Efficiency of a phone coaching program on adherence to continuous positive airway pressure in sleep apnea hypopnea syndrome: a randomized trial

Behavioral KSA Intervention Class to Boost Positive Airway Pressure Adherence Among Active Duty Military Personnel With Obstructive Sleep Apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is a treatable cause of daytime sleepiness and associated medical problems that can negatively impact soldier readiness and performance. This study examined adherence to positive airway pressure (PAP) by soldiers who were newly diagnosed with OSA and prescribed PAP therapy and participated in a Knowledge, Skills, and Attitudes (KSA) behavioral intervention class.

MATERIALS AND METHODS

The KSA was a one-time, interactive 90-minute class attended by up to 10 patients per class. PAP adherence was examined using Medicare standard at 30-, 60-, 90-, and 180 days post class. The analytic sample comprised 379 active duty patients (93% men; mean age 40.21 ± 8.06) categorized into 3 groups: KSA (n = 235), did not show (DNS; n = 61), and mandatory education class (MEC; n = 83). The MEC group comprised patients from an education class in a previous year.

RESULTS

Baseline scores on the apnea hypopnea index, body mass index, sleepiness, insomnia severity, and age were non-significant among the 3 groups. At 30 days, significantly more patients in KSA (48%) and MEC (51%) were adherent than the DNS group (16%). At 60 days, the adherence rates for the KSA, DNS, and MEC were significantly different at 39%, 22%, and 27%, respectively. At 90- and 180 days, the adherence rates among the KSA, DNS, and MEC groups did not differ significantly at 34%, 17%, and 26% (90 days) and 34%, 27%, and 25% (180 days), respectively. Consistently, more patients in KSA were adherent than those in DNS and MEC, except at 30 days. Additionally, adherence rates for KSA intervention declined more gradually over the 6 month period. The mean PAP usage on nights used was 4.6 hours that computed to a 34% non-use rate based on an optimal 7-hour/night sleep time.

CONCLUSION

KSA could be a behavioral intervention that enhances PAP adherence with a booster session implemented at the 90 days mark.

Boosting obstructive sleep apnea therapy by non-pharmacological approaches: A network meta-analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is the most common breathing-related sleep disorder with a considerable economic burden, low diagnosis and treatment rates. Continuous positive airway pressure (CPAP/PAP) is the principal therapy for OSA treatment; nevertheless, effectiveness is often limited by suboptimal adherence. The present network meta-analysis aims to systematically summarize and quantify different interventions' effects on CPAP/PAP adherence (such as mean usage CPAP or PAP in hours per night) in OSA patients, comparing Behavioral, Educational, Supportive and Mixed interventions in Randomized Control Trials (RCT).

METHODS

We conducted a computer-based search using the electronic databases of Pubmed, Psycinfo, Scopus, Embase, Chinal and Medline until August 2022, selecting 50 RCT.

RESULTS

By means of a random effect model network meta-analysis, results suggested that the most effective treatment in improving CPAP/PAP adherence was the Supportive approach followed by Behavioral Therapy focused on OSA treatment adherence.

CONCLUSION

This network meta-analysis might encourage the most experienced clinicians and researchers in the field to collaborate and implement treatments for improving CPAP/PAP treatment adherence. Moreover, these results support the importance of multidisciplinary approaches for OSA treatment, which should be framed within a biopsychological model.

Effect of telemonitoring and as-needed patient support on positive airway pressure therapy adherence

BACKGROUND

Obstructive sleep apnea (OSA) affects patient health and public welfare. Positive airway pressure (PAP) therapy is the preferred treatment of OSA, but therapy adherence rates remain suboptimal. Current literature demonstrates telemonitoring interventions to support improved PAP therapy adherence.

PURPOSE

To evaluate the effect of interval telemonitoring of PAP therapy data at 2 and 4 weeks after treatment initiation in patients with moderate-to-severe obstructive sleep apnea with as-needed patient support and troubleshooting by telephone consultation.

METHODOLOGY

Ninety-nine participants were enrolled in this study, 50 in the control group and 49 in the intervention group. Data were analyzed using descriptive and inferential statistics using SPSS 28.0 software. The primary outcome of interest was 90-day PAP adherence.

RESULTS

Mean PAP adherence scores diverged at 90 days after PAP initiation, with the intervention group having a significantly higher mean score (M = 49.24, SD = 38.18) relative to the control group (M = 36.38, SD = 37.69). Likewise, continued PAP usage at 90 days after therapy initiation diverged between participant groups, with the intervention group having a significantly higher mean score (M = 89.80, SD = 30.58) relative to the control group (M = 72.00, SD = 45.36).

CONCLUSIONS

The intervention resulted in significantly higher mean PAP adherence and a greater percentage of participants demonstrating continued PAP usage at 90 days after therapy initiation but did not result in a statistically significant increase in what is considered and defined as "good PAP adherence" (adherence of ≥70%).

IMPLICATIONS

Data-triggered telemonitoring protocols offer supplementary support to patients in need and improve PAP adherence.

