Sleep treatment experts are jumpy about a draft technology analysis from the Company for Healthcare Research and Quality (AHRQ) that casts doubt on the prolonged-time period medical profit for the gold typical treatment for sleep apnea.
Reviewers found that reviews of constant sure airway strain (CPAP) non-public consistently failed to display cowl improvements in non-sleep-connected outcomes linked to obstructive sleep apnea (OSA), corresponding to stroke, coronary heart attack, diabetes, and despair.
The characterize — online at the AHRQ web location and originate for public issue thru April 23 — concluded that the printed evidence “largely does no longer improve that CPAP prescription affects prolonged-time period, clinically most well-known outcomes,” and it highlighted learn gaps and methodological weaknesses in the readily available reviews, alongside with essential CPAP compliance points, which non-public all contributed to the failure to display cowl prolonged-time period advantages for the treatment.
OSA experts who spoke to MedPage This day about AHRQ’s learn overview agreed that CPAP remains by far the finest treatment for sleep-connected indicators of OSA. They jumpy that the characterize would be misinterpreted as which system that the treatment has free of price.
The learn overview used to be requested by CMS; Medicare covers 80% of a 3-month trial of CPAP for beneficiaries with a prognosis of OSA, with persevered coverage in step with treatment compliance.
One recent see of Medicare recipients found that more than half (56%) were at high threat for OSA and which that you just might maybe maybe recall to mind candidates for treatment. Total Medicare spending on CPAP quantities to an complete bunch of millions of bucks per annum.
“The astronomical anguish that I non-public, and a range of my colleagues non-public, is that the vogue this characterize is worded might maybe doubtless maybe with out disaster be misinterpreted as announcing that prescribing CPAP doesn’t make stronger these (prolonged-time period) outcomes, so we mustn’t be paying for it,” acknowledged David Rapoport, MD, who directs the sleep treatment learn program at the Icahn College of Medication at Mount Sinai in Unusual York City.
He acknowledged CPAP is well known because the finest treatment for making improvements to OSA indicators, corresponding to snoring and daylight sleepiness.
“Nothing else even comes shut,” he acknowledged. “CPAP s if truth be told a outstanding treatment for addressing the breathing disorder connected with obstructive sleep apnea. Nevertheless it no doubt has to be damaged-down, and compliance remains a astronomical advise.”
The AHRQ’s Evidence-primarily based Practice Facilities (EPC) incorporated records from 47 randomized medical trials and other reviews in their prognosis reporting prolonged-time period (≥6 or 12 months) medical outcomes in adult sufferers with OSA.
Investigators unparalleled that the reviews damaged-down “extremely inconsistent” definitions of breathing measures, respiratory occasions, and response to treatment, measured the use of the Apnea-Hypopnea Index (AHI) — a metric that the characterize moreover critiqued.
“No typical definition of this measure exists and whether AHI (and connected measures) are genuine surrogate measures of medical outcomes is unknown,” the characterize states.
Document co-author Elise Berliner, PhD, of the AHRQ Center for Outcomes and Evidence, told MedPage This day that addressing the inconsistencies and obstacles of the present reviews ought to be a top priority of the sleep learn neighborhood.
She added that while the characterize does no longer deal with whether CPAP is overprescribed, it does call on the sleep learn neighborhood to make stronger see designs by standardizing key measures corresponding to AHI, CPAP compliance, and the definition of severe OSA.
“I create think the neighborhood wants to get collectively and resolve out the vogue to create greater reviews,” she acknowledged. “We want increased and longer reviews, and there is moreover the advise of compliance. In loads of the reviews, people weren’t the use of these gadgets all night prolonged.”
Berliner’s neighborhood found that the present randomized managed trials present low power of evidence that CPAP affects all-region off mortality, stroke and myocardial infarction threat, or other cardiovascular outcomes. Researchers moreover concluded that insufficient evidence exists showing an impact for CPAP on the threat for automobile accidents, despair, and apprehension and hypertension.
Sanjay Patel, MD, of the College of Pittsburgh, agrees that lack of consistency and sad CPAP compliance in sleep reviews non-public made it subtle to assess the treatment’s impact on mortality and most other prolonged-time period outcomes.
Nevertheless like Rapoport, he expressed topic that the draft characterize findings will be interpreted by some as suggesting that CPAP is an ineffective treatment.
“The pondering in the field has been that treatment might maybe doubtless maybe wait on prevent diseases like diabetes and coronary heart disease which would be connected to sleep apnea,” he told MedPage This day. “This characterize says we manufacture no longer non-public lawful evidence on this, but it no doubt doesn’t if truth be told distinguish between outcomes the set we create and create no longer non-public ample learn to train definitively that treatment with CPAP isn’t famous.”
Patel served on the writing committee for the American Academy of Sleep Medication’s most contemporary medical note pointers on the treatment of adults with OSA the use of sure airway strain, which used to be printed in 2019.
He unparalleled that the up so far pointers differ from the AHRQ characterize in one key region, concluding that CPAP has been proven to lower blood strain in OSA sufferers with comorbid hypertension.
The AHRQ prognosis used to be restricted to those that were followed for more than 6 months, while the AASM’s writing committee understanding to be reviews with shorter note-up times.
“The label [of CPAP] on blood strain might maybe doubtless maybe also be viewed at 1 month,” he acknowledged. “More than one reviews with 3 months of note-up display cowl improvements in blood strain, but AHRQ failed to gaze at those reviews.”
While CPAP is calm understanding to be the finest treatment for OSA, Rapoport acknowledged there is a rising recognition in the direction of the sleep treatment field that it’s no longer for all people, given the continued points with compliance.
“Within the past, other treatments corresponding to mandibular boost gadgets non-public been marginalized,” he acknowledged. “These treatments manufacture no longer work virtually as properly as CPAP thru reducing AHI, but they create work properly for varied sufferers, and other people which would be prescribed them if truth be told use them. Except neutral at present, there wasn’t primary acceptance that this used to be lawful ample. Nevertheless there is now increased recognition that we ought to doubtless be prescribing treatments that are no longer ultimate if people usually have a tendency to use them.”
The AHRQ Evidence-primarily based Practice Facilities investigators reported no relevant conflicts.
David Rapoport, who commented on the characterize, cited monetary ties to the CPAP manufacturer Fischer and Paykel.