Obstructive sleep apnoea (OSA) is a common condition in which the upper airway collapses intermittently during sleep, resulting in obstructive apnoeas and hypopnoeas that are associated with arousals from sleep and sympathetic activation.1 It has been estimated that more than 900 million adults aged 30–69 years have OSA.2 This number, along with the societal burden of OSA, appears to be increasing.3 In France, an estimated 10 million individuals have OSA,4 and the proportion of these individuals being treated with continuous positive airway pressure therapy (CPAP) has increased over the last decade.5

CPAP is the gold standard therapy for OSA. However, poor adherence to CPAP and high rates of therapy termination for a variety of reasons remain a significant challenge to the clinical effectiveness of this treatment modality.6–9 This is because there is a dose–response effect regarding the effects of CPAP therapy on symptoms and incident comorbidities, and a growing body of evidence showing that there is an association between usage of/adherence to positive airway pressure (PAP) therapy and healthcare resource use and costs.8,10–27

In France, a new national CPAP telemonitoring and pay-for-performance scheme was implemented in 2018 (Fig. 1 and Table S1). This includes incentives to encourage the use of telemonitoring and a higher weekly fee paid to homecare providers if nightly CPAP usage hours increase (calculated based on 28-day moving windows). The system is applied continuously for the duration of CPAP therapy. In 2023, about 97% of CPAP-treated patient in France were being telemonitored. The weekly homecare package fees cover the CPAP device, mask and other consumables, mandatory home visits for device/interface set-up and adjustment, patient education, confirmation of tolerability, adherence monitoring, call centres, and support to improve adherence. Three visits during the first 4 months of CPAP therapy are mandatory, with annual visits thereafter for patients using telemonitoring. Homecare providers also need to provide a call centre service 24h a day, 7 days a week, a telemonitoring platform, and human resources to check telemonitoring data and inform the physician if adherence is poor. Homecare providers can deliver additional visits/calls to improve adherence but this does not result in payment of a higher weekly fee.

Fig. 1.

CPAP telemonitoring and pay-for-performance homecare provider scheme in France (2023 reimbursement amounts). CPAP: continuous positive airway pressure.

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Our hypothesis was that the system change that occurred in France in 2018 and the associated introduction of telemonitoring and a pay-for-performance reimbursement model for CPAP-treated patients would have an impact on how homecare providers performed patient follow-up, including additional actions directed to improve adherence in OSA patients who had poor initial CPAP device usage. Therefore, the IMPACT-PAP study investigated relationships between CPAP adherence during the first year of therapy in patients with OSA and the intensity of support provided by homecare providers in France.

In this cohort of CPAP-treated patients with OSA from France, the widespread national implementation of a telemonitoring and a pay-for-performance scheme for homecare providers had an important impact on the number of interactions targeting patient adherence during the first year after CPAP initiation. Patients with low or intermediate CPAP usage (<4h/night) in the first month after therapy initiation received a higher volume and different type of support than adherent patients. Homecare provider interactions for patients with low early adherence occurred primarily during the first five months after therapy initiation. In addition, there was a ceiling effect in terms of the number of interactions, whereby an increase above four interactions per patient was not associated with any further improvement in adherence, suggesting that interactions after that point become unhelpful, and potentially a waste of resources.

The increasing number of patients diagnosed with OSA and managed with CPAP therapy places a significant burden on finite healthcare resources. Therefore, new approaches to the management of CPAP therapy that strike a balance between remote monitoring utilising digital technologies and in-person patient-healthcare professional contacts are needed, as suggested by a study conducted in Finland.3 However, to date, little attention has been paid to the assessment of new management pathways, including pay-for-performance models, in terms of their effect on patient care and adherence to CPAP therapy. Our study is novel in highlighting the impact of the national deployment of a novel strategy for the management of CPAP therapy, and in showing that financial performance incentives encourage homecare providers to target resources and interactions to individuals who have the lowest CPAP adherence in the first month of therapy.

Our finding that >4 interactions per person were not associated with any incremental CPAP device usage benefit suggests that the reasons underlying persistent poor adherence are probably not related to technical aspects that can be addressed by homecare provider interactions. Instead persistent poor adherence might be explained by other factors such as health behaviours, attitudes and beliefs, the presence of insomnia or other comorbidities that result in disturbed sleep, and/or socioeconomic factors.6,28 The identification of these factors is essential to allow the application of different strategies to target these specific issues with the goal of improving CPAP device usage and therapy benefit.