Pulmonary Specialist-Supported Health Coaching Delivered by Lay Personnel Improves Receipt of Quality Care for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Purpose

Half of people living with chronic obstructive pulmonary disease (COPD) do not receive high-quality, evidenced-based care as described in international guidelines. We conducted secondary data analysis of a previously published study to assess the ability of a model of lay health coaching to improve provision of guideline-based care in a primary care setting.

Methods

As part of a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive usual care or 9 months of health coaching from primary care personnel informed by a pulmonary specialist practitioner. Outcome measures included prescription of appropriate inhaler therapy, participation in COPD-related education, engagement with specialty care, prescription of smoking cessation medications, and patient ratings of the quality of care.

Results

Baseline quality measures did not differ between study arms. At 9 months, coached patients were more likely (increase of 9.3% over usual care; P=0.014) to have received guideline-based inhalers compared to those in usual care. Coached patients were more likely to engage with pulmonary specialty care (increase of 8.3% over usual care with at least 1 visit; P=0.04) and educational classes (increase of 5.3% over usual care; P=0.03). Receipt of smoking cessation medications among patients smoking at baseline in the health coaching group increased 21.1 percentage points more than in usual care, a difference near statistical significance (P=0.06).

Conclusions

Health coaching may improve the provision of quality chronic illness care for conditions such as COPD.

A Hybrid Effectiveness/Implementation Clinical Trial of Adherence to Long-Term Oxygen Therapy for Chronic Obstructive Pulmonary Disease

Rationale: Interventions to promote adherence to long-term oxygen therapy (LTOT) in chronic obstructive pulmonary disease (COPD) are needed. Objectives: To examine the real-world effectiveness of phone-based peer coaching on LTOT adherence and other outcomes in a pragmatic trial of patients with COPD. Methods: In a hybrid effectiveness/implementation pragmatic trial, patients were randomized to receive phone-based proactive coaching (educational materials, five phone-based peer coaching sessions over 60 d), reactive coaching (educational materials, peer coaching when requested), or usual care. Study staff members collected baseline and outcome data via phone at 30, 60, and 90 days after randomization. Adherence to LTOT over 60 days, the primary effectiveness outcome, was defined as mean LTOT use ⩾17.7 h/d. LTOT use was calculated using information about home oxygen equipment use in worksheets completed by study participants. Comparisons of adherence to LTOT between each coaching group and the usual care group using multivariable logistic regression models were prespecified as the primary analyses. Secondary effectiveness outcomes included Patient Reported Outcome Management Information System measures for physical, emotional, and social health. We assessed early implementation domains in the reach, adoption, and implementation framework. Results: In 444 participants, the proportions who were adherent to LTOT at 60 days were 74% in usual care, 84% in reactive coaching, and 70% in proactive coaching groups. Although reach, adoption by stakeholder partners, and intervention fidelity were acceptable, complete LTOT adherence data were available in only 73% of participants. Reactive coaching (adjusted odds ratio, 1.77; 97.5% confidence interval, 0.80-3.90) and proactive coaching (adjusted odds ratio, 0.70; 97.5% confidence interval, 0.34-1.46) did not improve adherence to LTOT compared with usual care. However, proactive coaching significantly reduced depressive symptoms and sleep disturbance compared with usual care and reduced depressive symptoms compared with reactive coaching. Unexpectedly, LTOT adherence was significantly lower in the proactive compared with the reactive coaching group. Conclusions: The results were inconclusive about whether a phone-based peer coaching strategy changed LTOT adherence compared with usual care. Further studies are needed to confirm the potential benefits of proactive peer coaching on secondary effectiveness outcomes and differences in LTOT adherence between proactive and reactive peer coaching. Clinical trial registered with ClinicalTrials.gov (NCT02098369).

Effects of telemedicine-based follow-up management on adults with obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis aimed to investigate the effects of telemedicine-based follow-up management on adults with obstructive sleep apnea.

METHODS

Publications were searched in the Cochrane Library, PubMed, Scopus, Web of Science and Embase. Studies were selected according to the predefined screening criteria, and their qualities were assessed by the Revised Cochrane risk-of-bias tool for randomized trials. The statistical analyses were performed using Stata12.0 software. It was registered in PROSPERO with the number: CRD42021276414.

RESULTS

A total of 33 articles with 8,689 participants were included. Telemedicine-based follow-up management improved average daily continuous positive airway pressure usage by 36 min (weighted mean difference:0.61;95% confidence interval: 0.39 to 0.83), and the percentage of days with continuous positive airway pressure usage more than four hours by 10.67% in obstructive sleep apnea patients. The meta-analysis of good continuous positive airway pressure compliance showed telemedicine-based follow-up management did not lead to good continuous positive airway pressure compliance (odds ratio: 1.13;95% confidence interval: 0.72 to 1.76). The pooled mean difference of sleep quality was 0.15 (standardized mean difference:0.15; 95% confidence interval: -0.03 to 0.32), and daytime sleepiness was -0.26 (weighted mean difference: -0.26;95% confidence interval: -0.79 to 0.28). The pooled mean difference of apnea hypopnea index was -0.53 (95% confidence interval: -3.58 to 2.51). As for the overall quality of life, the pooled mean difference was -0.25 (standardized mean difference: -0.25;95% confidence interval: -0.25 to 0.76).

