COPD and OSA are each highly prevalent in the United States and are estimated to affect millions of adults. In addition, COPD often co-occurs in patients with OSA.
At CHEST 2022, experts discussed the current understanding of these diseases, how they interact, and strategies to optimize care during Challenges and Solutions for Care of COPD, OSA, and COPD/OSA Overlap on Sunday, October 16.
Session moderator, Nancy H. Stewart, DO, assistant professor of medicine at the University of Kansas Medical Center, spoke about understanding acute care sleep and its association with COPD/OSA. Valerie G. Press, MD, MPH, associate professor of medicine and pediatrics and executive medical director of specialty value-based care at the University of Chicago and medical director of Care Transition Clinic, discussed use of a team-based approach to optimize care for patients with COPD.
Lucas Donovan, MD, MS, assistant professor of medicine at the University of Washington and core investigator in health services research and development at VA Puget Sound Health Care System, highlighted how OSA is common among patients with COPD and is often associated with poor outcomes. He reviewed challenges to the diagnosis and treatment of OSA that are important for clinicians to recognize.
“The pathway from symptom recognition to effective treatment is fraught,” Dr. Donovan said.
Lack of access
Barriers exist at each step along the way, and particularly in the United States, lack of access to health care coverage has a major impact.
“You can’t get care if you don’t have coverage,” Dr. Donovan said.
About 10% of individuals in the US are uninsured, and the problem is worse in rural areas and among those with a lower education level, he said. Similarly, COPD disproportionately affects those same populations.
In addition, one-half of patients with COPD have a high-deductible health plan, which is associated with worse financial and clinical outcomes, Dr. Donovan noted.
Even patients who have access to insurance may not be able to find a specialized sleep provider. There is a market mismatch between the number of available and trained providers and the burden of sleep disorders across the population, Dr. Donovan said. Providers are also not equally distributed across the country and tend to be clustered in urban and more affluent areas.
Barriers to diagnosis and testing
OSA can often go undiagnosed because of barriers to symptom recognition.
“Patients frequently do not report sleep-related complaints. As few as 20% of individuals with concerns about sleep spontaneously report them,” Dr. Donovan said, also pointing out that clinicians document these reports in fewer than one-third of cases.
Among patients with recognized symptoms, there are barriers to testing.
“We know sleep referrals are often fumbled, and up to 50% of sleep testing referrals made by a primary care provider go nowhere,” Dr. Donovan said. “This is because we have an inadequate system to manage referrals and poor access to downstream services.”
Home sleep apnea testing offers one opportunity to mitigate barriers, but, unfortunately, patients with COPD are more likely to need polysomnography than other patients, he said. Recent guidelines also recommend polysomnography over home testing.
Risks for nonadherence
Among the existing barriers to treatment, one large representative study of a Centers for Medicare and Medicaid Services population showed that about 40% of patients with COPD and OSA were not adherent to CPAP. Lack of adherence was more likely in those who were younger, those with mood disorders, and those with Medicaid insurance.
In addition to the prominent health care disparities affecting many racial and ethnic populations, a greater risk for nonadherence exists among rural residents and those with lower education levels, Dr. Donovan said. Many patients with COPD may also need treatment beyond CPAP.
“Patients with COPD often need more of a hands-on role from specialists,” Dr. Donovan said.
More work should be done to anticipate risk among different patient populations and to streamline the process to optimize the progress from diagnosis to effective treatment, he concluded.