A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial

Background Continuous positive airway pressure (CPAP) is the most widely prescribed treatment for obstructive sleep apnoea syndrome (OSAS). Although it has been shown to improve the symptoms of OSAS, many patients have difficulty adhering to this treatment. The purpose of this study was to investigate the effectiveness of an automated telemedicine intervention to improve adherence to CPAP. Methods A randomised clinical trial was undertaken in 250 patients being started on CPAP therapy for OSAS. Patients were randomly assigned to use a theory-driven interactive voice response system designed to improve CPAP adherence (telephone-linked communications for CPAP (TLC-CPAP), n=124) or to an attention placebo control (n=126) for 12 months. TLC-CPAP monitors patients' self-reported behaviour and CPAP-related symptoms and provides feedback and counselling through a structured dialogue to enhance motivation to use CPAP. A Sleep Symptoms Checklist, the Functional Outcomes of Sleep Questionnaire, the Center for Epidemiological Studies Depression Scale and the Psychomotor Vigilance Task were administered at study entry and at 6-month and 12-month follow-up. Hours of CPAP usage at effective mask pressure were measured by the CPAP device stored in its memory and retrieved at each visit. Results Median observed CPAP use in patients randomised to TLC-CPAP was approximately 1 h/night higher than in the control subjects at 6 months and 2 h/night higher at 12 months. Using generalised estimating equation modelling, the intervention had a significant effect on CPAP adherence. For secondary analysis, the effect of CPAP adherence on the secondary outcomes was analysed. CPAP adherence was significantly associated with a greater reduction in sleep apnoea symptoms and depressive symptoms and a greater improvement in functional status. No significant association was observed between CPAP adherence and reaction time. Conclusions The TLC-CPAP intervention resulted in improved CPAP adherence, which was associated with improved functional status and fewer depressive symptoms. Clinical trial.gov NCT00232544.

[1]  Sonia Ancoli-Israel,et al.  Determinants of nasal CPAP compliance. , 2002, Sleep medicine.

[2]  A I Pack,et al.  Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. , 1993, The American review of respiratory disease.

[3]  Greg Maislin,et al.  Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. , 2007, Sleep.

[4]  N. Saunders,et al.  Long-term acceptance of continuous positive airway pressure in obstructive sleep apnea. , 1991, The American review of respiratory disease.

[5]  I. Deary,et al.  Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep Apnea/Hypopnea syndrome. , 1999, American journal of respiratory and critical care medicine.

[6]  R. Friedman.  Automated Telephone Conversations to Assess Health Behavior and Deliver Behavioral Interventions , 1998, Journal of Medical Systems.

[7]  Eric R. Ziegel,et al.  Generalized Linear Models , 2002, Technometrics.

[8]  J. Stradling,et al.  Relation between systemic hypertension and sleep hypoxaemia or snoring: analysis in 748 men drawn from general practice. , 1990, BMJ.

[9]  John E. Stollerman,et al.  A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. , 1996, American journal of hypertension.

[10]  M C Apps,et al.  Sleep-disordered Breathing , 2022 .

[11]  P. McCullagh,et al.  Generalized Linear Models , 1992 .

[12]  David F. Dinges,et al.  Microcomputer analyses of performance on a portable, simple visual RT task during sustained operations , 1985 .

[13]  ColinE. Sullivan,et al.  REVERSAL OF OBSTRUCTIVE SLEEP APNOEA BY CONTINUOUS POSITIVE AIRWAY PRESSURE APPLIED THROUGH THE NARES , 1981, The Lancet.

[14]  M W Gillman,et al.  Randomized Trial of a “Talking Computer” to Improve Adults' Eating Habits , 2001, American journal of health promotion : AJHP.

[15]  K. Rajagopal,et al.  Overnight nasal CPAP improves hypersomnolence in sleep apnea. , 1986, Chest.

[16]  A. O'donnell,et al.  Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. , 1990, Chest.

[17]  N J Douglas,et al.  Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? , 1999, American journal of respiratory and critical care medicine.

[18]  T. Young,et al.  The occurrence of sleep-disordered breathing among middle-aged adults. , 1993, The New England journal of medicine.

[19]  M Partinen,et al.  Long-term outcome for obstructive sleep apnea syndrome patients. Mortality. , 1988, Chest.

[20]  Delwyn J Bartlett,et al.  Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. , 2007, Sleep.

[21]  N J Douglas,et al.  Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. , 1994, Thorax.

[22]  K. Clark,et al.  Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community- Based Study , 2000 .

[23]  I. Deary,et al.  Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome , 1998, Thorax.

[24]  A. Bandura.  Social Foundations of Thought and Action: A Social Cognitive Theory , 1985 .

[25]  E. Fletcher,et al.  The effect of positive reinforcement on hourly compliance in nasal continuous positive airway pressure users with obstructive sleep apnea. , 1991, The American review of respiratory disease.

[26]  R. Friedman,et al.  A telephone-linked computer system for COPD care. , 2001, Chest.

[27]  D. Giles,et al.  Neuropsychological changes and treatment compliance in older adults with sleep apnea. , 2003, Journal of psychosomatic research.

[28]  A I Pack,et al.  Night-to-night variability in CPAP use over the first three months of treatment. , 1997, Sleep.

[29]  K M Hla,et al.  Sleep Apnea and Hypertension: A Population-based Study , 1994, Annals of Internal Medicine.

[30]  R. Chervin,et al.  Compliance with nasal CPAP can be improved by simple interventions. , 1997, Sleep.

[31]  Daniel J. Schwartz,et al.  For individuals with obstructive sleep apnea, institution of CPAP therapy is associated with an amelioration of symptoms of depression which is sustained long term. , 2007, Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine.

[32]  Erry,et al.  Prospective study of the association between sleep-disordered breathing and hypertension. , 2000, The New England journal of medicine.

[33]  D. Hui,et al.  Effects of augmented continuous positive airway pressure education and support on compliance and outcome in a Chinese population. , 2000, Chest.

[34]  M. Aloia,et al.  Clinical Management of Poor Adherence to CPAP: Motivational Enhancement , 2004, Behavioral sleep medicine.

[35]  C. Zwillich,et al.  Nasal CPAP: an objective evaluation of patient compliance. , 1994, American journal of respiratory and critical care medicine.

[36]  R. Millman,et al.  Brief Behavioral Therapies Reduce Early Positive Airway Pressure Discontinuation Rates in Sleep Apnea Syndrome: Preliminary Findings , 2007, Behavioral sleep medicine.

[37]  S. Zeger,et al.  Longitudinal data analysis using generalized linear models , 1986 .

[38]  R. Bhopal,et al.  IS SNORING A CAUSE OF VASCULAR DISEASE? An Epidemiological Review , 1989, The Lancet.

[39]  S. Dabbo,et al.  Motivational Interviewing: Preparing People to Change Addictive Behavior , 1993 .

[40]  Alexander Rokitansky,et al.  Thorax , 2009, Pediatric Surgery Digest.

[41]  M. Kryger,et al.  Mortality and apnea index in obstructive sleep apnea. Experience in 385 male patients. , 1988, Chest.

[42]  A I Pack,et al.  An instrument to measure functional status outcomes for disorders of excessive sleepiness. , 1997, Sleep.

[43]  D. Hillman,et al.  Association of sleep apnoea with myocardial infarction in men , 1990, The Lancet.

[44]  Robert H. Friedman,et al.  The Use of Computer Telephony to Provide Interactive Health Information , 2003, AMIA.

[45]  J. Conway,et al.  Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. , 1992, The American review of respiratory disease.