Neighborhoods with 25% Minority Residents Are Still Mostly White

To the Editor:

We applaud Borker and colleagues for bringing attention to the important subject of racial health disparities in the care of patients with obstructive sleep apnea (OSA) (1). Given the impact of OSA on overall health, disparities in OSA care can have massive societal health implications. The structural racism embedded in the healthcare system and in American neighborhoods that the authors highlight in the discussion is unquestionably an impediment to the health of Black and Hispanic Americans, and we appreciate the discussion of all these factors as they contribute to disparities.

Unfortunately, as designed, this study does not answer the question about racial health disparities in continuous positive airway pressure (CPAP) adherence; thus, we object to the authors’ conclusion that “our findings extend results from earlier studies which have reported consistently that Black patients have lower CPAP usage than White patients.” The authors go on to conclude that they have “observed racial and ethnic differences in adherence,” but they have not done so with the reported data. Although their conclusions about the differences in the neighborhoods may be valid, this study does not address racial or ethnic differences in adherence and should not be interpreted as evidence that Black and Hispanic patients are less adherent to CPAP.

This study compares neighborhoods that are <1% Black or Hispanic with those that are >25% Black or Hispanic. In other words, it compares majority non-Hispanic White neighborhoods with other majority non-Hispanic White neighborhoods. Given that the populations in these “minority” neighborhoods could be up to 74% non-Hispanic White, any findings from this study are more likely to reflect differences in the behavior of non-Hispanic White people than they are Hispanic or Black people. Based on the data presented in this study, it is equally logical to conclude that non-Hispanic White people who live among higher concentrations of Black and/or Hispanic neighbors are less likely to adhere to CPAP. It is the authors’ assumption of disadvantage and healthcare “mistrust” that leads them to assume it is the CPAP usage by the Black and Hispanic patients rather than by the White patients that accounts for their findings.

To learn about racial differences in CPAP adherence, we suggest including comparisons with neighborhoods that are at least 50% Black or Hispanic, preferably percentages that mirror the percentages of White people (e.g., comparing neighborhoods that are 99% White with those that are 99% Black). Otherwise, it is inappropriate to make conclusions about the behaviors of Black and Hispanic patients by comparing two populations in which they are significant minorities.