CONCLUSION

Telemedicine-based follow-up management was beneficial for continuous positive airway pressure compliance of obstructive sleep apnea patients within six months. However, it could not improve sleep quality, daytime sleepiness, the severity of obstructive sleep apnea, and quality of life in obstructive sleep apnea patients compared with traditional follow-up. Moreover, it was more cost-effective, but there was no consensus on whether it would increase the workload of medical staff.

Effectiveness of behavioral and psychosocial interventions for continuous positive airway pressure adherence among patients with obstructive sleep apnea: A systematic review and meta-analysis

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is the treatment of choice for Obstructive Sleep Apnea (OSA) syndrome; however, interventions to improve CPAP adherence are still inconclusive.

OBJECTIVE

This study aimed to examine the effectiveness of behavioral and psychosocial interventions on CPAP adherence.

METHODS

The PRISMA guidelines and JBI approach for Systematic Review and Meta-analysis were used. Participants included 1) newly diagnosed patients with OSA, naive to CPAP treatment; 2) any type of behavioral and/or psychosocial intervention delivered via individual or group level; 3) CPAP adherence as an outcome. Two reviewers independently selected studies, evaluated their methodological quality, and extracted data.

RESULTS

Critical appraisal was conducted on 34 of the 1657 studies, with 18 RCTs included in the final review. Telemonitoring increased the mean nightly hour of CPAP use compared to standard care (WMD = 0.76, 95 % CI = 0.31-1.20, p = 0.001, I² = 0 %, moderate certainty of evidence). Positive results were discovered in Motivational Enhancement Therapy (MET) (WMD = 1.22, 95 % CI = 0.28-2.16, p = 0.011, I² = 65 %, very low degree of certainty of evidence). The combined effects of cognitive therapy and education on CPAP adherence were inconclusive. Behavioral/supportive interventions improved mean nightly CPAP use in both the short term (WMD = 1.49, 95 % CI = 0.16-2.81, p = 0.029, I² = 30 %, very low certainty of evidence) and long-term follow-up (WMD = 1.67, 95 % CI = 1.55-1.79, p = 0, I² = 0 %, very low certainty of evidence).

CONCLUSIONS

Telemonitoring improved the mean nightly hour of CPAP utilization compared with standard care. Motivational Enhancement Therapy (MET) had the most significant effect on long-term adherence.

A telemonitoring system to support CPAP therapy in patients with obstructive sleep apnea: a participatory approach in analysis, design, and evaluation

Background

Continues positive airway pressure (CPAP) therapy is a gold standard treatment for moderate to severe cases of OSA (obstructive sleep apnea). The present research aimed to describe the analysis, design, and evaluation of a telemonitoring system to improve CPAP adherence in patients afflicted with OSA.

Methods

The telemonitoring system was developed in five phases. In the exploratory phase, the body of related literature was reviewed. Then a need analysis was conducted through a focus group discussion with sleep medicine specialists and sales company representatives and an interview with patients. The third phase involved data integration. Then the content and system development were done based on the previous phases. Finally, usability and functionality tests were used to evaluate the system.

Results

The exploratory phase and the needs analysis were conducted by four sleep medicine specialists, two medical informatics specialists, six key figures of the sales companies, two system developers, and 46 patients in different phases. Based on the results obtained from the data integration phase, the telemonitoring system involved three main parts: a patient’s application, a doctor’s portal, a selling companies’ portal (operator’s portal) along with facilitating software for patients to send the CPAP data. Usability and functionality tests were given to 7 and 10 patients, respectively. The total number of usability issues reported by users in the evaluation process was 18, with an average of 2.5 issues per user. The installation problems, disrupted links and improper playing of videos were the main functionalities problems that were solved.

Conclusion

The telemonitoring system, as a means of communication between patients, doctors, and selling companies, can be used to support patients clinically and technically. It has the potential to improve CPAP adherence in patients with OSA.

Telemedicine interventions for CPAP adherence in obstructive sleep apnea patients: Systematic review and meta-analysis

Continuous positive airway pressure (CPAP) is the preferred therapy in patients with obstructive sleep apnea (OSA). However, data suggests treatment adherence is low. In recent years, telemedicine-based intervention (TM) has been evaluated to increase adherence. In this systematic review and meta-analysis of randomized controlled trials (RCTs), we evaluated the efficacy of TM on CPAP adherence in patients with OSA. Two independent reviewers explored five databases; the risk of bias (RoB) was evaluated using the Cochrane tool. Outcomes were defined as the mean difference (MD) in CPAP use per night and the proportion of patients with increased CPAP adherence of ≥4 h/night. The meta-analysis was conducted following the DerSimonian-Laird method, and the certainty of the evidence was rated according to GRADE. We included 16 RCTs including 3039 participants. The RoB was low in 12/16 studies. TM was associated with an increase in CPAP adherence of 29.2 min/night, I² =75% (p < 0.01), and CPAP adherence ≧4 h/night, RR: 1.09 (1.02-1.17), I² =22%. Subgroup analyses reported better results between three and 6 months, in the sleepy subgroup. Finally, based on the results obtained in this systematic review, there is favorable evidence regarding the treatment with TM in patients with OSA using CPAP. REVIEW REGISTRATION NUMBER: CRD42020165367.

