Good afternoon. Whoa, this thing is loud. Thank you, everyone, for coming today to our session on CPAP adherence. My name is Gada Bourjali. I'm a professor of medicine at Brown University. And I'll be chairing the session and speaking a little bit later. And I have the pleasure of having two wonderful faculty members with me. Our first speaker is Dr. Lauren Tobias, who is an assistant professor of medicine at Yale University. She is the program director for the SLEAP Fellowship. And she is the medical director for the SLEAP program for the Connecticut VA Medical Center. And our second speaker is Dr. Amy Sawyer, who is associate professor of sleep and sleep behavior at Penn Nursing at University of Pennsylvania. And her research is on health behaviors that are relative to sleep. So we're going to start with Dr. Tobias, who's going to talk to us about race, ethnicity, and socioeconomic status as they influence CPAP adherence. Thank you so much, Dr. Bourjali, for the invitation to speak this afternoon and assembling this session on such an important topic. Here is an outline for my talk. And the main focus of my comments is going to be on PAP usage itself and how it differs by race, the reasons why disadvantaged populations might be at an elevated risk of poor PAP use. But just to put this into some broader context, we know that there exist disparities for other sleep related outcomes as well. So we have strong data to support the adverse impact of race and economic disadvantage on shorter sleep duration, on higher prevalence of insomnia and sleep disturbance, greater circadian disruption, and of course, also sleep disordered breathing, which is going to be the crux of my talk for this afternoon. So hopefully, I don't have to convince this audience why CPAP use is important. But just to spell out some of the reasons briefly, we know that OSA is independently associated with adverse outcomes, including daytime sleepiness, neurocognitive impairment, depression, cardiovascular disease, and all-cause mortality. And at least for now, CPAP remains the first line treatment for moderate to severe OSA, effectively reducing sleepiness, improving quality of life, and possibly reducing cardiovascular outcomes, such as hypertension and AFib recurrence. But CPAP's effectiveness is limited by suboptimal adherence. And this is something we all struggle with. We've seen some gains on some studies in CPAP use over time. But these have not been uniform across racial and ethnic groups. So what do we know about racial disparities in obstructive sleep apnea? There's a large body of evidence showing that black individuals are disproportionately impacted by cardiovascular disease. And so they likely stand to benefit to a much greater extent from the early identification and treatment of underlying OSA. We know that blacks and Hispanics are also less likely to be referred to sleep centers in the first place, but when they're actually tested, they tend to have more severe OSA, suggesting that there's a delay here in diagnosis. The Jackson Heart Study, which is led by Dana Johnson, has shown that underdiagnosis of sleep apnea remains common. And in their cohort, there was a very high prevalence of OSA with about a quarter of patients having moderate or severe OSA, but only 5% had been previously diagnosed. And beyond diagnosis, several trials have demonstrated lower PAP usage among racially and economically marginalized populations. I'm going to just show a few examples here. There was the HOME PAP trial that showed black participants used PAP for an average of 92 minutes less than whites. Another randomized control trial looking at sham versus active CPAP usage and showing that white race was associated with 75 minutes per day greater PAP usage. And then finally, this VA cohort that showed that black veterans use CPAP for 1.6 hours less than white subjects. And they had a lower odds of reaching CMS adherence criteria compared with other racial groups. And interestingly, these findings persisted even after adjustment for some neighborhood characteristics like socioeconomic status. And I think it's worth mentioning with this last bullet point that these are VA patients. They're actually not held to this criteria. And in fact, they have no limitations on their PAP device and supply coverage as opposed to those who rely on Medicare or private insurance. So the fact that black and lower SES veterans still had lower PAP use suggests there's something more than simple equipment and supply costs at play here in the disparities in PAP adherence. There are myriad reasons for the racial disparities that we see in PAP usage. And in many of our patients, several of these factors are at play. So these are the factors that, there are factors that influence sleep quality generally. Since if you're not sleeping well, your PAP adherence is likely to suffer. And these include neighborhood violence and crime, one's housing situation, noise, light pollution and shift work. There are other factors that influence whether a patient can actually make it into clinic to see us, including transportation, insurance coverage to access care. And then there are digital barriers, including access to internet and phone services to make appointments, to hold telemedicine calls, to engage in patient facing PAP adherence applications. And then there are factors that are related to structural and systemic racism. And these can include mistrust of the healthcare system, racism and discrimination, racial segregation. All of these factors can impact patient's ability to obtain an OSA diagnosis in the first place, and then to use their CPAP. And not surprisingly, household income predicts CPAP usage. So this study found that patients were progressively more likely to be adherent as shown in red as their household income increased. But household income doesn't appear to tell the whole story either. So this was a study using remote monitoring data from over 800,000 patients who were using Philips PAP devices. And they found that the racial composition of one's neighborhood predicted CPAP use over time. And this was independent of poverty and of educational level. So you can see the usage patterns on the right, and they show that the higher the percentage of black or