PURPOSE: Excessive daytime sleepiness (EDS) persists in some positive airway pressure (PAP)-treated patients with obstructive sleep apnea (OSA). This study examined prevalence and severity of EDS in a real-world population with OSA to understand how EDS, PAP adherence, and patient satisfaction with care relate.
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METHODS: US residents (aged ≥18 years, self-reported diagnosis of OSA [from 1/1/2015 to 3/31/2020]) completed a survey in Evidation Health’s mobile app assessing the Epworth Sleepiness Scale (ESS), PAP usage, and satisfaction with healthcare providers (HCPs) and overall OSA care. Patients were categorized by self-reported PAP use (nonuse [no PAP use], nonadherent [<4 h/night or <5 d/wk], intermediate [4-6 h/night, ≥5 d/wk], or highly adherent [≥6 h/night, ≥5 d/wk]; PAP-adherent refers to the intermediate and highly adherent groups). ESS >10 defined EDS. A linear model assessed relationship between PAP use and ESS score; a logistic regression model assessed the impact of PAP use and EDS on satisfaction with HCPs and overall OSA care. P-values are uncontrolled for multiplicity (nominal).
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RESULTS: In total, 2289 participants completed the survey (50.3% female; 82.5% White; mean±standard deviation [SD] age, 44.8±11.1 years; body mass index, 35.4±8.7 kg/m2). PAP use was: nonuse (n=700), nonadherent (n=153), or adherent (n=1436; intermediate n=225, high n=1211). Overall, 42.5% had EDS (ESS>10); mean (95% confidence interval [CI]) ESS scores were 14.1 (13.9, 14.3) in those with EDS and 6.7 (6.5, 6.8) in those without. The proportion (95% CI) with EDS per group were: nonuse (47% [43.7, 51.1]), nonadherent (52% [44.4, 60.2]), intermediate (53% [46.4, 59.4]), and highly adherent (36% [33.7, 39.1]). In a linear model (PAP users; n=1589), an additional h/night of PAP use was associated with lower ESS scores (β=–0.28; 95% CI=–0.40, –0.16; P<0.001). Overall, 72% were satisfied with HCPs and 65% with OSA care. Logistic regression (PAP users; n=1589) identified a positive association between PAP adherence (nonadherence=0, adherence=1) and satisfaction with HCPs (adjusted odds ratio [adjOR]=2.37; 95% CI=1.64, 3.43; P<0.001) and satisfaction with overall OSA care (adjOR=2.91; 95% CI=2.03, 4.17; P<0.001). EDS was associated with lower satisfaction with HCPs (adjOR=0.62; 95% CI=0.48, 0.80; P<0.001) and overall OSA care (adjOR=0.50; 95% CI=0.39, 0.64; P<0.001).
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CONCLUSIONS: In this real-world study, ESS scores decreased as PAP use increased, but EDS remained highly prevalent even among highly adherent patients. Adherence was associated with greater patient satisfaction with HCPs and overall care, whereas persistent EDS was associated with lower patient satisfaction with HCPs and overall OSA care.
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CLINICAL IMPLICATIONS: Strategies to improve patient satisfaction with OSA care should focus equally on PAP adherence and monitoring and resolution of residual EDS.

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