Telemedicine in Sleep-Disordered Breathing: Expanding the Horizons

Interest in telemedicine has increased exponentially. There is a growing body of published evidence on the use of telemedicine for patients using continuous positive airway pressure. Telemedicine-ready devices can support the transmission on use time, apnea-hypopnea index, and leakage. This approach enables early activation of troubleshooting. Automated, personalized feedback for patients and patient access to their own data provide unprecedented opportunities for integrating comanagement approaches, multiactor interactions, and patient empowerment. Telemedicine is likely cost effective, but requires better evidence. Notwithstanding barriers for implementation that remain, telemedicine has to be embraced, leaving the physician and patient to accept it or not.

Spanish Society of Pulmonology and Thoracic Surgery positioning on the use of telemedine in sleep-disordered breathing and mechanical ventilation

The rapid introduction of new information and communication technologies into medical practice has prompted Spanish Society of Pulmonology and Thoracic SurgeryR to publish a position paper on sleep-disordered breathing, especially in relation to positive pressure treatment. It should be pointed out that the scientific literature is to some extent controversial due to a paucity of large randomized multicenter studies with long-term follow-up. Moreover, the telematics devices and systems on the market vary widely. As a result, the recommendations are based primarily on a consensus of expert professionals. Another very important aspect addressed extensively in this document is the obvious lack of regulations on legal matters and the operations of commercial companies. The most important recommendations included in this position paper are that telemedicine is primarily advocated in subjects with travel problems or who live far from the hospital, in patients with poor CPAP compliance, and in most cases treated with non-invasive mechanical ventilation. A key element is patient individualization. It is imperative that the relevant technical, legal and ethical requirements (medical device regulations, data protection, and informed consent) are met. Finally, expert professionals from our society must contribute to and become involved in spearheading this technological change.

Summary and Update on Behavioral Interventions for Improving Adherence with Positive Airway Pressure Treatment in Adults

Continuous positive airway pressure (PAP) is still the most efficacious treatment for obstructive sleep apnea when used effectively. Since the availability of PAP 39 years ago there have been considerable technological advances, such as quieter, lighter and smaller machines with better humidification. However, adherence to treatment is still a major problem. This article reviews studies published on behavioral interventions aimed at improving the uptake and maintenance of PAP treatment (January 2016-February 2020). It discusses underlying factors in the poor uptake and discontinuation of treatment and the role of qualitative research to better understand the perspective of the patients.

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.

Pilot of Brief Health Coaching Intervention to Improve Adherence to Positive Airway Pressure Therapy

BACKGROUND

Adherence to positive airway pressure (PAP) therapies is poor, particularly among low-income populations and racial minorities. This study tested a low-resource, brief telephonic health coaching intervention to improve PAP adherence.

METHODS

Post hoc analysis of a quality improvement initiative in which English- and Spanish-speaking patients from a county-based public health system were randomly assigned to receive health coaching or usual care. An unlicensed, trained health coach called patients three times to resolve barriers to adherence. A per-protocol analysis was conducted for adherence measures collected by device modem at baseline and 30 days.

RESULTS

Of 131 people for whom device data were available, 56 were randomized to health coaching and 75 to usual care. At baseline, 47.3% of patients had used their device at any time in the past 30 days, with a mean of 2 hours of use per night. At 30 days, adjusting for baseline, patients in the coaching arm were more likely than usual care patients to use their device (55.4% vs. 41.3%, p = 0.03), and they increased their use for 0.4 hours over usual care (p = 0.04).

CONCLUSION

This pilot study suggests that a low-cost intervention could be effective at improving PAP adherence, even in a population known to have poor adherence and among long-term PAP users with poor adherence. Future research may examine whether a higher-touch intervention or one using videoconferencing yields greater improvements. This promising intervention warrants further study.

Telehealth, Telemedicine, and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

A Randomized Controlled Trial of Telemedicine for Long-Term Sleep Apnea Continuous Positive Airway Pressure Management

