1

[ Contemporary Reviews in Sleep Medicine ] 56

2 57
3 58
4 59
5 60
6
7
Adherence to CPAP 61
62
8 What Should We Be Aiming For, and How Can We Get There? 63
9 64
10 65
Q16 Q1 Jessie P. Bakker, PhD; Terri E. Weaver, PhD; Sairam Parthasarathy, MD; and Mark S. Aloia, PhD
11 66
12 67
13 68
The purpose of this review was to summarize what is currently known regarding two important
14 69
questions facing the field of sleep medicine today: (1) How many hours of CPAP use per night
15 70
16 are necessary to improve daytime symptoms and reduce cardiovascular risk associated with
71
17 OSA?; and (2) What strategies could be implemented to optimize adherence in clinical settings? 72
18 Despite the widespread adoption of a threshold approach to CPAP management, the literature 73
19 to date suggests a dose-response relationship between CPAP usage and a range of outcomes, 74
20 including sleepiness, functional status, and BP; the data also suggest that the optimal adher- 75
21 ence level differs depending on the outcome in question. Over the years, psychological mea- 76
22 sures of behavior change constructs have been increasingly recognized as the most consistent 77
23 predictors of CPAP adherence, and, as such, the most successful interventions for optimizing 78
24 79
adherence have been behavioral in nature. Unfortunately, behavioral therapies have not been
25 80
translated from highly controlled research settings to comparative-effectiveness studies and
26 81
finally into routine care, mainly due to feasibility and cost issues. More recently, theory-driven
27 82
telemedicine adherence interventions have emerged, which take advantage of the framework
28 83
29 that already exists in the United States for real-time remote-monitoring of CPAP. Combining
84
30 theory-driven behavioral approaches with telemedicine technology could hold the answer to 85
31 increasing real-world CPAP adherence rates, although randomized studies are still required, and 86
32 socioeconomic barriers to telemedicine will need to be addressed to promote health equity. 87
33 CHEST 2019; -(-):--- 88
34 89
KEY WORDS: adherence; behavioral therapy; CPAP; sleep apnea Q4
35 90
36 91
37 92
Decades of literature suggest that OSA is limited by suboptimal adherence. CPAP
38 93
independently associated with daytime adherence varies substantially across
39 94
sleepiness, neurocognitive impairment, different settings; it has been reported that
40 95
41
depression, cardiovascular disease, and all- between 29% and 83% of patients enrolled in 96
42 cause mortality.1-10 CPAP, the first-line research studies use CPAP < 4 h per night.19 97
43 therapy for moderate/severe OSA, is A systematic review of 66 clinical trials and 98
44 efficacious across a range of adverse cohort studies published between 1994 and 99
45 outcomes11-18; however, effectiveness is often 2015 found a weighted average adherence of Q2 100
46 101
47 102
48 103
ABBREVIATIONS: AHI = apnea-hypopnea index; CBT = cognitive- Sciences, Tucson, AZ; and National Jewish Health (Dr Aloia), Denver,
49 behavioral therapy; MET = motivational enhancement therapy CO. 104
50 AFFILIATIONS: From the Division of Sleep and Circadian Disorders CORRESPONDENCE TO: Jessie P. Bakker, PhD, Division of Sleep and 105
51 (Dr Bakker), Brigham and Women’s Hospital, Boston, MA; Division of Circadian Disorders, 221 Longwood Ave, Boston, MA 02115; e-mail: Q3 106
Sleep Medicine (Dr Bakker), Harvard Medical School, Boston, MA; jpbakker@bwh.harvard.edu
52 107
Center for Narcolepsy, Sleep, and Health (Dr Weaver), Department of Copyright Ó 2019 Published by Elsevier Inc under license from the
53 Biobehavioral Health Science, College of Nursing and Division of American College of Chest Physicians. 108
54 Pulmonary, Critical Care and Sleep Medicine, College of Medicine, DOI: https://doi.org/10.1016/j.chest.2019.01.012 109
University of Illinois at Chicago, Chicago, IL; University of Arizona
55 110
Health Sciences (Dr Parthasarathy), Center for Sleep and Circadian

chestjournal.org 1

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

111 4.5 h per night, with no meaningful improvement in There are also factors at play that go far beyond patient 166
112 adherence rates in the research setting discernible over demographic characteristics and disease characteristics, 167
113 168
the two decades of data available since objective CPAP such as cultural considerations,35-37 fragmented care
114 169
monitoring was introduced.20 Adherence rates in real- delivery,38 and policies related to diagnosis and
115 170
world clinical populations are less well understood. treatment reimbursement.39 Sleep medicine is a
116 171
multidisciplinary field, with involvement by
117 A 2004 quantitative review found that when placing 172
118
pulmonologists, neurologists, otolaryngologists, 173
CPAP adherence rates in the context of therapies for
119 psychiatrists, nurses, and dentists. Along the diagnostic 174
other chronic conditions, adherence to therapy for
120 and treatment pathway, a patient may also interact with 175
sleep disorders was the lowest of the 17 conditions
121 a primary care provider, nurse practitioner, sleep 176
studied, including HIV, cancer, cardiovascular
122 technologist, respiratory therapist, and/or clinical 177
disease, renal disease, and diabetes mellitus.21
123 psychologist, in addition to myriad staff associated with 178
124
Although CPAP is sometimes singled out as a therapy 179
clinics, hospitals, durable medical equipment providers,
125 with particularly poor adherence, it is worth noting 180
government/public health schemes, and private
126 that it is one of the few therapies in which detailed, 181
insurance companies. The complex pathway from
127 objective, daily adherence monitoring is standard 182
symptom recognition to long-term care can be
128 clinical practice.22 Self-reported measures of 183
confusing to navigate and, although beyond the scope of
129 adherence across disease states are generally higher 184
the present review, is undoubtedly a contributor to poor
130 than objective measures such as electronic 185
131
uptake of CPAP therapy. 186
monitoring, pill counts, pharmacy refill rates, and
132 physical tests,23 a conclusion that was highlighted in The purpose of the present review was to summarize 187
133 188
one of the earliest studies to incorporate objective what is currently known regarding two important
134 189
CPAP adherence monitoring.24 Even so, optimal questions facing our field today: (1) How many hours of
135 190
use of CPAP requires a level of patient engagement CPAP use per night are necessary to improve daytime
136 191
137
that exceeds what is needed to follow a pill-based symptoms and reduce cardiovascular risk?; and (2) 192
138 regimen. What strategies could be implemented to optimize 193
139 adherence in clinical settings? The term “CPAP” is used 194
An understanding of the factors that drive adherence to
140 throughout this review to encompass all therapy modes 195
CPAP is vital to design appropriate interventions
141 used to treat OSA (Table 1), as overall there is little 196
targeting those mechanisms. Over the years, it has
142 evidence that adherence is affected by mode.31-34 197
become evident that suboptimal adherence is difficult to
143 198
144
Q5 predict based on sociodemographic variables.25 It is 199
natural to ask patients what impedes their adherence Optimal Adherence for Controlling Daytime
145 200
146 and to use our intuition as clinicians and scientists to Symptoms 201
147 focus on the degree to which a patient experiences either Despite the widespread adoption of a threshold 202
148 symptomatic improvement or bothersome side effects. approach to CPAP management,40 the literature to date 203
149 Unfortunately, the relationships between adherence and suggests that the optimal usage level differs depending 204
150 these factors are not systematic.25-27 Instead, on the outcome in question. In an uncontrolled study of 205
151 psychological measures of behavior change constructs 149 patients with severe OSA, the average usage level at 206
152 207
have emerged as the most consistent predictors of CPAP which normalization of symptoms occurred differed
153 208
adherence. For example, in a multiethnic sample of 248 substantially for self-reported sleepiness (4 h per night),
154 209
patients, self-efficacy (which describes the extent to objective sleepiness (6 h per night), and functional status
155 210
which a patient believes that he or she is capable of (7.5 h per night).41 A similar study of 174 patients found
156 211
157
attaining positive outcomes from treatment) was that normalization of self-reported sleepiness occurred 212
158 significantly associated with adherence after adjusting in those using CPAP > 5 h per night; however, even in 213
159 for several other potential determinants.28 Behavioral those using CPAP for > 7 h per night, average scores did 214
160 determinants explain up to approximately 20% of the not reach normalization for either objective sleepiness or 215
161 total variance in CPAP adherence,29,30 emphasizing the functional status.42 Finally, an observational study of 58 216
162 complexity of adherence behaviors and providing an patients with OSA and memory impairment found that 217
163 explanation for why simplistic interventions such as 21%, 44%, and 68% of those with CPAP adherence < 218
164 alternative pressure modes have not made a substantial 2 h per night, 2 to 6 h per night, and > 6 h per night, 219
165 220
impact on adherence.31-34 respectively, reported normal verbal memory function

