Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City.
Division of Medical Informatics, Department of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, Kansas City.
JAMA Netw Open. 2024 Sep 3;7(9):e2432468. doi: 10.1001/jamanetworkopen.2024.32468.
Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited.
To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023.
Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis.
All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors.
Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90).
In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.
正压通气（PAP）是治疗阻塞性睡眠呼吸暂停（OSA）的一线治疗方法，但关于其对主要不良心血管事件（MACE）和死亡率预防的有益效果的证据有限。
确定在美国中部，OSA 老年患者中，PAP 的启动和使用是否与死亡率降低和 MACE 发生率降低相关。
设计、地点和参与者：这是一项回顾性临床队列研究，纳入了从多个州、全州、多年（2011-2020 年）的 Medicare 按服务付费数据中识别出的 2 项或更多明确 OSA 索赔的 Medicare 受益人的多状态、全州、多年数据。参与者的随访时间为死亡或 2020 年 12 月 31 日截止。分析于 2021 年 12 月至 2023 年 12 月进行。
基于 OSA 诊断后的 PAP 索赔，证据表明 PAP 的启动和使用。
全因死亡率和 MACE，定义为心肌梗死、心力衰竭、中风或冠状动脉血运重建的综合指标。使用双稳健 Cox 比例风险模型和逆概率治疗权重来估计治疗效果大小，同时控制社会人口统计学和临床因素。
在纳入分析的 888595 名 OSA 患者中（中位[IQR]年龄为 73 [69-78]岁；390598 名女性[43.9%]；8115 名亚洲人[0.9%]、47122 名黑人[5.3%]和 760324 名白人[85.5%]；中位[IQR]随访时间为 3.1 [1.5-5.1]年），那些有 PAP 启动证据的患者（290015[32.6%]）全因死亡率（风险比[HR]，0.53；95%CI，0.52-0.54）和 MACE 发生率风险（HR，0.90；95%CI，0.89-0.91）显著降低。每年 PAP 索赔的较高四分位数（Q）与死亡率降低（Q2 HR，0.84；95%CI，0.81-0.87；Q3 HR，0.76；95%CI，0.74-0.79；Q4 HR，0.74；95%CI，0.72-0.77）和 MACE 发生率风险降低（Q2 HR，0.92；95%CI，0.89-0.95；Q3 HR，0.89；95%CI，0.86-0.91；Q4 HR，0.87；95%CI，0.85-0.90）逐渐相关。
在这项对 Medicare 受益人的 OSA 队列研究中，PAP 的使用与全因死亡率和 MACE 发生率降低相关。结果可能为评估 OSA 治疗对降低老年人心血管风险和死亡率的重要性的试验提供信息。
