Sleep Apnea CPAP Compliance Craziness

One of my biggest pet peeves is how doctors use the word compliance. If a patient doesn’t comply, it usually implies it was the patient’s fault. In sleep medicine, compliance is often used to measure how well patients use their CPAP machines. But compliance is not the same thing as success.


Various studies report CPAP compliance rates at 29% to 83%. The problem is that the definition of compliance changes from study to study. More recently, we’ve adopted the new Medicare requirement for CPAP compliance, which requires that the patients use CPAP at least 70% of the time over a 30 day period, for at least 4 hours every night. Otherwise, the machine has to be returned.


If you sleep 7 hours every night, it comes to 210 total number of hours per 30 days that you’re sleeping. Seventy percent of 210 hours is 147 hours. If you sleep only 4 hours every night, then this figure drops to 88 hours, which means that you have to use your CPAP machine only 40% of the total time that you’re sleeping to be considered "compliant." This doesn’t take into consideration if you’re actually feeling better or if the machine is being used effectively. 


Since CPAP works only if you’re using it, if only 40% of people are still using CPAP regularly 5 years after beginning treatment, then the CPAP success rate is at best 40%. But not all people who use CPAP will benefit, so this figure is likely to be much lower. Many more people are likely to stop using CPAP as the years go by. 


There are many patients that are 100% compliant with CPAP, using their machines 100% of the time they are sleeping, with no leaks and a low AHI, and still feel no better. Sometimes they can even feel worse than when they don’t use CPAP.


From what I’ve seen with CPAP compliance studies or even with sleep apnea surgery studies, they all manipulate the numbers to make their results look great. In very tightly controlled research studies with frequent follow-up and intensive intervention, results are likely to be good. But in the real world, with fragmentation of care, poor follow-up and lack of patient education, true success (the patient feels much better AND the numbers show it) is disappointingly low, no matter which option you choose. 


Despite all these obstacles, there are proven ways to improve CPAP success. With a systematic and formalized education program, along  with intense counseling, follow-up, and long-term support, many more people can benefit from CPAP. Ultimately, a major part of poor CPAP compliance is due to the health care system that’s dropping the ball.


Am I being realistic or too pessimistic? Let me know what you think of this issue in the comments box below.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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101 thoughts on “Sleep Apnea CPAP Compliance Craziness

  1. I was diagnosed with severe sleep apnea 9 months ago. Having 80 episodes a night with my oxygen levels going down to 36%. I was given a cpap and with a pressure set to 15 with a 3 point variable on this setting.

    I have used it every night since getting it but felelt really ill with all the symptoms I had before starting the cpap, even with the pressure set to 15. My data card said my AHI was down to 3 and that all is well.
    The pressure suddenly went up to 17 for approx 1 month and I began to feel better which was great. Then it dropped again and all the symptoms came back including the neurological problems with memory and clear speech. The sleep clinic told me there is no way my symptoms have anything to do with the OSA. Im feeling confused because on a pressure of 17 I feel ok and anything lower I feel dreadful. Is it possible to have great clinical data and still suffer the symptoms of OSA if the setting is not suited to an individual therapuetic level?
    I think I’ve had this a long time and with the severity of my OSA, how can I find out about any potential brain damage that might have occured? My cognitive ability is definitely a lot less than it used to be. My left foot also drags at times now.
    The other thing that has started to happen is that when I wake up, I can be fully awake, have a conversation etc but cannot get my eyelids to open without physically pulling them open.