What should I do if the VA modifies the rating for obstructive sleep apnea?

In February 2022, the VA proposed to modernize the rating criteria for DC 6847, “Sleep Apnea Syndromes (Obstructive, Central, Mixed)” and retitle that DC as “Sleep Apnea Syndromes (Obstructive, Central, or Mixed)”. Specifically, the VA proposes to assign a 0 percent evaluation when sleep apnea syndrome is asymptomatic, with or without treatment. The VA would assign a 10 percent evaluation when treatment yields “incomplete relief.” The VA would assign ratings above 10 percent (e.g., 50 and 100 percent) only when treatment is either ineffective or the veteran is unable to use the prescribed treatment due to comorbid conditions.

This proposal is based on the faulty assumption that CPAP cures the veteran from obstructive sleep apnea (OSA), and therefore, the veteran is no longer disabled.  By definition, the veteran is only “cured” when he returns to his normal health and is NO LONGER IN NEED OF TREATMENT.  The VA recognizes diabetics as disabled even when their blood sugar is normalized by using insulin.  The VA provides a 30% rating for veterans who undergo joint replacement even though their range of motion returns to normal.  No medical study has ever shown that CPAP treatment restores an OSA patient to full health, and that treatment can be discontinued.

 

Rotenberg[1] et al reports in the study Trends in CPAP adherence over twenty years of data collection: a flattened curve:

 

“OSA has predictable effects on decreasing economic outcomes, and is also a source of car accidents.[2] [3]  Since the pervasive health effects of untreated OSA are so well described, practice parameters published by the American Academy of Sleep Medicine (AASM) recommend that continuous positive airway pressure (CPAP) should be considered both first-line and gold-standard treatment for OSA; many prominent published studies make similar statements.[4] [5] [6] [7]

 

…Despite numerous advances in machine dynamics including quieter pumps, softer masks, and improved portability, adherence to CPAP continues to be a problem frequently encountered in clinician’s offices, with adherence rates generally ranging from 30 to 60 %.[8] [9]  There are many reasons for this problem including comfort, convenience, claustrophobia, and cost.[10] It is also understood that many patients who start on a path to non-adherence frequently remain non-adherent and eventually abandon the machine altogether, with consequent return of symptoms and OSA-specific adverse consequences. Finally, although “optimal” adherence rates in the literature range from 4 to 6 h per night, it is becoming increasingly recognized that data used to define “optimal” or even “sufficient” use also very much related the outcome measure being studied as well as patient self-perception of their own OSA severity…”

 

The report reviewed the medical literature:

 

“A total of 82 papers were identified for analysis. These included trials comparing CPAP versus sub-therapeutic (sham) CPAP [1141], CPAP versus an oral placebo [404249], CPAP versus conservative or no therapy [17295060], CPAP versus an oral appliance [111242576169], CPAP versus postural therapy [7073], and CPAP alone assessing different means to modify adherence…

Sixty-six studies published between 1994 and 2015, inclusive, were identified in the literature that had CPAP adherence data…

In our review of 82 CPAP trials, 10.7 % of patients overall were unable to tolerate and thereby remain on CPAP over the duration of the trial in which they were participants, and the mean duration of nightly use was merely 4.7 h. This means that the average patient in bed for 7 h across these 83 closely supervised clinical trials (i.e. under the most optimal of circumstances and the best chance for success at the therapy) was not using it an average of 32.9 % of the time; extrapolating to 8-h nights, this time off CPAP rises to 41.3 %. When the nights per week of CPAP non-use have been examined, the percentages range from 10 to 40 % [12445661707476], with one in three out of 25 patients in a very brief, 2-week cross-over trial by Ferguson et al. only using CPAP one out of every three nights or less [62]. These are highly alarming percentages, given that several published RCT have documented that at least a minimum level of CPAP use is required to reap benefits from it and that this therapeutic threshold generally falls between 5 and 6 h nightly [1643457477]. It is, therefore, reasonable to assume that there is a sizeable subset, possibly a majority, of patients on CPAP who either cease to use it altogether, or fail to use it enough hours per night and/or nights per week to achieve clinically-significant benefits. This does call into question the validity of the results of some of these trials.”

