Vol. 14 •Issue 14 • Page 21

By James R. Criasia, MA, RRT

Obstructive Sleep Apnea (OSA), characterized by recurrent obstructions of the upper airway, results in episodic asphyxia, oxygen desaturation, and disruptions of normal sleep pattern.

Most OSA patients have symptoms related to poor quality sleep (excessive daytime tiredness and sleepiness, lack of concentration, memory impairment) and psychological disturbances at times.

OSA is associated with both cardiovascular and cerebrovascular morbidity and mortality. Because of these impairments, OSA patients often report having a poor quality of life in social, emotional and physical domains.

There is, of course, hope for these patients in the form of CPAP, an effective treatment as many studies can attest to. But in order for the therapy to work, patients must use it in the privacy of their own bedrooms. And getting compliance is often easier said than done. There are some reasonable ways to monitor patient compliance. And at the top of the list is a need to explain to patients their own success with CPAP can be hampered by poor compliance.

It is not hard for therapists to understand why wearing a cumbersome facemask or irritating nose pillows throughout sleep every night would be difficult.


Various studies on CPAP compliance have relied on patients’ reported use. These data generally show compliance rates of 75 percent to 85 percent or better, with use pegged at about five hours or more per night. Data relying on built-in timers and other independent monitors show much poorer compliance rates (only 40 percent to 70 percent) with hours used varying between 4 to 6 hours per night.

The most widely accepted definition of compliance is four hours per night for 70 percent or more of the nights. It is clear patient-reported compliance is not accurate.

OSA can be devastating. If not properly treated, the patient can expect to die within 10 years. During that 10 years, the patient will experience physical and psychological problems, frequent and costly hospital stays, and a poor quality of life.

Getting patients to comply is difficult and expensive. CPAP compliance programs do add to costs and do cut into profits. Most of the increased cost to monitor compliance is not reimbursed by third-party insurance payers, but that notion is changing, and some insurance providers will negotiate, because they are now realizing that CPAP use reduces long-term health costs in OSA patients.

Home care companies remain the main providers of CPAP equipment, and for the most part, home company staff provide only minimal compliance monitoring, if any at all.

At our home care agency, we have found compliance adds about $100 in costs per CPAP start to offer both a monitoring program and an evaluation program.

We are not directly reimbursed for it; but in the long run, providing the service is not only good for the patient, it is definitely good for business.


There are numerous CPAP compliance monitoring systems available, so choosing the right one for your patients’ needs can be a bit tricky. Don’t be drawn in by sophisticated systems that offer auto-adjusting pressure, pressure monitoring, leak measurement and apnea-hypopnea index measurement. These systems are indicated for only a small number of CPAP patients. These types of systems can be large, bulky, and expensive.

On the other hand, systems that offer a simple recording modem that calls you or a data recording card are both simple to use and less costly. Such data can be easily downloaded to the most convenient collection point.

We use the modem-based system because it allows us easy, concurrent data to monitor the patient’s daily progress. Using this system we are able to maintain a CPAP compliance rate of 85 to 90 percent. This is substantially better then the 60 percent to 70 percent generally reported in the literature.

The second part of our program allows us to monitor quality of life improvements in patients who have been compliant for at least six months. To gain data for that study, we use the SF-12, a simple quality of life questionnaire that has established validity and reliability in monitoring quality of life changes in both general and specific populations.

SF-12 monitors and reports scores in two specific domains: physical component score (PCS) and mental component score (MCS). Both PCS and MCS scales are scored using norm-based methods with regression weights and a constant to reflect normal for the general U.S population. This yields a mean score of 50 and a standard deviation of 10 for both the PCS and MCS.

The accompanying graph shows the results of 291 CPAP-compliant patients monitored over an eight-month time span. Patients compliant with their therapy experienced a significant 7 point (7/10 of a standard deviation unit) improvement in their MCS. This section of the SF-12 looks at the patient’s vitality, social functioning, emotional-functioning, and general mental health. The PCS improved by only 1 point in this group.

This is consistent with other studies that have shown the greatest amount of improvement in OSA patients occurs in their vitality and emotional domains.

What this shows is that by implementing a monitoring and evaluation system in your home care practice, you will be providing a valuable service to your patients and an ongoing quality monitor. The monitoring system will help you demonstrate that your patients are using their equipment and benefiting from it. n

James R. Criasia, Canton, Mass., is the director of Respiratory Care Services, Home Health Corp. of America.