Earlier Treatment Linked to Better Outcomes in Sleep-Disordered Breathing


System interventions could be used to modify patient behavior, leading to improved adherence and better clinical outcomes for those with sleep-disordered breathing, according to new data.

Study results from a noninferiority randomized clinical trial (NCT02191085) demonstrated that better positive airway pressure (PAP) adherence and greater improvements in daytime sleepiness and patient satisfaction were associated with earlier initiation of treatment in patients with severe sleep-disordered breathing (SDB).

Of the 156 patients included in the study (71.8% male [n = 112]; mean age, 56 years [standard deviation (SD), 12]), shorter wait time to treatment initiation was associated with adherence to PAP therapy (odds ratio [OR], 0.99; 95% CI, 0.98—0.99; P = .04), greater improvement in Epworth Sleepiness Scale score (ESS; mean coefficient, ­—9.37; 95% CI, –18.51 to –0.24; P = .04) and higher Visit-Specific Satisfaction Instrument­-9 score (mean coefficient, —0.024; 95% CI, –0.047 to –0.015; P = .04) at 3 months.

Data also showed that those who were adherent to treatment waited a mean of 15 fewer days (95% CI, 12—19; P = .07) for initial assessment and 30 fewer days (95% CI, 23—35; P = .008) for treatment initiation compared with those who were nonadherent. Failure to attend an appointment for polysomnography (PSG) was associated with longer delays for treatment, but there was no association of missed clinician appointments with wait time for treatment initiation.

“The findings of this study suggest that adherence was higher in patients with severe SDB who had shorter wait times for treatment initiation. Furthermore, earlier initiation of therapy also led to greater benefits in sleepiness and visit-specific satisfaction,” first author Christina Thornton, MD, PhD, respiratory fellow, Alberta Health Services, and colleagues, concluded.

The study aimed to evaluate the association of wait times for care with clinical outcomes for patients with severe SDB. Results of this study were secondary to a previous analysis from October 2014 and May 2017 that compared management by alternative care practitioners (ACPs) with traditional sleep physician-led care.

The mean respiratory event index (REI) was 52 (SD, 28) events per hour, with 123 patients (79%) using continuous PAP therapy, and the mean ESS score was 10 (SD, 6). Among the 156 patients included in the study, mean time from referral to initial visit was 88 days (95% CI, 79—96), and the mean time to treatment was 123 days (95% CI, 112–133) for all patients regardless of study group.

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Of the 156 patients included in the study, 81 were assigned to the ACP group while 75 were in the sleep physician group. Although the difference between study groups was diminished, the wait time from referral to treatment initiation remained shorter in the ACP group, with a mean of 119 days (95% CI, 94—125) versus 134 days (95% CI, 121–147; P = .01).

Patients included in the study had severe cases of SDB defined as a REI >30 events per hour during home sleep apnea testing, with a mean nocturnal oxygen saturation <85%, or had suspected sleep hypoventilation syndrome. Those with a concomitant sleep disorder other than SDB or had been previously treated with PAP therapy for SDB were excluded from the study. Performed at Foothills Medical Sleep Center, a tertiary care multidisciplinary sleep clinic at the University of Calgary, researchers assessed outcomes at 3 months after treatment initiation with adherence to PAP therapy as the primary outcome.

Associations between wait times and each of the outcomes were measured using multiple regression models, while t tests were used to compare wait times for patients who were adherent to PAP therapy (>4 hours per night for 70% of nights) with those for nonadherent patients.

“Strategies to improve wait times could improve patient experience, clinical outcomes, and subsequently reduce costs. Such innovations would align strongly with the triple aim (i.e., improving the patient experience of care, improving the health of populations, and reducing the per-capita cost of health care) for optimizing health care quality,” Thornton and colleagues concluded.


Thornton CS, Willis TH, Santana MJ, et al. Effects of wait times on treatment adherence and clinical outcomes in patients with severe sleep-disordered breathing: a secondary analysis of a noninferiority randomized clinical trial. JAMA Netw Open. 2020;3(4):e203088. doi: 10.1001/jamanetworkopen.2020.3088.

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