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CPAP Compliance vs. Adherence

Throughout all the talks and papers on CPAP usage at this year's SLEEP 2010 Meeting, it seems like the word compliance is being used less and less, and instead, sleep researchers are using the word adherence. Unfortunately, the practical meaning hasn't changed—it describes how long users are able to use CPAP on a nightly basis. Various researchers use different definitions, but one definition that is commonly used (since it's what Medicare uses) is at least 4 hours per night in at least 70% of nights in a 30 day period. So if there are 56 total hours in a week if you sleep for 8 hours, on average you have to sleep at least 20 hours per week on CPAP to be "adherent." That's about 35% of your total sleep time. 

 

Considering that most people aren't able to use CPAP at all (published "adherence" rates range from under 20% to over 80'%), this is a very liberal criteria for what is considered the minimum time that's considered "acceptable" by the sleep community. 

 

Even if you're considered "adherent," it's assuming that you're receiving optimal CPAP pressures with no leaks. So if your final AHI at your "optimal" CPAP pressure is 16, then if you use your CPAP machine enough hours per week, then you're considered "adherent."

 

There has to be a better way to measure how well and for how long people use their CPAP machines. We should also incorporate the quality of CPAP use, in addition to quantity.

 

What do you think about these definitions? 

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.

How To Achieve CPAP Success

 

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