Positive Airway Pressure Benefits Older Adults with Sleep Apnea

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Positive airway pressure (PAP) use is associated with lower all-cause mortality as well as incidence of major adverse cardiovascular events among older adults with sleep apnea, according to recent findings.¹

These data resulted from new research into initiation of PAP as a first-line treatment for obstructive sleep apnea, given the limited data available on its benefits on patient mortality and major adverse cardiovascular events.

This study was authored in part by Diego R. Mazzotti, PhD, from the Division of Medical Informatics at the University of Kansas Medical Center in Kansas City. Mazzotti and colleagues noted that there had been a previous study evaluating French patients which found that continuous PAP termination was linked to all-cause mortality as well as heart failures.²

“This study aimed to determine the association of PAP utilization with all-cause mortality and incidence of (major adverse cardiovascular events) and its components among Medicare beneficiaries in the central US by leveraging a robust analytical approach,” Mazzotti et al. wrote.

Trial Design

The investigators evaluated Medicare beneficiaries who were over the age of 65, with each reporting at least 2 separate claims associated with occurrences of obstructive sleep apnea (OSA). They were identified for the team’s study Medicare fee-for-service claims data which had been drawn from the Greater Plains Collaborative Reusable Observable Unified Study Environment.

The research team excluded, for their analysis of major adverse cardiovascular events, beneficiaries who were shown to have a history of such events prior to their OSA diagnosis. Two complementary designs were implemented by the team in this study to estimate subjects’ average impacts due to PAP therapy.

In their PAP initiation analysis, the investigators utilized a prescription time-distribution matching method for the purposes of establishing a point of baseline (time 0) for those labeled as non-PAP initiators. This would align with the time from the point of diagnosis to PAP initiation among such users.

Those who were beneficiaries and had also not experienced any cardiovascular events within the first year of initiation of this treatment were included in the investigators' PAP utilization assessment. Initiation of the treatment was noted using the first claim that had been filed following an OSA diagnosis.

The distribution of total claims was noted as bimodal, suggesting 2 distinct utilization patterns: 1 pattern centered around 3 claims and another around 14 claims, likely reflecting the reimbursement models used in the Centers for Medicare and Medicaid Services (CMS) for PAP therapy.

The investigators tested several different exposure group definitions with the goal of deciding upon necessary cutoffs. This resulted in the research team’s selection of quartile-based utilization cohorts, including Q1 (1–7 claims), Q2 (8–12 claims), Q3 (13–15 claims), and Q4 (more than 15 claims).

The 2 main outcomes evaluated were all-cause mortality and the first occurrence of heart failure, myocardial infarction, stroke, or coronary revascularization. These were noted by using diagnostic and procedure codes.

Findings

The research team’s assessment included 888,835 total beneficiaries who had obstructive sleep apnea, with these subjects also having a median age of 73 years. 43.9% of them were reported to be women, with the racial stratification of participants being 5.3% Black, 0.9% Asian, and 85.5% White.

There was a median follow-up period which lasted 3.1 years, and the investigators found that 32.6% of the subjects had started implementing PAP therapy. A significant risk reduction of all-cause mortality was observed by the team among those who initiated PAP, with a hazard ratio (HR) of 0.53. They also concluded that the incidence of major adverse cardiovascular events had been lower among these subjects, with an HR of 0.90.

PAP utilization increases were also shown to be linked to progressively lower rates of death (HRs of 0.84, 0.76, and 0.74 for the second, third, and fourth quartiles, respectively). Increases also were noted as having led to major adverse cardiovascular events incidence rate drops (HRs of 0.92, 0.89, and 0.87 for the same quartiles).

“This study has the potential to inform future trials assessing the importance of OSA therapy initiation and maintenance toward minimizing adverse health outcomes leading to healthier lives,” they wrote. “These results may also help to inform more personalized strategies to improve PAP adherence and efficacy among older adults.”

References

1. ^{Mazzotti DR, Waitman LR, Miller J, et al. Positive Airway Pressure, Mortality, and Cardiovascular Risk in Older Adults With Sleep Apnea. JAMA Netw Open. 2024;7(9):e2432468. doi:10.1001/jamanetworkopen.2024.32468.}
2. ^{Pépin JL, Bailly S, Rinder P, et al; medXcloud Group. Relationship between CPAP termination and all-cause mortality: a French nationwide database analysis. Chest. 2022;161(6):1657-1665. doi:10.1016/j.chest.2022.02.013.}