The Impact of Socioeconomic Status on CPAP Adherence and Treatment Outcomes
Adherence to treatment has continued to be a problem for CPAP therapy, remaining at roughly 34 percent nationwide and causing its overall success rate to remain flat despite the proven effectiveness of CPAP devices in reducing or eliminating sleep apnea symptoms. As a result, studies have taken a closer look at treatment outcomes and the reasons for nonadherence, in many cases finding that social factors such as a patient’s socioeconomic status can have as much influence on sleep behaviors as individual attitudes or personality type. In particular, where a patient lives can have a significant effect on treatment outcomes, irrespective of the quality of care received. Economic hardship, as it turns out, has a direct affect on health, as it makes it more difficult to prioritize, leading to a circular pattern in which financial and health-related problems become counter-reinforcing. It is for this reason that healthcare providers focus a lot of attention on the first few weeks of therapy, a crucial transition period when patients are vulnerable to negative impressions, technical problems, or ambivalence. While using sleep equipment is a personal decision, it is the hope of providers that standardized follow-up support and better intervention strategies will lead to more positive therapy experiences and help patients recognize the extensive health benefits of long-term adherence.
What is Adherence?
While the terms adherence and compliance are often used interchangeably, adherence is meant to describe a more involved experience than mere compliance, which is simply following a doctor’s recommendations for a prescribed treatment. Adherence implies patient feedback, ongoing communication with a healthcare provider, and lifestyle changes to promote treatment effectiveness.
In regard to CPAP therapy, adherence and/or compliance is often defined specifically as using a device for at least 4 hours a night on 70 percent of the nights in a given period, for example, each week. Some may count this period as 21 of 30 consecutive days at any time within 90 days of titration.This definition, while widely used, is meant for clinical purposes as a measuring parameter only, and should not be considered optimal for all patients. There has been some debate over whether these minimums should be increased, especially for moderate to severe cases of sleep apnea, but even with the four-hour standard, doctors often recommend as many sleep hours as possible with CPAP in use. Since apnea events can occur at any time during sleep, it is generally safer to use CPAP as much as possible.
Socioeconomics and Adherence
Socioeconomic factors can affect treatment adherence in a number of ways, not only due to the cost of treatment but as an influence on patient values, beliefs, and lifestyles In fact, the cost of obtaining CPAP equipment is less of a factor than social influences such as location or support networks. Even after adjusting data for individual demographic characteristics, such as age or gender, the effects of low socioeconomic status remain consistent. Although studies have found some racial groups, such as African Americans, to be less likely to adhere in the long term, it can be difficult to distinguish minority race from socioeconomics in some communities. The effects of socioeconomic status on adherence, researchers believe, are as much of an influence on treatment outcomes as the existence of comorbid conditions. A large study published this year in the journal Sleep identifies lower socioeconomic status and comorbidities as independent risk factors for nonadherence. The study provides the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States, and is the largest study to date on predictors of CPAP adherence. And because the study focused on older patients eligible for Medicare, adherence rates were generally lower than previously reported in smaller, clinic-based studies, according to study lead Emerson M. Wickwire, Ph.D., of the Sleep Disorders Division of Pulmonary and Critical Care Medicine at the University of Maryland, and his colleagues.
In Dr. Wickwire’s study, nonadherent patients tended to be slightly younger (mean, 72.5 years vs. 79.2 years; P < .001) and had a higher number of some common comorbidities (35.2% vs. 30.4%; P = .002) compared with individuals with higher adherence. Those with lower adherence were also more likely to be eligible for Medicaid, considered an indicator of lower socioeconomic status. While these individuals had higher rates of some comorbidities such as anxiety, anemia, and traumatic brain injury, the strongest association was with socioeconomic factors, especially for long-term adherence. As with other studies of its kind, Dr. Wickwire’s findings have also shown that short-term adherence is an important indicator of long-term adherence. Whether early problems are technical, personal, or social in nature, they often escalate or reemerge over time if not dealt with immediately.
Dr. Wickwire and his colleagues concluded that a clinician’s job is not only to diagnose and initiate treatment, but also to identify and address reasons for nonadherence, including socioeconomic factors. The team also acknowledged the need for more research in this area, particularly for at-risk individuals.Right now, during an ongoing pandemic, it has become even more important to remain adherent to treatment but even more difficult to stay financially stable, which makes the job of clinicians more difficult as well.
While the benefits of CPAP are well documented, it only works if patients can maintain adherence for prolonged periods. Despite new and more efficient CPAP models, more comfortable, adaptable masks with reduced pressure loss, and extensive public education campaigns to better inform the general population about the dangers of sleep apnea, many patients still show ambivalence toward cpap treatment. These studies show that now, more than ever, we should be doing what we can to promote public health as a number-one priority. Those who live in poor, low education, and low employment neighborhoods struggle more with CPAP adherence than patients from more affluent neighborhoods. To reverse this trend, we not only need clinical support, but also need social support, family support, and support from the patient community as a whole.
For More Information
If you or someone you know has symptoms of sleep apnea, consult with a primary care physician or a sleep specialist as soon as possible. Sleep apnea is a common disorder with effective treatments available. Even if you have reservations about CPAP, it is always best to consult with a healthcare professional before making any decisions.
More information about CPAP and sleep apnea is available at the Sleepeducation.com CPAP information page, also known as “CPAP Central.” For more general information on sleep and sleep disorders, their treatments, and current research on a range of sleep-related topics, the SleepEducation.com website provides a comprehensive list of resources for further study.
ATSJournals.org – https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201510-723ED
CPAP Treatment for Adults with Obstructive Sleep Apnea: Review of the Clinical and Cost-Effectiveness and Guidelines – https://www.ncbi.nlm.nih.gov/books/NBK195810/
International Journal of Enviromental Research and Public Health – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352250/
Journal of Clinical Sleep Medicine – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695983/
Journal of Otolaryngology – Head and Neck Injury – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992257/
Medscape – https://www.medscape.com/viewarticle/934373
Sleep – 2009 – https://pubmed.ncbi.nlm.nih.gov/19544757/