Hispanic individuals in a neighborhood, the lower the PAP usage. While in white neighborhoods, the adherence over the course of the 90 day study that they were looking at was fairly consistent. Usage actually declined in neighborhoods with a higher percentage of black or Hispanic residents. Short sleep duration is another factor that impacts PAP adherence, since I think we can logically assume that less sleep opportunity likely translates to lower PAP usage. We all know that continued payer coverage for PAP at this point requires usage four hours a night for at least 70% of nights. And we have some data from an earlier, the HomePAP trial showing that patients with shorter self-reported sleep duration exhibited lower PAP usage at three months. And the graph here on the right drives home the point that disparities in sleep duration persist. So this was from a large multi-institutional survey, and they found that the incidence of short sleep duration was seen in 11% more black patients than white. So it does not appear we have made much headway with regard to eliminating disparities in sleep duration over time, at least over the 14 year period of this trial. Studies have also examined the role of exposure to discrimination, and it appears that this contributes to sleep disturbance independent of race, socioeconomic status, and depression. The mechanisms by which discrimination may disrupt sleep are not clear. One may be by increasing the odds of having insomnia. And a study that's actually currently in chest showed that adults with OSA who report having experienced racial discrimination are less likely to exhibit less PAP usage than those who do not experience racial discrimination. And this was actually independent of self-identified race. There's also this concept of the digital divide, meaning that the gap between demographic groups in access to modern communications technology and digital literacy may drive some of these differences we see in PAP adherence. This was a study out of the RAND Corporation. It wasn't specifically designed to look at CPAP use, but just an overall willingness to use telehealth during the COVID pandemic. They followed patients longitudinally, and between the pre-pandemic period, which is shown here in green, and the mid-pandemic period, which is shown in yellow, they saw that willingness to use telehealth increased among nearly all of the subgroups, but especially among black adults and adults with lower educational attainment. So perhaps this is some good news that maybe the digital divide is lessening to some degree. However, even at the end of the study, I think it's worth noting that the only group here that had over 70% of members willing to use telehealth was those with a bachelor's degree or higher. So clearly digital interventions are still not the whole answer and are not going to work for all of our patients. So considering all of these factors that mediate PAP adherence in racially marginalized groups, we can think about how each one comes into play along this path from diagnosis to treatment of obstructive sleep apnea. Unlike a lot of medical care, I think we were asking our patients to go through many different steps from the suspicion of having OSA in the first place to getting a referral, to actually showing up for the sleep consultation, to being appropriately sent for testing, to have that test actually scheduled and completed, to getting their CPAP prescribed and set up successfully, then to using the device initially and to sticking with it and following up with their provider in the long term. And so this long path is of course fraught with many of the barriers that I've mentioned. And although my talk is focusing primarily here on black patients because we do have the most literature for that group, I couldn't resist highlighting this recent article from JCSM that specifically looked at PAP adherence in Native Hawaiians and Pacific Islanders. So this was a retrospective study that was in fact conducted at a sleep center in Utah that happened to have a high proportion of Native Hawaiian and Pacific Islander patients. And they found that OSA was severe in the majority of the patients tested, but adherence in this population was low. And these findings, oops. And I think these findings are most likely related to probably barriers to diagnosis in this population. And I want to point out that disparities exist for other forms of OSA treatment aside from just PAP as well. This was a study that looked at whether race impacts who's referred for upper airway stimulation therapy using data from the large adhere registry. And they found that out of nearly 3000 patients, only 125 or 5% of them were non-white. So after propensity matching a subgroup of these non-white patients to white patients, the authors found that there was in fact no difference in adherence to therapy or efficacy. So I think the take home here is that we're referring a disproportionately low percentage of PAP intolerant patients for this therapy, even though it appears that the intervention is equally effective across racial groups. So you're going to hear soon from Amy Sawyer about the interventions to improve PAP adherence more generally, but I'd like to share a few thoughts related specifically to PAP use in marginalized groups. This was a study out of the group at NYU led by Dr. Jean-Louis, and it was the Metabolic Syndrome Outcome Study or METSO study. It was designed to enhance adherence using culturally and linguistically tailored OSA health messages. They enrolled patients who were black and had metabolic syndrome. And the intervention here was a series of phone calls over a six month period by trained health educators to speak with patients and assess what were their unique barriers and facilitators of both diagnosis and treatment. Their results were that the intervention group who had received these brief phone calls were three times more likely to receive initial sleep consultation than the control group. And there was no difference in PAP adherence rates, although there was actually a pretty high dropout rate from the study, so that may have been part of that. And they concluded here that the fundamental barrier for PAP usage was actually just getting care in the first place in a patient