Positive airway pressure (PAP) therapy is widely known as the gold standard of care for patients with sleep apnea,1 and PAP compliance and adherence are common terms in the realm of sleep medicine. PAP compliance reports can help to determine if a set pressure is working, whether or not the range for an auto-PAP is appropriate and a treasure trove of other data that can help paint the picture for how a patient is tolerating, or better yet, succeeding with their PAP therapy.
Thanks to technology advancements such as the switch from SD card manual downloads to cloud-based data storage, up-to-date data reports can be retrieved quickly. Additionally, reports can be customized and altered to show a number of different vantage points to evaluate how a patient is using, or in some cases not using, their PAP machine. Despite these advancements, PAP therapy terminology is becoming more and more misused, particularly when it comes to the terms compliance and adherence. While compliance and adherence are often used synonymously, the terms are slightly different and should be approached accordingly.
In an article by Brown and Bussell,2 a key point providing the difference between the terms is discussed. "Often the terms adherence and compliance are used interchangeably. However, their connotations are somewhat different; adherence presumes the patient's agreement with recommendations, whereas compliance implies patient passivity." The guidelines from the Centers for Medicare and Medicaid (CMS) reiterate this idea of conformity given the specificity underlined in what is expected for patients. In reading them through PAP use, it appears to be a simplistic, easy-to-follow therapy; certain hours per night for a certain number of nights per month.1
However, the linear tone of CMS's PAP usage provides limited space for patients to acclimate in a way that works for them. Such a definition of compliance does not allow for subjective input from patients or for any problems that may occur. Issues, such as pressure sensitivity, mask discomfort or physiological complications like nasal dryness are not taken into consideration despite these issues occurring in the timeframe when the patient is to become "compliant." Since many insurance companies follow these guidelines for reimbursement purposes, some patients are put in a difficult position from the beginning. PAP usage is not like taking a new prescription. It is a change in lifestyle that needs adaptation and fluidity in order to succeed. Passivity therefore does not set the stage for success and compliance merely serves as the means to an end; to get a patient using PAP regularly to meet specific requirements with the hope of being able to help them become adherent for long-term success.
Adherence, unlike compliance, is a more dynamic and engaging process on the part of the patient. The World Health Organization (WHO) defines adherence as "the degree to which the person's behavior corresponds with the agreed recommendations from a health care provider."3 PAP usage then, in terms of adherence, suggests that not only does the patient follow set recommendations but also internalizes them and makes the necessary lifestyle changes and adaptations as needed. Again, adherence is not a simple task and various factors should be considered when working towards adherence with patients.
WHO considers five factors to be at play in determining ease of helping patients with adherence.4 Such factors include socioeconomic factors like age, gender, social support and clinical related issues such as a patient's airway structure, severity of OSA or comorbidities, as well as patient-related factors like level of commitment and subjective perception. In addition, there can be health care system issues such as the length of time from a test to receiving equipment and factors related directly to the therapy like nasal dryness, mask discomfort or pressure issues.
Considering the various difficulties patients and providers face in achieving long-term success with PAP therapy, each case should be approached with a personalized plan in mind. For some, initial compliance for insurance purposes may not be an issue, but long-term adherence six to nine months following the start of PAP therapy may be challenging. Likewise, there are patients who may struggle to meet initial compliance but flourish with extended PAP use due to working with their durable medical equipment (DME) provider or sleep technologist for corrective mask fittings, pressure relief options and humidity settings.
Weaver et al. created the Self-Efficacy Measure for Sleep Apnea (SEMSA) as a way for providers to gain insight into which patients may or may not be appropriate candidates for PAP therapy. It asks questions regarding acknowledging the use of PAP in front of a bed partner, financial obligations that may occur and other poignant ideas that help to broaden the scope of what PAP therapy entails before the patient begins the journey from compliance to adherence.5
PAP has a long-standing history of low, long-term usage. Acknowledging that there are differences between the terminology frequently used is an important step, not only for patients but also for providers and support staff. For some, compliance comes easily and subsequently adherence follows suit. For many, compliance and adherence are a difficult process. Recognizing, or even foreseeing, some of the various factors involved in their struggle can help them to become more successful. While masks and machines have evolved throughout the years, it's time to take a look at the terminology used in determining patients' success.
- Naik S, Al-Halawani M, Kreinin L and Kryger M. Centers for Medicare and Medicaid Services Positive Airway Pressure Adherence Criteria May Limit Treatment to Many Medicare Benefciaries. Journal of Clinical Sleep Medicine. 2019;15(2):245-51. doi: 10.5664/jcsm.7626
- Brown MT, Bussell JK. Medication Adherence: WHO Cares? Mayo Clinic Proceedings. 2011;86(4):304-314. doi: 10.4065/mcp.2010.0575.
- Ross SM. Key Differences Between Treatment Adherence vs Compliance. Cureatr. 2019. Retrieved from https://blog.cureatr.com/key-differences-between-treatment-adherence-vs-compliance
- Gast A and Mathes T. Medication adherence influencing factors-an (updated) overview of systemic reviews. Systematic Reviews. 2019;8(112). Retrieved from https://systematicreviewsjournal. biomedcentral.com/articles/10.1186/s13643-019-1014-8#:~:text=Adherence%20is%20a%20 multifactorial%20phenomenon,factors%20%5B10%2C%2011%5D.
- Weaver TE, Maislin G, Dinges DF, Younger J, Cantor C, McCloskey S and Pack AI. Self-efcacy in sleep apnea: instrument development and patient perceptions of obstructive sleep apnea risk, treatment beneft, and volition to use continuous positive airway pressure. Sleep. 2003;26(6):727-32. doi: 10.1093/sleep/26.6.727
Jocelyn Zakri, MPH, RRT, RPSGT, RST, CCSH