Positive Airway Pressure Adherence, Mortality, and Cardiovascular Events in Patients with Sleep Apnea.

Rationale: Randomized controlled trials showed no effect of positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA) on cardiovascular (CV) risk. However, patient selection and low PAP adherence preclude the generalization of their data to clinical samples. Objectives: To evaluate the association between hours of PAP use, mortality, and CV morbidity in real-life conditions. Methods: Data from the Pays de la Loire Cohort were linked to health administrative data to identify incident major adverse cardiovascular events (MACEs; a composite outcome of mortality, stroke, and cardiac diseases) in patients with OSA who were prescribed PAP. Cox proportional hazards analyses were conducted to evaluate the association between MACEs and quartiles of average daily PAP use over the study period. Measurements and Main Results: After a median follow-up of 6.6 years, 961 of 5,138 patients experienced MACEs. Considering nonadherent patients (0-4 h/night) as the reference group, adjusted hazard ratios (95% confidence intervals) for MACEs were 0.87 (0.73-1.04) for the 4-6 h/night group, 0.75 (0.62-0.92) for the 6-7 h/night group, and 0.78 (0.65-0.93) for the ⩾7 h/night group (P = 0.0130). Sensitivity analyses using causal inference approaches confirmed the association of PAP use with MACEs. The association was stronger in male patients (P value for interaction = 0.0004), patients without overt CV disease at diagnosis (P < 0.0001), and those belonging to the excessively sleepy symptom subtype (P = 0.060). Conclusions: These real-life clinical data demonstrate a dose-response relationship between PAP adherence and incident MACEs in OSA. Patient support programs may help improve PAP adherence and CV outcomes in patients with OSA.

Sleep Apnea-Specific Hypoxic Burden, Symptom Subtypes, and Risk of Cardiovascular Events and All-Cause Mortality.

Rationale: Data from population-based cohorts suggest that symptom subtypes and obstructive sleep apnea (OSA)-specific hypoxic burden (HB) could help to better identify patients with OSA at high cardiovascular (CV) risk. Objectives: We aimed to evaluate whether those new markers are associated with the risk of major adverse CV events (MACE) in clinical setting. Methods: Data from the Pays de la Loire cohort were linked to health administrative data to identify the occurrence of MACE (a composite outcome including all-cause mortality, acute myocardial infarction, stroke, and unplanned coronary revascularization) in patients with newly diagnosed OSA and no overt CV disease. Latent class analysis was used to identify subtypes based on eight clinically relevant variables. HB was defined as the total area under the respiratory event-related desaturation curve. Cox proportional hazards models were used to evaluate the association of symptom subtypes and HB with MACE. Measurements and Main Results: Four symptom subtypes were identified (minimally symptomatic [22.0%], disturbed sleep [17.5%], excessively sleepy [49.8%], and moderately sleepy [10.6%]). After a median follow-up of 78 months (interquartile range, 52-109), 592 (11.05%) of 5,358 patients experienced MACE. In a fully adjusted model, HB and overall nocturnal hypoxemia assessed by sleep time with oxygen saturation <90% were the only predictors of MACE (hazard ratio, 1.21; 95% confidence interval, 1.07-1.38; and hazard ratio, 1.34; 95% confidence interval, 1.16-1.55, respectively). The association appeared stronger toward younger patients and women. Conclusion: In clinical setting, patients with OSA who demonstrate elevated OSA-specific HB are at higher risk of a CV event and all-cause mortality. Symptom subtypes were not associated with MACE after adjustment for confounders.

Cancer risk in patients with sleep apnoea following adherent 5-year CPAP therapy.

BACKGROUND: Increasing evidence suggests that obstructive sleep apnoea (OSA) contributes to cancer risk; however, limited data are available on the impact of continuous positive airway pressure (CPAP) therapy on cancer incidence. We aimed to determine whether adherence to CPAP therapy is associated with a reduction in all-cancer incidence compared with nonadherent patients with OSA. METHODS: The study relied on data collected by the multicentre Pays de la Loire Sleep Cohort study, linked to health administrative data, so as to identify new-onset cancer. We included patients who were prescribed CPAP for OSA, with no history of cancer before the diagnostic sleep study or during the first year of CPAP. Patients with documented CPAP use for ≥4 h per night were defined as adherent. Those who discontinued or used CPAP <4 h per night constituted the nonadherent group. A propensity score inverse probability of treatment weighting analysis was performed to assess the effect of CPAP adherence on cancer risk. RESULTS: After a median (interquartile range) follow-up of 5.4 (3.1-8.0) years, 437 (9.7%) out of 4499 patients developed cancer: 194 (10.7%) in the nonadherent group (n=1817) and 243 (9.1%) in adherent patients (n=2682). The final weighted model showed no significant impact of CPAP adherence on all-cause cancer risk (subdistribution hazard ratio 0.94, 95% CI 0.78-1.14). CONCLUSIONS: Adherence to CPAP therapy in OSA patients was not associated with a reduction in all-cancer incidence. Whether adherent CPAP therapy of OSA might reduce the risk of specific cancer sites should be further evaluated.