where there's suspected OSA actually simply presenting for care. Another study from the same group at NYU was the TASHI study or the Tailored Approach to Sleep Health Education. So this group here developed a culturally tailored web-based tool to improve OSA self-efficacy among community dwelling black adults. They recruited their patients from community-based settings. So they went to faith-based organizations, community centers, barbershops, beauty salons, and the intervention arm here received two months of web-based sleep education. The control group got standard sleep information just off the National Sleep Foundation website. And they found that being exposed to this web-based education significantly improved this outcome of OSA self-efficacy, which was assessed with the SAMHSA, which is a standardized scale. And the importance here I think is that patients who have higher self-efficacy with regard to their OSA have been shown in other studies to have higher CPAP adherence in the end. And then Vivian Asari is a physician at our group at Yale who's tackled a different aspect of this disparity in PAP usage. She's focused particularly on access and recognizing that the cost barriers of CPAP equipment and supplies are substantial. She has established a program actually several years ago now called the Yale Compassionate CPAP Service. This aims to provide our uninsured and underinsured patients with equipment and supplies. And pre-COVID, this program was dependent on charitable organizations donating refurbished supplies primarily, but she just recently received a community sleep health grant from the ASM Foundation to further develop this really wonderful program. So how can we improve CPAP adherence for our marginalized patients? Obviously the barriers and the solutions here are complicated and can really come on many levels, but from where we stand as sleep physicians, I think I'll share a few ideas here. So as I've mentioned, we can think about employing tailored solutions like those used in the Metso and Tashi studies. We can think about how to optimize digital solutions, mobile health and telehealth within our clinics to expand access. And we can also recognize that it's probably beneficial to have race concordance between physicians and patients when possible, since this has been associated with better outcomes for other sleep disorder, for other disease processes rather. We don't have data specifically with OSA on the importance of concordance. But with regard to this last point, we really have a problem in the pipeline as far as recruitment of underrepresented sleep providers at this point. So on the lower left is data from the 2023 AASM Diversity, Equity and Inclusion Annual Report. And you can see that of those who identified their race, which was a good amount of the sample at this point, only 4% identified as black or African-American. And African-Americans comprise only 1.5% of AASM leadership positions at this point. Related to this, a recent study looked at physicians at federally qualified health centers that tend to serve lower socioeconomic status patients and found that of the 44,000 physicians surveyed, only 0.06% were sleep medicine trained. None of these were practicing in medically underserved areas. So getting back to our solutions, the final idea that I'll leave you with is we need to consider our policies for CPAP adherence. If you haven't seen this document, I highly suggest taking a look at it, both as a review of all the issues that I've been discussing and just a beautiful summary of why our CPAP adherence thresholds really need to change. The authors here make a strong case that reducing health inequity in OSA care depends on our revising the current CMS PAP coverage requirements. This is a core feature of their recommendations, which I will read. So they say, we recommend defining adherence as consistent long-term use of PAP therapy that yields sustained patient benefits, and they list the symptoms, over a six-month period. We favor a patient-centered definition on the basis of goals rather than a specific time use cutoff to define adherence. However, a reasonable minimum PAP use threshold would be two hours per night, averaged after a six-month trial to continue coverage. So obviously very different from what we have right now. So I'll leave you with this summary. Marginalized populations, including racial and ethnic minorities, have a greater burden of poor sleep overall, including higher rates of OSA and more severe OSA at the time of diagnosis. And OSA likely mediates the racial disparities demonstrated in trials of cardiovascular disease. We now have many trials clearly demonstrating that CPAP adherence is lower in black individuals and other racial minorities. And finally, when we develop interventions to improve PAP use among minoritized racial and ethnic groups, they have to be culturally tailored, evidence-based, and ideally include more flexible, patient-centered definitions of PAP adherence. So I'll end just with a plug for our Sleep Network Open Forum, which is gonna be held tomorrow at 10.30 in the morning. This is an opportunity to help plan sleep-related content for the next meeting. So please join us. This is open to everybody. And thank you. So next we'll have Dr. Amy Sawyer, who's going to speak to us about interventions and how to improve strategies. Great. Thank you very much. Good afternoon, everyone. It's great to be here with you. I'm Amy Sawyer. I'm an associate professor at the University of Pennsylvania and we'll be talking about improving PAP adherence for the general adult population of PAP users. So we'll talk about barriers and facilitators that are evidence-based in terms of PAP use outcomes, and then also intervention strategies, but more importantly, move on to what are clinically applicable intervention approaches that we can think about using in our everyday clinical settings. So this session was not designated as an automated response system session. However, I would like to go the old-fashioned route and ask that as I go through these clinical indicators of barriers for PAP use, if you've heard this from patients in your clinics, if you'll just please stand up and stay standing, consider it a little bit of exercise mid-afternoon. So