Positive airway pressure (PAP) is the most effective therapy for obstructive sleep apnoea (OSA), a condition affecting an estimated 936 million adults worldwide [1]. Adequate PAP adherence has been defined as 4 h of average use in most research studies. Many US insurance carriers and national payers, including the Centers for Medicaid and Medicare Services (CMS), determine coverage of PAP and supplies based on this metric. If Medicare patients do not meet the threshold of 4 h per night for 70% of nights, their PAP may be confiscated in the USA [2]. This policy may have detrimental consequences for Medicare beneficiaries with OSA [3]. In France, however, a 3-h average use is required for PAP coverage, established more than 20 years ago as a legal minimal usage not corresponding to any physiological threshold. Suboptimal adherence to PAP is exceptionally common, with only ～50% using PAP4 h per night at 1 year in most trials [4–6]. PAP adherence may considerably vary from one country to another with improved global management of the disease [7]. Additionally, differences in adherence inconsistently correlate with baseline symptoms of sleepiness, or OSA severity; many subjective benefits of PAP similarly do not correspond in a clear dose-dependent fashion [8–11].
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