2 Contemporary Reviews in Sleep Medicine [ -#- CHEST - 2019 ]

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578
221 TABLE 1 ] Pressure Delivery Modes Q13 276
222 277
Mode (Generic Names) Description
223 278
CPAP Sometimes referred to as “fixed CPAP,” this mode entails delivery of a constant
224 279
pressure throughout the night, usually within the range of 4-20 cm H2O. Fixed CPAP
225 requires titration to determine therapeutic pressure; this process can be undertaken
280
226 manually (in-laboratory) or by setting the fixed pressure to the 90th or 95th percentile 281
227 pressure administered during a period of automated PAP use 282
228 Flexible pressure Sometimes referred to as “pressure relief,” this mode administers therapeutic pressure 283
229 during inhalation, reduced pressure during early expiration, and a return to 284
230 therapeutic pressure during late expiration and subsequent inhalation. The pressure 285
reductions can be fixed (usually 1-3 cm H2O) or proportional to expiratory effort.
231 286
Another form of flexible pressure relies on an algorithm aiming to identify irregular
232 breathing indicative of wakefulness, reducing pressure in response. Flexible pressure 287
233 requires titration to determine therapeutic pressure 288
234 Bi-level positive Bi-PAP devices deliver two distinct pressures for inspiration and expiration. Unlike 289
235 airway pressure flexible pressure, the two bi-PAP pressures can be set further apart than 3 cm H2O, 290
236 (Bi-PAP or Bi-level) and the transitions between inspiratory and respiratory pressures are usually faster. 291
237 The maximum pressure is often higher than other devices (25 cm H2O). Bi-PAP 292
requires titration to determine therapeutic pressures
238 293
239 Auto-adjusting APAP relies on manufacturer-specific algorithms to detect flow limitation and respiratory 294
positive airway events in the flow signal and responds by delivering the appropriate pressure on a
240 295
pressure (APAP or breath-by-breath basis. The pressure range can vary across the full range (usually
241 auto-PAP) 4-20 cm H2O) or be restricted to a smaller range. APAP does not require titration 296
242 297
Combination modes Many manufacturers require combination modes, such as auto-flexible pressure,
243 auto-bi-PAP, or bi-flexible pressure 298
244 299
245 300
246 301
following 3 months of therapy.43 In this study, the three nonrandomized studies have shown that
247 302
248
average adherence of the group exhibiting normal patients with OSA using CPAP exhibit reduced rates 303
249 memory performance was 5.2 h per night, compared of cardiovascular morbidity and mortality compared 304
250 with 3.4 h per night in those with residual memory with patients with low/nonadherence.11,47,48 305
251 impairment. 306
There is some evidence that sleepier patients may
252 307
experience greater reductions in BP resulting from
253 308
Optimal Adherence for Controlling CPAP, including a 2012 meta-analysis which found
254 309
255
Cardiovascular Symptoms that each 5-point increase in the baseline Epworth 310
256 There is also evidence that greater CPAP use is Sleepiness Scale score was associated with a drop in 311
257 associated with improvements in surrogate systolic BP of 1.9 mm Hg (P ¼ .06) and diastolic BP of 312
258 cardiovascular outcomes. A secondary analysis of a 1.4 mm Hg (P ¼ .04) following CPAP.49 Similar 313
259 2010 randomized trial in which 359 nonsleepy conclusions have been reported elsewhere.50,51 These 314
260 patients with OSA and hypertension were observations may be explained, at least in part, by the 315
261 randomized to receive CPAP or conservative occurrence of arousals at the termination of 316
262 317
treatment indicated that the reductions in BP were respiratory events, leading to surges in overnight BP,
263 318
increasingly evident in patients grouped according to as well as sleep fragmentation and hypersomnolence.
264 319
adherence (# 3.6, 3.61-5.65, and > 5.65 h per The relationship between BP, sleepiness, and CPAP
265 320
night).44 Similarly, a 2013 trial found a positive adherence, however, is far from clear-cut, as
266 321
267
correlation between CPAP adherence and reductions evidenced by a regression model including 968 322
268 in BP.45 A meta-analysis of 12 trials (572 patients) patients drawn from eight trials, in which baseline 323
269 concluded that each 1-h improvement in CPAP BP had a far greater bearing on the reduction in BP 324
270 adherence was associated with a reduction in mean BP with CPAP than the baseline apnea-hypopnea index 325
271 of 1.4 mm Hg.46 These secondary analyses may be (AHI), baseline sleepiness, or adherence.14 The 326
272 confounded by factors such as greater adherence to complexity of this relationship emphasizes the need 327
273 antihypertensive medications or lifestyle for methods to identify different OSA phenotypes, 328
274 recommendations. Although fewer studies have which may also inform the development of targeted 329
275 330
focused on hard cardiovascular end points, data from treatments.52

chestjournal.org 3

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

331 Exploring the Concept of a “Dose-Response” The Role of CPAP for Patients With Mild OSA 386
332 Relationship Between Adherence and 387
Although there is a positive association between AHI
333 388
Outcomes and symptoms such as sleepiness, the correlation is far
334 389
It is widely accepted that a dose-response relationship from perfect, such that there are patients with very high
335 390
336 exists between CPAP usage and a range of outcomes, AHIs who report little if any daytime impact of OSA and 391
337 with “dose” in this context referring to hours of usage also patients with low AHIs who report debilitating 392
338 per night rather than the pressure setting. In considering impairment. In the latter group, it is generally agreed 393
339 a dose-response relationship, however, it is important to that a trial of CPAP may be warranted.56 Whether to 394
340 account for the sensitivity of each outcome measure, the prescribe CPAP to patients in the former group is less 395
341 level of impairment pretreatment, and the habitual sleep clear.57,58 Regardless, several trials recruiting patients 396
342 duration of each patient. CPAP adherence is usually with an average baseline AHI # 20 events per hour have 397
343 shown adherence > 3.5 h per night,59-62 which is 398
defined as simply hours per night rather than as a
344 399
proportion of total sleep time,53 which is usually not comparable to what has been observed in trials of more
345 400
measured; it is therefore unclear as to whether short severe OSA. In the CPAP Apnea Trial North America
346 401
sleep duration (eg, 4 h) with 100% CPAP adherence Program (CATNAP), in which 63% of participants had
347 402
would lead to greater impairment than longer sleep an AHI < 15 events per hour, those undergoing 8 weeks
348 403
349 duration (eg, 8 h) with 50% CPAP adherence, even of CPAP reported a difference in mean change on the 404
350 though the CPAP usage is identical in both instances. Functional Outcomes of Sleep Questionnaire of 0.95 405
351 compared with sham CPAP (P ¼ .006); this outcome 406
Another important consideration is that none of the corresponds to an effect size of 0.41.63 Thus, the
352 407
353
aforementioned analyses was based on randomization to common misconceptions that patients with mild OSA 408
354 different levels of usage, and therefore the strength of are both less likely to adhere to CPAP and less likely to 409
355 these associations may be overestimated due to bias experience symptomatic benefit should not factor into 410
356 from the healthy-user effect. Accordingly, a few large- the decision of treatment options. Instead, this decision 411
357 scale randomized trials have been conducted that were requires careful consideration and discussion with the 412
358 designed to elucidate the impact of CPAP on 413
patient regarding the overall goals of therapy.
359 cardiovascular morbidity and mortality. Unfortunately, 414
360 all three trials reported negative results in intention-to- 415
361 treat analyses. Average adherence in two of these studies 416
362
Alternative Care Providers, Augmented 417
was 3.3 h per night54 and 5.0 h per night16; in the Support, and Educational Interventions to
363 418
remaining study, adherence was only reported for those
364 Increase Adherence 419
who remained on treatment55 and is therefore not a
365 Several studies have concluded that the approaches used 420
366
reflection of overall usage in the randomized sample. 421
in primary care or nurse-led management can have a
367 Despite the negative intention-to-treat results, 422
positive effect on adherence and clinical outcomes.64-66
368 prespecified per-protocol analyses of patients using 423
Results are conflicting as to whether the provision of
369 CPAP $ 4 h per night suggested a beneficial effect of 424
educational materials67-70 and/or augmented clinical
370 CPAP on cardiovascular health in all three 425
support such as more frequent appointments, telephone
371 studies.16,54,55 426
372
calls, and home visits71-73 have a major impact on CPAP 427
373 Based on these three trials, it is impossible to adherence. Most clinics offer a combination of these 428
374 conclusively state whether cardiovascular risk is not interventions. A simpler alternative to traditional 429
375 attributable to OSA—despite the wealth of observational educational strategies involves the patients viewing 430
376 data suggesting an independent association—or whether results of their diagnostic study.74 Jurado-Gamez et al75 431
377 CPAP adherence was below the level at which beneficial tested an intervention involving each patient viewing his 432
378 effects might have been realized. Regardless, OSA has a or her polysomnogram with an explanation of the 433
379 serious impact on sleepiness, mood, cognition, frequency and duration of respiratory events. Compared 434
380 functional status, driving ability, and workplace with usual care, the intervention resulted in increased 435
381 436
performance, even in the absence of any cardiovascular adherence of 0.7 h per night on average. A similar study
382 437
effects. Thus, identifying ways to increase CPAP found increased adherence compared with control
383 438
adherence is a key priority for both clinical practice and subjects of 1.2 h per night in patients who viewed
384 439
385
research purposes. polysomnograms recorded on- and off-treatment.76 440

