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Cochrane Database of Systematic Reviews

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

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Information

DOI:
https://doi.org/10.1002/14651858.CD007736.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 08 January 2014see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Airways Group

Copyright:
  1. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Dariusz R Wozniak

    Correspondence to: Respiratory Support and Sleep Centre, Papworth Hospital, Cambridge, UK

    [email protected]

  • Toby J Lasserson

    Cochrane Editorial Unit, The Cochrane Collaboration, London, UK

  • Ian Smith

    Respiratory Support and Sleep Centre, Papworth Hospital, Cambridge, UK

Contributions of authors

DRW: Study assessment (2013); data extraction, data entry and analysis (2013); write‐up (2013).

TJL: Study assessment (2009); data extraction, data entry and analysis (2009); write‐up (2013).

IS: Study assessment; data extraction and analysis, write‐up (2009 and 2013).

Previous author(s) no longer contributing to this version of the review:

Vidya Nadig (2009): study assessment; data extraction; write‐up.

Sources of support

Internal sources

  • St George's, University of London, UK.

  • Papworh NHS Trust, UK.

External sources

  • No sources of support supplied

Declarations of interest

None known.

Acknowledgements

We are very grateful to the members of the Cochrane Airways Group editorial base, who provided support with searching for and retrieving studies for inclusion in the review, and to Prof John Wright for constructive comments on the protocol and the review. We are very grateful for assistance given to us by study authors who responded to our requests for additional data and information: Mark Aloia (Aloia 2001; Aloia 2012a; Aloia 2012b); Keir Lewis (Lewis 2006); Carol Smith (Schiefelbein 2005, Smith 2006); Carl Stepnowsky (Stepnowsky 2007); Delwyn Bartlett (Bartlett 2010); Domagoj Damjanovic (Damjanovic 2009); Ozen K Basoglu (Basoglu 2011); George Zaldivar (Shaikh 2009); Sairam Parthasarathy (Parthasarathy 2012); and Simon Smith (Olsen 2012). We acknowledge the contribution of Vidya Nadig to the previous version of this review.

John White was the Editor for this review and commented critically on the review.

Version history

Published

Title

Stage

Authors

Version

2020 Apr 07

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

Review

Kathleen Askland, Lauren Wright, Dariusz R Wozniak, Talia Emmanuel, Jessica Caston, Ian Smith

https://doi.org/10.1002/14651858.CD007736.pub3

2014 Jan 08

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

Review

Dariusz R Wozniak, Toby J Lasserson, Ian Smith

https://doi.org/10.1002/14651858.CD007736.pub2

2009 Apr 15

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

Review

Ian Smith, Vidya Nadig, Toby J Lasserson

https://doi.org/10.1002/14651858.CD007736

Differences between protocol and review

This review incorporates a risk of bias table for eligible studies, and we performed post hoc subgroup analysis based on awareness of machine monitoring and average compliance with CPAP in the control arm using four hours/night as the cutoff.

We have incorporated summary of findings tables for the three comparisons in this review.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figures and Tables -
Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Forest plot of comparison: 1 Increased psychological and/or practical support during follow‐up + CPAP versus usual care + CPAP, outcome: 1.1 Machine usage (hours/night)—first arm/parallel studies.
Figures and Tables -
Figure 3

Forest plot of comparison: 1 Increased psychological and/or practical support during follow‐up + CPAP versus usual care + CPAP, outcome: 1.1 Machine usage (hours/night)—first arm/parallel studies.

Forest plot of comparison: 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, outcome: 1.3 Machine usage, sensitivity analysis: adherence in control group =< four hours/night.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, outcome: 1.3 Machine usage, sensitivity analysis: adherence in control group =< four hours/night.

Funnel plot of comparison: 1 Increased practical support and encouragement + CPAP versus usual care + CPAP, outcome: 1.1 Machine usage (hours/night).
Figures and Tables -
Figure 5

Funnel plot of comparison: 1 Increased practical support and encouragement + CPAP versus usual care + CPAP, outcome: 1.1 Machine usage (hours/night).

Forest plot of comparison: 2 Educational interventions + CPAP versus usual care + CPAP, outcome: 2.1 Machine usage (hours/night).
Figures and Tables -
Figure 6

Forest plot of comparison: 2 Educational interventions + CPAP versus usual care + CPAP, outcome: 2.1 Machine usage (hours/night).

Forest plot of comparison: 4 Behavioural therapy + CPAP versus control + CPAP, outcome: 4.1 Machine usage.
Figures and Tables -
Figure 7

Forest plot of comparison: 4 Behavioural therapy + CPAP versus control + CPAP, outcome: 4.1 Machine usage.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 1 Machine usage (hours/night).
Figures and Tables -
Analysis 1.1

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 1 Machine usage (hours/night).