Long-term dentoskeletal side effects of mandibular advancement therapy in patients with obstructive sleep apnea: data from the Pays de la Loire sleep cohort.

OBJECTIVES: Mandibular advancement devices (MADs) are the main therapeutic alternative to continuous positive airway pressure for obstructive sleep apnea. Our aim was to evaluate the long-term dentoskeletal side effects of MADs and to identify the predictive factors for these side effects. MATERIALS AND METHODS: Patients from the Pays de la Loire cohort treated with a custom-made MAD for at least 1 year were included in this retrospective study. Digital cephalometric analyses were performed at baseline and at follow-up. RESULTS: We included a total of 117 patients, treated with a MAD for a median [interquartile range] of 4.6 [2.6-6.6] years. The main significant side effects were a decrease in overbite (- 0.5 ± 1 mm), overjet (- 0.7 ± 1 mm) and maxillary incisor inclination (- 2.5 ± 2.8°) and an increase in mandibular incisor inclination (+ 2.2 ± 2.7°). Subjective side effects were not linked to the observed dentoskeletal changes. Current smokers were at higher risk of overjet modifications. A pre-existing anterior open-bite was associated with a greater decrease in overbite. Treatment duration was associated with a more pronounced mandibular incisor proclination. Propulsion was negatively associated with maxillary incisor retroclination. CONCLUSIONS: Long-term dentoskeletal side effects were mainly moderate dental side effects. Some predictive factors were shown to be associated with more pronounced changes. Subjective side effects did not appear to be reliable tools to detect dentoskeletal side effects. CLINICAL RELEVANCE: Regular follow-up with clinical examination and regular radiographs is mandatory. The predictive factors could be of interest for a better selection of patients and to individualize follow-up.

Impacts of a navigation program based on health information technology for patients receiving oral anticancer therapy: the CAPRI randomized controlled trial.

BACKGROUND: The emergence of oral delivery in cancer therapeutics is expected to result in an increased need for better coordination between all treatment stakeholders, mainly to ensure adequate treatment delivery to the patient. There is significant interest in the nurse navigation program's potential to improve transitions of care by improving communication between treatment stakeholders and by providing personalized organizational assistance to patients. The use of health information technology is another strategy aimed at improving cancer care coordination that can be combined with the NN program to improve remote patient follow-up. However, the potential of these two strategies combined to improve oral treatment delivery is limited by a lack of rigorous evidence of actual impact. METHODS/DESIGN: We are conducting a large scale randomized controlled trial designed to assess the impact of a navigation program denoted CAPRI that is based on two Nurse Navigators and a web portal ensuring coordination between community and hospital as well as between patients and navigators, versus routine delivery of oral anticancer therapy. The primary research aim is to assess the impact of the program on treatment delivery for patients with metastatic cancer, as measured by Relative Dose Intensity. The trial involves a number of other outcomes, including tumor response, survival, toxic side effects, patient quality of life and patient experience An economic evaluation adopting a societal perspective will be conducted, in order to estimate those health. care resources' used. A parallel process evaluation will be conducted to describe implementation of the intervention. DISCUSSION: If the CAPRI program does improve treatment delivery, the evidence on its economic impact will offer important knowledge for health decision-makers, helping develop new follow-up services for patients receiving oral chemotherapy and/or targeted therapy. The process evaluation will determine the best conditions in which such a program might be implemented. TRIAL REGISTRATION: NCT 02828462 . Registered 29 June 2016.

Sleep Apnea and Incident Unprovoked Venous Thromboembolism: Data from the Pays de la Loire Sleep Cohort.