This study also determined the relative impact of different types of homecare interactions (phone call, home visit, mask change). Mask resupply has already been shown to be associated with improved long-term adherence to CPAP therapy.29,30 In this analysis, our data suggested that face-to-face visits were more effective than phone calls at improving CPAP device usage. In contrast, it has previously been shown that telemonitoring with automated feedback messaging was sufficient to improve 90-day adherence to CPAP therapy in an unselected population.31

Consistent with existing evidence,32–34 our data showed that when CPAP adherence is achieved early, it is generally maintained over time (between 1 month and 1 year based on our data). Homecare provider interactions are generally concentrated in the first 5 months after CPAP therapy initiation and reduce thereafter. Our findings support this approach, because more than four interactions within the first year of therapy was not associated with any incremental benefit on CPAP device usage at 1 year.

Overall, our study clearly shows that regular reassessment of device usage (adherence) by telemonitoring combined with a pay-for-performance strategy means that homecare provider actions are targeted to individuals with lower CPAP adherence, which was associated with overall improved adherence and a greater number of patients achieving adherence of >4h/night. Telemonitoring is a key component of this approach, and enables or triggers the appropriate educational or supportive actions by the homecare provider.35,36 Another important message from our analysis is that the current French model, which includes three compulsory visits in the first 4 months after CPAP therapy initiation, does not consider the diversity of patients and OSA phenotypes. Therefore, the current system could potentially be revised to allow avoidance of home visits for individuals with good early adherence that is stable over time. This may contribute to more efficient allocation of healthcare resources. A better approach might be to allow homecare providers to operate using a patient-centred model, with varying levels and types of support based on each individual's profile, within the current pay-for-performance-based strategy.

Strengths of this study include the representativeness of the study population, which covers approximately 6% of the total number of incident individuals starting CPAP in France in 2018–2019. In addition, the data were obtained from a range of different providers, non-profit organisations and private companies, who may have had different processes for patient management. There are also some limitations that need to be considered when interpreting our results. Firstly, we did not have any data on sleep duration, OSA severity (symptoms, AHI at diagnosis), comorbidities or socioeconomic factors to allow us to adjust for the impact of these potential confounders on adherence.13,37 Secondly, although we had information about the number and type of homecare provider interactions, we did not have details about the specific reason for each interaction. Finally, this study included patients who had a full year of follow-up data after CPAP therapy initiation and are therefore only applicable to similar individuals who have persisted with CPAP therapy and accept interactions with their homecare provider. The findings also relate to the current CPAP management policies and protocols in France and therefore may not be directly applicable to different healthcare settings and practices.

In conclusion, this study shows for the first time that a CPAP telemonitoring and pay-for-performance scheme for homecare providers can have a positive impact on adherence to CPAP therapy and redirects interactions to those with low early adherence. This facilitates a more personalised approach to CPAP therapy management, and has the potential to contribute to improved outcomes.

Representatives of the study sponsor were involved in the design of the study. Data from the different homecare companies involved in the study were collated by an independent clinical research organisation (Alira Health), which also performed data cleaning and homogenisation. The first draft of the manuscript was prepared by JLP, SB and JT with the assistance of an independent medical writer funded by FEDEPSAD. The manuscript was reviewed and edited by all the authors. All authors made the decision to submit the manuscript for publication and assume responsibility for the accuracy and completeness of the analyses and for the fidelity of this report to the trial protocol.

This study was funded by two French professional representative unions (FEDEPSAD, Fédération Des Prestataires de Santé à Domicile and UPSADI, Union des Prestataires de SAnté à Domicile Indépendants) and ResMed. JLP and SB are supported by the French National Research Agency in the framework of the “Investissements d’avenir” program (ANR-15-IDEX-02) and the “e-health and integrated care and trajectories medicine and MIAI artificial intelligence” chairs of excellence from the Grenoble Alpes University Foundation. This work was partially supported by MIAI @ Grenoble Alpes (ANR-19-P3IA-0003).

JLP, SB and JT prepared the outline for the first draft manuscript. The first draft of the manuscript was prepared by JLP, SB and JT with the assistance of an independent medical writer (Nicola Ryan) funded by FEDEPSAD. The manuscript was reviewed and edited by all the authors. All authors approved the final version of the manuscript and made the decision to submit the manuscript for publication.

JT is an employee of Air Liquide Healthcare. J-CB is an employee of AGIR à Dom. AS is an employee of SOS Oxygène. JLP has received lecture fees or conference traveling grants from ResMed, Perimetre, Philips, Fisher and Paykel, AstraZeneca, Jazz Pharmaceuticals, Agiradom and Teva, and has received unrestricted research funding from ResMed, Philips, GlaxoSmithKline, Bioprojet, Fondation de la Recherche Medicale (Foundation for Medical Research), Direction de la Recherche Clinique du CHU de Grenoble (Research Branch Clinic CHU de Grenoble), and fond de dotation “Agir pour les Maladies Chroniques” (endowment fund “Acting for Chronic Diseases”). SB has no conflicts of interest to declare.