Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multi-society commentary.

This multi-society commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea (OSA). The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services (CMS) and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure (CPAP), the variability of sleep disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary, is that the AHRQ report inadequately acknowledges the benefits of CPAP for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of CPAP treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials (RCTs) and non-randomized controlled studies (NRCS), and the challenges of conducting future RCTs. A research agenda to address these challenges is proposed including study designs which may include both high quality RCTs and NRCS studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with OSA if the AHRQ report alone was used by payers to limit coverage for the treatment of OSA, while not considering the totality of available evidence.