A recent study from the Cleveland Clinic highlights what sleep physicians to often turn a blind eye to. We do a terrible job for patients who refuse or cannot tolerate CPAP. Obstructive sleep apnea is an incredibly important public health concern. Untreated sleep apnea increases population risk for overall mortality, cardiovascular health, decreases quality of life, increases risks for motor vehicle accidents, job absenteeism and contributes to rising costs of healthcare.
This study from the Cleveland clinic is powerful because with the breadth of its EMR and institutional scope, the sleep program was able to achieve a high rate of follow up. The adherence rate for patients who accept CPAP and follow up regularly was 70%, an extremely high rate that they should justifiably be proud of and that very few institutions consistently track and report. Given this statistic, it is then even more remarkable that nearly half of those initially diagnosed in the study did not have documented adherence. Interestingly, authors counted any attempt at utilization of CPAP as evidence of patient adherence. Even using these liberal criteria for adherence, of the 241 untreated patient
s only 35% were even referred for further attempts at management of diagnosed OSA.
The Good and Bad News
I would first of all like to applaud the authors of this study for highlighting what is a national issue. As sleep physicians, we have a treatment option in CPAP that we know cures sleep apnea in those patients that use it. We congratulate ourselves when patients do well – but unfortunately, we turn a blind eye to the “other half” that we know have a significant medical problem, but remain untreated. It’s time for sleep physicians to wake up.
Sleep physicians often fail to take patients preferences into account and ignore the patients that do not tolerate the only option for treatment offered. Not every patient can or should be forced to tolerate CPAP. Recent AASM/AADSM guidelines on Continuous Open Airway Therapy (COAT) for OSA reviews the large body of evidence for this treatment option, and confirms the efficacy of COAT for the treatment of obstructive sleep apnea.
COAT – An Alternative Treatment Option for CPAP
A number of peer-reviewed studies now confirm that patients prefer and tolerate this treatment option when clinically appropriate. Recent studies confirm important positive health outcomes that are equivalent to CPAP. Also, with the introduction of compliance monitoring, we now have the capability of monitoring objective treatment adherence.
Patients with obstructive sleep apnea who struggle with CPAP should feel empowered to ask their physicians for reasonable effective alternative treatment options. CPAP works well but is not the only option. Sleep physicians have a responsibility to treat ALL their patients taking their preference into account and not just the half who can comply with CPAP.
Referral Patterns and Positive Airway Pressure Adherence upon Diagnosis of Obstructive Sleep Apnea : Jonathon O. Russell, MD1, Jordan Gales1, Charles Bae, MD1, and Alan Kominsky, MD1
Otolaryngol Head Neck Surg. 2015 Jul 24.
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Dr. Jagdeep Bijwadia is the Chief Medical Officer at SomnoMed. He has an active Sleep and Pulmonary practice at the HealthPartners Medical Group in Saint Paul, MN and is an Assistant Professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Minnesota. He served as Department Head for the Pulmonary and Sleep group and Director of Sleep Medicine at HealthPartners Medical Group from 2006 to 2013, and was Director of the Sleep Program at the University of Minnesota from the 2006 to 2012.
He completed residency in Internal Medicine at Nassau University Medical Center, NY and fellowship training in Pulmonary and Critical Care at University of Southern California. Board certified in Sleep Medicine since 2000, he is a faculty member in the Sleep fellowship program at the University of MN, actively participating in both teaching and research. Dr. Bijwadia has a strong background and experience as a physician leader and is a certified Health Insurance Executive through the Kellogg School of business and the American Health Insurance Plan, and is currently completing an executive MBA at the University of St Thomas in Minneapolis. He is also President Elect of the Minnesota Sleep Society.