As you all know, I am a Registered Respiratory Therapist (RRT) who works with the diagnosis and treatment of sleep disordered breathing. As discussed in previous blogs, Obstructive Sleep Apnea (OSA) and Continuous Positive Airway Pressure (CPAP) are my bread and butter. OSA is defined as "repeated episodes of upper airway collapse and obstruction during sleep" (Rundo, J. V., 2019, para. 1).
When determining why someone may or may not adhere to their CPAP therapy, there are countless factors at play. The Social-Ecological Model (SEM) of Health will help to explain a number of these factors. The Centres for Disease Control and Prevention (CDC) breaks this model down into four categories that factor into our health: individual, personal relationships, community settings and society (CDC, 2022).
When looking at the first category of the SEM, we are analyzing individual factors that may influence a patient's CPAP adherence. According to Wolkove et al. (2008), patients who continued to be compliant with their therapy noticed improvements in their quality of life such as better sleep quality and more energy, while those that discontinued the use of therapy did so for a number of reasons, though the most common reason was the dislike or discomfort with CPAP.
The next thing to consider after discomfort with therapy would be health determinants that may influence the patient. According to the Canadian Public Health Association (CPHA), there are 14 social determinants of health (CPHA, n.d.). Among those 14 health determinants, there are a few that stand out more than others as possible influencing factors for those remaining untreated for their OSA. Firstly, income is a major contributing factor for patients. In New Brunswick, we do not have any government funding for CPAP therapy. This means the financial burden is put solely on the patient. This becomes a huge issue for those with lower incomes or lack of private insurance and often results in discontinuation of therapy despite any improvements the patient may notice.
Education is another major influencing factor for CPAP adherence. Lack of education about OSA and the risks associated with remaining untreated can be a huge contributing factor for adherence to therapy. When looking at the number of patients who are discontinuing CPAP therapy due to "no perceived need", that is of extreme concern to me and only further enhances the need for education (Wolkove et al., 2008, table 5). One thing to consider when looking at education provided to patients on the risks of untreated OSA is the impact this may have on other chronic diseases. Due to the negative impact of untreated OSA on many other chronic diseases, it is not uncommon for CPAP therapy to be of utmost importance in management of other chronic diseases. Untreated OSA has been linked with conditions such as myocardial infarction, stroke, atrial fibrillation, hypertension and diabetes, to name a few (Laratta et al., 2017, para. 7). In order to improve chronic disease management of patients with OSA and other comorbidities, these patients must be educated on the associated risks. It is also important to note that since CPAP is a treatment for OSA, it is a management tool for OSA as a chronic disease as well, in the presence of other comorbidities and on its own.
Unfortunately, another influencing factor is Aboriginal status (CPHA, n.d.). Within my personal career, I am aware that some companies do not work with Non-Insured Health Benefits (NIHB), a program that provides health benefit coverage to First Nations patients (Government of Canada, 2022), when it comes to funding for CPAP therapy for Indigenous patients. To me, this should be a non-issue as all patients should be treated equally, however that is not the case and these patients are required to seek treatment elsewhere.
While the individual category of the SEM includes a lot of contributing factors for CPAP adherence, there are other influences as well. The next category of the SEM includes personal relationships. These relationships may be significant others, close friends, family, etc. (CDC, 2022). In my own personal experience, these relationships typically have a positive influence on CPAP adherence. Often, snoring and OSA in general have a negative impact on the sleep quality of a bed partner therefore, CPAP helps improve these relationships. It can be the case however that a patient feels forced into a therapy that they do not want and this can sometimes put a damper on their relationship.
The community level of the SEM is one which includes "schools, workplaces, and neighborhoods" (CDC, 2022). This level is of extreme influence for some patients with CPAP therapy as some workplaces require proof of treatment for their workers with diagnosed OSA. This is often due to risk of falling asleep on the job and for the most part results in these patients adhering to their CPAP therapy. It may also have an impact on students who are unable to focus on schoolwork. In my personal experience, adherence to CPAP therapy often helps with concentration and attention as they are feeling as though they have more energy throughout the day.
The final level of the SEM is the societal level. This level is of extreme influence for our patients here in New Brunswick as well, due to funding issues. As previously mentioned, there is no government funding for CPAP therapy in New Brunswick and this certainly plays into long-term use of therapy. If a patient does not have a private insurance plan or funding agency that covers these units, they have to pay for the CPAP out of pocket. Unfortunately, we also run into some insurance plans not covering this type of therapy. This is especially common for seniors plans in NB. For instance, New Brunswick has a number of seniors with BlueCross coverage that do not have coverage for any CPAP supplies (Medavie Blue Cross, 2022). When looking at the lack of coverage and the fact that a number of seniors are living on a fixed income, the thought of paying for a CPAP machine out of their own pocket is just not an option. This often leads to these patients remaining untreated for their OSA despite the need for therapy. Often these patients are also the ones who have the most comorbidities, which could be improved and better managed if using CPAP therapy to treat their OSA.
When looking to the future of healthcare in relation to CPAP therapy and adherence to therapy, in my opinion, the most important thing to address is education. Whether it be education to other clinicians on the importance of CPAP therapy and the risks associated with untreated OSA, so that we are all on the same page, or education to the patient themselves, so that they are aware and able to make the most informed health decisions, education is a must. Another future (potential) change that would be of extreme benefit to all patients, would be for all provinces to follow suit and add CPAP therapy to the list of covered items. This is already the case in some provinces such as Ontario and Alberta but is not universal across all provinces, especially in the Atlantic provinces. This would eliminate the income component of the health determinants and result in more patients being treated for their OSA. At the end of the day, the proper assessment of a need for CPAP and adherence to the therapy is of great consequence to the public, the provinces and Canada as a whole.
References
Alila Medical Media (n.d.). Obstructive Sleep Apnea. [Photograph]. News Medical Life Sciences. https://www.news-medical.net/health/Obstructive-Sleep-Apnea-in-Children.aspx
Canadian Public Health Association. (n.d.) What are the social determinants of health? https://www.cpha.ca/what-are-social-determinants-health
Centers for Disease Control and Prevention. (2022). The Social-Ecological Model: A Framework for Prevention. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Government of Canada. (2021). About the Non-Insured Health Benefits Program. https://www.sac-isc.gc.ca/eng/1576790320164/1576790364553
Laratta, C. R., Ayas, N. T., Povitz, M., & Pendharkar, S. R. (2017). Diagnosis and treatment of obstructive sleep apnea in adults. Canadian Medical Association Journal, 189(48), 1481-1488. https://doi.org/10.1503/cmaj.170296
Medavie Blue Cross. (2022). Seniors' Health Program. https://www.medaviebc.ca/en/plans/seniors-health-program
Rundo, J. V. (2019). Obstructive sleep apnea basics. Cleveland Clinic Journal of Medicine, 86, 2-9. https://doi.org/10.3949/ccjm.86.s1.02
Sunshine Community Health Centre. (n.d.). Social Determinants of Health. [Photograph]. https://www.sunshineclinic.org/blog/social-determinants-of-health/
Wolkove, N., Baltzan, M., Kamel, H., Dabrusin, R., & Palayew, M. (2008). Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Canadian Respiratory Journal, 15(7), 365-369. 10.1155/2008/534372
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