BACKGROUND: Previous studies have reported inconsistent findings regarding the association between obstructive sleep apnea (OSA) and incident venous thromboembolism (VTE). More specifically, the association between OSA and unprovoked VTE was barely evaluated. We aimed to evaluate whether apnea hypopnea index (AHI) and nocturnal hypoxemia markers were associated with unprovoked VTE incidence in patients investigated for OSA. MATERIAL AND METHODS: Data from the Pays de la Loire Sleep Cohort were linked to the French health administrative data to identify incident unprovoked VTE in patients suspected for OSA and no previous VTE disease. Cox proportional hazards models were used to evaluate the association of unprovoked VTE incidence with AHI and nocturnal hypoxemia markers including the time spent under 90% of saturation (T90), oxygen desaturation index, and hypoxic burden (HB), a more specific marker of respiratory events related to hypoxia. The impact of continuous positive airway pressure (CPAP) was evaluated in the subgroup of patients who were proposed the treatment. RESULTS: After a median [interquartile range] follow-up of 6.3 [4.3-9.0] years, 104 of 7,355 patients developed unprovoked VTE, for an incidence rate of 10.8 per 1,000 patient-years. In a univariate analysis, T90 and HB predicted incident VTE. In the fully adjusted model, T90 was the only independent predictor (hazard ratio: 1.06; 95% confidence interval: [1.01-1.02]; p = 0.02). The CPAP treatment has no significant impact on VTE incidence. CONCLUSION: Patients with more severe nocturnal hypoxia are more likely to have incident unprovoked VTE.

Overnight pulse rate variability and risk of major neurocognitive disorder in older patients with obstructive sleep apnea.

BACKGROUND: Increasing evidence links obstructive sleep apnea (OSA) to cognitive decline. Autonomic dysfunction assessed by heart rate variability is a promising early biomarker of cognitive impairment in populations without major neurocognitive disorder (MND). We aimed to determine whether nocturnal pulse rate variability (PRV) extracted from oximetry signal and OSA severity could predict MND onset among older OSA patients. METHODS: This study relied on data collected within the multicenter longitudinal Pays de la Loire Sleep Cohort, linked to health administrative data to identify new-onset MND. We included patients ≥60 years with newly diagnosed OSA, and no history of MND or atrial fibrillation. Cox proportional-hazards models were used to evaluate the association of MND with indices of PRV and OSA severity generated from sleep recordings. RESULTS: After a median follow-up of 6.8 [4.7-9.4] years, 70 of 3283 patients (2.1%) had been diagnosed with MND. In multivariable Cox models, MND incidence was associated with age (p < 0.0001), depression (p = 0.013), and PRV assessed by the root mean square of the successive normal-to-normal (NN) beat interval differences (RMSSD; p = 0.008) and standard deviation of NN beat intervals (SDNN; p = 0.02). Patients with the highest quartile of RMSSD had a 2.3-fold [95%CI 1.11-4.92] higher risk of being diagnosed with MND. Indices of OSA and nocturnal hypoxia severity were not associated with MND. CONCLUSIONS: Within a large clinic-based cohort of older patients with OSA, we found an association between oximetry-based indices of PRV and the onset of MND. Nocturnal oximetry-derived PRV indices could allow the early identification of OSA patients at higher risk of MND.

Risk Factors for Sleepiness at the Wheel and Sleep-Related Car Accidents Among Patients with Obstructive Sleep Apnea: Data from the French Pays de la Loire Sleep Cohort.

PURPOSE: We aimed to determine the risk factors of sleepiness at the wheel among patients with obstructive sleep apnea (OSA) and to determine factors that were independently associated with reported sleep-related near-miss accidents or car accidents. PATIENTS AND METHODS: This retrospective study was conducted on 843 OSA patients from the French Pays de la Loire sleep cohort database. Each patient completed surveys including anthropometric data, medical history, professional status, and data on alcohol and tobacco use. Epworth sleepiness scale (ESS) and sleep quality questionnaires were administered. Regarding driving, data were collected on occurrence of sleepiness-related near-misses or car accidents, and on distance driven per year. The primary dependent variable of interest was reported sleepiness at the wheel. RESULTS: On multivariable regression analysis, reported sleepiness at the wheel (n=298) was independently associated with younger age (p=0.02), male gender (p=0.009), marked nocturnal hypoxemia (p=0.006), lower BMI (p=0.03), absence of cardiovascular disease (p=0.022), executives or high degree jobs (p=0.003) and reported difficulty-maintaining sleep (p=0.03). Only past experience of sleepiness at the wheel (OR 12.18, [6.38-23.25]) and an ESS ≥11 (OR 4.75 [2.73-8.27]) were independently associated with reported car accidents (n=30) or near-miss accidents (n=137). CONCLUSION: In patients newly diagnosed with OSA, the risk of car accident seems multifactorial, and its evaluation should include multiple parameters such as patient self-reported sleepiness at the wheel, occurrence of sleepiness-related accidents, anthropometry, professional status, and insomnia complaints. Thus, it is possible to evaluate this risk and advise patients as early as the first visit at the sleep medicine clinic without waiting for the results of the sleep study.