CPAP noise disturbs my partner. Has anyone heard this in your clinics? Yes, please stay standing. How about mask leaves red marks on my face, hence I'm not wearing this anymore. The mask is uncomfortable, it's painful, just not good for me to use at night. Mask leaks, right? It wakes me, wakes my partner, causes my eyes to feel dry and irritated. The headgear leaves marks on my face. I can't go to work looking like this every day. We almost have a standing ovation. That's what I was going for. Headgear hair. Have you heard that one? I hear that all the time from women patients. I feel self-conscious around, yes, even my cats and my dogs. I'm embarrassed about this situation at night. CPAP keeps me from sleeping and you're telling me this is going to help me sleep. Have you heard that one? I can't breathe with a mask on my face. I feel panic, right? I can't take a deep breath. This is supposed to help me breathe. And I panic when I put the mask on, just put the mask on. Thank you for the standing ovation. Look around, full room. So that is clinical evidence of real barriers that patients face when we recommend PAP treatment. And we say, here you go, good luck. We'll see you back in three months, right? Or we'll see you back in six months. And we leave it possibly to our medical equipment partners to problem solve device challenges, if you will. And yet we also know that the evidence shows us there are evidence-based facilitators and barriers that are potential opportunities for intervention targets that we could be using in our everyday clinics. So starting with this table, these are evidence-based barriers. And you'll notice that I have barriers marked, but I also have marked if these are potentially modifiable barriers. So characteristic factors, low AHI, relatively low daytime sleepiness, female, younger adults, low SES or lower SES. And as we just heard, underrepresented minorities or minoritized populations face barriers. These are factors that have been shown to predict low adherence. And largely these are not modifiable directly. However, it does help us to understand who may be at risk for being non-adherent or having additional challenges to meeting adherence thresholds, if you will. Treatment-related factors. So these include things like high pressure, full face mask interface, low nasal volume, the experience of side effects or adverse responses while wearing PAP, early negative experience. So that first night using PAP during a titration study or at home on auto titrating PAP. If it's a negative experience, that typically the evidence shows will lead to a greater likelihood for non-adherence. Certainly those who express mass claustrophobia or anxiety or panic attack with wearing the mask is particularly early on in treatment are likely to have lower adherence. And then high residual AHI. So those are treatment-related factors and many of those are modifiable, but it would require that we are well aware of what the patient is experiencing during the early phase of treatment exposure, including during a titration interval on APAP and thereafter as we approach that golden threshold of 90 days, if you will, for payer criteria. Symptoms and treatment response factors. So the absence of daytime sleepiness or minimally symptomatic sleep apnex tend to have lower PAP use. Absence of impaired function or daily function that is affected by their sleep apnea or no awareness of that is a barrier to achieving PAP adherence. Psychological factors is another category of factors that predict non-adherence, particularly short-term non-adherence, low self-efficacy, as we've heard about self-efficacy. The absence of being ready to change, to take on the challenge of wearing PAP each and every night or during the majority of their sleep periods. Personality D type has been shown to be predictive of low adherence. Passive coping styles as compared to active coping styles is also predictive of non-adherence or is a barrier. And then social factors, and we've heard a lot about some of the social factors for underrepresented minorities or minoritized groups, but also think about social factors being those around patients each and every day. So a spouse, a bed partner, a family, those in their immediate household and how the relationship with those individuals may in fact be a deterrent or a barrier to using PAP. So many of these are modifiable. Then let's look at the facilitators. So there are numerous evidence-based facilitators for PAP use, including some of these same categories. And if you just flip-flop the table from barriers to facilitators, we actually have good evidence that some of these individual factors, when they are addressed through intervention studies, which we'll get to next, do in fact improve short-term PAP use. So these include treatment-related factors, so a nasal mask interface as opposed to other types, positive early experience on treatment, positive first impressions, whether the experience was positive or not, but understanding that that was the first night and I'm going to have to be, have tenacity for sticking with it and getting used to it over time. And then early troubleshooting. These are all facilitators to short-term PAP use. As well, symptom and treatment response factors, psychological factors, and again, social factors. So if we understand barriers and facilitators, it seems that we should be well-positioned with interventions. And I always say it takes a team to make this happen, especially when we consider what some of the evidence-based interventions are and delivering them in the clinical setting. So from the clinical guidelines that are underpinned by a meta-analysis, we have really quite impressive data in terms of what are intervention strategies that do improve short-term PAP use. And that is most often out to three months. But some of the evidence also addresses outcomes at six months. So as we look at this, this is kind of the pathway to getting started on PAP, if you will. And each of these intervention approaches do in fact improve PAP use in the short term. And this is meta-analytic data to demonstrate that in clinical trials that were rigorously conducted, these intervention strategies do improve PAP use in the short term. Now I'd like to point out at