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 2 Machine usage, sensitivity analysis: excluding participants aware of machine usage monitoring.
Figures and Tables -
Analysis 1.2

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 2 Machine usage, sensitivity analysis: excluding participants aware of machine usage monitoring.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 3 Machine usage, sensitivity analysis: adherence in control group < four hours/night.
Figures and Tables -
Analysis 1.3

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 3 Machine usage, sensitivity analysis: adherence in control group < four hours/night.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 4 N deemed adherent (≥ four hours/night).
Figures and Tables -
Analysis 1.4

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 4 N deemed adherent (≥ four hours/night).

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 5 Epworth Sleepiness Scale scores.
Figures and Tables -
Analysis 1.5

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 5 Epworth Sleepiness Scale scores.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 6 Quality of life: Functional Outcomes of Sleep Questionnaire.
Figures and Tables -
Analysis 1.6

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 6 Quality of life: Functional Outcomes of Sleep Questionnaire.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 7 Quality of life: Sleep Apnoea Quality of Life Index (SAQLI).
Figures and Tables -
Analysis 1.7

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 7 Quality of life: Sleep Apnoea Quality of Life Index (SAQLI).

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 8 Mood.
Figures and Tables -
Analysis 1.8

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 8 Mood.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 9 Withdrawals.
Figures and Tables -
Analysis 1.9

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 9 Withdrawals.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 10 AHI on treatment.
Figures and Tables -
Analysis 1.10

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 10 AHI on treatment.

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 11 Maintenance of Wakefulness Test (MWT).
Figures and Tables -
Analysis 1.11

Comparison 1 Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP, Outcome 11 Maintenance of Wakefulness Test (MWT).

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 1 Machine usage (hours/night).
Figures and Tables -
Analysis 2.1

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 1 Machine usage (hours/night).

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 2 N deemed adherent (≥ four hours/night).
Figures and Tables -
Analysis 2.2

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 2 N deemed adherent (≥ four hours/night).

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 3 Epworth Sleepiness Scale scores.
Figures and Tables -
Analysis 2.3

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 3 Epworth Sleepiness Scale scores.

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 4 Quality of life: Sleep Apnoea Quality of Life Index (SAQLI).
Figures and Tables -
Analysis 2.4

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 4 Quality of life: Sleep Apnoea Quality of Life Index (SAQLI).

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 5 HAD Scale for Depression.
Figures and Tables -
Analysis 2.5

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 5 HAD Scale for Depression.

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 6 Withdrawal.
Figures and Tables -
Analysis 2.6

Comparison 2 Educational interventions + CPAP versus usual care + CPAP, Outcome 6 Withdrawal.

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 1 Machine usage (hours/night).
Figures and Tables -
Analysis 3.1

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 1 Machine usage (hours/night).

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 2 Sensitivity analysis: excluding participants aware of machine usage monitoring.
Figures and Tables -
Analysis 3.2

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 2 Sensitivity analysis: excluding participants aware of machine usage monitoring.

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 3 N deemed adherent (≥ four hours/night).
Figures and Tables -
Analysis 3.3

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 3 N deemed adherent (≥ four hours/night).

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 4 Epworth Sleepiness Scale score.
Figures and Tables -
Analysis 3.4

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 4 Epworth Sleepiness Scale score.

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 5 Quality of life: Functional Outcomes of Sleep Questionnaire.
Figures and Tables -
Analysis 3.5

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 5 Quality of life: Functional Outcomes of Sleep Questionnaire.

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 6 Withdrawal.
Figures and Tables -
Analysis 3.6

Comparison 3 Behavioural therapy + CPAP versus control + CPAP, Outcome 6 Withdrawal.

Summary of findings for the main comparison. Increased practical support and encouragement for adults with sleep apnoea

Increased practical support and encouragement for adults with sleep apnoea

Patient or population: adults with sleep apnoea
Intervention: increased practical support and encouragement and CPAP

Comparison: CPAP

Settings: community

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Increased practical support and encouragement

Machine usage
Hours per night
Follow‐up: median 12 weeks

Average CPAP machine usage ranged across control groups from
1.75 to 6.3 hours per night

Mean machine usage in the intervention groups was
0.82 hours higher
(0.36 to 1.27 higher)

803
(13 studies)

⊕⊕⊝⊝
low1,2

N deemed adherent (≥ four hours/night)
Follow‐up: median 12 weeks

59 per 100

75 per 100
(64 to 83)

OR 2.06
(1.22 to 3.47)

268
(4 studies)

⊕⊕⊝⊝
low1,3

Symptoms of sleepiness
Epworth Scale: zero to 24
Follow‐up: median 12 weeks

Average Epworth symptom scores in control groups ranged from

4.5 to 13

Mean symptoms of sleepiness in the intervention groups was
0.6 lower
(1.81 lower to 0.62 higher)

501
(8 studies)

⊕⊝⊝⊝
very low1,4,5

Quality of life
Functional Outcomes of Sleep Questionnaire

Mean quality of life in the intervention groups was
0.98 higher
(0.84 lower to 2.79 higher)

70
(2 studies)

⊕⊕⊝⊝
low1,6

Quality of life
Sleep Apnoea Quality of Life Index (SAQLI)