Cardiovascular risk and mortality prediction in patients suspected of sleep apnea: a model based on an artificial intelligence system.

Objective. Cardiovascular disease (CVD) is one of the leading causes of death worldwide. There are many CVD risk estimators but very few take into account sleep features. Moreover, they are rarely tested on patients investigated for obstructive sleep apnea (OSA). However, numerous studies have demonstrated that OSA index or sleep features are associated with CVD and mortality. The aim of this study is to propose a new simple CVD and mortality risk estimator for use in routine sleep testing.Approach. Data from a large multicenter cohort of CVD-free patients investigated for OSA were linked to the French Health System to identify new-onset CVD. Clinical features were collected and sleep features were extracted from sleep recordings. A machine-learning model based on trees, AdaBoost, was applied to estimate the CVD and mortality risk score.Main results. After a median [inter-quartile range] follow-up of 6.0 [3.5-8.5] years, 685 of 5234 patients had received a diagnosis of CVD or had died. Following a selection of features, from the original 30 features, 9 were selected, including five clinical and four sleep oximetry features. The final model included age, gender, hypertension, diabetes, systolic blood pressure, oxygen saturation and pulse rate variability (PRV) features. An area under the receiver operating characteristic curve (AUC) of 0.78 was reached.Significance. AdaBoost, an interpretable machine-learning model, was applied to predict 6 year CVD and mortality in patients investigated for clinical suspicion of OSA. A mixed set of simple clinical features, nocturnal hypoxemia and PRV features derived from single channel pulse oximetry were used.

Association of Nocturnal Hypoxemia and Pulse Rate Variability with Incident Atrial Fibrillation in Patients Investigated for Obstructive Sleep Apnea.

Rationale: Nocturnal hypoxemia and sympathetic/parasympathetic imbalance might contribute to the occurrence or atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA). During sleep recordings, pulse rate variability (PRV) derived from oximetry might provide an accurate estimation of heart rate variability, which reflects the autonomic cardiovascular control. Objectives: We aimed to evaluate whether indices of oxygen desaturation and PRV derived from nocturnal oximetry were associated with AF incidence in patients investigated for OSA. Methods: Data from a large multicenter cohort of AF-free patients investigated for OSA between May 15, 2007, and December 31, 2017, were linked to health administrative data to identify hospitalized and nonhospitalized patients with new-onset AF. Cox proportional hazards models were used to evaluate the association between AF incidence and oximetry-derived indices automatically generated from sleep recordings. Results: After a median (interquartile range) follow-up of 5.34 (3.3-8.0) years, 181 of 7,205 patients developed AF (130 were hospitalized for AF). After adjusting for confounders, including anthropomorphic data, alcohol intake, cardiac, metabolic and respiratory diseases, ß blocker/calcium channel blocker medications, type of sleep study, study site, and positive airway pressure adherence, AF risk was associated with increasing nocturnal hypoxemia (P trend = 0.004 for quartiles of percentage of recording time with oxygen saturation <90%) and PRV (P trend < 0.0001 for quartiles of root mean square of the successive normal-normal beat interval differences), and decreasing sympathetic/parasympathetic tone (P trend = 0.0006 for quartiles of low-frequency power/high-frequency power ratio). The highest risk of AF was observed in patients with the highest quartiles of both the percentage of recording time with oxygen saturation <90% and the root mean square of the successive normal-normal beat interval differences compared with those with neither of these conditions (adjusted hazard ratio, 3.61; 95% confidence interval, 2.10-6.22). Similar associations were observed when the analyses were restricted to hospitalized AF. Conclusions: In patients investigated for OSA, nocturnal hypoxemia and PRV indices derived from single-channel pulse oximetry were independent predictors of AF incidence. Patients with both marked nocturnal hypoxemia and high PRV were at higher risk of AF. Oximetry may be used to identify patients with OSA at greatest risk of developing AF.

Association Between Nocturnal Hypoxemia and Cancer Incidence in Patients Investigated for OSA: Data From a Large Multicenter French Cohort.

