CPAP funding impacts treatment choice, diagnosis method for obstructive sleep apnea
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More patients without continuous airway positive pressure coverage in their region said that cost affected their choice of treatment than patients with CPAP coverage, according to results published in Annals of the American Thoracic Society.
Further, in regions without funding for continuous airway positive pressure (CPAP), 69% of patients with obstructive sleep apnea received their diagnosis through a home test, according to researchers.
“A key finding from our study was that participants from regions without public CPAP funding weighed cost more heavily in deciding to pursue treatment and were less likely to report weight loss and exercise as part of their treatment plan,” Sachin R. Pendharkar, MD, MSc, associate professor of medicine and community health sciences at the University of Calgary, told Healio. “The latter may have been related to the finding that in these regions, physician follow-up was less common and more participants had follow-up through a private CPAP company. In spite of this model of care, the majority of participants across both groups indicated that they would prefer a physician manage and follow their OSA.”
In a survey study, Pendharkar and colleagues analyzed 600 online survey responses (median age, 59 years; interquartile range, 49-66; 57% men; 21% rural living) that represented every Canadian province and territory to understand how OSA diagnosis and treatment differs between jurisdictions that have government funding for CPAP and regions that do not.
Researchers sent a 52-question survey that asked about OSA diagnosis and treatment wait times, patient-borne costs and model of care delivery to adults with a physician diagnosis of OSA.
With the responses they received, researchers divided them according to if the patient’s province provided full or partial funding (n = 181) or no funding (n = 419) for CPAP to compare the results.
Diagnosis, treatment
Compared with those living in areas with CPAP funding, those living in areas without funding had a higher likelihood of receiving their OSA diagnosis through home sleep apnea testing rather than a laboratory polysomnography (20% vs. 69%; P = .00019).
During the first month of diagnosis, 44% of respondents reported that they were offered treatment, whereas 70% of respondents were offered treatment within 3 months of diagnosis.
Adjusting for demographics, disease characteristics and model of care, researchers observed comparable wait times and distance travelled for treatment between regions with and without funding, which was unexpected, Pendharkar told Healio.
“We expected that in regions without public funding for CPAP (many of which also have limited public funding for sleep testing), patients would experience greater barriers to access due to limited availability of resources,” Pendharkar said. “However, after adjustment for important factors, we found that distance travelled for care and wait times were similar.”
Based on survey responses, a greater number of patients living with CPAP funding reported receiving recommendations for lifestyle interventions along with their OSA treatment than those in regions without funding.
Of the total cohort, 70% used CPAP, 9% used a dental appliance and 12% did not use any therapy for treating OSA. Researchers reported that the use of therapy did not differ between the two region categories; however, more patients who lived where there was no CPAP funding reported that their treatment choice was influenced by cost (23% vs. 16%; P = .02). On the other hand, researchers found that those who lived where there was coverage reported fewer treatment options to choose from (17% vs. 11%; P = .02).
Costs, follow-up appointments
In terms of sleep diagnostic testing cost, a greater percentage of patients living in regions without funding reported paying for it through private insurance (16% vs. 12%; P = .0002) or out of pocket (8% vs. 4%; P = .0002) than patients living in regions with funding.
Sixty percent of those from regions without CPAP funding paid out of pocket for treatment, whereas only 48% of those with CPAP funding paid this way (P < .00001).
For treatment costs not covered by private insurance, researchers observed no differences in yearly patient-borne costs based on the funding status of the region, which was another surprising finding, according to Pendharkar.
CPAP funding was linked to more care involvement from sleep specialists (71% vs. 60%; P = .008), according to researchers.
Almost 70% of respondents reported long-term OSA follow-up, which was more frequently found in association with CPAP coverage, meanwhile 14% reported no follow-up, with slightly more of these respondents belonging to a region without coverage.
Further, follow-up at a private CPAP company was observed in more patients in regions without coverage (33% vs. 18%; P = .003).
“An important limitation of this study is that individuals who did not seek care for OSA due to medical, social or financial reasons were not surveyed; it is likely that many of these individuals experience barriers to care that are less commonly faced by those who obtain a diagnosis,” Pendharkar told Healio. “Future studies could include undiagnosed individuals at high risk of OSA to address this limitation. In the future, objective clinical data on each participant’s OSA, treatment and outcomes could be included as these factors may influence OSA care. Larger samples would also permit additional analyses that account for nuanced differences in care delivery between provinces, even among those with CPAP funding.”
Despite limitations, Pendharkar told Healio he hopes findings from this study bring attention to potential barriers in OSA care.
“We hope that our findings spark important conversations about improving access to OSA care regardless of province of residence, and hopefully motivate health care decision-makers to explore new models of care delivery and funding that will reduce the burden of OSA in Canada,” he told Healio.
This study by Pendharkar and colleagues shows that whether a region does or does not have funding for CPAP plays a role in OSA care and that more effort should be put into understanding who would benefit the most from CPAP coverage, according to an accompanying editorial by Kevin I. Duan, MD, MS, and Lucas M. Donovan, MD, MS, of the division of pulmonary, critical care and sleep medicine at University of Washington.
“The work by Chiu and colleagues begs the question: what is the right coverage policy for CPAP?” Duan and Donovan wrote. “Ideally, coverage decisions should be designed such that they incentivize patients and clinicians to pursue diagnostic and management approaches that are evidence based and patient centered. This is easier said than done.”
Duan and Donovan suggested a focus on enhancing value may be a possible approach.
“Rather than limiting care on the basis of patients’ ability to pay or their ability to spend the night in a sleep laboratory, we might consider prioritizing coverage on the basis of patients’ likelihood of benefiting from therapy,” they wrote. “For instance, we might consider prioritizing CPAP coverage among those with excessive daytime sleepiness, the indication with the strongest evidence of benefit from CPAP.”
For more information:
Sachin R. Pendharkar, MD, MSc, can be reached at sachin.pendharkar@ucalgary.ca.