Performance of Claims-Based Algorithms for Adherence to Positive Airway Pressure Therapy in Commercially Insured Patients With OSA

Abstract

Background: Positive airway pressure (PAP) therapy is first-line therapy for OSA, but consistent use is required for it to be effective. Previous studies have used Medicare fee-for-service claims data (eg, device, equipment charges) as a proxy for PAP adherence to assess its effects. However, this approach has not been validated in a US commercially insured population, where coverage rules are not standardized.

Research question: In a commercially insured population in the United States, how well do claims-based algorithms for defining PAP adherence correspond with objective PAP device usage?

Study design and methods: Deidentified administrative claims data of commercially insured patients (aged 18-64 years) with OSA were linked to objective PAP therapy usage data from cloud-connected devices. Adherence was defined based on device use (using an extension of Centers for Medicare & Medicaid Services 90-day compliance criteria) and from claims-based algorithms to compare usage metrics and identify potential misclassifications.

Results: The final sample included 213,341 patients. Based on device usage, 48% were adherent in the first year. Based on claims, between 10% and 84% of patients were identified as adherent (accuracy, sensitivity, and specificity ranges: 53%-68%, 12%-95%, and 26%-92%, respectively). Relative to patients who were claims-adherent, patients who were device-adherent had consistently higher usage across all metrics (mean, 339.9 vs 260.0-290.0 days of use; 6.6 vs 5.1-5.6 d/wk; 6.4 vs 4.6-5.2 h/d). Consistent PAP users were frequently identified by claims-based algorithms as nonadherent, whereas many inconsistent users were classified by claims-based algorithms as adherent.

Interpretation: In aggregate US commercial data with nonstandardized PAP coverage rules, concordance between existing claims-based definitions and objective PAP use was low. Caution is warranted when applying existing claims-based algorithms to commercial populations.

Keywords: OSA; adherence; administrative claims; positive airway pressure.

Graphical abstract

Figure 1

A-D, Number of days of use in the first year after the index date, by defined adherence groups. Blue represents patients who were defined as adherent, yellow represents those who were intermediate, red represents those who were nonadherent, and gray represents those who were identified as untreated, for a given adherence definition. A, When adherence was defined based on device usage (number of 90-d quarters where Centers for Medicare & Medicaid Services compliance criteria was met: adherent [4], intermediate [1-3], nonadherent [0]), patients who were adherent consistently used their devices on most days, whereas patients who were nonadherent did not. There was clear differentiation between groups. For (B) claims-based definition 1 (number of positive airway pressure-related claims > 90 d after index: adherent [≥ 1], nonadherent [0]), (C) claims-based definition 2 (number of device claims in the 13 mo from index date: adherent [> 12], intermediate [4-12], nonadherent [< 4]), and (D) claims-based definition 3 (number of 6-mo periods with one or more positive airway pressure-related claim in 2 y after diagnosis: adherent [≥ 3], nonadherent [1-2], untreated [0]), differentiation across groups was poor. Many patients defined as adherent used their devices on very few days, whereas many defined as intermediate or nonadherent used their devices every day or nearly every day.

Figure 2

A-D, Average number of days of use per week, by defined adherence groups. Blue represents patients who were defined as adherent, yellow represents those who were intermediate, red represents those who were nonadherent, and gray represents those who were identified as untreated, for a given adherence definition. A, When adherence was defined based on device usage (number of 90-d quarters where Centers for Medicare & Medicaid Services compliance criteria was met: adherent [4], intermediate [1-3], nonadherent [0]), patients who were adherent most often averaged 6 to 7 d of use per week, whereas patients who were nonadherent mostly averaged use on 0 to 2 d/wk. There was clear differentiation between groups. For (B) claims-based definition 1 (number of positive airway pressure-related claims > 90 d after index date: adherent [≥ 1], nonadherent [0]), (C) claims-based definition 2 (number of device claims in the 13 mo from index date: adherent [> 12], intermediate [4-12], nonadherent [< 4]), and (D) claims-based definition 3 (number of 6-mo periods with one or more positive airway pressure-related claim in 2 y after diagnosis: adherent [≥ 3], nonadherent [1-2], untreated [0]), differentiation across groups was poor. Patients in all adherence groups had use ranging from 0 to 7 d/wk.

Figure 3

A-D, Average hours of use per day, by defined adherence groups. Blue represents patients who were defined as adherent, yellow represents those who were intermediate, red represents those who were nonadherent, and gray represents those who were identified as untreated, for a given adherence definition. A, When adherence was defined based on device usage (number of 90-d quarters where Centers for Medicare & Medicaid Services compliance criteria was met: adherent [4], intermediate [1-3], nonadherent [0]), patients who were adherent most often used for a full night, whereas patients who were nonadherent most often averaged < 1 h/d. There was clear differentiation between groups. For (B) claims-based definition 1 (number of positive airway pressure-related claims > 90 d after index: adherent [≥ 1], nonadherent [0]), (C) claims-based definition 2 (number of device claims in the 13 mo from index date: adherent [> 12], intermediate [4-12], nonadherent [< 4]), and (D) claims-based definition 3 (number of 6-mo periods with one or more positive airway pressure-related claim in 2 y after diagnosis: adherent [≥ 3], nonadherent [1-2], untreated [0]), differentiation across groups was poor. Patients identified as adherent frequently averaged < 1 h/d of use, whereas many patients identified as intermediate or nonadherent used positive airway pressure on average for the full night.