Rationale: The effects of telemedicine on adherence in patients with obstructive sleep apnea with long-term continuous positive airway pressure (CPAP) use have never been investigated.Objectives: To examine effects of a telemedicine intervention on adherence in long-term CPAP users.Methods: In a prospective, randomized, multicenter noninferiority trial conducted in 17 sleep centers across Japan, patients who had used CPAP for >3 months and were receiving face-to-face follow-up by physicians every 1 or 2 months were randomized by a coordinating center in a blind manner to the following three groups: 1) follow-up every 3 months accompanied by a monthly telemedicine intervention (telemedicine group: TM-group), 2) follow-up every 3 months (3-month group: 3M-group), or 3) monthly follow-up (1-month group: 1M-group). Each group was followed up for 6 months. The change in percentage of days with ≥4 h/night of CPAP use from baseline to the end of the study period was evaluated. A decline of ≥5% from baseline was considered deterioration of adherence. Noninferiority of TM- and 3M-groups compared with the 1M-group according to the number of patients with deterioration of adherence was evaluated with the Farrington and Manning test (noninferiority margin 15%).Results: A total of 483 patients were analyzed (median duration of CPAP use, 29 [interquartile range, 12-71] mo), and deterioration of adherence was found in 41 of 161 (25.5%), 55 of 166 (33.1%), and 35 of 156 (22.4%) patients in the TM-, 3M-, and 1M-groups, respectively. The noninferiority of the TM-group compared with the 1M-group was verified (difference in percentage of patients with adherence deterioration, 3.0%; 95% confidence interval [CI], -4.8% to 10.9%; P < 0.01). Conversely, the 3M-group did not show noninferiority to the 1M-group (percentage difference, 10.7%; 95% CI, 2.6% to 18.8%; P = 0.19). In the stratified analysis, adherence in TM- and 1M-group patients with poor adherence at baseline improved (TM: 45.8% ± 18.2% to 57.3% ± 24.4%; P < 0.01; 1M: 43.1% ± 18.5% to 53.6% ± 24.3%; P < 0.01), whereas that of the 3M-group did not (39.3% ± 20.8% to 39.8% ± 24.8%; P = 0.84).Conclusions: Intensive telemedicine support could help to optimize CPAP adherence even after long-term CPAP use.Clinical trial registered with www.umin.ac.jp/ctr/index.htm (trial number: UMIN000023118).

Effectiveness of eHealth Interventions in Improving Treatment Adherence for Adults With Obstructive Sleep Apnea: Meta-Analytic Review

Background

Poor adherence to continuous positive airway pressure (CPAP) treatment by adults with obstructive sleep apnea (OSA) is a common issue. Strategies delivered by means of information and communication technologies (ie, eHealth) can address treatment adherence through patient education, real-time monitoring of apnea symptoms and CPAP adherence in daily life, self-management, and early identification and subsequent intervention when device or treatment problems arise. However, the effectiveness of available eHealth technologies in improving CPAP adherence has not yet been systematically studied.

Objective

This meta-analytic review was designed to investigate the effectiveness of a broad range of eHealth interventions in improving CPAP treatment adherence.

Methods

We conducted a systematic literature search of the databases of Cochrane Library, PsycINFO, PubMed, and Embase to identify relevant randomized controlled trials in adult OSA populations. The risk of bias in included studies was examined using seven items of the Cochrane Collaboration risk-of-bias tool. The meta-analysis was conducted with comprehensive meta-analysis software that computed differences in mean postintervention adherence (MD), which was defined as the average number of nightly hours of CPAP use.

Results

The meta-analysis ultimately included 18 studies (N=5429 adults with OSA) comprising 22 comparisons between experimental and control conditions. Postintervention data were assessed at 1 to 6 months after baseline, depending on the length of the experimental intervention. eHealth interventions increased the average nightly use of CPAP in hours as compared with care as usual (MD=0.54, 95% CI 0.29-0.79). Subgroup analyses did not reveal significant differences in effects between studies that used eHealth as an add-on or as a replacement to care as usual (P=.95), between studies that assessed stand-alone eHealth and blended strategies combining eHealth with face-to-face care (P=.23), or between studies of fully automated interventions and guided eHealth interventions (P=.83). Evidence for the long-term follow-up effectiveness of eHealth adherence interventions remains undecided owing to a scarcity of available studies and their mixed results.

Conclusions

eHealth interventions for adults with OSA can improve adherence to CPAP in the initial months after the start of treatment, increasing the mean nightly duration of use by about half an hour. Uncertainty still exists regarding the timing, duration, intensity, and specific types of eHealth interventions that could be most effectively implemented by health care providers.

Cost-effectiveness strategies in OSAS management: a short review

Obstructive sleep apnoea (OSAS) is an underdiagnosed chronic disease with a high prevalence in adults. It is becoming a significant social problem, since it is associated with a worsening in quality of life and increase in mortality. The cost-effectiveness ratio of diagnostic and therapeutic management of OSAS is a strategic issue to counteract the expected increasing demand of objective testing. OSAS patients with any clinical evidence of comorbidities must be studied using simplified and less expensive systems such as Home Sleep Testing (HST). On the other hand, Sleep Laboratory Polysomnography (PSG) is the gold standard to manage OSAS patients with comorbidities. It should be pointed out that the use of HST can lead to incorrect diagnosis in poorly selected OSAS subjects. This short review discusses various topics for the proper diagnosis and treatment of OSAS in view of epidemiological factors and results in terms of costs and social benefit of the disease. Whatever the strategy chosen and/or the organisational model adopted for managing OSAS, it cannot and should not take into account only cost-effectiveness. Long-term prospective studies evaluating cost-effectiveness ratios and outcomes of OSAS treatment of hospital management models versus home care models are needed.

Erickson health coaching: An innovative approach for weight management in obese patients with obstructive sleep apnoea?

