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The authors note that various studies have shown poor compliance with CPAP in one-quarter to one-half of patients who receive it. Alternative treatments like surgery and dental appliances have been used for these patients, but few studies have examined ways of improving CPAP compliance. One study, of only 10 subjects, failed to show any effect of "frequent positive reinforcement by phone" but didn't separate new CPAP users from those continuing on CPAP at the time of intervention. The present study was designed as a randomized, controlled trial comparing CPAP use separately in new CPAP vs. continuing CPAP users given one of three interventions: frequent phone calls, brief written information about CPAP, or neither.
Of the 40 subjects initially recruited, only 33 were included because the rest were unreachable by phone or gave impossible readings of the usage counters installed in their CPAPs. These were two-third (21/33) male and averaged 52 years old.
On enrollment, subjects completed the Epworth sleepiness scale (ESS) and a questionnaire about whether CPAP was being started or continuing, educational level, occupation, income, living situation (alone or with others), presence or absence of a friend or relative using CPAP, and whether the subject felt he/she understood what CPAP was and what it was for. Also available were polysomnographic variables of apnea/hypopnea index (AHI), lowest oxygen saturation, CPAP pressure assigned, and mean sleep latency on Multiple Sleep Latency Test (MSLT).
The first group (12 subjects) received one telephone call each week from one of the investigators who asked if they had any problems with CPAP, put them in touch with a physician if problems seemed to require that, and encouraged them to use CPAP nightly. The second group (14) received two documents, a pamphlet from the American Sleep Disorders Association called "Sleep Apnea and Snoring" and a half-page document written by the investigators called "Guidelines for CPAP Use." The third group (7) received nothing more than the usual verbal explanation by the clinic physicians.
Subjects read their own CPAP counters, measuring the number of hours CPAP machines were on, and reported them 1-2 months after enrollment, the hours being divided by the number of elapsed days to estimate the mean duration of nightly CPAP use.
Overall, subjects were estimated to use CPAP an average of 6 hours per night. One subject, in the third group, never used CPAP because he never received his machine and didn't notify anyone of the problem, but he was included in the analyses anyway. Another subject, in the first group, had said he was using CPAP nightly but when confronted that his counter showed only 1 hour of use per night, he "recalled" that he had neglected to use the machine at all for most of the study period. On average, subjects in the second group (documents only) used CPAP 2.7 hours/night longer than than subjects in the third group (no added intervention) and 1.3 hours/night longer than subjects in the first group (weekly phone calls). Only the difference between the second and third group reached a marginal level of statistical significance.
Interventions seemed more helpful to subjects new to CPAP than those continuing on it, more helpful to less educated subjects, more helpful to subjects who had a friend or relative on CPAP, and subjects who initially had increased daytime sleepiness on the ESS. It is noteworthy that all subjects indicated a "moderate" or "good" understanding of CPAP on intake. They noted that their third (control) group showed mean nightly hours of CPAP use similar to those reported in several other studies without specific interventions to improve compliance.
The authors indicated that, as far as they knew, theirs was the first study to show a helpful effect of intervention to improve CPAP compliance.
To me, the most amazing thing about this article is that final statement of the authors, reflecting the fact that there appear to have been only two controlled studies of interventions to improve CPAP compliance, both done with very small groups of patients! It is amazing because of the amount of concern that sleep specialists have expressed about CPAP noncompliance, the proliferation of masks and machines supposed to make CPAP more tolerable, and the frequent resort to surgery when CPAP is adjudged "intolerable." How can researchers have neglected attending to ways of improving compliance? Probably these interventions, typically "psychosocial" rather than "medical" in nature, are of little interest to sleep specialists who mostly consist of pulmonologists, neurologist, and otolaryngologists.
Also amazing to me is that fact that, despite the many limitations of their study (the small size of the groups being compared, the mixing of new and continuing CPAP users in these small groups, the lack of control over what introduction to CPAP various doctors gave the patients in the first place, and the fact that patients could presumably figure out what their counter readings meant and make false reports to cover up poor compliance, nevertheless the authors were able to show some beneficial effects of so slight an intervention as handing out two documents, one of which might be routinely available in many sleep clinics, the other of which consisted of three paragraphs of unremarkable content. Of course, the authors gave their statistical analyses a helping hand by including the patient in the third group who never received a CPAP machine in the first place!
But, for the sake of argument, let's assume that the two documents really did make a difference and the weekly phone calls didn't. What can this mean? The documents contained nothing that should not have been told to the patients by their treating physicians; though of course this imparting of essential information might have been omitted, more likely it was just more than an anxious patient could attend to, absorb, and retain at a single sitting. Written material has the advantage of not only reminding the patient of information imparted verbally but not heard or forgotten, it also has the advantage of being available to return to as often as necessary to clarify continuing uncertainties. Phone contacts, on the other hand, didn't necessarily offer any information, just nonspecific support, and without an established trusting relationship of the patient to the caller, it is no surprise that patients would conceal sensitive issues--like not using their CPAP. The amount of problem-solving involved in these contacts seemed minimal, merely a referral back to a physician, without any other suggestions for coping.
In contrast, the amount of support, information-sharing, and conjoint problem-solving that can go on in support groups is of another order of magnitude. Their main drawback is that infrequent meetings, sometimes only a few times a year, will fail to capture patients in the critical first week or two of CPAP use, as patterns of noncompliance become rapidly established. Here there are advantages to on-line apnea support systems such as offered by America On-Line and the sleep disorders newsgroup: that meetings are available weekly or even more often, and feedback from fellow patients is available almost immediately at any time. Too bad no one has studied the effect of these less "simple" interventions!
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