Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial

Health & Wellness Coaching Services: Making the Case for Reimbursement

In 2020, a consortium composed of three national coach credentialing organizations, four medical societies, and 72 healthcare organizations led by National Board for Health and Wellness Coaching (NBHWC) was formed to advocate for the reimbursement of Health and Wellness Coaching (HWC) services in the U.S. healthcare system. Building on that, the NBHWC and the Veterans Health Administration (VHA) initiated a pivotal collaboration in 2023, with a target audience comprised influential reimbursement policymakers, notably the American Medical Association's Current Procedural Terminology (CPT®) Panel and the Centers for Medicare & Medicaid Services (CMS). This concerted effort led to CMS announcing the temporary inclusion of HWC services on the 2024 Medicare Telehealth list. This ongoing advocacy work is crucial while understanding its key components is imperative for wider participation. This paper aims to distill the essence of the advocacy to date into a coherent narrative. By doing so, we seek to share with stakeholders-health and wellness coaches, medical professionals, healthcare organizations, patient advocates, and policy experts-a robust framework to support advocacy for reimbursement to both government and private insurers, at local and national levels. This initiative marks a significant milestone in healthcare policy, reflecting a growing recognition and impact of HWC.

The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study

STUDY OBJECTIVES

Although treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy is effective, adherence is often poor. Understanding the patient perspective is needed to inform adherence-promoting interventions. This qualitative study assessed the experiences, preferences, facilitators, and barriers surrounding PAP therapy for the management of OSA in patients from adolescence to older adulthood.

METHODS

Eligible participants ages 19 and older were identified from administrative health care claims; adolescent participants ages 12-18 and their parents/caregivers were identified via electronic health records of a tertiary sleep specialty clinic at a large children's hospital. Forty English-speaking patients and 10 parents of adolescents diagnosed with OSA and prescribed PAP therapy completed semistructured 60-minute telephone interviews conducted by a trained facilitator. Common themes and illustrative quotes were identified.

RESULTS

Themes around OSA diagnosis, initiating OSA treatment, learning about OSA/PAP, decision to start PAP, PAP benefits and challenges, and reasons for nonadherence were identified. Participants suggested design and delivery changes to improve PAP devices. Issues unique to adolescents and their parents were discussed.

CONCLUSIONS

The unique perspectives of patients regarding PAP therapy should be taken into consideration when developing interventions to increase PAP adherence and improve clinical care. Based on identified themes, opportunities for intervention may exist at all stages of care, from diagnosis to treatment initiation. Involving partners, parents, and other caregivers in PAP therapy may be beneficial for optimizing adherence.

CITATION

Simon SL, Stephenson JJ, Haynes K, et al. The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study. J Clin Sleep Med. 2024;20(3):407-416.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist.

OBJECTIVES

This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes.

METHODS

We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed.

RESULTS

Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers.

DISCUSSION

Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

Motivational interviewing-an evidence-based, collaborative, goal-oriented communication approach in lifestyle medicine: A comprehensive review of the literature

The global threat of noncommunicable diseases (NCDs) is alarmingly increasing. The health and economic burden of improper lifestyle choices is immense. Reducing modifiable risk factors has been demonstrated to significantly prevent chronic diseases. At this crucial time, lifestyle medicine (LM) has been recognized as an evidence-based medical domain applicable to NCDs. Among the tools used in LM, motivational interviewing (MI) is a patient-centered, collaborative counseling approach. In this evidence-based review article, we discuss recent literature on the application of MI in the six LM pillars defined by the British Society of LM (BSLM): healthy eating, mental wellbeing, healthy relationships, physical activity, minimizing harmful substances, and sleep. MI helps strengthen patients' motivation to ameliorate behaviorally influenced health problems, improve treatment adherence, and optimize medical interventions. Technically correct, theoretically congruent, and psychometrically sound MI interventions yield satisfactory outcomes and help improve patient quality of life. Lifestyle change is often a gradual process involving multiple efforts and setbacks. MI is based on the idea that change is a process rather than an event. Extensive literature evidence supports the benefits of MI treatment, and interest in research on MI application is increasing across all BSLM pillars. MI helps people alter their thoughts and feelings about making changes by recognizing obstacles to change. Even interventions of short duration have been reported to yield better outcomes. Healthcare professionals must understand the relevance and importance of MI in clinical practice.

Investigating changes in cognition associated with the use of CPAP in cognitive impairment and dementia: A retrospective study

STUDY OBJECTIVES

To characterize the impact of CPAP use on cognition in a clinical cohort with obstructive sleep apnea (OSA) and cognitive impairment due to neurodegenerative or vascular etiologies after controlling for baseline sleepiness.

METHODS

We retrospectively analyzed data from 171 patients with cognitive impairment and an OSA diagnosis confirmed with in-laboratory polysomnography or home sleep apnea testing (mean age 69.8 ± 10.6; 66% male) who were eligible to use CPAP. Baseline and follow-up Epworth Sleepiness Score (ESS), Montreal Cognitive Assessment (MoCA), and Mini-Mental Status Examination (MMSE) were obtained from clinical and research visits conducted before and after CPAP initiation. Good CPAP adherence was defined as CPAP use ≥4 h/night, for 7 days/week at follow-up. Associations between CPAP adherence and follow-up cognitive scores were analyzed using multivariable linear mixed-effects models.

RESULTS

After adjusting for age, sex, body mass index, baseline ESS, duration of CPAP therapy, relevant comorbidities and the random effect of research study cohort, good CPAP adherence (compared to poor CPAP adherence or no use of CPAP) for a duration of 2-12 months was associated with a 2.3-point (1.2-3.3 95% CI) higher follow-up MoCA score (p < 0.001) and a 1.2-point (0.3-2.3 95% CI) higher follow-up MMSE score (p = 0.01).