Obstructive sleep apnoea (OSA) is a highly prevalent medical condition and amajor cardiovascular risk factor. Obesity is present in ∼70% of patients with OSA, nevertheless, continuous positive airway pressure (CPAP) ventilation - the gold standard therapy for moderate and severe OSA - has no appreciable long-term beneficial effects on obesity, body composition, energy metabolism, physical activities or the incidence of major cardiovascular events. Therefore, effective weight loss strategies in conjunction with CPAP therapy in OSA are critically needed. Since lifestyle interventions may positively impact body weight, there is a strong rationale to testing the hypothesis that Erikson coaching intervention as a form of lifestyle intervention to obese patients with OSA may increase their adherence to healthy lifestyle behaviour and thus result in weight reduction, improved body composition (reduction in %body fat) and improvements in glucose and lipid metabolism. There are three lines of evidence to justify testing this hypothesis: First, health coaching significantly facilitates uptake of healthy behaviours across a broad variety of chronic conditions; second, several randomized clinical trials suggested positive impact of health coaching on weight management and on cardiometabolic risk factors in overweight/obese otherwise healthy persons; third, Erickson coaching approach empowers the three key elements of health coaching (patient-centeredness, patient-determined goals, use of a self-discovery process) further, namely by introducing two other specific core elements into the coaching process: a) solution-focus and outcome frame, b) orientation at the patient-formulated positive outcomes (i.e., positive values resulting from behavioural change). Importantly, results of our recent pilot observational cohort study suggested that Erickson coaching is a powerful tool to address behavioural modification in obesity. In conclusion, testing our hypothesis may have significant clinical implications: if clinical randomized trials indicate that Erickson health coaching is an efficient approach to behavioural change and weight management in OSA then combining Erickson coaching with CPAP therapy may result in reductions in cardiovascular morbidity and mortality in these high-risk patients.

Predicting Success of Oral Appliance Therapy in Treating Obstructive Sleep Apnea Using Drug-Induced Sleep Endoscopy

STUDY OBJECTIVES

Oral appliance therapy (OAT) can be an effective treatment option for patients with obstructive sleep apnea unable to tolerate continuous positive airway pressure. We hypothesize that drug-induced sleep endoscopy (DISE) can be useful in identifying patients who will benefit from OAT.

METHODS

A retrospective review of all patients who underwent DISE (DISE group) between January 2014 and June 2016 was carried out. We included patients if they received OAT based on recommendations made by DISE findings. A control group was designed by selecting a sample of patients undergoing polysomnography (PSG) with an oral appliance in place who had not undergone prior DISE (no DISE group). The two cohorts were compared to evaluate the hypothesis.

RESULTS

A total of 20 patients fit inclusion criteria for the DISE group and 20 patients for the no DISE group. There was no difference between the DISE and no DISE cohorts with respect to mean age, sex, pre-OAT body mass index, post-OAT body mass index, or pre-OAT PSG characteristics including: apneahypopnea index (AHI), oxygen desaturation nadir, or Epworth Sleepiness Scale score. There was a significantly lower treatment AHI (P = .04) and increased number of patients reaching an AHI less than 5 events/h with OAT therapy (P = .04) in the DISE group.

CONCLUSIONS

Patients showing increased airway dimensions at the level of the velum and/or oropharynx with a jaw thrust may benefit the most from OAT. The use of DISE to identify this subset of patients is helpful in optimizing outcomes with OAT.

Untreated Sleep Apnea: An Analysis of Administrative Data to Identify Risk Factors for Early Nonadherence

STUDY OBJECTIVES

Discontinuation of positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) is widely reported, but research has not adequately addressed nonadherence with diagnostic testing for sleep disorders and initiation of PAP. This study sought to identify drivers of nonadherence with diagnostic sleep testing and PAP treatment initiation among patients preauthorized for these services.

METHODS

This observational cohort study used preauthorization records from a sleep management program and administrative medical claims from a large commercial health insurer. Participants included adults preauthorized for sleep testing and a subset in whom OSA was diagnosed and who were preauthorized for PAP treatment. Outcome measures were nonadherence with diagnostic sleep testing and PAP treatment initiation, identified as lack of a claim for a preauthorized service within 3 months of preauthorization of that service. Risk factors for nonadherence included patient demographics, prescribing factors, signs and symptoms of OSA, comorbidities, and prior health service utilization.

RESULTS

Of 51,749 patients preauthorized for diagnostic testing, 23.5% did not undergo testing. Among 19,968 patients preauthorized for PAP treatment, 11.1% did not initiate treatment. Testing and treatment ordered by primary care providers, residence outside the Midwest region, and two or fewer office visits within 6 months before preauthorization were strong predictors of nonadherence. Apnea-hypopnea index score < 30 events/h was also a strong predictor of nonadherence with treatment initiation.

CONCLUSIONS

This study adds to existing knowledge about risk factors for nonadherence with sleep testing and treatment initiation following preauthorization. Health plans and providers should develop strategies to better engage patients with higher risk of nonadherence.