4 Contemporary Reviews in Sleep Medicine [ -#- CHEST - 2019 ]

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578
441 The literature regarding supportive and educational therapy alone; it has a longstanding literature base 496
442 interventions is difficult to interpret, as many studies showing improvements in adherence to other medical 497
443 498
have used a combination of interventions, thus masking recommendations. The principles of MET differ
444 499
individual effects. There might also be interactions fundamentally from other approaches by focusing on
445 500
between interventions, making certain combinations the patient more than on the therapy itself. Given the
446 501
more effective than others. Of the studies aiming to consistency in this literature, it is fair to say that, to date,
447 502
448
assess the impact of education, few have included an the behavioral approach has been most fruitful in the 503
449 assessment of whether the materials provided did in fact CPAP field. 504
450 lead to a thorough understanding of OSA and CPAP, 505
The major drawback of the aforementioned trials is the
451 and thus the mechanism underlying any improvements 506
expense involved with administering an intervention
452 in adherence is unclear. Furthermore, comparisons 507
requiring one-on-one time with a therapist. In 2007,
453 across studies are complicated by the fact that the 508
454
Richards et al84 attempted to address this concern by 509
intervention of some studies resembles the comparator
455 testing cognitive-behavioral therapy (CBT) in groups of 510
of others. On the whole, the provision of a minimum
456 approximately 10 patients, which included a video of 511
level of clinical support and education seems to be
457 actual CPAP users describing their experiences. The 512
necessary, but probably not sufficient, in terms of
458 intervention was associated with higher scores for self- 513
achieving adequate CPAP adherence.
459 efficacy and outcome expectancy (the extent to which a 514
460 patient believes that treatment is associated with positive 515
Behavioral Therapy
461 outcomes), as well as significantly increased CPAP 516
462 The first study to use a cognitive-behavioral approach to 517
adherence of 2.9 h per night after 4 weeks compared
463 increase CPAP adherence recruited 12 adults who were 518
with usual care. As a follow-up to this study, the same
464 randomized to receive the intervention, consisting of 519
authors performed a randomized trial incorporating an
465 two 45-min one-on-one therapy sessions, or an 520
attention-matched comparator, which did not lead to a
466 attention-control condition.77 The difference in usage 521
467
significant improvement in adherence over the first 522
between the two groups over 12 weeks was substantial,
468 6 months of treatment.85 Thus, one possible contributor 523
at 3.2 h per night. In 2004, the same authors published
469 to the large effect observed in the study by Richards 524
an in-depth description of the applicability of
470 et al84 may have been the increased time spent 525
motivational enhancement therapy (MET) on CPAP
471 discussing OSA with the therapist and other patients, as 526
adherence.78 MET is a theory-driven approach based on
472 well as hearing about real-world experiences of CPAP 527
the principles of motivational interviewing, which aims
473 users via the video, in addition to any impact the 528
474
to elicit critical thought in the patient regarding his or 529
behavioral therapy alone may have had on adherence. A
475 her ambivalence toward treatment and highlight the 530
beneficial effect of group sessions has been noted in
476 patient’s own motivating statements around therapy. A 531
nonrandomized trials assessing educational sessions.86,87
477 2007 study showed that compared with standard care, 532
478 MET was associated with a significantly lower CPAP An alternative, potentially more feasible, approach to 533
479 discontinuation rate.79 A subsequent trial found that CBT/MET targeting the same mechanistic pathway 534
480 although adherence did not differ significantly across (self-efficacy) involves patients experienced with CPAP 535
481 groups, the impact of MET and education was providing support and encouragement, a strategy that 536
482 537
moderated by adherence over the first week, such that has been endorsed in focus groups of patients with
483 538
patients exhibiting moderate adherence (2-6 h per night) OSA88 and has been implemented in other chronic
484 539
benefited more from MET, whereas patients exhibiting conditions requiring self-management.89,90 Availability
485 540
high adherence ($ 6 h per night) benefited more from of social support is positively associated with CPAP
486 541
487
education. Patients exhibiting poor adherence during adherence,91 and there is evidence that patients perceive 542
488 the first week (< 2 h per night) did not benefit from peers with similar comorbidities as having more 543
489 either MET or education over standard care.80 Three credibility than health-care professionals in delivering a 544
490 subsequent randomized trials of MET/motivational behavioral intervention.92 In a small randomized trial of 545
491 interviewing initiated prior to at-home CPAP treatment peer support administered in a group setting vs one-on- 546
492 showed significantly increased adherence of 1.5 h per one education, there was no difference in the percentage 547
493 night,81 1.7 h per night,82 and 2.0 h per night,83 of patients in each randomized group who used CPAP > 548
494 compared with control conditions. It is important to 4 h per night at 6 weeks based on randomized group 549
495 550
note that MET has not been developed for CPAP (65% in each group); however, 72% of those who

chestjournal.org 5

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

551 attended at least one peer-support session used CPAP > adherence in all three intervention arms declined to the 606
552 4 h per night over 6 weeks, compared with 59% of those same level as the usual care arm by month 12. 607
553 608
receiving individual education.93 A pilot trial of one-on- Interestingly and fortuitously, the investigators
554 609
one peer support found significantly increased discovered a protocol deviation whereby a small subset
555 610
adherence of 1.25 h per night on average during the first (n ¼ 73) continued to receive automated feedback over
556 611
Q6 week, which persisted over the first 90 days of therapy.94 the entire 12-month period. These patients used CPAP
557 612
558
The investigators have since launched a larger trial to on 58.4% of the days between month 3 and month 12, 613
559 test the impact of a peer-driven intervention designed to compared with 48.1% of days used by all other patients, 614
560 facilitate care coordination.95 suggesting that simple feedback is helpful in the short 615
561 term but not enough to sustain a long-term beneficial 616
Overall, behavioral interventions have shown promise in
562 effect on adherence. 617
clinical trials (summarized in Table 2).77,79-85,93,94
563 618
564
Behavioral therapy for CPAP is low risk and can be A notable 2018 study by Pépin et al104 took a 619
565
implemented in a standardized, systematic fashion; multimodal approach by incorporating data from 620
566 however, approaches such as CBT/MET rely on the connected physical activity and sleep trackers, home BP 621
567 availability of highly trained staff, including clinical monitors, and oximetry in addition to CPAP 622
568 psychologists and nurses, which has limited applicability telemonitoring data. In patients with moderate/severe 623
569 in clinical settings. OSA and cardiovascular risk, BP at 6 months did not 624
570 differ between the intervention and usual care groups; 625
571 Remote Monitoring and Telemedicine however, the multimodal intervention was associated 626
572 627
The ability to monitor CPAP adherence remotely, as with increased physical activity, improved daytime
573 628
well as important therapy parameters such as estimated sleepiness and quality of life, and significantly greater
574 629
residual disease, pressure profiles, and mask leak, CPAP adherence (5.3 vs 4.8 h per night). In this study, Q7
575 630
provides potential to use this technology for the physical activity and BP results were provided to
576 631
577 implementation of Web-based adherence interventions participants in real time; however, no coaching or advice 632
578 (summarized in Table 3).96-106 The scope for was provided on the basis of these metrics, which may 633
579 telemedicine in CPAP includes automated, personalized have led to a greater response. 634
580 feedback for patients, targeted troubleshooting and 635
In these and other randomized studies, trends toward
581 support based on individual patient data, Web- or app- 636
increased CPAP adherence with various telemedicine
582 based education, and combinations of these via a 637
583
interventions were evident,96,98 as well as data to suggest 638
coaching Website or smartphone app.
584 that telemedicine is associated with reduced staff time 639
585 Early studies using telemedicine focused on the use of and/or cost.100,102 The effect sizes for adherence for 640
586 this technology to provide patients with real-time telemedicine approaches, however, are not as large as 641
587 feedback regarding their usage patterns. A 2015 study what has been achieved with the use of theory-driven 642
588 showed that access to Web-based feedback resulted in approaches such as CBT and MET, and the impacts on 643
589 average adherence of 5.0 h per night, compared with patient and provider satisfaction and cost-effectiveness 644
590 3.8 h per night in control subjects.99 A financial are not yet clear. Moreover, there are barriers to 645
591 646
incentive, offered in addition to Web-based feedback, accessing telemedicine services in patients with lower
592 647
was not associated with increased adherence, although socioeconomic status. This limitation is particularly
593 648
this component of the study was not tested individually. important considering that investigators have shown
594 649
Financial incentives for CPAP use, based on adherence that lower socioeconomic status is associated with worse
595 650
596 monitored remotely, have not been widely studied.107,108 adherence to CPAP therapy.35-37 Multicomponent 651
597 103 approaches to tackle poor adherence in 652
In 2018, Hwang et al compared both Web-based
598 socioeconomically deprived populations must be 653
education and automated feedback in a trial of 1,455
599 undertaken to promote health equity. Considering that 654
patients randomized to undergo usual care, Web-based
600 treatment of OSA is preventative care, downstream 655
education, remote CPAP monitoring with automated
601 consequences for disparities in cardiovascular disease 656
602
feedback, and the combination of both. Average CPAP 657
may be magnified by poor CPAP adherence.
603 adherence at 3 months was 3.8, 4.0, 4.4, and 4.8 h per 658
604 night, respectively. Longer term follow-up, after the In recent years, manufacturers of CPAP machines have 659
605 interventions were withdrawn at month 3, showed that designed and implemented theory-driven coaching and 660

6 Contemporary Reviews in Sleep Medicine [ -#- CHEST - 2019 ]

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578
 715
714
713
712
711
710
709
708
707
706
705
704
703
702
701
700
699
698
697
696
695
694
693
692
691
690
689
688
687
686
685
684
683
682
681
680
679
678
677
676
675
674
673
672
671
670
669
668
667
666
665
664
663
662
661
TABLE 2 ] A Summary of Studies Assessing the Impact of Behavioral Interventions on CPAP Adherence
chestjournal.org

Average AHI/RDI Adherence (Primary

Study/Year Study Design Sample Size Average Age (y) Male (Events/Hour) Intervention Comparator Outcome/s Only)
Aloia et al77/ Parallel, 2-arm N ¼ 12 63.4  4.5, Not reported 40.9  11.1, Two 45-min, Attention Average adherence
2001 RCT; 12 wk intervention; intervention; one-on-one control 3.2 h/night higher
67.6  4.7, 46.1  25.2, therapy with intervention
REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

comparator comparator sessions (P < .04)

