Performance of claims-based algorithms for adherence to positive airway pressure therapy in commercially insured patients with obstructive sleep apnea

BACKGROUND:Positive airway pressure (PAP) therapy is first line therapy for obstructive sleep apnea (OSA), but consistent use is required for it to be effective. Previous studies have used Medicare fee-for-service claims data (e.g., device and equipment charges) as a proxy for PAP adherence to assess its effects. However, this approach has not been validated in a United States (US) commercially insured population, where coverage rules are not standardized. RESEARCH QUESTION:In a commercially insured population in the US, how well do claims-based algorithms for defining PAP adherence correspond with objective PAP device usage? STUDY DESIGN AND METHODS:De-identified administrative claims data of commercially insured patients (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 and 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, specificity ranges: 53-68%, 12-95%, 26-92%, respectively). Relative to claims-adherent patients, device-adherent patients 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 days per week; 6.4 vs. 4.6-5.2 hours per day). Consistent PAP users were frequently identified by claims-based algorithms as non-adherent, while many inconsistent users were classified by claims-based algorithms as adherent. INTERPRETATION:In aggregate US commercial data with non-standardized 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. CLINICAL TRIALS REGISTRATION NUMBER:Not applicable.