Erickson solution-focused coaching for weight management in obese patients with obstructive sleep apnoea: ECOHEALTH pilot study

Coaching as a lifestyle modification approach to weight management is insufficiently explored in obstructive sleep apnoea. We investigated anthropometry and body composition after 20 weeks of Erickson coaching in 26 obstructive sleep apnoea patients (19 males; 47.6 ± 2.4 years). Body weight, neck circumference, waist-to-hip ratio and %body fat significantly decreased after 20 weeks. The mean weight loss was 5.2 per cent ± 1.0 per cent; 20 (77%) participants achieved target reduction of >3 per cent. Coaching session attendance (p = 0.006) and reaching personal goal related to physical performance (p = 0.044) were independently associated with weight loss (multiple regression model R² = 0.608, p < 0.001). Erickson solution-focused coaching supports adherence to healthy lifestyle and weight reduction in obstructive sleep apnoea.

Doing It Better for Less: Incorporating OSA Management Into Alternative Payment Models

As the cost of health care continues to escalate, payers are adapting by moving away from models based on traditional fee-for-service reimbursement to models focused on rewarding care delivery that reduces costs and improves quality. These alternative payment models (APMs) are being introduced by government and commercial payers and will likely become the norm over time. Recent changes in sleep medicine related to advances in technology and approaches by payers for the management of OSA make this an appropriate time to incorporate the delivery of sleep medicine services into APMs. For OSA, the approaches that should lead to success include the appropriate use of home sleep apnea testing and automatic positive airway pressure; lower cost providers to manage less complex patients; evolving technologies including cloud-based positive airway pressure adherence monitoring, telemedicine, and Internet-based coaching to improve adherence with treatments; data analytics to better identify high-risk populations and to more appropriately allocate resources; and appropriate referrals of more complex cases to sleep specialists for management. All of these approaches should improve the value of care for payers, providers, and patients while allowing sleep specialists to more appropriately allocate their efforts to overseeing APM program development and administration and allowing them to focus on the management of more complicated patients.

CPAP Adherence is Associated With Attentional Improvements in a Group of Primarily Male Patients With Moderate to Severe OSA

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a widespread condition that adversely affects physical health and cognitive functioning. The prevailing treatment for OSA is continuous positive airway pressure (CPAP), but therapeutic benefits are dependent on consistent use. Our goal was to investigate the relationship between CPAP adherence and measures of sustained attention in patients with OSA. Our hypothesis was that the Psychomotor Vigilance Task (PVT) would be sensitive to attention-related improvements resulting from CPAP use.

METHODS

This study was a secondary analysis of a larger clinical trial. Treatment adherence was determined from CPAP use data. Validated sleep-related questionnaires and a sustained-attention and alertness test (PVT) were administered to participants at baseline and at the 6-month time point.

RESULTS

Over a 6-month time period, the average CPAP adherence was 3.32 h/night (standard deviation [SD] = 2.53), average improvement in PVT minor lapses was -4.77 (SD = 13.2), and average improvement in PVT reaction time was -73.1 milliseconds (standard deviation = 211). Multiple linear regression analysis showed that higher CPAP adherence was significantly associated with a greater reduction in minor lapses in attention after 6 months of continuous treatment with CPAP therapy (β = -0.72, standard error = 0.34, P = .037).

CONCLUSIONS

The results of this study showed that higher levels of CPAP adherence were associated with significant improvements in vigilance. Because the PVT is a performance-based measure that is not influenced by prior learning and is not subjective, it may be an important supplement to patient self-reported assessments.

CLINICAL TRIAL REGISTRATION

Name: Effect of Self-Management on Improving Sleep Apnea Outcomes, URL: https://clinicaltrials.gov/ct2/show/NCT00310310, Identifier: NCT00310310.

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.

Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: An Evaluation and Comparison of Outcomes at Two Academic Centers

STUDY OBJECTIVES

Data from patients at Thomas Jefferson University Hospital (TJUH) and University of Pittsburgh Medical Center (UPMC) undergoing upper airway stimulation (UAS) were analyzed. We hypothesize that treatment with UAS will improve both subjective and objective outcome measures and results will be reproducible between institutions.

METHODS

We reviewed patients undergoing UAS between May 2014 and August 2016. We recorded demographic data, Epworth Sleepiness Scale (ESS), and preoperative and postoperative polysomnographic information. We compared outcome data between institutions and subsequently combined the cohorts and compared baseline to posttreatment results.

RESULTS

The TJUH cohort consisted of 30 males and 18 females with a mean age of 60.88 years and body mass index of 29.29. The mean preoperative apnea-hypopnea index (AHI), O₂ nadir, and ESS were 35.88, 80.96, and 11.09, respectively. The mean postoperative AHI, O₂ nadir, and ESS were 6.34, 88.04, and 5.77, respectively. The UPMC cohort consisted of 30 males and 19 females with a mean age of 62.84 years and body mass index of 27.74. The mean preoperative AHI, O₂ nadir, and ESS were 35.29, 79.58, and 10.94, respectively. The mean postoperative AHI, O₂ nadir, and ESS were 6.28, 84.35, and 6.60, respectively. We found no difference in patients reaching a postoperative AHI less than 15, 10, and 5 when comparing the cohorts. After combining cohorts, we found a significant improvement in postoperative AHI, O₂ nadir, and ESS compared to preoperative values.