CONCLUSIONS

In patients with OSA and cognitive impairment due to a neurodegenerative or vascular etiology, use of CPAP is associated with improved cognitive outcomes. The findings of this study may aid in motivating patients to use CPAP and support future randomized controlled trials in this area.

Shared decision making: A novel approach to personalized treatment in obstructive sleep apnea

Study objectives

i) To describe a novel approach of phenotyping by shared decision making (SDM) in obstructive sleep apnea (OSA) discharge consultations ii) to describe correlation between patient and observer based evaluations of SDM and iii) to describe treatment adherence.

Methods

Consecutive patients referred to the otorhinolaryngology department at Akershus University Hospital with suspected OSA between 2015 and 2016 participated. Patients with body mass index >30 were oversampled. Four male communication-trained doctors aged from 30 to 60 years participated. SDM was evaluated by modified content analysis and by the CollaboRATE self-report questionnaire and the "Observer OPTION (Young et al., 2008) [5]" rating scale. Positive airway pressure (PAP) treatment adherence and weight reduction was assessed by interview at six year follow-up.

Results

Eighteen consultations were video filmed. The content analysis revealed that the patient perspectives only briefly were explored. PAP was chosen by 17 of 18 patients. Median CollaboRATE questionnaire score was 29 (26, 30). Mean OPTION (Young et al., 2008) [5] score was 65.6 (SD 6.6, range 55-80). The correlation between SDM assessed by CollaboRATE self-report and by the "Observer OPTION (Young et al., 2008) [5]" rating scale was low (Pearson's r = 0.09). At follow up, 11 patients (64.7%) were PAP adherent and no one achieved 10% weight loss.

Conclusions

Despite a high degree of SDM compared to studies of non-OSA populations, the sub-optimal exploration of the patient perspective by communication-trained doctors precluded identification of patients willing to cope actively. SDM assessed by self-report and by a rating scale may represent two different constructs. PAP adherence was good.

Patient-Centered Therapy for Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA) is one of the most common sleep problems defined by cessation or decreased airflow despite breathing efforts. It is known to be related to multiple adverse health consequences. Positive airway pressure (PAP) is considered an effective treatment that is widely used. Various modes of PAP and other emerging treatment options are now available. A multidisciplinary approach, understanding diverse phenotypes of OSA, and shared decision-making are necessary for successful OSA treatment. Patient-centered care is an essential modality to support patient care that can be utilized in patients with OSA to help improve outcomes, treatment adherence, and patient satisfaction.

Motivational Interviewing Effects on Positive Airway Pressure Therapy (PAP) Adherence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This systematic review and meta-analysis examined Motivational Interviewing (MI) effects on positive airway pressure (PAP) adherence and related outcomes.

METHOD

Medline, CIHANL, Psych Info, Web of Science, PubMed, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials published from peer-reviewed journals in English from 1990 to 2021 that compared objective PAP adherence among adults with obstructive sleep apnea (OSA) in a MI and non-MI intervention. A random effects meta-analysis model was completed at the 1-to-2-week, and 1-, 2-, 3-, and 12-month follow-up, and risk of bias was analyzed with the Cochrane Risk of Bias Tool.

RESULTS

In 10 trials of naïve PAP users and one trial of non-naïve PAP users, 14 to 277 middle-aged adults with moderate-to-severe OSA generally engaged in a brief, individual, face-to-face, MI intervention with standard care or a control condition. Several trials of naïve PAP users demonstrated that MI increased PAP use 1-2.6 hours per night, but a similar number of trials showed comparable conditions. Secondary outcomes were mixed. Among non-naïve PAP users, MI did not significantly increase adherence or secondary outcomes. The meta-analysis of PAP-naïve participants revealed that MI had a small to moderate significant effect on PAP adherence at 1, 2, and 3 months after beginning PAP (Hedges' g = 0.38 to 0.48; 95% CI = 0.04, 0.75) compared to standard care alone.

CONCLUSIONS

Despite heterogeneity, MI moderately increased PAP adherence among PAP-naïve adults with moderate-to-severe OSA, suggesting an effective strategy for short-term (1-3 months) adherence.

Factors Associated with Free Medicine Use in Patients with Hypertension and Diabetes: A 4-Year Longitudinal Study on Full Coverage Policy for Essential Medicines in Taizhou, China

Full coverage policies for medicines have been implemented worldwide to alleviate medicine cost burden and promote access to medicines. However, few studies have explored the factors associated with free medicine use in patients with chronic diseases. This study aimed to analyze the utilization of free medicines by patients with hypertension and diabetes after the implementation of the full coverage policy for essential medicines (FCPEM) in Taizhou, China, and to explore the factors associated with free medicine use. We conducted a descriptive analysis of characteristics of patients with and without free medicine use and performed a panel logit model to examine factors associated with free medicine use, based on an electronic health record database in Taizhou from the baseline year (12 months in priori) to three years after FCPEM implementation. After FCPEM implementation, the proportion of patients without any free medicine use decreased from 31.1% in the baseline year to 28.9% in the third year, while that of patients taking free medicines rose from 11.0% to 22.8%. Patients with lower income or education level, those with agricultural hukou, patients aged 65 and above, married patients, and patients in the Huangyan district were more likely to take free medicines. In conclusion, FCPEM contributed to improved medicine access, especially in vulnerable populations. Local policy makers should consider expanding the coverage of FCPEM to other types of medicines and cultivate the potential of social supports for patients to enhance the effectiveness of FCPEM policies.