Aloia et al79/ Parallel, 3-arm N ¼ 142 50.1  10.9, 63%, MET 43.4  22.9, Two 45-min, Usual care Treatment
2007 RCT; 13 wk MET intervention; MET one-on-one discontinuation
intervention; 62%, intervention; sessions, 26% (MET),
47.4  10.5, education 44.8  25.1, either MET or 30% (education)
education intervention; education education and 51%
intervention; 78%, intervention; (comparator) (P ¼
51.7  11.4, comparator 49.3  25.4, .04) Usage > 4 h/
comparator comparator night 67% (MET),
68% (education),
and 61%
(comparator) (P ¼
.76)
Richards Parallel, 2-arm N ¼ 100 53.1  11.8, 86% 27.6  21.2, Two, 60-min, Usual care Average adherence
et al84/2007 RCT; 4 wk intervention; intervention; group-based 2.9 h/night higher
56.2  12.5, 25.3  23.1, CBT sessions with intervention
comparator comparator (P < .0001)
Olsen et al81/ Parallel, 2-arm N ¼ 106 55.1  12.6, 69% 36.2  27.8, Three one-on- Usual care Average adherence
2012 RCT; 3 mo intervention; intervention; one 1.5 h/night higher
(additional 57.7  9.5, 32.4  20.3, motivational with intervention
follow-up at comparator comparator interviewing (P ¼ .005)
12 mo) sessions
Aloia et al80/ Parallel, 3-arm N ¼ 227 51.7  10.0, 66% 45.7  23.8, Two 45-min, Usual care Average adherence
2013 RCT; 12 mo MET MET one-on-one 3.9 (MET), 4.3
intervention; intervention; sessions, (education), and
47.0  11.4, 46.1  23.2, either MET or 3.7 h/night
education education education (comparator) (P ¼
intervention; intervention; .71)
52.4  11.8, 48.2  26.2,
comparator comparator
Bartlett Parallel, 2-arm N ¼ 206 49.3  12.3, 68% 30.4  28.0, One 35-min, Attention Usage $ 4 h/night
et al85/2013 RCT; 6 mo intervention; intervention; group-based control 55% (intervention)
46.8  14.3, 39.9  25.1, social and 47%
comparator comparator cognitive (comparator) (P ¼
therapy .36) Device
session acceptance 82%
(intervention) and
88% (comparator)
7

(P ¼ .35)

(Continued)
740
744
748
760
764

749

746
768
769

766

750

730

720
770

754

745

743
742

734

724
758

747

738

728
765

763
762

759

756

739

736

729

726
767

755

753
752

741

735

733
732

725

723
722
757

737

727

718
761

719

716
751

731

721

717
 825
824
823
822
821
820
819
818
817
816
815
814
813
812
811
810
809
808
807
806
805
804
803
802
801
800
799
798
797
796
795
794
793
792
791
790
789
788
787
786
785
784
783
782
781
780
779
778
777
776
775
774
773
772
771
TABLE 2 ] (Continued)
8 Contemporary Reviews in Sleep Medicine

Average AHI/RDI Adherence (Primary

Study/Year Study Design Sample Size Average Age (y) Male (Events/Hour) Intervention Comparator Outcome/s Only)
Parthasarathy Parallel, 2-arm N ¼ 39 53  14, 100% 36.7  28.6, Two one-on- Usual care Average adherence
et al94/2013 RCT; 3 mo intervention; intervention; one peer- 1.25 h/night higher
50  14, 37.5  36.9, support with intervention at
comparator comparator sessions and 1 wk (P ¼ .08 for
REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

eight 30-min adherence at 1 wk;

follow-up P ¼ .04 for
peer-support adherence at 3 mo)
calls (secondary
outcomes)
Lai et al83/ Parallel, 2-arm N ¼ 100 53  10, 83% 30.7 One 45-min, Usual care Average adherence
2014 RCT; 3 mo intervention; (interquartile one-on-one 2.0 h/night higher
51  10, range, 20.6- MET session with intervention
comparator 52.2), and one 10- (P < .001)
intervention; min follow-up
28.2 MET call
(interquartile
range, 20.3-
53.6),
comparator
Bakker Parallel, 2-arm N ¼ 83 53  10, 66% 21.8 Two 60-min, Usual care Average adherence
et al82/2016 RCT; 6 mo intervention; (interquartile one-on-one 1.7 h/night higher
(additional 51  10, range, 17.4- MET sessions with intervention
follow-up at comparator 31.0), and six 10- (P ¼ .003)
12 mo) intervention; 30 min
23.7 follow-up
(interquartile MET calls
range, 15.9-
31.4),
comparator
Bakker Parallel, 2-arm N ¼ 40 52 interquartile 70% 11.4 Two 90-min, One 90-min Usage $ 4 h/night
et al93/2017 RCT; 6 wk range, 39-62 (interquartile group-based one-on- 65% (intervention)
[

(all patients) range, 7.2- peer-support one and 65%

(comparator) (P ¼
-#- CHEST - 2019

24.6), all sessions education

patients session 1.0). Per-protocol Q14

usage $ 4 h/night
72% (intervention)
and 59%
(comparator) (P ¼
.8)

Data are presented as mean  SD unless otherwise indicated. AHI ¼ apnea-hypopnea index; CBT ¼ cognitive-behavioral therapy; MET ¼ motivational enhancement therapy; RCT ¼ randomized controlled trial; RDI ¼
respiratory disturbance index.
]

840
880

844
848
860
864

849

846
868
869

866

850

830
870

854

845

843
842

834
874

858

847

838

828
878

865

863
862

859

856

839

836

829

826
879

876

867

855

853
852

841

835

833
832
875

873
872

857

837

827
877

861

851

831
871
 935
934
933
932
931
930
929
928
927
926
925
924
923
922
921
920
919
918
917
916
915
914
913
912
911
910
909
908
907
906
905
904
903
902
901
900
899
898
897
896
895
894
893
892
891
890
889
888
887
886
885
884
883
882
881
TABLE 3 ] A Summary of Studies Assessing the Impact of Remote Monitoring and Telemedicine Interventions on CPAP Adherence
chestjournal.org

Average AHI/RDI Adherence (Primary

Study/Year Study Design Sample Size Average Age (y) Male (Events/Hour) Intervention Comparator Outcome/s Only)
Stepnowsky Parallel, 2-arm N ¼ 45 60  11, 98% 44.8  17.9, Clinical care based Usual care Average
et al96/2007 RCT; 2 mo intervention; intervention; on adherence adherence 1.3
58  14, 37.6  14.3, and efficacy data h/night higher
REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

comparator comparator via with

telemonitoring intervention
(P ¼ .07)
Sparrow et al97/ Parallel, 2-arm N ¼ 250 56.0 82% 36.0 Up to 15 digital Attention control Average
2010 RCT; 12 mo (interquartile (interquartile voice-response adherence 1.7
range, 48.0- range, 22.0- telephone calls h/night higher
63.0), 63.0), based on with
intervention; intervention; motivational intervention
54.0 40.5 interviewing (P ¼ .006)
(interquartile (interquartile
range, 45.0- range, 21.0-
62.0), 64.0),
comparator comparator
Fox et al98/2012 Parallel, 2-arm N ¼ 75 52.0  10.8, 80% 44.3  24.8, Clinical care based Usual care Average
RCT; 3 mo intervention; intervention; on adherence adherence 1.5
55.2  11.5, 39.5  19.6, and efficacy data h/night higher
comparator comparator via with
telemonitoring intervention
(P ¼ .006)
Kuna et al99/ Parallel, 3-arm N ¼ 138 49.8  11.7, 60% 35.7  19.8, Web-based Usual care Average
2015 RCT, 3 mo adherence adherence adherence adherence 5.0
feedback þ feedback þ feedback; Web- (adherence
financial financial based adherence feedback only),
incentive; incentive; 38.1 feedback þ 4.8 (adherence
53.2  11.7,  28.3, financial feedback þ
adherence adherence incentive financial
feedback only; feedback only; incentive), 3.8
49.6  2.7, 39.1  30.1, (comparator)
comparator comparator (P < .0002 for
adherence
feedback þ
financial
inventive vs
comparator,
and adherence
feedback only
vs comparator)

(Continued)
9

940
980

944
984

948
990

988

960
964

949

946
989

986

968
969

966

950
970

954

945

943
942
985

983
982

974

958

947

938
987

978

965

963
962

959

956

939

936
979

976

967

955

953
952

941
981

975

973
972

957

937
977

961

951
971
 1045
1044
1043
1042
1041
1040
1039
1038
1037
1036
1035
1034
1033
1032
1031
1030
1029
1028
1027
1026
1025
1024
1023
1022
1021
1020
1019
1018
1017
1016
1015
1014
1013
1012
1011
1010
1009
1008
1007
1006
1005
1004
1003
1002
1001
1000
999
998
997
996
995
994
993
992
991
TABLE 3 ] (Continued)
10 Contemporary Reviews in Sleep Medicine

Average AHI/RDI Adherence (Primary

Study/Year Study Design Sample Size Average Age (y) Male (Events/Hour) Intervention Comparator Outcome/s Only)
Munafo et al100/ Parallel, 2-arm N ¼ 122 52.3  10.6, 78% 33.4  24.5, Clinical care and Four Medicare criteria
2016 RCT intervention; intervention; automated prescheduled met by 70%
50.0  11.7, 27.4  18.0, e-mails/texts telephone calls (intervention)
comparator comparator (ResMed and 68%
REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