the bottom, the most common approaches to improving PAP use is all about troubleshooting the device typically. We do lots of mask changes and refitting the mask and teaching again as to how you apply the mask and tighten the headgear. These interventions actually don't demonstrate a positive effect on short-term PAP use. But without them, it's a persistent barrier and may actually lead to abandonment of the treatment. And so although these were not significant by meta-analysis, I would say you can't set these intervention approaches aside from those that tend to be more effective. So as we think about clinically applicable approaches based on the evidence to date for both facilitators and barriers as well as the intervention strategies that have demonstrated positive efficacy for improving short-term PAP use outcomes, I would like to say that I think it's critically important that we build partnerships with patients, that we encourage engagement of patients and their significant others in the process of being diagnosed with sleep apnea and moving on to starting treatment and then sustaining treatment over time. And as well that this is done through a collaborative approach. We think about using education and hands-on training with feedback at the time of initiating PAP in order to set individual patients up to be successful in troubleshooting their device on their own at home when they're using it each and every night. We think about assessment and monitoring and encouraging reflection on where did you start from in terms of your symptoms and how you feel, and where did you get to in terms of I've been on PAP one week, I've been on PAP one month, three months, maybe even six months and 12 months is when we need to be asking that question about remember where we started from, now how do you feel. Amid this process, it's critically important that we're building relationships with each and every patient. That includes us as providers but as well our staff and team in the clinical sleep center so that when patients are faced with barriers and need to reach out for assistance, they feel that they have a partner who will help them problem solve or address any issues or challenges they're having. And then of course encouraging participation from patients and their important others or what I call their VIPs, really engaging the team at home with each individual patient to be part of this process. So if we want to drill a little bit further into some of these strategies, certainly for education and hands-on training with the device in our current clinical practice guidelines published in the Journal of Clinical Sleep Medicine by AASM, certainly education is a recommendation at the outset of beginning PAP treatment. But remember it's more than education. It's really helping them be successful with that device, that mask, and that headgear and giving them the hands-on experience of using the device independently with coaching during those first few attempts at applying the mask and the headgear. Be sure to include important others in that training session and in fact consider our group training sessions an opportunity to build peer support. There is evidence within the past five years that peer buddies and group cognitive behavioral sessions for PAP adherence as well as group education sessions actually translate to improved PAP acceptance and use outcomes. And so think about is there an opportunity to have patients come together and start to learn to manage their PAP device and the treatment as a group. Also recall that or realize that we provide a lot of education up front to patients and patients, the evidence demonstrates, take up two to three messages in one education session. And so when we give them five handouts and we speak to them for 15 minutes about being successful with their PAP and probably that includes 15 separate messages, educational messages, it is highly unlikely that patients are going to retain all of that information that we've shared. And so thinking about how can you deliver booster education over time to kind of refresh and bring that back to the surface and maybe that's weekly messages through our EHR portals that can be shared that are educational in nature. Maybe it's follow-up phone calls, maybe it's at return to clinic visits. So getting creative about how you bring that education, that information back to the patient at a time when we're not delivering 15 messages simultaneously. And then also realize that standardized education materials that are available from many of our practice organizations far exceed literacy levels of adults in the U.S. And so if we're using those standardized patient education materials, many of our patients will not be able to take up the content. So think about what is an opportunity in your own clinical setting to deliver simplified patient education materials. Certainly it can stem from some of our practice organization documents or pamphlets, but really simplifying that content so that every patient can access that information and share it with their families as well. Behavioral intervention strategies have been shown to be the most efficacious at improving PAP adherence outcomes in the short term. The reality is that many of us don't have behavioral specialists in our clinic to deliver things like cognitive behavioral therapy and motivational enhancement therapy. And so other ways that we could think about leveraging that evidence in our everyday practice is by using brief behavioral messages or motivation messages and asking patients at the beginning of starting CPAP treatment, how important is it for us, for you to use PAP each and every night on a scale of 0 to 10. If it's 7 or greater, they're probably at a stage of readiness to change where they're optimally prepared to take up a new treatment. If it's less than 7, it's likely that we have some work to do in conversation with patients about what would it take to move this from a 6 to a 7, and talking about what their values are for having their sleep apnea treated. And it's not necessarily what we say are the reasons to treat sleep apnea, right? So really understanding what are the values from the patient's perspective for using CPAP treatment. We can also think about assessment, monitoring, and