Thus, the proposed rating, by the VA, is based on a faulty understanding that Obstructive Sleep Apnea is uniformly and completely cured by CPAP; nothing is further from the truth.  The poor adherence to CPAP may be even higher if a veteran suffers from comorbidities such as PTSD or tinnitus.  A study published by the American College of Physicians in the Chest Journal investigated the impact of PTSD on CPAP adherence in patients with OSA.[11] According to their conclusions, therapeutic adherence or compliance to the CPAP mask is frequently poor among patients with PTSD.  Veterans suffering from mood disorder have insomnia and fragmented sleep with nightmares.  CPAP treatment, with its attendant noise and mask discomfort, only exacerbate the veteran’s ability to fall asleep.

 

The proposed revision additionally argues that instead of CPAP treatment, veterans should simply lose weight.  Studies show that Obstructive Sleep Apnea symptoms were reduced when patients lost 35 lbs.  I did not find a study where all patients were able to lose 35 lbs and remained at the goal weight forever.  Weight loss is specifically problematic for veterans suffering from PTSD, since PTSD is known to cause weight gain.

 

What is the optimal use of CPAP?

 

Weaver[12] at al. reviewed the results of CPAP treatment looking for the optimal use of the device:

“Thresholds above which further improvements were less likely relative to nightly duration of CPAP were identified for Multiple Sleep Latency Test (6 hours), and Functional Outcomes associated with Sleepiness Questionnaire (7.5 hours). A linear dose-response relationship (P < 0.01) between increased use and achieving normal levels was shown for objective and subjective daytime sleepiness, but only up to 7 hours use for functional status.”

 

CPAP adherence in veterans suffering from PTSD and mood disorder

 

The proposed change in the rating of obstructive sleep apnea recognizes that there is a class of veterans who cannot be “cured” by CPAP treatment: “The VA would assign ratings above 10 percent ( e.g., 50 and 100 percent) only when treatment is either ineffective or the veteran is unable to use the prescribed treatment due to comorbid conditions.”

 

The Journal of Clinical Sleep Medicine is the official publication of the American Association for Sleep Medicine, an association tasked in establishing best practices for obstructive sleep apnea.  Collen[13] et al. reported that:

 

“Obstructive sleep apnea (OSA) is a common comorbid condition in patients with posttraumatic stress disorder (PTSD); insufficiently treated OSA may adversely impact outcomes. Sleep fragmentation and insomnia are common in PTSD and may impair CPAP adherence…

 

There was a trend towards a higher rate of comorbid insomnia among patients with PTSD (25.8% vs. 11.1%, p = 0.10). PTSD was associated with significantly less use of CPAP. Specifically, CPAP was used on 61.4% ± 22.2% of nights in PTSD patients compared with 76.8% ± 16.4% in patients without PTSD (p = 0.001). Mean nightly use of CPAP was 3.4 ± 1.2 h in the PTSD group compared with 4.7 ± 2.2 h among controls (p < 0.001). Regular use of CPAP (> 4 h per night for > 70% of nights) was also lower among PTSD patients (25.2% vs. 58.3%, p = 0.01)…”

 

The authors concluded:

 

“Among soldiers with OSA, comorbid PTSD was associated with significantly decreased CPAP adherence. Given the potential for adverse clinical outcomes, resolution of poor sleep quality should be prioritized in the treatment of PTSD and potential barriers to CPAP adherence should be overcome in patients with comorbid OSA.”

 

Only 25% of PTSD patients were able to use CPAP for up to 4 hours and only for 70% of the time, instead of 7.5 hours and 100% as recommended for optimal use. Clearly, veterans using CPAP for only 3.4 hours at night and for only 70% of the time cannot be considered cured, when optimal results occur only with the use of CPAP for 7.5 hours per night, every night.