U-Sleep) based (comparator)

on adherence (P ¼ .85)
and efficacy data
via
telemonitoring
Hostler et al101/ Parallel, 2-arm, N ¼ 61 44.5  11.3, Not 19.3 Web-based Usual care Usage > 4 h/
2017 nonrandomized; intervention; reported (interquartile engagement tool night 78%
11 wk 42.1  6.8, range, 10.1- (Philips (intervention)
comparator 25.3), SleepMapper) and 56%
intervention; (comparator)
18.1 (P ¼ .02)
(interquartile
range, 10.3-
29.5),
comparator
Turino et al102/ Parallel, 2-arm N ¼ 100 56  13, 77% 52  25, Clinical care based Usual care Average
2017 RCT; 3 mo intervention; intervention; on adherence adherence 0.2
54  12, 53  26, and efficacy data h/night higher
comparator comparator via with
telemonitoring intervention
(P ¼ .63)
Hwang et al103/ Parallel, 4-arm N ¼ 1,455 49.7  12.3, 49% 23.2  23.1, Automated Usual care Average
2018 RCT; 3 mo telemedicine þ telemedicine þ e-mails/texts adherence 4.8
education; education; (ResMed (telemedicine
47.2  12.5, 22.8  25.2, U-Sleep) based þ education),
telemedicine telemedicine on adherence 4.4
only; 49.1  only; 22.6  and efficacy data (telemedicine
[

12.2, 3.8, education via only), 4.0

only; 22.0 
-#- CHEST - 2019

education telemonitoring; (education

only; 50.2  23.4, Web-based only), and 3.8
12.7, comparator education h/night
comparator program; or both (comparator)
(P ¼ .0002 for
telemedicine
þ education vs
comparator,

(Continued)
]

1080
1084

1048
1090

1088

1060
1094

1064

1049

1046
1098

1089

1086

1068
1099

1096

1069

1066

1050
1070

1054
1085

1083
1082

1074

1058

1047
1087

1078
1095

1093
1092

1065

1063
1062

1059

1056
1097

1079

1076

1067
1100

1055

1053
1052
1081

1075

1073
1072

1057
1077
1091

1061

1051
1071
 1155
1154
1153
1152
1151
1150
1149
1148
1147
1146
1145
1144
1143
1142
1141
1140
1139
1138
1137
1136
1135
1134
1133
1132
1131
1130
1129
1128
1127
1126
1125
1124
1123
1122
1121
1120
1119
1118
1117
1116
1115
1114
1113
1112
1111
1110
1109
1108
1107
1106
1105
1104
1103
1102
1101
TABLE 3 ] (Continued)
chestjournal.org

Average AHI/RDI Adherence (Primary

Study/Year Study Design Sample Size Average Age (y) Male (Events/Hour) Intervention Comparator Outcome/s Only)
and
telemedicine
only vs
REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

comparator; P
¼ .10 for
education vs
comparator)
Pépin et al104/ Parallel, 2-arm N ¼ 306 60.8 74% 47.0 Remote activity, Usual care Average
2018 RCT; 6 mo (interquartile (interquartile sleep, BP, adherence 0.5
range, 53.8- range, 35.0- oximetry, and h/night higher
66.0), 60.5), adherence with
intervention; intervention; monitoring with intervention
61.8 45.0 coaching (P ¼ .05)
(interquartile (interquartile
range, 54.7- range, 35.4-
66.1), 61.2),
comparator comparator
Woehrle et al105/ Retrospective N ¼ 1,000 55  12, 88% Not reported Web-based Clinical care Usage $ 4 h/
2018 (nonrandomized) intervention; engagement tool based on night 77%
analysis, 2 56  13, (ResMed myAir) review of (intervention)
groups, 6 mo comparator adherence and and 63%
efficacy data (comparator)
via (P < .001)
telemonitoring
Malhotra et Retrospective N¼ 51.8  13.0, Not Not reported Web-based Clinical care Medicare criteria
al106/2018 (nonrandomized) 128,037 intervention; reported engagement tool based on met by 87%
analysis, 2 52.2  13.4, (ResMed myAir) review of (intervention)
groups, 3 mo comparator adherence and and 70%
efficacy data (comparator)
via (P < .0001)
telemonitoring

Data are presented as mean  SD unless otherwise indicated. See Table 1 legend for expansion of abbreviations.
11

1200
1204
1208
1209

1206
1205

1203
1202
1207

1180
1184
1190

1188

1160
1194

1164
1198

1189

1186

1168
1199

1196

1169

1166
1210

1201

1170
1185

1183
1182

1174

1158
1187

1178
1195

1193
1192

1165

1163
1162

1159

1156
1197

1179

1176

1167
1181

1175

1173
1172

1157
1177
1191

1161
1171
1211 support services compatible with their devices, including services but also because suboptimal CPAP usage has 1266
1212 components such as a dashboard summarizing therapy prevented a thorough understanding of important trials 1267
1213 1268
data, troubleshooting and educational materials, and designed to clarify the impact of OSA on cardiovascular
1214 1269
goal-focused automated e-mails/text messages. A 2018 risk and the role of CPAP in mitigating that risk. Many
1215 1270
retrospective analysis of 1,000 patients found that studies have tested the impact of a range of interventions
1216 1271
77% of those who opted to engage with such a tool used designed to promote adherence; however, despite
1217 1272
1218
CPAP for $ 4 h per night, compared with 63% of those showing efficacy in some approaches, few interventions 1273
1219 who opted out.105 Similarly, a retrospective analysis of have been translated from highly controlled clinical 1274
1220 128,037 patients found that a greater proportion of those trials to comparative effectiveness studies and finally to 1275
1221 who opted into the same patient engagement technology routine care. This lack of momentum is due in part to a 1276
1222 were adherent according to Medicare criteria compared dearth of large-scale trials, as well as a tendency to focus 1277
1223 with those who did not (87.3% vs 70.4%, on adherence as a primary end point rather than as a 1278
1224 respectively).106 A smaller, prospective, nonrandomized mediator. This deficiency of translational research, as 1279
1225 study of a different Web-based engagement tool found well as current policies (within the United States) related 1280
1226 1281
that 78% of patients who used the coaching program to reimbursement for both primary and adjunct therapy
1227 1282
met an adherence threshold of $ 4 h per night, for OSA, means that CPAP adherence has remained
1228 1283
compared with 56% of those who did not use the tool.101 stubbornly at a plateau. To be implemented clinically, it
1229 1284
Finally, a 12-month randomized trial of 250 patients is critical that an adjunct therapy to promote CPAP
1230 1285
1231
comparing a theory-driven interactive voice response adherence be cost-effective, feasible in a wide range of 1286
1232 system vs an attention control found increased settings, and scalable to large and diverse patient 1287
1233 adherence of 1.7 h per night with the intervention.97 populations. The most efficacious interventions tested to 1288
1234 Overall adherence in this study was lower than what has date have been behavioral in nature; when combined 1289
1235 been observed in previous research; however, the with the remote-monitoring capabilities available in 1290
1236 intervention was not initiated until following 1 week of modern CPAP machines, these theory-driven methods 1291
1237 CPAP usage. There is evidence that this early period is could hold the answer to increasing real-world CPAP 1292
1238 critical in terms of establishing long-term usage adherence rates. 1293
1239 1294
patterns,109,110 consistent with the American Academy
1240 In addition to such an approach contributing to 1295
of Sleep Medicine guidelines emphasizing the
1241 improving the health and quality of life of patients with 1296
importance of follow-up support within the first few
1242 OSA, research of this kind could lead to substantial gains 1297
weeks of treatment.56
1243 in other fields. There is evidence that within individuals, 1298
1244 Advantages of telemedicine include the ability to scale to CPAP adherence is correlated with adherence to other 1299
1245 1300
large patient populations, including those in remote or medical treatments111,112; moreover, OSA often co-exists
1246 1301
underserved areas, as well as the potential to decrease with other chronic conditions in which adherence is low,
1247 1302
the burden on clinical systems by reducing the need for such as hypertension, dyslipidemia, depression, diabetes,
1248 1303
office visits. Sleep medicine was an early adopter of and coronary artery disease. As such, patients with OSA
1249 1304
1250
remote diagnostic and therapeutic services, through are representative of a more general population of 1305
1251 both home sleep-testing as well as the use of wireless patients who are required to self-manage complex 1306
1252 technology in CPAP machines. In the United States, the treatment regimens. Unlike pill-based treatments, CPAP 1307
1253 framework required for telemedicine adherence is unique in that detailed, night-by-night adherence data 1308
1254 interventions to be viable is therefore already in place, are collected routinely and can be made available in real 1309
1255 providing a method for rapid clinical implementation. time to both patients and providers. As such, OSA 1310
1256 Exciting opportunities also exist for combining sleep- represents an ideal disease model for designing and 1311
1257 focused telemedicine with lifestyle interventions for testing feasible, scalable, and affordable interventions to 1312
1258 common comorbidities such as diabetes. 1313
promote treatment adherence. Given that adherence to
1259 1314
therapy for chronic disease in developed nations is
1260 1315
Conclusions estimated to be approximately 50%, and that 10% of
1261 1316
Poor acceptance of and adherence to CPAP therapy is annual health-care costs in the United States are
1262 1317
1263
one of the major issues facing our field, not only because attributable to medication nonadherence,113 sleep 1318
1264 it is associated with ongoing disease burden despite researchers have a unique opportunity to tackle this 1319
1265 widespread availability of diagnostic and treatment widespread and important problem. 1320