reflection measures, both at baseline but recurrently over time. So this can be as simple as an EPRA sleepiness scale recorded repeatedly over the first three months, and can we do that through our EHR portals? Can we use an app that allows the patient to see movement in their daytime sleepiness in response to CPAP treatment? Other opportunities we could think about are things like the PVT, the Psychomotor Vigilance Task Test, which is available in a three-minute app form. It's a valid measure of executive function and response time. And this is a great way to demonstrate to patients that once you're on treatment for a period of time, there is improvement. And by visualizing that movement in response to treatment, graphically in particular, it can be a strong message to encourage patients to continue to use CPAP. And then obviously reviewing PAP use data early and often. We know the telemonitoring studies have demonstrated a positive influence on PAP use outcomes. So how can we leverage the power of our digital age to really ensure that patients can see that their use each and every night has either improved or it's been stagnant, and how can we work with them to use that data to inform activities to promote their ongoing use or overcome barriers that they're experiencing. And always keep in mind that although patients may tell you about one major barrier to using PAP each and every night, there may be a package of those barriers that they're experiencing. And so if we fix one barrier and leave three others on the table, it may be that patients still are not able to be successful with their PAP. And so understanding all the complexities of using PAP in patients' everyday life is really important. And work to solve one barrier at a time with them and help them understand that we'll work at this one barrier at a time or one challenge at a time. And as we are able to be successful with one barrier, we'll move on to the next. And really encouraging patients to be persistent with the troubleshooting and barrier reduction process. So, if we are good detectives in understanding what the experience with PAP is for each and every patient at the individual level and we work together with patients and their VIPs, if you will, we can help patients become successful with using PAP and we can leverage what we understand in the current evidence including strong meta-analytic evidence for what intervention strategies do work in the short term. We can leverage that and think about how we can apply that in our everyday clinical setting. Thank you. So I will be speaking about CPAP adherence and pregnancy. So I have received some honoraria and equipment support. The objectives of today's talk, because we don't always talk about sleep apnea in pregnancy, is to recognize what a prevalent problem this is and to think about the impact of OSA in pregnancy and then understand the adherence data that is available for the pregnant population currently and then appreciate some of the barriers and facilitators that are unique to this population. So this is a slide that summarizes how prevalent objectively defined sleep disordered breathing is in the pregnant population and you can see it varies quite a bit in that this is a low risk population but as you start looking at higher risk populations like women that have gestational diabetes, the OSA diagnosis increases significantly. Sorry about that. And then if you start looking at women that have obstetric complications, the prevalence is pretty high. In some studies it is up to 50%. So this is a really prevalent problem and if we think about nearly 6 million women getting pregnant in the U.S. every year this percentage is a really high percentage of a newer population every year that we have to deal with. So the reason why we care about sleep apnea in pregnancy is because it is associated with some pregnancy specific cardiovascular and metabolic outcomes and severe maternal morbidity. This is the new mom-to-be study where whether sleep disordered breathing was diagnosed early in pregnancy or later in pregnancy there was a two-fold increase in the prevalence of preeclampsia after adjusting for multiple covariates including body mass index. This was a large ICD-9 code population based study. This was from the nationwide inpatient sample that examined a diagnosis of obstructive sleep apnea with some markers of severe maternal morbidity and it identified that there was again a risk for gestational hypertension, preeclampsia and eclampsia and gestational diabetes which you see in here but also some markers of severe maternal morbidity like cardiovascular outcomes, stroke and cardiomyopathy and even in-hospital mortality. But the in-hospital mortality was not reproduced in other studies. A few years ago we also demonstrated that women that have sleep disordered breathing in a different data set, it was the National Perinatal Information Center, were at an increased risk for an ICU admission, about two and a half fold increased risk and had a longer hospital stay, about five days compared to three days in women that did not have the diagnosis. And in this sample of about 75,000 women that had preeclampsia we looked whether having a diagnosis of obstructive sleep apnea impacted outcomes such as severe maternal morbidity, severe cardiovascular morbidity or increased healthcare utilization and as you could see there was a significant increase in all of these. So what I'm trying to say here is that sleep apnea is a relevant diagnosis to know in the pregnant population even though pregnancy is self-limited and only lasts for nine months but the outcomes that OSA impacts in that course of nine months is really important and I didn't even talk about the risk for the offspring as well but there is a risk in there. So it's really important to recognize this and then figure out what to do with it. So what do we know about treating OSA in pregnancy? There have been some not many studies and I'm probably listing all of them in here. So there have been some short term studies and RCTs that have demonstrated a hemodynamic improvement after CPAP treatment in women that had preeclampsia not women that had OSA. So once women were placed on CPAP at night there was an improvement in nighttime blood