A post-hoc analysis investigates the financial viability of extending tele-messaging to three years for enhancing CPAP adherence in patients with obstructive sleep apnea.

Interview by Alyx Arnett

Tele-messaging interventions have been shown to increase adherence to CPAP therapy among patients with obstructive sleep apnea (OSA). While these automated, device-driven communications have proven effective in the short term, little research exists on the cost-effectiveness of extending such interventions.

Recent research addresses this gap by evaluating the economic impacts of tele-messaging over three years. The post-hoc analysis builds on the Tele-OSA trial, which highlighted short-term benefits of tele-messaging.

The study compares three groups—those who received no messages, those who received messages for three months, and those who received messages for three years.

It centered on a willingness-to-pay threshold of $1,825 per year, or $5 per day, and researchers reviewed healthcare utilization from electronic health records, including metrics like hospitalizations, pharmacy services, office visits, and emergency interventions, to assess the potential reduction in overall healthcare costs due to improved CPAP use.

Study author Jaejin An, BPharm, PhD, discussed the study with Sleep Review via email. Her answers were prepared in consultation with the paper’s senior author, Dennis Hwang, MD.

[Editor’s Note: Read the study, “Cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure use,” in The American Journal of Managed Care.]

What led you to investigate the topic?

OSA poses a significant public health challenge, impacting the quality of life of many and likely increasing the risk of cardiovascular diseases and other conditions. Epidemiological studies suggest it could affect up to 30% of the population. PAP [positive airway pressure] therapy is highly efficacious in eliminating OSA and improving clinical outcomes. However, its real-world effectiveness is often compromised by poor adherence. This underscores the importance of implementing follow-up strategies to ensure sustained use of PAP therapy.

Given OSA’s widespread prevalence and the necessity for long-term management, there’s a critical need for cost-effective follow-up solutions, especially in the face of limited healthcare resources. The Tele-OSA study highlighted the positive effects of remote patient monitoring of PAP with automated feedback messaging on enhancing PAP adherence. This follow-up publication delves into a formal cost-effectiveness analysis of the intervention, emphasizing its potential benefits in managing OSA effectively.

Could you summarize your key findings?

The study results showed that three years of tele-messaging had the lowest average healthcare costs ($5,825/year) while having the highest average hours of PAP use (4.11 hours/day).

These findings were significant when compared with short-term messaging ($7,376/year and 2.84 hours/day) and usual care ($5,889/year and 3.03 hours/day) groups. These findings suggest that long-term tele-messaging is highly likely to be cost-effective if we are willing to pay $3.28 per day to increase average PAP use by one hour.

Were there any surprising findings?

The healthcare cost savings from the long-term tele-messaging group were somewhat surprising. Since patients are likely to use more PAP equipment (mask replacement, headgear, and other supplies), we expected costs from the long-term tele-messaging group may be higher than the other groups. However, we found significant cost savings from hospitalization, which were offset by increased costs in PAP equipment.

Also, higher costs and lower use of PAP among patients who received the short-term tele-messaging compared to the usual care group are somewhat unexpected. This may be due to a lack of randomization; long-term and short-term messaging groups were not randomly assigned. Therefore, we were not able to avoid potential unmeasured factors influencing the results.

How do you believe tele-messaging over three years influences patient behavior and adherence to PAP therapy more effectively than shorter interventions or usual care?

The tele-messaging intervention offers regular feedback to patients, potentially as often as every two to three days, when they fail to meet predetermined PAP usage goals. This approach ensures ongoing engagement and accountability over the long term. The positive impact of this messaging on PAP usage behavior is evident from the observation that patients receiving these messages did not have an increased number of clinician visits. This suggests that the improved adherence was directly related to the messaging itself rather than an increase in direct clinical interventions.

Moreover, the effectiveness of the messaging was apparent when it was discontinued. Patients whose messaging was stopped after three months began to show a decline in adherence levels. By the eight-month mark, their adherence rates were no different from the patients randomized to usual care. Conversely, for patients who continued to receive messages, adherence levels remained significantly higher, indicating that continuous messaging plays a crucial role in sustaining long-term adherence to PAP therapy.

Given the findings, what would you recommend to payers and healthcare policymakers regarding implementing long-term telehealth interventions for patients with OSA?

Cost-effective, technology-based, and data-driven approaches are crucial for enhancing outcomes for patients and healthcare systems, particularly in managing chronic diseases like OSA. Such tools can encompass remote patient monitoring, the evolution of workflow practices via case management teams, and the application of artificial intelligence. Expanding the incentives to encourage the use of innovative solutions, such as those demonstrated in the Tele-OSA study, is an essential step toward adoption.

What are the clinical implications for sleep medicine specialists?

Sleep medicine specialists play a critical role in managing OSA, encouraging adherence to PAP therapy, and enhancing patient outcomes. The tele-messaging intervention, as demonstrated in the Tele-OSA study, is an effective and cost-efficient method to boost adherence while not increasing the frequency of clinician-patient encounters.

What further research should be done?

The tele-messaging intervention described in the Tele-OSA study represents a straightforward approach to remote patient monitoring and automated patient engagement. Currently, we are advancing toward developing more sophisticated automated management systems. These systems aim to offer more detailed feedback, covering a wider range of behavioral domains such as education, cognitive behavioral modifications, motivational enhancement, and empowering patients to self-troubleshoot.

We are customizing content into Spanish to better serve minority populations, who have historically faced poorer outcomes in OSA management compared to the general population. The incorporation of artificial intelligence into these automated management and case management strategies holds promising potential for enhancing precision medicine and delivering personalized care.