title: The Effect of Patient Neighborhood Income Level on the Purchase of Continuous Positive Airway Pressure Treatment among Patients with Sleep Apnea.
abstract: BACKGROUND
  The cost of continuous positive airway pressure (CPAP) treatment for patients with low socioeconomic status may be an important barrier to successful treatment of obstructive sleep apnea under a copayment health care system.
  
  
  OBJECTIVE
  We evaluated an association between patient neighborhood income level and the purchase of a CPAP device under a cost-sharing health care insurance system.
  
  
  METHODS
  All adults who underwent a first diagnostic sleep study at St. Michael's Hospital (Toronto, ON, Canada) between 2004 and 2010 were included. Severity of obstructive sleep apnea was determined by the apnea-hypopnea index (AHI) and level of daytime sleepiness (by the Epworth Sleepiness Scale). Patient data were linked to provincial health administrative data from 1991 to 2013 to determine the purchase of CPAP equipment, comorbidities, neighborhood income, and rural status at baseline. Neighborhood income was categorized into quintiles, ranked from poorest (Q1) to wealthiest (Q5). Assuming that the majority of participants with severe obstructive sleep apnea (AHI > 30 events/h) and excessive daytime sleepiness (Epworth Sleepiness Scale ≥ 10) would have been strongly recommended CPAP, we evaluated the association between patient neighborhood income and purchase of a CPAP device in this group via multivariable Cox regressions.
  
  
  RESULTS
  Of the 695 participants with severe obstructive sleep apnea and excessive daytime sleepiness, 400 (58%) purchased a CPAP device. Patients who accepted CPAP were more likely to live in a higher-income neighborhood. Cumulative incidence of CPAP acceptance at 6 months was 43% for individuals in a low-income neighborhood (Q1) and 52% in combined higher-income neighborhoods (Q2-5) (P = 0.05). Controlling for sex and age, living in higher-income neighborhoods was associated with a 27% increased chance of accepting CPAP compared with the lowest-income neighborhood (hazard ratio Q2-5 vs. Q1, 1.27; 95% confidence interval, 0.98-1.64; P = 0.07).
  
  
  CONCLUSIONS
  Living in an unfavorable neighborhood is not an obstacle to CPAP treatment among symptomatic patients with severe obstructive sleep apnea under a copayment health care system. However, a potential 27% improvement in CPAP acceptance associated with higher neighborhood income is not inconsequential. Also, the overall CPAP acceptance rate was relatively low, suggesting that obstacles other than finances are primarily responsible.
authors.affiliation: 1 Faculty of Medicine, and.|2 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|3 Sunnybrook Health Sciences Centre/Sunnybrook Research Institute, Toronto, Ontario, Canada.
authors.forename: Tetyana
authors.identifier: http://orcid.org/0000-0002-5301-1796
authors.initials: T
authors.lastname: Kendzerska
authors.affiliation: 1 Faculty of Medicine, and.|4 Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.|2 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|3 Sunnybrook Health Sciences Centre/Sunnybrook Research Institute, Toronto, Ontario, Canada.
authors.forename: Andrea S
authors.initials: AS
authors.lastname: Gershon
authors.affiliation: 4 Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.|5 Department of Medicine, University Health Network/Mt. Sinai Hospital, Toronto, Ontario, Canada; and.
authors.forename: George
authors.initials: G
authors.lastname: Tomlinson
authors.affiliation: 1 Faculty of Medicine, and.|6 Department of Medicine, St. Michael's Hospital, Toronto, Toronto, Ontario, Canada.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Leung
mesh_terms: D000328:Adult; D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D045422:Continuous Positive Airway Pressure / Q000295:instrumentation* / Q000379:methods; D003365:Costs and Cost Analysis; D004864:Equipment and Supplies / Q000191:economics; D005260:Female; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D020181:Sleep Apnea, Obstructive / Q000191:economics / Q000453:epidemiology / Q000628:therapy
keywords: continuous positive airway pressure; neighborhood income; patient acceptance of health care; sleep apnea syndromes