pressure and an improvement in nighttime cardiac output as well and some improvement in fetal outcomes and these were studies that were like that are at least a decade old now. Now more recently there was this non-randomized study that had 50 participants that were started on CPAP and 41 participants who did not accept CPAP. I don't know what the circumstances behind that were but these participants were placed on CPAP and comparing the ones that went on CPAP to the ones that did not there was an improvement in the prevalence of preeclampsia and we're talking 8% compared to 24%. So it was a significantly lower prevalence. In a randomized study that looked at women that had gestational diabetes there was a significant improvement. This was a small study. It was only, and I'll show you details of it later, it was only about 18 participants that received CPAP and 18 that did not. But there was an improvement in insulin disposition index after per protocol analysis and when they used the counterfactual analyses they were significant improvement in multiple measures of glucose metabolism. And then a recent RCT which is the largest one today had about 300 women that were randomized to either CPAP or no CPAP demonstrated that there was a significantly lower diastolic blood pressure in women that had CPAP. So what is the issue here and why are we talking about it? So I'm going to start with some data about the non-pregnant population and this is data from Dr. Patel that was recently published and it did show that if you look, so red are women, blue are men. So if you look at men versus women women had a lower adherence and then younger women, so reproductive age women, had the lowest adherence of all age groups. And then when you look at CPAP adherence at PAP initiation compared to 90 days in here, it looks like men and women start about the same and then they diverge later. But again look at that reproductive age group, they're starting at a lower PAP adherence to begin with. But then when you look at the 90 day adherence it seems like women fall off again. So all these people, we don't have any data about how many of them were pregnant but probably not many because we don't currently, well hopefully we'll start screening for CPAP in pregnancy but this is not common practice. So this is one of the studies that I showed you earlier, the one that took women with gestational diabetes and randomized them. So they only followed them for two weeks and they started CPAP at 30 weeks of gestation. But only 46% were adherent to CPAP and average use was about 3.5 hours per night. This other study, this was the non-randomized study that had 51 patients, no I'm sorry, this is a randomized study that I didn't talk about earlier. It randomized the CPAP in two phases. The first phase was a sham CPAP and they noticed that their adherence was very bad. And then the second phase was CPAP versus sleep hygiene rather than sham CPAP. So what they had was an adherence of 4% in phase 1 or an average of about 20 minutes per night and 18% in phase 2 with an average of 1.3 hours. So these women are barely putting it on and probably not even falling asleep with it yet. And this was the last study that I said was the biggest one. So here they had 153 women that were randomized to CPAP and a similar number that were controls. They selected women that were high risk, so either obesity or hypertension or a history of diabetes, etc. And they started early in pregnancy and followed them throughout pregnancy. Their adherence to therapy was only 7.2% and their average usage was 2.5%. So this is a major issue obviously and where are we going wrong with this population? And when I started looking at this, my thought had been that when I'm seeing these patients in the office and I start them on CPAP they're coming to see me because they're symptomatic. And I put them on CPAP and the majority, I never counted or went back and looked but I need to, the majority are motivated because they have a baby. But what is the reality of this and how does it happen? So let's talk about this. These are unpublished data so no pictures please. So CPAP adherence could be because of the factors that we heard about today. So a lot of nonspecific factors that could happen in young women or in people in general. And we had some survey data that talked about patients worried about drooling inside the mask, not liking the mask, their face gets swollen in pregnancy so the mask gets more uncomfortable, etc. But we didn't have a lot of in-depth data. And then there are these specific factors to pregnancy and some factors that may happen in others but they could be exacerbated by pregnancy. So we set out to do a qualitative study where we had women that were not pregnant but reproductive age women about the same age as the pregnant patients and then we had a group of pregnant women and we ran a 60 to 90 minute qualitative interview with each one of them. And we talked to them about different things and we used both deductive and inductive coding so the parameters that were coming up were either things that we thought would be important or things that were coming up during the interview that we had not considered. So there were some things that were not specific to pregnancy such as concern for own health. So patients were very, very, very alarmed when they heard about the severity of their sleep apnea. They were hoping that they would have more energy if they got treated. They were hoping that they would sleep better, live longer as well, and then they say you need to breathe to live so this had been a real concern to me. And all of these are facilitators, obviously the fact that they worry about their own health so everything in green. The red that you'll see next is barriers. So then there were some factors that were specific to pregnancy and like we had expected, the health of the fetus or the child was a major motivator for these women to use PAP in pregnancy. So many of them were saying I was having a baby, I did it for the baby, I want to be around for the baby so I need to be healthy for them. It wasn't just me, it was the baby and this kept coming back in so many interviews like nearly most of them. So they think that being pregnant also makes you more motivated