CPAP treatment persistence following nasal procedures in obstructive sleep apnea: a real-world claims-based analysis of 1.3 million patients.

OBJECTIVE

To evaluate the association between nasal procedures and long-term continuous positive airway pressure (CPAP) treatment persistence in a large US administrative claims database.

METHODS

Retrospective cohort study using the Komodo Health Sentinel Database (2020-2026). Adults with sleep apnea (ICD-10 G47.3x) who initiated CPAP were classified into six cohorts: temperature-controlled radiofrequency (TCRF) nasal valve remodeling (n = 920), septoplasty (n = 24,575), functional rhinoplasty (n = 758), combined functional rhinoplasty and septoplasty (n = 3,910), other nasal surgery (n = 12,995), and no nasal surgery (n = 1,297,292). The primary outcome was CPAP discontinuation, defined as a ≥180-day gap in positive airway pressure claims. Covariate-adjusted Cox regression and coarsened exact matching (CEM) on six variables assessed the association between nasal procedures and discontinuation. Sensitivity analyses included inverse probability of censoring weighting (IPCW), alternative gap thresholds (90-365 days), E-values, and insurance stratification.

RESULTS

Among 1,340,450 CPAP initiators, the overall discontinuation rate was 29.0%. TCRF was associated with the lowest discontinuation (HR 0.62, 95% CI 0.53-0.72; p < 0.001); IPCW addressing informative censoring strengthened this association (HR 0.48, 0.41-0.56). Other nasal procedures showed more modest associations: combined FR and septoplasty (HR 0.84, 0.79-0.90), other nasal surgery (HR 0.86, 0.83-0.89), septoplasty (HR 0.87, 0.84-0.89), and functional rhinoplasty (HR 0.90, 0.78-1.02). CEM confirmed these findings, with TCRF showing HR 0.57-0.61 across model specifications. One-year persistence was 84.2% for TCRF versus 76.1% for no surgery. The TCRF association was consistent across insurance types and all sensitivity analyses. The E-value was 2.61 (CI bound 2.12).

CONCLUSIONS

Nasal procedures were associated with higher CPAP persistence compared with no surgery, with TCRF showing the strongest and most consistent association. These findings suggest that treating nasal obstruction may help sustain long-term CPAP use, though prospective studies are needed to confirm causality.