily with CPAP “makes it an important clinical and public health disease to target.”

Investigators gathered data for 345 hospitalized patients with OSA who were admitted to the VA Long Beach (Calif.) Healthcare System between January 2007 and December 2015.

Both the adherent and nonadherent groups were mostly white males. The 183 adherent patients were, on average, slightly older than the patients in the nonadherent group (66.3 vs. 62.3 years), while the nonadherent group had a larger proportion of African Americans (19.1%) than did the adherent group (10.4%).

In an analysis of both groups, 28% of nonadherent patients were readmitted within 30 days of discharge, compared with 10.2% of those in the adherent group (P less than .001). Readmission rates were significantly higher for nonadherent patients brought in for all-causes (adjusted odds ratio, 3.52; P less than .001), as were their rates of cardiovascular-related readmission (AOR, 2.31; P = .02).

The cardiovascular-related readmissions were most often caused by atrial fibrillation (29%), myocardial ischemia (22.5%), and congestive heart failure (19.3%) in the group who were not using CPAP. In this same group, urologic problems (10.7%), infections (8.0%), and psychiatric issues (5.3%) were the most common causes for hospital readmissions.

Investigators were surprised to find that the rate of pulmonary-related readmissions was not higher among nonadherent patients, considering the shared characteristics of OSA and COPD.

While nonadherent patients had an adjusted rate of pulmonary-related readmissions of 3.66, the difference between nonadherent and adherent patients was not significant.

“Those with OSA and COPD are considered to have overlap syndrome and, without CPAP therapy, are at higher risk for COPD exacerbation requiring hospitalization, pulmonary hypertension, and mortality,” according to Dr. Truong and her colleagues. “However, the number of patients with pulmonary readmissions was very small, and analysis did not reach statistical or clinical significance.”

Given the single-center nature of the study, these findings have limited generalizability. The study may also have been underpowered to uncover certain differences between the two groups because of the small population size.

Investigators reported no relevant financial disclosures.

SOURCE: K. Truong et al. J Clin Sleep Med. 2018;14(2):183–9.

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