because you're taking care of your baby as well. So this was an important thing to understand. And then we wanted to examine whether a partner, like how does the partner influence CPAP use in women that were pregnant. So is the partner as concerned about the health of the baby and could they be a motivator for the use of CPAP? So the things in green were like if I use the machine that way I didn't snore, that way I didn't keep him up. So the women were using the CPAP in order to help their husband or partner or whatever it is to help them sleep as well. But then some other women so there were both barriers and facilitators, some other women were saying well he's generally supportive, he wants me to be healthy but I'm sure he wasn't thrilled about this. And then the husband happened to be there during the interview there sometimes in the background. So yeah he's shrugging, I know he's definitely not thrilled about that. So that's definitely something that we need to think about. And then we asked them about like what about the CPAP, like how do you think about it when you see it, what were your thoughts about it. And like women were saying things like I was mad, I was mad about putting it on, mad about how to do it, this is disgusting like they really did not like the way it looked. And then other women were talking about everything is changing at a different time period like one thing I need to change every two months, another thing I need to change every three months. And these are women that have monthly appointments at least until they're about seven months and then after that it's a doctor's appointment every week if they don't need to be monitored. So they have a lot of healthcare needs that are happening so having to worry about yet another thing was not an easy thing to do. Intimacy was an issue. So mothers claimed that the appearance of CPAP negatively impacted intimacy. So one patient was saying like the first time around I was like hesitant to use it because I didn't want him to see me. But the second time around I was like oh well I don't care because I'm pregnant now so it doesn't really matter what he thinks. And then one other person was saying well the romance is dead, we're going to have a baby that's going to change things but here's this thing that is the CPAP that's going to kill it even before the baby is here. And one person was saying there's no way that I could cuddle my husband when I'm sleeping. I'm basically an elephant. Cost concerns were definitely an issue and I know that varies throughout the states. In our state pregnant women that are on state insurance can get CPAP. In other states that is not covered because it's considered a chronic condition and then Medicaid would not cover that. So patients were concerned about it and I'm not going to read all of this. And then the trust in providers. So one of our concerns about this, so we wanted to look at pregnant versus non-pregnant but also look at women of color versus white women. So we haven't finished all these analyses yet but this is one person that was black and her doctor was not. And she was saying the doctor prescribed Flonase and said that it didn't affect me or the baby but I don't know how much I really believe that. I'm not saying that she would lie to me. I just don't know if I believe all these studies and things. I feel she's nice and trustworthy and honest but the things she learns from her profession I believe that people lie and are just like how they say vaccines don't cause autism. I don't believe that. So that is a major issue and we don't know yet whether if the patient's doctor had been black as well if that message would have been transmitted differently like Amy was talking about earlier. There were some postpartum concerns as well. One of the and this was something that we did not expect because we were not interviewing them postpartum. We were interviewing them during pregnancy but some of them we couldn't catch to interview during pregnancy and we caught them after they had delivered and some had some anticipated concerns about what the postpartum period was going to be like and it was really interesting because I had not thought about many of these things. So I don't want it meaning the CPAP to wake him up. I can't do this right now. The baby needs me more than that. Meaning that if I spend my energy on the CPAP then the baby is going to be lacking in attention. And then many women had said that they are concerned that if they take the CPAP off the air that's coming out of it is going to wake the baby up and if anybody has had a baby they know they don't want them to wake up in the middle of the night. And what if I don't hear the baby? The CPAP machine is a little bit loud. What if there's something wrong with the baby and I need to wake up for them? And these were women that were anticipating what the postpartum period was going to be like. They had not experienced it yet. But they're talking about every time putting it on between feedings that's going to suck. But then they say that they want to focus on the end goal and making sure that they're healthy for the baby. And then others were saying I don't think it's feasible with everything that you have to do. It's going to be a disaster. And then others talking about this is something that I had not thought about. They're talking about not having the CPAP tubings fall into the bassinet with the baby. So I started using that when I talked to my patients. So in summary, obstructive sleep apnea is associated with adverse perinatal outcomes. CPAP therapy does show some promise in that it improves, it seems to improve cardiovascular outcomes, but we're waiting on larger trials to be able to demonstrate that. But again, if we don't have good CPAP adherence, how can we do large trials and then trust these end points? We might end up with how we are with a non-pregnant population. And then adherence to CPAP is problematic with barriers that are influenced by pregnancy and some other barriers that are not specific to pregnancy. And that's it. Thank you. Applause. Music

CPAP adherence

race

ethnicity

socioeconomic status

pregnancy

marginalized populations

sleep apnea

disparities

culturally tailored interventions

patient-centered interventions