12 Contemporary Reviews in Sleep Medicine [ -#- CHEST - 2019 ]

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578
1321 Acknowledgments 13. Martinez-Garcia MA, Soler-Cataluna JJ, Ejarque-Martinez L, 1376
1322 et al. Continuous positive airway pressure treatment reduces 1377
Q15 Q8 Financial/nonfinancial disclosures: The authors have reported to mortality in patients with ischemic stroke and obstructive sleep
1323 Q9 CHEST the following: M. S. A. and J. P. B. are both full-time employees apnea: a 5-year follow-up study. Am J Respir Crit Care Med. 1378
1324 of Philips, which is a company that focuses on sleep and respiratory 2009;180(1):36-41. 1379
care. M. S. A. holds a part-time appointment at National Jewish Health.
1325 J. P. B. holds a part-time appointment at Brigham and Women’s
14. Bakker JP, Edwards BA, Gautam SP, et al. Blood pressure 1380
improvement with continuous positive airway pressure is
1326 Hospital. The interests of J. P. B. were reviewed and are managed by 1381
independent of obstructive sleep apnea severity. J Clin Sleep Med.
1327 Brigham and Women’s Hospital and Partners HealthCare in 2014;10(4):365-369. 1382
accordance with their conflict of interest policies. T. E. W. receives
1328 personal fees from UpToDate and royalty fees for use of the Functional 15. Campos-Rodriguez F, Pena-Grinan N, Reyes-Nunez N, et al. 1383
1329 Outcome of Sleep Questionnaire from Philips Respironics, Nyxoah, Mortality in obstructive sleep apnea-hypopnea patients treated with 1384
ResMed, Jazz Pharmaceuticals, Bayer AG, NightBalance, and Cook positive airway pressure. Chest. 2005;128(2):624-633.
1330 1385
Medical; she received grant funding from Jazz Pharmaceuticals as a site 16. Barbe F, Duran-Cantolla J, Sanchez-de-la-Torre M, et al. Effect of
1331 for a pharmaceutical clinical trial. S. P. reports grants from the continuous positive airway pressure on the incidence of 1386
1332 National Institutes of Health (NIH)/National Heart, Lung, and Blood hypertension and cardiovascular events in nonsleepy patients with 1387
Institute, Patient Centered Outcomes Research Institute, US obstructive sleep apnea: a randomized controlled trial. JAMA.
1333 1388
Department of Defense, NIH (National Cancer Institute), and Johrei 2012;307(20):2161-2168.
1334 Institute; personal fees from the American Academy of Sleep Medicine; 1389
17. Tomfohr LM, Ancoli-Israel S, Loredo JS, Dimsdale JE. Effects of
1335 nonfinancial support from the National Center for Sleep Disorders continuous positive airway pressure on fatigue and sleepiness in 1390
1336 Research of the NIH (National Heart, Lung, and Blood Institute); patients with obstructive sleep apnea: data from a randomized 1391
personal fees from UpToDate, Philips Respironics, Merck, and controlled trial. Sleep. 2011;34(1):121-126.
1337 Vapotherm; and grants from Younes Sleep Technologies, Niveus 1392
18. Siccoli MM, Pepperell JC, Kohler M, Craig SE, Davies RJ,
1338 Medical, and Philips Respironics, outside the submitted work. In Stradling JR. Effects of continuous positive airway pressure on 1393
1339 addition, S. P. has a patent (UA 14-018 U.S.S.N. 61/884,654; PTAS quality of life in patients with moderate to severe obstructive sleep 1394
502570970 [home breathing device]). apnea: data from a randomized controlled trial. Sleep. 2008;31(11):
1340 1395
1551-1558.
1341 1396
Q10 References 19. Weaver TE, Grunstein RR. Adherence to continuous positive
1342 airway pressure therapy: the challenge to effective treatment. Proc 1397
1. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea
1343 and risk of motor vehicle crash: systematic review and meta- Am Thorac Soc. 2008;5(2):173-178. 1398
1344 analysis. J Clin Sleep Med. 2009;5(6):573-581. 20. Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence 1399
over twenty years of data collection: a flattened curve. J Otolaryngol
1345 2. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered 1400
breathing, sleep apnea, and hypertension in a large community- Head Neck Surg. 2016;45(1):43.
1346 1401
based study. Sleep Heart Health Study. JAMA. 2000;283(14):1829- 21. DiMatteo MR. Variations in patients’ adherence to medical
1347 1836. recommendations: a quantitative review of 50 years of research. 1402
1348 3. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the Med Care. 2004;42(3):200-209. 1403
1349 association between sleep-disordered breathing and hypertension. 22. Schwab RJ, Badr SM, Epstein LJ, et al. An official American 1404
N Engl J Med. 2000;342(19):1378-1384. Thoracic Society statement: continuous positive airway pressure
1350 adherence tracking systems. The optimal monitoring strategies and 1405
4. Desai A, Fang JC. Heart failure with preserved ejection fraction:
1351 hypertension, diabetes, obesity/sleep apnea, and hypertrophic outcome measures in adults. Am J Respir Crit Care Med. 1406
1352 and infiltrative cardiomyopathy. Heart Fail Clin. 2008;4(1):87- 2013;188(5):613-620. 1407
1353 97. 23. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for 1408
5. Redline S, Yenokyan G, Gottlieb DJ, et al. Obstructive sleep apnea- enhancing medication adherence. Cochrane Database Syst Rev.
1354 2014;11:CD000011. 1409
hypopnea and incident stroke: the Sleep Heart Health Study. Am J
1355 Respir Crit Care Med. 2010;182(2):269-277. 24. Rauscher H, Formanek D, Popp W, Zwick H. Self-reported 1410
1356 6. Gottlieb DJ, Yenokyan G, Newman AB, et al. Prospective study of vs measured compliance with nasal CPAP for obstructive sleep 1411
apnea. Chest. 1993;103(6):1675-1680.
1357 obstructive sleep apnea and incident coronary heart disease and 1412
heart failure: the Sleep Heart Health Study. Circulation. 25. Chai-Coetzer CL, Luo YM, Antic NA, et al. Predictors of long-term
1358 1413
2010;122(4):352-360. adherence to continuous positive airway pressure therapy in
1359 patients with obstructive sleep apnea and cardiovascular disease in 1414
7. Nieto FJ, Peppard PE, Young T, Finn L, Hla KM, Farre R. Sleep-
1360 disordered breathing and cancer mortality: results from the the SAVE study. Sleep. 2013;36(12):1929-1937. 1415
1361 Wisconsin Sleep Cohort Study. Am J Respir Crit Care Med. 26. Ball EM, Banks MB. Determinants of compliance with nasal 1416
2012;186(2):190-194. continuous positive airway pressure treatment applied in a
1362 community setting. Sleep Med. 2001;2(3):195-205. 1417
8. Marshall NS, Delling L, Grunstein RR, et al. Self-reported sleep
1363 apnoea and mortality in patients from the Swedish Obese Subjects 1418
27. Drake CL, Day R, Hudgel D, et al. Sleep during titration predicts
1364 study. Eur Respir J. 2011;38(6):1349-1354. continuous positive airway pressure compliance. Sleep. 2003;26(3): 1419
1365 9. Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and 308-311. 1420
1366 mortality: eighteen-year follow-up of the Wisconsin Sleep Cohort. 28. Wallace DM, Shafazand S, Aloia MS, Wohlgemuth WK. The 1421
Sleep. 2008;31(8):1071-1078. association of age, insomnia, and self-efficacy with continuous
1367 positive airway pressure adherence in black, white, and Hispanic U. 1422
10. Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered
1368 breathing and mortality: a prospective cohort study. PLoS Med.
S. veterans. J Clin Sleep Med. 2013;9(9):885-895. 1423
1369 2009;6(8):e1000132. 29. Stepnowsky CJ Jr, Marler MR, Ancoli-Israel S. Determinants of 1424
1370 nasal CPAP compliance. Sleep Med. 2002;3(3):239-247. 1425
11. Marin JM, Agusti A, Villar I, et al. Association between treated and
1371 untreated obstructive sleep apnea and risk of hypertension. JAMA. 30. Stepnowsky CJ, Marler MR, Palau J, Annette Brooks J. Social- 1426
2012;307(20):2169-2176. cognitive correlates of CPAP adherence in experienced users. Sleep
1372 Med. 2006;7(4):350-356. 1427
12. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term
1373 cardiovascular outcomes in men with obstructive sleep apnoea- 31. Ayas NT, Patel SR, Malhotra A, et al. Auto-titrating versus 1428
1374 hypopnoea with or without treatment with continuous positive standard continuous positive airway pressure for the treatment of 1429
airway pressure: an observational study. Lancet. 2005;365(9464): obstructive sleep apnea: results of a meta-analysis. Sleep.
1375 1430
1046-1053. 2004;27(2):249-253.