BACKGROUND: Previous studies have yielded inconsistent findings regarding the association between OSA and cancer in humans. RESEARCH QUESTION: Is there an association between indexes of sleep-disordered breathing severity and cancer incidence in patients investigated for suspected OSA? STUDY DESIGN AND METHODS: Data from a large multicenter cohort of cancer-free patients investigated for OSA were linked to health administrative data to identify new-onset cancer. Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate the association of cancer incidence with OSA severity and nocturnal hypoxemia. RESULTS: After a median follow-up period of 5.8 years (interquartile range, 3.8-7.8), 718 of 8,748 patients (8.2%) had received a diagnosis of cancer. On unadjusted Kaplan-Meier survival analyses, cancer incidence was associated with increasing severity of OSA (log-rank test, P < .0005) and nocturnal hypoxemia (log-rank test, P < .0001 for both oxygen desaturation index and percent night time with oxygen saturation < 90% [T90]). After adjustment for anthropomorphic data, smoking and alcohol consumption, comorbid cardiac, metabolic, and respiratory diseases, marital status, type of sleep study, and study site, only T90 was associated with cancer incidence (adjusted hazard ratio, 1.33; 95% CI, 1.05-1.68 for T90 ≥ 13% vs < 0.01%; P = .02). On stratified analyses, the association between T90 and cancer appeared stronger in older patients with obesity and no adequate OSA therapy. Among the most frequent cancer sites, nocturnal hypoxemia was associated with lung and breast malignancies. INTERPRETATION: Nocturnal hypoxemia was associated with all-cancer incidence in patients investigated for OSA. Whether OSA therapy might reduce the risk of cancer needs further evaluation.

[Entre dynamique d'amélioration de la qualité des soins et conformisme administratif : comportements des établissements de santé français face au paiement à la performance (P4P)].

Le paiement à la performance (P4P) continue de se développer dans les systèmes de santé des pays industrialisés, malgré des preuves encore assez limitées de son efficacité. Cette étude propose de comprendre le comportement des établissements de santé face à ce nouveau mode de paiement en se basant sur l'expérimentation de P4P hospitalier conduite en France. Nous avons, pour cela, combiné une approche quantitative basée sur un questionnaire auprès des établissements participants et une analyse qualitative dans neuf établissements afin de mieux identifier les processus à l'œuvre. L'étude montre que des actions correctives ont été réalisées dans certains établissements mais que les effets du programme sur l'organisation restent en fait assez limités puisqu'ils s'opèrent davantage à la marge. Les comportements semblent être essentiellement le reflet d'une volonté de conformation des organisations aux attentes de la tutelle, sans transformations organisationnelles majeures. Il sera toutefois intéressant de voir comment des perceptions différentes structurent ces comportements sur le long terme.

Economic evaluation of patient navigation programs in colorectal cancer care, a systematic review.

Patient navigation has expanded as a promising approach to improve cancer care coordination and patient adherence. This paper addresses the need to identify the evidence on the economic impact of patient navigation in colorectal cancer, following the Health Economic Evaluation Publication Guidelines. Articles indexed in Medline, Cochrane, CINAHL, and Web of Science between January 2000 and March 2017 were analyzed. We conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality assessment of the included studies was based on the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Inclusion criteria indicated that the paper's subject had to explicitly address patient navigation in colorectal cancer and the study had to be an economic evaluation. The search yielded 243 papers, 9 of which were finally included within this review. Seven out of the nine studies included met standards for high-quality based on CHEERS criteria. Eight concluded that patient navigation programs were unequivocally cost-effective for the health outcomes of interest. Six studies were cost-effectiveness analyses. All studies computed the direct costs of the program, which were defined a minima as the program costs. Eight of the reviewed studies adopted the healthcare system perspective. Direct medical costs were usually divided into outpatient and inpatient visits, tests, and diagnostics. Effectiveness outcomes were mainly assessed through screening adherence, quality of life and time to diagnostic resolution. Given these outcomes, more economic research is needed for patient navigation during cancer treatment and survivorship as well as for patient navigation for other cancer types so that decision makers better understand costs and benefits for heterogeneous patient navigation programs.

Willingness to pay for informal care in France: the value of funding support interventions for caregivers.

OBJECTIVES: This article aims to assess the relationship between the monetary value of informal care - approximated with the caregiver's willingness to pay to reduce caregiving time - and the caregiver's need of three types of support services: care training, respite care and support group. Developing such services may be the only way to provide sustainable informal care in the future, along with efficient allocation. DATA & METHODS: Data used stemmed from two representative national surveys conducted by French National Institute of Statistics and Economic Studies and the French Head Office of Research, Studies, Evaluation and Statistics of the Social Affairs Ministry in 2008. The contingent valuation method was used to approximate the monetary value of informal care. The model was run on 223 informal caregivers of people with Alzheimer's Disease. Statistical analyses were performed using Heckman's two-step estimation strategy, which is known to correct selection bias. RESULTS: On average, one hour of informal care was estimated at 12.1. Monetary value of informal care was influenced by the caregiver's need of care training (p<0.01). No similar association was found for respite care or support group. DISCUSSION: Since informal caring value increases with caregivers' need of care training, improving caring skills and capabilities through training support is likely to improve its benefits.