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Sleep and PAP TherapyOctober 20, 2026

CPAP Adherence After Year One: Why Patients Drop Off

Matteo

Updated October 2026. Written by Matteo Grassi, clinical psychologist and cofounder of HANA Health.

CPAP adherence slips after the first year, and no single cause explains it. CPAP is the nightly mask therapy for obstructive sleep apnea. In a French analysis of 480,000 new users, 23.1% had stopped by year one and 47.7% by year three. The evidence points to early habits, mask fit and perceived benefit as the levers.

I'm a clinical psychologist, so I read this as a habit problem more than a machine problem. Habits need support after the novelty wears off.

Key facts

Why does CPAP adherence drop after the first year?

It drops because nothing in the system keeps asking whether the therapy still works for the patient. The first 90 days are watched closely. Medicare's adherence test sits in that window, and our guide to Medicare CPAP compliance requirements shows how tight it is. After that, the patient is mostly alone with a mask.

That's an interpretation, not a finding. No study tests it directly. What the data do show is steady attrition. In the French cohort, termination climbed from 23.1% at year one to 37.1% at year two and 47.7% at year three. In the US commercial cohort, only 48% of patients cleared the CMS standard in every quarter of year one, so the slide starts inside the first year for many people.

Two things make the pattern hard to fix. Patients stop quietly, with no call to the DME and no visit. And the reasons differ by person: a leaky cushion, a dry nose, a partner who sleeps badly, or a sense that nothing has changed. A single reminder can't solve four different problems.

How many patients stop CPAP in the first three years?

Between about a third and a half stop within three years, depending on the country and the definition. The numbers aren't directly comparable, so here they are side by side with their limits.

  • France, 480,000 patients, 2015 to 2016 starters. Termination meant reimbursement stopped. Rates were 23.1%, 37.1% and 47.7% at years one, two and three. The data had no nightly hours, so a patient who kept the machine but rarely used it counts as still on therapy.
  • US commercial, 213,341 patients aged 18 to 64. Device data showed 48% adherent, 30% intermediate and 22% nonadherent over year one. This measures consistent use, a stricter bar than staying on therapy.
  • Japan, 13,007 patients. Persistence was 90.1% at 90 days, 77.1% at one year, 70.3% at two years and 66.5% at three years.

Japan's numbers are better than France's, and the Japanese authors note persistence improved for patients who started in 2020 and 2021 compared with 2016. The honest summary is that roughly one in three to one in two patients leave CPAP within three years, and I couldn't find a clean national figure for the US Medicare population.

One more caution. Several studies here, including Alpert and Benjafield, have authors from ResMed, a device maker, and use data from its cloud connected devices. They were peer reviewed, but the patients use one company's equipment.

What do studies say about why people quit CPAP?

The research gives patterns, not a ranked list. Weaver and Grunstein reviewed the field and found no single factor consistently predicts adherence. Patient perception of symptoms and improvement in sleepiness and daytime function may matter more than how severe the apnea is on paper.

The French analysis adds who is more likely to stop. Compared with patients aged 61 to 70, the hazard of termination was about twice as high at ages 18 to 30 (adjusted hazard ratio 1.97) and 1.44 times as high above age 80. Women had a slightly higher risk (1.09). Diabetes and COPD raised risk, while hypertension was linked to staying on therapy. The authors point out their data can't see severity, weight, smoking or income.

A 2023 review by Mendelson and colleagues in Expert Review of Respiratory Medicine reaches a similar place. Up to half of patients stop within three years, and strategies should be tailored to the person, including telehealth and behavioral support. Mendelson et al., 2023.

For a DME, that means age and comorbidity can help you decide whom to call first. They can't tell you why someone stopped.

Why does the first week matter for what happens in year two?

The first week matters because early use predicts later use. Weaver and Grunstein reported that the pattern of adherence is established within the first week of treatment and predicts long term use. Patients who skip nights also use CPAP for shorter stretches when they do wear it, about 3 hours on average compared with roughly 6 for nightly users.

This is easy to misread. It doesn't mean a patient with a rough start is lost. It means the habit forms early, so the first month is the cheapest time to intervene, and the habit then needs maintenance.

There's a limit worth stating. In the review by Weaver and Sawyer, one randomized trial of an audio habit program produced more adherent patients at one month but not at three or six months. Early help can fade if nothing follows it. For that reason, the best case for support after day 90 is that early gains don't last by themselves. It's an argument from fading effects, not proof that late outreach works. Weaver and Sawyer, 2010.

Does mask resupply help patients stay on CPAP?

Resupply is associated with better adherence, but the evidence is observational. Benjafield and colleagues matched 50,185 patients who received mask or cushion resupply with 50,185 who didn't. All had met Medicare adherence criteria. From day 91 to day 360, mean use was 5.6 hours a night with resupply and 4.5 without. Therapy termination was 14.7% versus 31.9%.

