ABSTRACT & COMMENTARY
Medical Treatment Is Effective, But Only if It is Used
By Barbara A. Phillips, MD, MSPH
Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington
Dr. Phillips serves on the speakers bureau for PotomaCME.
In this randomized controlled trial, those sleep apnea patients who received a brief (< 1 hour, total) motivational education program had substantially better continuous positive airway pressure adherence in a short-term follow-up.
SOURCE: Lai AY, et al. The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: A randomized controlled trial. Chest 2014;146:600-610.
This was a randomized, controlled trial (RCT)of 100 Chinese patients with obstructive sleep apnea (OSA). All patients were provided with continuous positive airway pressure (CPAP) machines for the 3-month study period, and adherence was objectively measured. Patients were randomized to usual care or to intervention.
Usual care was provided by nurses in the sleep disorders center and included a 15-minute talk about CPAP, an opportunity to try CPAP before titration, a post-titration meeting with the medical officer-in-charge (who explained OSA and that patient’s particular test results), and another 15-minute talk by nurses on the importance of CPAP therapy and care of accessories.
The brief motivational enhancement education program included the usual care component, but also an additional session in the morning after CPAP titration and a telephone call on day 2 of CPAP use. During the session on the morning after titration, the subject was shown a 25-minute video about OSA and CPAP that featured real-life experiences of a current CPAP user. This was followed by a 20-minute, patient-centered, face-to-face brief motivational interview that included exploration of the barriers and facilitators of using CPAP, use of a decision matrix to discuss the positive and negative aspects of using or not using CPAP, and looking forward to the expected outcomes or benefits of using CPAP. This interview was conducted by one of the investigators who was both a nurse and polysomnographic technologist and who had received prior training to conduct motivational interviews by a clinical psychologist. In addition, a 10-minute phone call was made to the subjects by the same interviewer on day 2 of CPAP use.
There was no significant difference between the two groups in any important measure at baseline; for the group as a whole, the mean age was 52 years, mean Epworth Sleepiness Scale score was 9, and mean AHI was 29/hr. During 3 months of follow-up, only two subjects dropped out, one in each group.
During the follow-up period, the subjects in the intervention group had greater mean daily CPAP use by 2.0 h/d (4.4 vs 2.4 h/d; P < 0.001) In addition, there was a four-fold increase in the number using CPAP for ≤ 70% of days with ≤ 4 h/d (P < 0.001), and greater improvements in daytime sleepiness and treatment self-efficacy (P = 0.012) in the intervention group.
In the control group, compared with 1 week, CPAP adherence decreased at 1 month (P < 0.05) and 3 months (P < 0.05) in all measures. In the intervention group, CPAP adherence did not change between 1 week and 1 month (P > 0.05) but decreased at 3 months (P < 0.05).
There were positive relationships between CPAP adherence and treatment self-efficacy and outcome expectancies at 1 month and 3 months, but there was no association between CPAP usage and risk perceptions during the study period. There was also no significant improvement in any score of the three health-related quality-of-life scales in the intervention group compared with the control group.
COMMENTARY
OSA is a highly prevalent and deadly condition, and CPAP is clearly the most effective intervention.1-4 As with any nonsurgical treatment, adherence to CPAP treatment is important; improvement in important outcomes such as hypertension and sleepiness is contingent on a certain amount of CPAP use.1,3 The current “standard” definition of “CPAP adherence” is use for at least 4 hours for at least 70% of nights; it is not totally arbitrary, since that threshold has been used in several studies that have demonstrated improved outcomes in those who met it compared to those who did not.5
Unlike adherence with medications, CPAP adherence is now easily and routinely measured, and is not actually worse than adherence to any chronic medical treatment, depending on how adherence is defined.6 Unlike adherence with medications, continued payment for CPAP (masks, parts, supplies, monthly rental) by many payers is contingent on meeting the definition of adherence described above. (In my opinion, however, we are quickly moving to an environment where CPAP parts and supplies will be readily and cheaply available at large retail outlets and on the Internet, and some of the current angst about adherence will become moot).
Thus, clinicians are focused on helping patients meet adherence requirements, not only because this is much more likely to improve health-related outcomes, but also because this may be necessary for continued access to therapy.
This study is important because it is an RCT and because the intervention was so brief and did not require a physician to administer it. It is also very likely that the findings of this study are relevant to adherence with all medical therapies.
So, what was so magical about the “brief intervention”? The authors explain that there were three particular aspects that they aimed to improve: knowledge, motivation, and self-efficacy. Of these, knowledge is probably the best documented tool to change behavior.7,8 But the control group in this study also got education. What was different about what the intervention group got was that the additional education was presented by a patient just like them (in a video), and they also got a motivational interview and follow-up phone call. It probably didn’t hurt that this intervention took place just as sleep study results were disclosed and right before CPAP was initiated, in a way and place that was convenient for the participants.
I spend a lot of my clinical time trying to help patients use CPAP. The take-home messages for me are that personalized education, specific to the individual patient, can really make a difference. And it doesn’t have to be done by a doctor.
REFERENCES
- Barbe F, et al. Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: A randomized controlled trial. JAMA 2012;307:2161-2168.
- Mulgrew AT, et al. Risk and severity of motor vehicle crashes in patients with obstructive sleep apnoea/hypopnoea. Thorax 2008;63:536-541.
- Mart¨ªnez-Garc¨ªa MA, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: A 5-year follow-up study. Am J Respir Crit Care Med 2009;180:36-41.
- Young T, et al. Sleep disordered breathing and mortality: Eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep 2008;31:1071-1078.
- http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/PAP_DocCvg_Factsheet_ICN905064.pdf. Accessed Oct. 24, 2014.
- Simpson SH, et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ 2006;333:15.
- Bandura A. Health promotion by social cognitive means. Health Educ Behav 2004;31:143-164.
- Mazzuca SA. Does patient education in chronic disease have therapeutic value? J Chronic Dis 1982;35:521-529.
