Personalization, In-Home Adaptation Necessary to Improve CPAP Adherence

by Brenda Mooney

April 16, 2019

INDIANAPOLIS—To improve adherence to continuous positive airway pressure treatment, more emphasis needs to be put on support for sleep apnea patients in their homes, where the equipment actually is used.

That’s according to a new study noting that better solutions are required because as many as half of patients prescribed CPAP have difficulty following their treatment regimen, leading to issues such daytime sleepiness, motor vehicle accidents and increased risk for cardiovascular diseases, including stroke.

Researchers from the Richard M. Roudebush VAMC, the Regenstrief Institute, both in Indianapolis, and Yale University School of Medicine in New Haven, CT, suggested that new, personalized patterns of behavior with physical, psychological and cognitive adaptations are required to make patients more adherent to CPAP therapy.

The research was published in the journal Cureus.1

Pamela Dubrow (right), a registered sleep technologist and certified sleep educator, provides CPAP education and proper fitting for Navy veteran Jim Mitchell (left) in the Oscar G. Johnson VAMC’s CPAP clinic. In Iron Mountain, MI. VA photo.

“Telling patients they should exercise more or go on a diet is not a prescription for success, and neither is just handing them a CPAP machine with basic use instructions,” explained lead researcher Edward Miech, EdD. “Simple actions, such as discussing the patient’s specific concerns during the crucial initial period, can successfully introduce CPAP treatment and could increase the likelihood of successful adherence.

“Unlike taking a pill, personal context—especially in the home situation—can make an enormous difference in terms of how well individual patients adapt to CPAP after receiving a diagnosis of obstructive sleep apnea,” he said. “Given the irritating, ongoing challenges associated with CPAP adherence, helping patients adapt the treatment to the specifics of where and how they live represents a major opportunity to improve CPAP adherence and improve obstructive sleep apnea outcomes.”

The objective of the new study was to understand the processes that help explain successful (and unsuccessful) CPAP therapy and to evaluate how and why external assistance and advice improved its use. Study staff talked in person with participants in their homes.

The Sleep Apnea in Transient Ischemic Attack and Stroke: Reducing Cardiovascular Risk with Positive Airway Pressure (sleep tight) study was a randomized controlled trial that sought to evaluate the effectiveness of a diagnosis and treatment strategy for obstructive sleep apnea among patients with a recent stroke or transient ischemic attack.

CPAP After OSA Diagnosis

Study authors said they sought to understand how CPAP therapy was personalized for patients after an OSA diagnosis.

For the study, 252 patients from six clinical sites in Connecticut and Indiana were randomly assigned to one of three groups: a usual care control group and two intervention groups, with patients in the intervention groups receiving polysomnography at home soon after their cerebrovascular event. Sleep apnea was diagnosed if the apnea-hypopnea Index was 5 or greater.

Participants with OSA were offered CPAP for a minimum of six months and up to one-year post-enrollment. Intervention patients also were randomly assigned to either the “standard intervention” or a multifaceted “enhanced intervention.” Here is how the two protocols differed:

  • In the “standard intervention,” patients received five in-person contacts and one telephone contact over the course of the up to 12-month follow-up period. The standardized educational session covered sleep apnea and CPAP, the results of the diagnostic sleep study and instruction regarding CPAP equipment during the initial in-person contact. During the in-person contacts, reviews of CPAP adherence data, discussions regarding symptom improvement and adverse effects and encouragement of continued use were offered.
  • The “enhanced intervention,” meanwhile, involved more-intense encouragement of CPAP adherence than is typically provided at sleep centers in routine clinical practice settings. It was based on the conceptual frameworks of the narrative model of patient decision-making and self-determination theory and consisted of intensive in-person patient contact during the first month of CPAP treatment and then telephone follow-up or in-person contacts for continuing support during the rest of the study period.

Study authors said they determined, based on the comparative case studies, that adherence to CPAP therapy is an adaptive process “where personal context matters. The case studies also demonstrated how some patients overcame challenges and barriers by themselves to integrate CPAP therapy into their own lives, while others required help from study staff to overcome these barriers, and some were never able to successfully adapt CPAP therapy in order to fit their personal contexts, despite study staffs’ best efforts.”

Co-author Dawn Bravata, MD, emphasized the importance of helping OSA patients adapt to CPAP, explaining, “In a study we published in 2018, we found that, for individuals who have had a stroke or a TIA—a Transient Ischemic Attack, also known as a mini-stroke, treatment of sleep apnea with CPAP provides significant benefits. But if patients don’t use their CPAP machines because the mask doesn’t fit right, the noise is bothersome or other reasons, patients with sleep apnea, aren’t getting the treatment they need.”

How to do that varies, according to co-author, Marianne Matthias, PhD. She pointed out that “opportunities exist when CPAP commences, as well as at critical junctures when a patient is vacillating between being a user or a nonuser as they fit the device into their home context. Extra support or a nudge could make a big difference.”

Study authors stressed the importance of clinician involvement in assuring adherence. “As with the initiation of many medical treatments (e.g., antihypertensive medications), physicians are likely to guide patient encounters toward a discussion of the medical benefits of using therapy and/or the adverse outcomes that may result from failure to comply with therapy,” they wrote. “For example, in our experience, most sleep physicians’ initial encounters with patients newly diagnosed with OSA focus on the improvements in daytime sleepiness and cognitive functioning that may result from good CPAP adherence, and the adverse cerebrovascular, cardiovascular and metabolic consequences of untreated OSA. However, the simple provision of CPAP and the communication of evidence related to OSA may be inadequate for successful CPAP adaptation. CPAP adaption is a process that unfolds over time, and our current single-visit model may be insufficient to drive consistent use.”

Researchers added that patients with stroke or TIA might be less symptomatic for sleepiness and, therefore, less likely to seek medical help specifically for sleep-related problems. “This lack of specific sleep-related symptoms might negatively affect motivation to persevere with CPAP and adapt it to the personal context,” they noted.

Miech EJ, Bravata DM, Yaggi H, et al. (February 15, 2019) Adapting Continuous Positive Airway Pressure Therapy to Where Patients Live: A Comparative Case Study. Cureus 11(2): e4078. doi:10.7759/cureus.4078

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