Improving Patient Understanding and Treatment Adherence in Obstructive Sleep Apnea


William Noah, MD, director and founder of the Sleep Centers of Middle Tennessee discussed issues in caring for patients with OSA.

William Noah, MD, director and founder of the Sleep Centers of Middle Tennessee

William Noah, MD

Patients with obstructive sleep apnea (OSA) receiving positive airway pressure (PAP) therapy machines through an integrated sleep practice (ISP) had better long term-adherence to the therapy than those who received it from traditional durable medical equipment suppliers (DMEs), data from a recent study suggest.

Study co-author William Noah, MD, director and founder of the Sleep Centers of Middle Tennessee, and colleagues found that the ISP group had a 71% (n = 1296) rate of PAP adherence at 30 days, a 66% (n = 1212) rate at 90 days, and a 52% (n = 961) rate at 1 year. These rates were significantly higher than those in the DME group, which had a 66% (n = 1327) rate of adherence at 30 days (P = .004), a 56% (n = 1116) rate at 90 days (P <.00001), and a 33% (n = 665) rate of adherence at 1 year (P <.00001). The ISP group also had a significantly duration of PAP use, with 357 minutes compared to 345 in the DME group at 30 days (P = .002), 348 compared to 319 at 90 days (P <.00001) and 312 compared to 164 at 1 year (P <.00001).

NeurologyLive spoke with Noah to learn more about the differences in care between an ISP and DME as it relates to OSA treatment. He also stressed the importance of raising awareness and understanding of OSA.

NeurologyLive: How does working with an ISP differ from obtaining a PAP machine through a traditional supplier?

William Noah, MD: ISPs require a lot more staff, a lot more focus and a lot more time, but it gives you a really great sense of accomplishment. In the normal web of sleep, the patient has to go back and forth between the doctor, the sleep lab, and then the DME which could take 6 months before they end up with a cPAP. With an ISP, referrals come to us and all testing and consultations are done in-house, all the same staff are taking care of the same patients and building relationships. Everyone has a consistency in speech, consistency in terms between sleep physicians and respiratory therapists. It's a Board-Certified sleep physician who is overseeing all that care. 

Plus, we're also managing restless legs, insomnia, or other sleep issues, and are knowledgeable about hypertension, diabetes, heart disease and other things that OSA causes. And so, we integrate the treatment. In other words, they know that they're wearing cPAP not just for OSA, but to improve their blood pressure, blood sugar, and decrease the risk of heart attack. A respiratory therapist alone wouldn't be trained or have the expertise to really explain how sleep norepinephrine release is triggering these events and how wearing cPAP is blocking that triggering, so these conditions are all integrated. Plus, we have clinical psychiatrists in our practice, and I think we were the first practice to use cognitive behavioral therapy to get patients used to the idea of OSA and PAP therapy. To have a lifestyle change of wearing this contraption at night or even having a machine next to your bed — it's something hard to accept.

Can you expand on the problem of undiagnosed sleep apnea?

There is a huge disparity there. About 37% of adults have sleep apnea, of which half are moderate or severe. So that's 18%. People with moderate or severe OSA have a marked increase in mortality. People think that OSA means you hold your breath at night, which is wrong. We're trying to change the name of sleep apnea to sleep airflow obstruction, because apnea, complete obstructions, aren’t the big problem. It's the partial obstructions called hypopnea, which you usually hear with a snoring noise. Sleep airflow obstruction would include both partial obstructions which are more common, and the complete obstructions. It's not the degree of obstruction that is dangerous, it's the duration of the obstruction.

What determines the problem is if the event triggers norepinephrine release? So that's where we have created the term sleep norepinephrine release — S-nore-R. It’s important to raise awareness and understanding of OSA, otherwise undiagnosed people are missing the opportunity to lower their hemoglobin A1c, to lower their blood pressure, decrease the risk of heart disease and feel better each day.

Transcript edited for clarity.

Andry JM, Tobin G, Shafin C, Noah W. Positive airway pressure therapy supplied by an integrated sleep practice associated with greater adherence among pre–Medicare-aged patients with sleep-disordered breathing. J Clin Sleep Med. 2021. 17(1):31-36. doi: 10.5664/jcsm.8786
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