The authors say plainly that the study isn't randomized, and patients who reorder supplies may simply be more motivated. The average patient in the resupply group received about five items, far below what coverage allows, which suggests supplies are underused. Our post on the Medicare CPAP resupply schedule covers the allowances by code.

A German homecare study adds a useful detail. Among 12,551 patients, mask change or renewal made no difference for people already using CPAP 4 hours or more. For those using it under 4 hours, it was associated with about 55 more minutes of use, and earlier action worked better. Schoebel et al., Annals of the American Thoracic Society, 2024.

That points to targeting. A new mask isn't a cure for everyone, but for a patient whose use is sliding it may be worth a call.

What can a DME do between month 4 and year two?

A DME can build a simple follow up rhythm around the points where patients tend to slip. These steps are reasonable ideas drawn from the studies above, not a proven protocol.

  1. Watch device data for use drifting below 4 hours, the group where a mask change showed the clearest gain.
  2. Offer a mask and cushion check before the supply window opens, rather than waiting for the patient to ask.
  3. Call around month 4, once Medicare's early adherence checks are behind the patient and attention usually fades.
  4. Call again near month 13, when the capped rental ends. Our guide to the 13 month capped rental explains why that date matters for ownership.
  5. Ask about benefit, such as mornings, sleepiness and a partner's view, and not only about the machine.
  6. Track termination as its own metric, separate from adherence, since a patient who has stopped can't be coached.

What this means for your DME

Attrition after year one is a revenue and a clinical issue at once. Commercial payers differ on whether they keep checking use, so see how commercial payers handle CPAP adherence after day 90. The money side is laid out in what a non adherent CPAP patient costs a DME.

Start small. Pick one cohort, such as patients in months 4 to 12, and decide who owns the call, what data triggers it and what you'll record afterward. Measure termination before and after.

HANA Health works with DMEs on PAP adherence and resupply outreach, and you can see how on the HANA sleep page.

Frequently asked questions

Is it normal to stop using CPAP after a year?

It's common. In the French national analysis, 23.1% of new users had terminated by year one, and the rate kept rising to 47.7% by year three. Other countries show lower rates, so the exact figure depends on where and how it's measured.

Does Medicare check CPAP use after the first three months?

The adherence test in LCD L33718 applies to the first three months of therapy, with a face to face visit between day 31 and day 91. Other payers may keep checking, and policies vary, so confirm with each payer.

Do younger or older patients quit CPAP more often?

In the French analysis, both ends of the age range had higher termination risk than patients aged 61 to 70. The hazard ratio was 1.97 for ages 18 to 30 and 1.44 above age 80. Age is a flag for outreach, not a diagnosis.

Can a new mask bring a low use patient back above 4 hours?

Sometimes. In the German homecare study, patients using CPAP under 4 hours gained about 55 minutes after a mask change or renewal, while patients already above 4 hours saw no change. The study was observational.

Do habit programs keep patients on CPAP long term?

The evidence is thin. One randomized audio habit trial reviewed by Weaver and Sawyer improved adherence at one month but not at three or six months, which suggests ongoing support matters.

Sources

  1. Pépin JL, et al. CPAP Therapy Termination Rates by OSA Phenotype: A French Nationwide Database Analysis. Journal of Clinical Medicine, 2021. MDPI and PubMed Central.
  2. Alpert N, et al. Performance of Claims Based Algorithms for Adherence to Positive Airway Pressure Therapy in Commercially Insured Patients With OSA. Chest, 2024. PubMed.
  3. Takahashi H, et al. Real world status of CPAP persistence in patients with sleep apnea syndrome, Japan claims data. 2025. PubMed Central.
  4. Weaver TE, Grunstein RR. Adherence to Continuous Positive Airway Pressure Therapy: The Challenge to Effective Treatment. Proceedings of the American Thoracic Society, 2008. PubMed Central.
  5. Weaver TE, Sawyer AM. Adherence to CPAP treatment for obstructive sleep apnoea: implications for future interventions. 2010. PubMed.
  6. Benjafield AV, et al. Positive Airway Pressure Therapy Adherence with Mask Resupply: A Propensity Matched Analysis. Journal of Clinical Medicine, 2021. MDPI.
  7. Schoebel C, et al. Effects of Mask Change/Renewal on Adherence to Positive Airway Pressure Therapy. Annals of the American Thoracic Society, 2024. DOI.
  8. Mendelson M, et al. The individual and societal prices of non adherence to CPAP. Expert Review of Respiratory Medicine, 2023. DOI.
  9. CMS. Local Coverage Determination L33718, Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea. Medicare Coverage Database.

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill. If you'd like to talk through adherence and resupply outreach for your DME, book a discovery call.