The Efficacy of a Brief Motivational Enhancement Education Program on CPAP Adherence in OSA: A Randomized Controlled Trial

doi:10.1378/chest.13-2228

Chest

Volume 146, Issue 3, September 2014, Pages 600-610

https://doi.org/10.1378/chest.13-2228 Get rights and content

BACKGROUND

Poor adherence to CPAP treatment in OSA adversely affects the effectiveness of this therapy. This randomized controlled trial (RCT) examined the efficacy of a brief motivational enhancement education program in improving adherence to CPAP treatment in subjects with OSA.

METHODS

Subjects with newly diagnosed OSA were recruited into this RCT. The control group received usual advice on the importance of CPAP therapy and its care. The intervention group received usual care plus a brief motivational enhancement education program directed at enhancing the subjects' knowledge, motivation, and self-efficacy to use CPAP through the use of a 25-min video, a 20-min patient-centered interview, and a 10-min telephone follow-up. Self-reported daytime sleepiness adherence-related cognitions and quality of life were assessed at 1 month and 3 months. CPAP usage data were downloaded at the completion of this 3-month study.

RESULTS

One hundred subjects with OSA (mean ± SD, age 52 ± 10 years; Epworth Sleepiness Scales [ESS], 9 ± 5; median [interquartile range] apnea-hypopnea index, 29 [20, 53] events/h) prescribed CPAP treatment were recruited. The intervention group had better CPAP use (higher daily CPAP usage by 2 h/d [Cohen d = 1.33,P< .001], a fourfold increase in the number using CPAP for ≥ 70% of days with ≥ 4 h/d [P< .001]), and greater improvements in daytime sleepiness (ESS) by 2.2 units (P= .001) and treatment self-efficacy by 0.2 units (P= .012) compared with the control group.

CONCLUSIONS

Subjects with OSA who received motivational enhancement education in addition to usual care were more likely to show better adherence to CPAP treatment, with greater improvements in treatment self-efficacy and daytime sleepiness.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01173406; URL: www.clinicaltrials.gov

Section snippets

Study Designs and Participants

This was a randomized (1:1) controlled parallel-group clinical trial. Chinese subjects with OSA who fulfilled the inclusion and exclusion criteria were invited to participate in this study. The inclusion criteria were the following: (1) age ≥ 18 years old with newly diagnosed OSA (apnea-hypopnea index [AHI] ≥ 5), (2) receiving in-laboratory auto-CPAP titration for the first time, and (3) no prior OSA or CPAP education classes. Subjects were excluded if they had central sleep apnea, periodic leg

Patient Recruitment

Figure 3 shows the subjects' disposition. A total of 212 subjects with OSA referred for CPAP titration were screened during the study period. One hundred six subjects did not meet the inclusion criteria, and six subjects refused to participate. Thus, 100 subjects were recruited. They were randomized to either control group (usual care) (n = 51) or intervention group (brief motivational enhancement education plus usual care) (n = 49). There were two dropouts. One subject in the control group who

Discussion

This is the first RCT, to our knowledge, demonstrating that a brief motivational enhancement education program, using one session and one phone follow-up call, was able to enhance adherence to CPAP treatment with a large effect size (Cohen d = 1.33). These results were consistent from 1 week to 3 months of CPAP use. The intervention group had a higher daily CPAP usage by 2 h/d, fourfold the number of adherent CPAP users, and greater improvements in treatment self-efficacy and daytime

Acknowledgments

Author contributions: A. Y. K. L. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. A. Y. K. L., D. Y. T. F., J. C. M. L., and M. S. M. I. contributed to the study concept and design; A. Y. K. L. contributed to the acquisition and analysis of data; A. Y. K. L., D. Y. T. F., J. C. M. L., T. E. W., and M. S. M. I. contributed to the interpretation of data; A. Y. K. L. contributed to drafting of the

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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).
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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).
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.
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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.
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).
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.
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The first-line treatment for obstructive sleep apnoea is (OSA) continuous positive airway pressure (CPAP) therapy, which achieves a high level of efficacy with continuous use. However, daily application of this therapy requires a motivated patient profile, as lack of adherence is the main problem with this therapy. The aim of this study was to determine whether an educational and training program based on motivational interviewing and proper feedback, improved adherence.
A randomized, controlled, single-center trial design was performed. The interventions were standard of care vs MEntA Program based on motivational interview for adherence. The main outcome was the adherence with the CPAP therapy after 90 days of treatment. Secondary outcomes were the motivation, perceived competence, quality of life, sleepiness, emotional state, activities and social relations.
For adherence, statistically significant results were obtained in favor of the interventional arm with the MEntA (p < 0.01), with a mean difference of 1.60 h (95% CI, 0.60 to 2.61). The Questionnaire of Evaluation of Perceived Competence in Adherence to CPAP in OSA show also a statistically significant change in favor of the MEntA intervention with a mean difference of 4.61 (95% CI, 3.49 to 5.72) (p < 0.001), as well as quality of life p < 0.001.
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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Chest

Original Research: Sleep DisordersThe Efficacy of a Brief Motivational Enhancement Education Program on CPAP Adherence in OSA: A Randomized Controlled Trial

BACKGROUND

METHODS

RESULTS

CONCLUSIONS

TRIAL REGISTRY

Section snippets

Study Designs and Participants

Patient Recruitment

Discussion

Acknowledgments

Sleep Med Rev

Chest

Patient Educ Couns

Patient Educ Couns

Psychiatry Res

Sleep Med Rev

Sleep Med

J Clin Epidemiol

J Clin Epidemiol

Chest

J Chronic Dis

Chest

Sleep Med

Sleep Med

Early CPAP use identifies subsequent adherence to CPAP therapy

Sleep

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

Cochrane Database Syst Rev

Long-term adherence to CPAP treatment in patients with obstructive sleep apnea: importance of educational program

Patient Prefer Adherence

Compliance with continuous positive airway pressure therapy: assessing and improving treatment outcomes

Curr Opin Pulm Med

Behavioral management of sleep-disordered breathing

Prim Psychiatry

Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: preliminary findings

Behav Sleep Med

Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial

Sleep

Improving compliance with nasal CPAP and vigilance in older adults with OAHS

Sleep Breath

Predicting treatment adherence in obstructive sleep apnea using principles of behavior change

J Clin Sleep Med

Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study

J Consult Clin Psychol

Negotiating behaviour change in medical settings: the development of brief motivational interviewing

J Ment Health

The impact of educational message framing on adherence to continuous positive airway pressure therapy

Behav Sleep Med

Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome?

Am J Respir Crit Care Med

Telehealth services to improve nonadherence: a placebo-controlled study

Telemed J E Health

Original Research: Sleep Disorders
The Efficacy of a Brief Motivational Enhancement Education Program on CPAP Adherence in OSA: A Randomized Controlled Trial