chestjournal.org 13

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

1431 32. Bakker JP, Marshall NS. Flexible pressure delivery modification of reduces daytime blood pressure over 6 months. Respirology. 1486
1432 continuous positive airway pressure for obstructive sleep apnea 2009;14(3):404-410. 1487
does not improve compliance with therapy: systematic review and
1433 51. Robinson GV, Langford BA, Smith DM, Stradling JR. Predictors of 1488
meta-analysis. Chest. 2011;139(6):1322-1330.
blood pressure fall with continuous positive airway pressure
1434 33. Bogan RK, Wells C. A randomized crossover trial of a pressure (CPAP) treatment of obstructive sleep apnoea (OSA). Thorax. 1489
1435 relief technology (SensAwakeÔ) in continuous positive airway 2008;63(10):855-859. 1490
pressure to treat obstructive sleep apnea. Sleep Disord. 2017;2017:
1436 3978073.
52. Zinchuk AV, Gentry MJ, Concato J, Yaggi HK. Phenotypes in 1491
1437 obstructive sleep apnea: a definition, examples and evolution of 1492
34. Powell ED, Gay PC, Ojile JM, Litinski M, Malhotra A. A pilot study approaches. Sleep Med Rev. 2017;35:113-123.
1438 assessing adherence to auto-bilevel following a poor initial 1493
encounter with CPAP. J Clin Sleep Med. 2012;8(1):43-47. 53. Bianchi MT, Alameddine Y, Mojica J. Apnea burden: efficacy
1439 versus effectiveness in patients using positive airway pressure. Sleep 1494
1440 35. Platt AB, Field SH, Asch DA, et al. Neighborhood of residence is Med. 2014;15(12):1579-1581. 1495
associated with daily adherence to CPAP therapy. Sleep. 2009;32(6):
1441 799-806. 54. McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of 1496
1442 cardiovascular events in obstructive sleep apnea. N Engl J Med. 1497
36. Bakker JP, O’Keeffe KM, Neill AM, Campbell AJ. Ethnic disparities 2016;375(10):919-931.
1443 in CPAP adherence in New Zealand: effects of socioeconomic 1498
status, health literacy and self-efficacy. Sleep. 2011;34(11):1595- 55. Peker Y, Glantz H, Eulenburg C, Wegscheider K, Herlitz J,
1444 Thunstrom E. Effect of positive airway pressure on cardiovascular 1499
1603.
1445 outcomes in coronary artery disease patients with nonsleepy 1500
37. Billings ME, Auckley D, Benca R, et al. Race and residential obstructive sleep apnea. The RICCADSA Randomized Controlled
1446 socioeconomics as predictors of CPAP adherence. Sleep. Trial. Am J Respir Crit Care Med. 2016;194(5):613-620. 1501
1447 2011;34(12):1653-1658. 1502
56. Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the
1448 38. Redline S, Baker-Goodwin S, Bakker JP, et al. Patient partnerships evaluation, management and long-term care of obstructive sleep 1503
transforming sleep medicine research and clinical care: perspectives apnea in adults. J Clin Sleep Med. 2009;5(3):263-276.
1449 1504
from the Sleep Apnea Patient-Centered Outcomes Network. J Clin
1450 Sleep Med. 2016;12(7):1053-1058. 57. Littner MR. Mild obstructive sleep apnea syndrome should not be 1505
treated. Con. J Clin Sleep Med. 2007;3(3):263-264.
1451 39. Billings ME, Kapur VK. Medicare long-term CPAP coverage policy: 1506
a cost-utility analysis. J Clin Sleep Med. 2013;9(10):1023-1029. 58. Brown LK. Mild obstructive sleep apnea syndrome should be
1452 treated. Pro. J Clin Sleep Med. 2007;3(3):259-262. 1507
1453 40. Masa JF, Corral-Penafiel J. Should use of 4 hours continuous 1508
positive airway pressure per night be considered acceptable 59. Marshall NS, Barnes M, Travier N, et al. Continuous positive
1454 compliance? Eur Respir J. 2014;44(5):1119-1120. airway pressure reduces daytime sleepiness in mild to moderate 1509
1455 obstructive sleep apnoea: a meta-analysis. Thorax. 2006;61(5):430- 1510
41. Weaver TE, Maislin G, Dinges DF, et al. Relationship between 434.
1456 hours of CPAP use and achieving normal levels of sleepiness and 1511
daily functioning. Sleep. 2007;30(6):711-719. 60. Barnes M, Houston D, Worsnop CJ, et al. A randomized
1457 controlled trial of continuous positive airway pressure in mild 1512
1458 42. Antic NA, Catcheside P, Buchan C, et al. The effect of CPAP in obstructive sleep apnea. Am J Respir Crit Care Med. 1513
normalizing daytime sleepiness, quality of life, and neurocognitive 2002;165(6):773-780.
1459 function in patients with moderate to severe OSA. Sleep. 1514
1460 2011;34(1):111-119. 61. Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive 1515
airway pressure and oral appliance in mild to moderate
1461 43. Zimmerman ME, Arnedt JT, Stanchina M, Millman RP, Aloia MS. obstructive sleep apnea. Am J Respir Crit Care Med. 1516
1462 Normalization of memory performance and positive airway 2004;170(6):656-664. 1517
pressure adherence in memory-impaired patients with obstructive
1463 sleep apnea. Chest. 2006;130(6):1772-1778. 62. Monasterio C, Vidal S, Duran J, et al. Effectiveness of continuous 1518
1464 positive airway pressure in mild sleep apnea-hypopnea syndrome. 1519
44. Barbe F, Duran-Cantolla J, Capote F, et al. Long-term effect of Am J Respir Crit Care Med. 2001;164(6):939-943.
1465 continuous positive airway pressure in hypertensive patients with 1520
sleep apnea. Am J Respir Crit Care Med. 2010;181(7):718-726. 63. Weaver TE, Mancini C, Maislin G, et al. Continuous positive
1466 airway pressure treatment of sleepy patients with milder 1521
45. Martinez-Garcia MA, Capote F, Campos-Rodriguez F, et al. Effect
1467 obstructive sleep apnea: results of the CPAP Apnea Trial North 1522
of CPAP on blood pressure in patients with obstructive sleep apnea American Program (CATNAP) randomized clinical trial. Am J
1468 and resistant hypertension: the HIPARCO randomized clinical Respir Crit Care Med. 2012;186(7):677-683. 1523
1469 trial. JAMA. 2013;310(22):2407-2415. 1524
64. Antic NA, Buchan C, Esterman A, et al. A randomized controlled
1470 46. Haentjens P, Van Meerhaeghe A, Moscariello A, et al. The impact trial of nurse-led care for symptomatic moderate-severe obstructive 1525
of continuous positive airway pressure on blood pressure in sleep apnea. Am J Respir Crit Care Med. 2009;179(6):501-508.
1471 patients with obstructive sleep apnea syndrome: evidence from a 1526
1472 meta-analysis of placebo-controlled randomized trials. Arch Intern 65. Chai-Coetzer CL, Antic NA, Rowland LS, et al. Primary care 1527
Med. 2007;167(8):757-764. vs specialist sleep center management of obstructive sleep apnea
1473 and daytime sleepiness and quality of life: a randomized trial. 1528
1474 47. Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, JAMA. 2013;309(10):997-1004. 1529
Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM.
1475 Cardiovascular mortality in women with obstructive sleep apnea 66. Sanchez-de-la-Torre M, Nadal N, Cortijo A, et al. Role of primary 1530
1476 with or without continuous positive airway pressure treatment: a care in the follow-up of patients with obstructive sleep apnoea 1531
cohort study. Ann Intern Med. 2012;156(2):115-122. undergoing CPAP treatment: a randomised controlled trial.
1477 Thorax. 2015;70(4):346-352. 1532
48. Martinez-Garcia MA, Campos-Rodriguez F, Catalan-Serra P, et al.
1478 Cardiovascular mortality in obstructive sleep apnea in the elderly: 67. Meurice JC, Ingrand P, Portier F, et al. A multicentre trial of 1533
1479 role of long-term continuous positive airway pressure treatment: a education strategies at CPAP induction in the treatment of severe 1534
prospective observational study. Am J Respir Crit Care Med. sleep apnoea-hypopnoea syndrome. Sleep Med. 2007;8(1):37-42.
1480 1535
2012;186(9):909-916. 68. Wang W, He G, Wang M, Liu L, Tang H. Effects of patient
1481 1536
49. Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of education and progressive muscle relaxation alone or combined on
1482 continuous positive airway pressure treatment on blood pressure: a adherence to continuous positive airway pressure treatment in 1537
1483 systematic review and meta-analysis of randomized controlled obstructive sleep apnea patients. Sleep Breath. 2012;16(4):1049- 1538
trials. J Clin Sleep Med. 2012;8(5):587-596. 1057.
1484 1539
50. Middleton S, Vermeulen W, Byth K, Sullivan CE, Middleton PG. 69. Basoglu OK, Midilli M, Midilli R, Bilgen C. Adherence to
1485 1540
Treatment of obstructive sleep apnoea in Samoa progressively continuous positive airway pressure therapy in obstructive sleep