 

What should I do if the rating for obstructive sleep apnea changes?

 

The VA proposal clearly excludes veterans suffering from PTSD and mood disorder, who are unable to meet the optimal result of care:

 

“The VA would assign ratings above 10 percent (e.g., 50 and 100 percent) only when treatment is either ineffective or the veteran is unable to use the prescribed treatment due to comorbid conditions.”

 

It is essential that you keep a diary, recording the number of the hours you use the CPAP and any symptoms of daytime fatigue.  Provide this diary to your physician and ask that he/she record the diary in the clinical notes.  You do not need a letter from your provider; just that the less than optimal adherence to CPAP is noted in your medical records.

 

[1] Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016 Aug 19;45(1):43. doi: 10.1186/s40463-016-0156-0. PMID: 27542595; PMCID: PMC4992257.

[2] Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217–1239. doi: 10.1164/rccm.2109080.

[3] Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408–1413.

[4] Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408–1413.

[5] Gay P, Weaver T, Loube D, Iber C. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29(3):381–401.

[6] Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;31(1):141–147.

[7] Yaremchuk K, Tacia B, Peterson E, Roth T. Change in Epworth Sleepiness Scale after surgical treatment of obstructive sleep apnea. Laryngoscope. 2011;121(7):1590–1593. doi: 10.1002/lary.21823.

[8] Weaver TE, Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: implications for future interventions. Indian J Med Res. 2010;131:245–258.

[9] Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–178. doi: 10.1513/pats.200708-119MG.

[10] Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408–1413.

[11] Collen J, Hoffman M, Lettieri, C. The Impact of Posttraumatic Stress Disorder on Continuous Positive Airway Pressure Adherence in Patients with Comorbid OSA. J Chest 2011 Oct 23,. 140( 4), Supplement, 1073A. doi:https://doi.org/10.1378/chest.1116721

[12] Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007 Jun;30(6):711-9. doi: 10.1093/sleep/30.6.711. PMID: 17580592; PMCID: PMC1978355.

[13] Collen JF, Lettieri CJ, Hoffman M. The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med. 2012 Dec 15;8(6):667-72. doi: 10.5664/jcsm.2260. PMID: 23243400; PMCID: PMC3501663.

[1] Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016 Aug 19;45(1):43. doi: 10.1186/s40463-016-0156-0. PMID: 27542595; PMCID: PMC4992257.

[1] Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217–1239. doi: 10.1164/rccm.2109080.

[1] Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408–1413.

[1] Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408–1413.

[1] Gay P, Weaver T, Loube D, Iber C. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29(3):381–401.

[1] Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;31(1):141–147.

[1] Yaremchuk K, Tacia B, Peterson E, Roth T. Change in Epworth Sleepiness Scale after surgical treatment of obstructive sleep apnea. Laryngoscope. 2011;121(7):1590–1593. doi: 10.1002/lary.21823.

[1] Weaver TE, Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: implications for future interventions. Indian J Med Res. 2010;131:245–258.

[1] Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–178. doi: 10.1513/pats.200708-119MG.

[1] Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408–1413.

[1] Collen J, Hoffman M, Lettieri, C. The Impact of Posttraumatic Stress Disorder on Continuous Positive Airway Pressure Adherence in Patients with Comorbid OSA. J Chest 2011 Oct 23,. 140( 4), Supplement, 1073A. doi:https://doi.org/10.1378/chest.1116721

[1] Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007 Jun;30(6):711-9. doi: 10.1093/sleep/30.6.711. PMID: 17580592; PMCID: PMC1978355.

[1] Collen JF, Lettieri CJ, Hoffman M. The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med. 2012 Dec 15;8(6):667-72. doi: 10.5664/jcsm.2260. PMID: 23243400; PMCID: PMC3501663.

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