CONCLUSIONS

UAS appears to provide a viable alternative to continuous positive airway pressure, producing improvement in both polysomnographic and quality-of-life measures. Results are reproducible at high-volume centers.

Mobile Phone Interventions for Sleep Disorders and Sleep Quality: Systematic Review

Background

Although mobile health technologies have been developed for interventions to improve sleep disorders and sleep quality, evidence of their effectiveness remains limited.

Objective

A systematic literature review was performed to determine the effectiveness of mobile technology interventions for improving sleep disorders and sleep quality.

Methods

Four electronic databases (EBSCOhost, PubMed/Medline, Scopus, and Web of Science) were searched for articles on mobile technology and sleep interventions published between January 1983 and December 2016. Studies were eligible for inclusion if they met the following criteria: (1) written in English, (2) adequate details on study design, (3) focus on sleep intervention research, (4) sleep index measurement outcome provided, and (5) publication in peer-reviewed journals.

Results

An initial sample of 2679 English-language papers were retrieved from five electronic databases. After screening and review, 16 eligible studies were evaluated to examine the impact of mobile phone interventions on sleep disorders and sleep quality. These included one case study, three pre-post studies, and 12 randomized controlled trials. The studies were categorized as (1) conventional mobile phone support and (2) utilizing mobile phone apps. Based on the results of sleep outcome measurements, 88% (14/16) studies showed that mobile phone interventions have the capability to attenuate sleep disorders and to enhance sleep quality, regardless of intervention type. In addition, mobile phone intervention methods (either alternatively or as an auxiliary) provide better sleep solutions in comparison with other recognized treatments (eg, cognitive behavioral therapy for insomnia).

Conclusions

We found evidence to support the use of mobile phone interventions to address sleep disorders and to improve sleep quality. Our findings suggest that mobile phone technologies can be effective for future sleep intervention research.

Educational video to improve CPAP use in patients with obstructive sleep apnoea at risk for poor adherence: a randomised controlled trial

BACKGROUND

Suboptimal adherence to CPAP limits its clinical effectiveness in patients with obstructive sleep apnoea (OSA). Although rigorous behavioural interventions improve CPAP adherence, their labour-intensive nature has limited widespread implementation. Moreover, these interventions have not been tested in patients at risk of poor CPAP adherence. Our objective was to determine whether an educational video will improve CPAP adherence in patients at risk of poor CPAP adherence.

METHODS

Patients referred by clinicians without sleep medicine expertise to an urban sleep laboratory that serves predominantly minority population were randomised to view an educational video about OSA and CPAP therapy before the polysomnogram, or to usual care. The primary outcome was CPAP adherence during the first 30 days of therapy. Secondary outcomes were show rates to sleep clinic (attended appointment) and 30-day CPAP adherence after the sleep clinic visit date.

RESULTS

A total of 212 patients met the eligibility criteria and were randomised to video education (n=99) or to usual care (n=113). There were no differences in CPAP adherence at 30 days (3.3, 95% CI 2.8 to 3.8 hours/day video education; vs 3.5, 95% CI 3.1 to 4.0 hours/day usual care; p=0.44) or during the 30 days after sleep clinic visit. Sleep clinic show rate was 54% in the video education group and 59% in the usual care group (p=0.41). CPAP adherence, however, significantly worsened in patients who did not show up to the sleep clinic.

CONCLUSIONS

In patients at risk for poor CPAP adherence, an educational video did not improve CPAP adherence or show rates to sleep clinic compared with usual care.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT02553694.

Randomized Factorial Trial of Phone-Delivered Support Counseling and Daily Text Message Reminders for HIV Treatment Adherence

BACKGROUND

HIV infection is clinically managed with antiretroviral therapy (ART), but only with sustained adherence. Cost-efficient interventions to improve and sustain ART adherence remain a pressing priority for populations challenged by nonadherence. The aim of this study was to test the independent and interactive effects of (1) brief phone-delivered self-regulation counseling and (2) daily phone-delivered text message medication reminders on HIV adherence and HIV viral suppression.

METHOD

A randomized 2 (5 sessions of phone-delivered adherence support counseling vs. contact-matched control) × 2 (daily ART text reminders vs. no reminders) trial with primary end points of monthly phone-based unannounced pill count-determined ART adherence and HIV viral suppression monitored over 12 months.

RESULTS

Self-regulation adherence counseling demonstrated significant improvements in achieving 90% ART adherence relative to the control group over the first 6 months of follow-up. Effects remained significant in sensitivity analyses conducted at 85% and 95% adherence. Counseling also demonstrated modest but significant effects on HIV suppression. There were no main effects or interactions for daily text message reminders, with some evidence for adverse effects on adherence self-efficacy.

CONCLUSIONS

Brief adherence support counseling delivered by phone demonstrates clinically meaningful improvements in ART adherence and HIV suppression, although these benefits were not evidenced in all patients or in the long-term. Advancing adherence interventions along with an effective means for sustaining gains in adherence remain priorities if ART is to achieve its potential clinical and public health benefits.