14 Contemporary Reviews in Sleep Medicine [ -#- CHEST - 2019 ]

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578
1541 apnea syndrome: effect of visual education. Sleep Breath. 88. Bakker JP, O’Keeffe KM, Neill AM, Campbell AJ. Continuous 1596
1542 2012;16(4):1193-1200. positive airway pressure treatment for obstructive sleep apnoea: 1597
Maori, Pacific and New Zealand European experiences. J Prim
1543 70. Guralnick AS, Balachandran JS, Szutenbach S, et al. Educational 1598
Health Care. 2014;6(3):221-228.
video to improve CPAP use in patients with obstructive sleep
1544 apnoea at risk for poor adherence: a randomised controlled trial. 89. Deering KN, Shannon K, Sinclair H, Parsad D, Gilbert E, 1599
1545 Thorax. 2017;72(12):1132-1139. Tyndall MW. Piloting a peer-driven intervention model to increase 1600
access and adherence to antiretroviral therapy and HIV care among
1546 71. Hui DS, Chan JK, Choy DK, et al. Effects of augmented 1601
continuous positive airway pressure education and support on street-entrenched HIV-positive women in Vancouver. AIDS
1547 Patient Care STDS. 2009;23(8):603-609. 1602
compliance and outcome in a Chinese population. Chest.
1548 2000;117(5):1410-1416. 90. Lorig K, Ritter PL, Villa FJ, Armas J. Community-based peer-led 1603
1549 72. Bouloukaki I, Giannadaki K, Mermigkis C, et al. Intensive versus diabetes self-management: a randomized trial. Diabetes Educ. 1604
standard follow-up to improve continuous positive airway pressure 2009;35(4):641-651.
1550 1605
compliance. Eur Respir J. 2014;44(5):1262-1274. 91. Simon-Tuval T, Reuveni H, Greenberg-Dotan S, Oksenberg A,
1551 Tal A, Tarasiuk A. Low socioeconomic status is a risk factor for 1606
73. Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ.
1552 Can intensive support improve continuous positive airway CPAP acceptance among adult OSAS patients requiring treatment. 1607
1553 pressure use in patients with the sleep apnea/hypopnea Sleep. 2009;32(4):545-552. 1608
1554 syndrome? Am J Respir Crit Care Med. 1999;159(4 pt 1):1096- 92. Solomon P. Peer support/peer provided services underlying 1609
1100. processes, benefits, and critical ingredients. Psychiatr Rehabil J.
1555 2004;27(4):392-401. 1610
74. Nadeem R, Rishi MA, Srinivasan L, Copur AS, Naseem J. Effect of
1556 visualization of raw graphic polysomnography data by sleep apnea 93. Bakker JP, Cailler M, Khan N, et al. A randomized trial 1611
1557 patients on adherence to CPAP therapy. Respir Care. 2013;58(4): demonstrating the feasibility of a group-based peer-support 1612
607-613. intervention for maximizing CPAP adherence [abstract]. Am J
1558 1613
75. Jurado-Gamez B, Bardwell WA, Cordova-Pacheco LJ, Garcia- Respir Crit Care Med. 2017;195:A6541.
1559 1614
Amores M, Feu-Collado N, Buela-Casal G. A basic intervention 94. Parthasarathy S, Wendel C, Haynes PL, Atwood C, Kuna S. A pilot
1560 improves CPAP adherence in sleep apnoea patients: a controlled study of CPAP adherence promotion by peer buddies with sleep 1615
1561 trial. Sleep Breath. 2015;19(2):509-514. apnea. J Clin Sleep Med. 2013;9(6):543-550. 1616
1562 76. Falcone VA, Damiani MF, Quaranta VN, Capozzolo A, Resta O. 95. ClinicalTrials.gov. Peer-Driven Intervention for Sleep Apnea 1617
Polysomnograph chart view by patients: a new educational strategy (PCORI). NCT02056002. https://clinicaltrials.gov/ct2/show/
1563 to improve CPAP adherence in sleep apnea therapy. Respir Care. 1618
NCT02056002. Q11
1564 2014;59(2):193-198. 1619
96. Stepnowsky CJ, Palau JJ, Marler MR, Gifford AL. Pilot randomized
1565 77. Aloia MS, Di Dio L, Ilniczky N, Perlis ML, Greenblatt DW, trial of the effect of wireless telemonitoring on compliance and 1620
1566 Giles DE. Improving compliance with nasal CPAP and vigilance in treatment efficacy in obstructive sleep apnea. J Med Internet Res. 1621
older adults with OAHS. Sleep Breath. 2001;5(1):13-21. 2007;9(2):e14.
1567 1622
78. Aloia MS, Arnedt JT, Riggs RL, Hecht J, Borrelli B. Clinical 97. Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine
1568 management of poor adherence to CPAP: motivational 1623
intervention to improve adherence to continuous positive airway
1569 enhancement. Behav Sleep Med. 2004;2(4):205-222. pressure: a randomised controlled trial. Thorax. 2010;65(12):1061- 1624
1570 79. Aloia MS, Smith K, Arnedt JT, et al. Brief behavioral therapies 1066. 1625
reduce early positive airway pressure discontinuation rates in sleep 98. Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a
1571 1626
apnea syndrome: preliminary findings. Behav Sleep Med. 2007;5(2): telemedicine monitoring system on positive airway pressure
1572 89-104. adherence in patients with obstructive sleep apnea: a randomized 1627
1573 80. Aloia MS, Arnedt JT, Strand M, Millman RP, Borrelli B. controlled trial. Sleep. 2012;35(4):477-481. 1628
1574 Motivational enhancement to improve adherence to positive airway 99. Kuna ST, Shuttleworth D, Chi L, et al. Web-based access to positive 1629
pressure in patients with obstructive sleep apnea: a randomized airway pressure usage with or without an initial financial incentive
1575 controlled trial. Sleep. 2013;36(11):1655-1662. 1630
improves treatment use in patients with obstructive sleep apnea.
1576 81. Olsen S, Smith SS, Oei TP, Douglas J. Motivational interviewing Sleep. 2015;38(8):1229-1236. 1631
1577 (MINT) improves continuous positive airway pressure (CPAP) 100. Munafo D, Hevener W, Crocker M, Willes L, Sridasome S, 1632
1578 acceptance and adherence: a randomized controlled trial. J Consult Muhsin M. A telehealth program for CPAP adherence 1633
Clin Psychol. 2012;80(1):151-163. reduces labor and yields similar adherence and efficacy when
1579 1634
82. Bakker JP, Wang R, Weng J, et al. Motivational enhancement for compared to standard of care. Sleep Breath. 2016;20(2):777-
1580 increasing adherence to CPAP: a randomized controlled trial. 785. 1635
1581 Chest. 2016;150(2):337-345. 101. Hostler JM, Sheikh KL, Andrada TF, Khramtsov A, 1636
1582 83. Lai AY, Fong DY, Lam JC, Weaver TE, Ip MS. The efficacy of a Holley PR, Holley AB. A mobile, web-based system can 1637
brief motivational enhancement education program on CPAP improve positive airway pressure adherence. J Sleep Res.
1583 2017;26(2):139-146. 1638
adherence in OSA: a randomized controlled trial. Chest.
1584 2014;146(3):600-610. 1639
102. Turino C, de Batlle J, Woehrle H, et al. Management of continuous
1585 84. Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. positive airway pressure treatment compliance using 1640
1586 Increased adherence to CPAP with a group cognitive behavioral telemonitoring in obstructive sleep apnoea. Eur Respir J. 1641
treatment intervention: a randomized trial. Sleep. 2007;30(5):635- 2017;49(2).
1587 640. 1642
103. Hwang D, Chang JW, Benjafield AV, et al. Effect of telemedicine
1588 85. Bartlett D, Wong K, Richards D, et al. Increasing adherence to education and telemonitoring on continuous positive airway 1643
1589 obstructive sleep apnea treatment with a group social cognitive pressure adherence. The Tele-OSA Randomized Trial. Am J Respir 1644
therapy treatment intervention: a randomized controlled trial. Crit Care Med. 2018;197(1):117-126.
1590 1645
Sleep. 2013;36(11):1647-1654. 104. Pépin JL, Jullian-Desayes I, Sapene M, et al. Multimodal remote
1591 1646
86. Lettieri CJ, Walter RJ. Impact of group education on continuous monitoring of high cardiovascular risk OSA patients initiating
1592 positive airway pressure adherence. J Clin Sleep Med. 2013;9(6): CPAP: a randomized trial [published online ahead of print 1647
1593 537-541. November 22, 2018]. Chest. https://doi.org/10.1016/j.chest.2018. Q12
1648
1594 87. Likar LL, Panciera TM, Erickson AD, Rounds S. Group education 105. Woehrle H, Arzt M, Graml A, et al. Effect of a patient engagement 1649
sessions and compliance with nasal CPAP therapy. Chest. tool on positive airway pressure adherence: analysis of a German
1595 1650
1997;111(5):1273-1277. healthcare provider database. Sleep Med. 2018;41:20-26.

chestjournal.org 15

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578

1651 106. Malhotra A, Crocker ME, Willes L, Kelly C, Lynch S, 110. Weaver TE, Kribbs NB, Pack AI, et al. Night-to-night variability in 1706
1652 Benjafield AV. Patient engagement using new technology to CPAP use over the first three months of treatment. Sleep. 1707
improve adherence to positive airway pressure therapy: a 1997;20(4):278-283.
1653 retrospective analysis. Chest. 2018;153(4):843-850. 1708
111. Dieffenbach P, Bravata D, Ferguson J, et al. Investigating the
1654 107. Stevens J. Behavioral economics strategies for promoting adherence healthy user effect: correlating CPAP use and medication adherence 1709
1655 to sleep interventions. Sleep Med Rev. 2015;23:20-27. [abstract]. Chest. 2012;142:A142. 1710
1656 108. Tarasiuk A, Reznor G, Greenberg-Dotan S, Reuveni H. Financial 112. Platt AB, Kuna ST, Field SH, et al. Adherence to sleep apnea 1711
incentive increases CPAP acceptance in patients from low therapy and use of lipid-lowering drugs: a study of the healthy-user
1657 socioeconomic background. PLoS One. 2012;7(3):e33178. effect. Chest. 2010;137(1):102-108. 1712
1658 109. Budhiraja R, Parthasarathy S, Drake CL, et al. Early CPAP use 113. Adherence to long-term therapies. World Health Organization 1713
1659 identifies subsequent adherence to CPAP therapy. Sleep. website. http://www.who.int/chp/knowledge/publications/ 1714
1660 2007;30(3):320-324. adherence_full_report.pdf. Accessed March 29, 2018. 1715
1661 1716
1662 1717
1663 1718
1664 1719
1665 1720
1666 1721
1667 1722
1668 1723
1669 1724
1670 1725
1671 1726
1672 1727
1673 1728
1674 1729
1675 1730
1676 1731
1677 1732
1678 1733
1679 1734
1680 1735
1681 1736
1682 1737
1683 1738
1684 1739
1685 1740
1686 1741
1687 1742
1688 1743
1689 1744
1690 1745
1691 1746
1692 1747
1693 1748
1694 1749
1695 1750
1696 1751
1697 1752
1698 1753
1699 1754
1700 1755
1701 1756
1702 1757
1703 1758
1704 1759
1705 1760

16 Contemporary Reviews in Sleep Medicine [ -#- CHEST - 2019 ]

REV 5.5.0 DTD
CHEST2120_proof
11 February 2019
11:13 pm
EO: CHEST-18-1578