Sleep Testing and Mortality in a Propensity-matched Cohort of Patients with Chronic Obstructive Pulmonary Disease

Many advocate the application of propensity matching methods to 'real world' data to answer key questions around Obstructive Sleep Apnea (OSA) management. One such question is whether identifying undiagnosed OSA impacts mortality in high-risk populations like Chronic Obstructive Pulmonary Disease (COPD).Assess the association of sleep testing with mortality among patients with COPD and high likelihood of undiagnosed OSA.We identified patients with COPD and high likelihood of undiagnosed OSA. We then distinguished those receiving sleep testing within 90 days of index COPD encounters. We calculated propensity scores for testing based on 37 variables and compared long-term mortality in matched groups. In sensitivity analyses, we compared mortality using inverse propensity weighting and instrumental variable (IV) methods. We also compared incidence of non-fatal events including adverse outcomes (hospitalizations and COPD exacerbations) and routine services that are regularly indicated in COPD (influenza vaccination and pulmonary function testing). We compared the incidence of each non-fatal event as a composite outcome with death and separately compared the marginal probability of each non-fatal event independently with death as a competing risk.Among 135,958 patients, 1,957 (1.4%) received sleep testing. We propensity matched all patients with sleep testing to an equal number without testing, achieving excellent balance on observed confounders with standardized differences <0.10. We observed lower mortality risk among patients with sleep testing (IRR 0.88, 95%CI, 0.79-0.99) and similar results using inverse propensity weighting and IV methods. Contrary to mortality, we found that sleep testing was associated with similar or greater risks for non-fatal adverse events including inpatient COPD exacerbations (SHR 1.29, 95%CI 1.02-1.62) and routine services like influenza vaccination (SHR 1.26, 95% CI 1.17-1.36).Our disparate findings can be interpreted in multiple ways. Sleep testing may indeed cause both reduced mortality and greater incidence of non-fatal adverse outcomes and routine services. However, it is also possible that our findings stem from residual confounding by patients' likelihood of accessing care. Given the limitations of propensity-based analyses, we cannot confidently distinguish these two possibilities. This uncertainty highlights the limitations of using propensity-based analyses to guide patient care and policy decisions.