See comment

See comment

108
(1 study)

⊕⊕⊝⊝
low1,6

Single study estimate

Withdrawals
Follow‐up: median 12 weeks

17 per 100

11 per 100
(eight to 16)

OR 0.65
(0.44 to 0.97)

903
(12 studies)

⊕⊕⊕⊝
moderate1

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Risk of bias (‐1): In the absence of blinding across studies, the study effect estimates are at risk of performance bias.
2Inconsistency (‐1): Substantial variation was seen in the direction and magnitude of effect across studies (I2 = 66%). Removal of studies when average machine use in control groups was high yielded a more consistent, larger effect in favour of intervention.
3Imprecision (‐1): Low number of participants across studies was seen despite lower limit of the CI favouring intervention.
4Inconsistency (‐1): Substantial variation was seen in the direction and magnitude of effect across studies.
5Imprecision (‐1): Width of the confidence intervals does not exclude substantial improvement in deterioration of symptoms.
6Imprecision (‐1): Low number of participants and very wide confidence intervals were compatible with benefit and harm.

Figures and Tables -
Summary of findings for the main comparison. Increased practical support and encouragement for adults with sleep apnoea
Summary of findings 2. Educational interventions for adults with sleep apnoea

Educational interventions for adults with sleep apnoea

Patient or population: adults with sleep apnoea
Intervention: educational interventions and CPAP

Comparison: CPAP

Settings: community

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Educational interventions

Machine usage
Hours per night
Follow‐up: 12 to 24 weeks

Average CPAP machine usage ranged across control groups from

2.6 to 5.7 hours per night

Mean machine usage in the intervention groups was
0.6 higher
(0.27 to 0.93 higher)

508
(7 studies)

⊕⊕⊕⊝
moderate1

N deemed adherent (≥4 hours/night)
Follow‐up: 12 to 24 weeks

57 per 100

71 per 100
(59 to 80)

OR 1.8
(1.09 to 2.95)

285
(3 studies)

⊕⊕⊝⊝
low1,2

Symptoms of sleepiness
Epworth Scale: 0 to 24
Follow‐up: median 12 weeks

Mean Epworth Sleepiness Scale scores across control groups ranged from

5.4 to 10.8

Mean Epworth Sleepiness Scale scores in the intervention groups was
1.17 lower
(2.07 to 0.26 lower)

336
(5 studies)

⊕⊕⊕⊝
moderate1

Quality of life: Sleep Apnoea Quality of Life Index (SAQLI)
Follow‐up: 4 weeks

See comment

See comment

Not estimable

89
(1 study)

⊕⊝⊝⊝
very low1,3

Single study estimate

Withdrawal
Follow‐up: 4 to 24 weeks

24 per 100

18 per 100
(13 to 24)

OR 0.67
(0.45 to 0.98)

683
(8 studies)

⊕⊕⊝⊝
low1,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Risk of bias (‐1): In the absence of blinding across studies, effect estimates may be biased because of performance bias.
2Imprecision (‐1): We downgraded because of the low number of participants in the analysis, in spite of the statistically significant increase in the number of participants deemed compliant.
3Imprecision (‐2): In view of the very low number of participants and the wide confidence intervals, we downgraded by two points.
4Inconsistency (‐1): The direction and magnitude of effect varied across studies.

Figures and Tables -
Summary of findings 2. Educational interventions for adults with sleep apnoea
Summary of findings 3. Behavioural therapy for adults with sleep apnoea who are using CPAP

Behavioural therapy for adults with sleep apnoea who are using CPAP

Patient or population: adults with sleep apnoea
Intervention: behavioural therapy and CPAP

Comparison: CPAP

Settings: community

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Behavioural therapy

Machine usage
Hours per night

See comment

Average machine usage in the intervention groups was
1.44 higher
(0.43 to 2.45 higher)

584
(6 studies)

⊕⊕⊝⊝
low1,2

Data analysed as generic inverse variance

N deemed adherent (≥4 hours/night)
Follow‐up: four to 52 weeks

28 per 100

47 per 100
(36 to 58)

OR 2.23
(1.45 to 3.45)

358
(3 studies)

⊕⊝⊝⊝
very low1,3

Symptoms
Epworth scores

See comment

See comment

100
(1 study)

⊕⊕⊝⊝
low1,4

Single study estimate

Quality of life
Functional Outcomes of Sleep Questionnaire

See comment

See comment

100
(1 study)

⊕⊕⊝⊝
low1,4

Single study estimate

Withdrawal
Follow‐up: 4 to 52 weeks

23 per 100

20 per 100
(15 to 27)

OR 0.85
(0.57 to 1.25)

609
(5 studies)

⊕⊝⊝⊝
very low1,2,5

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Risk of bias (‐1): In the absence of blinding across studies, effect estimates may be biased because of performance bias.
2Inconsistency (‐1): Variation was seen in the magnitude and direction of effect across studies.
3Inconsistency (‐2): Very substantial variation was seen between direction and results of studies.
4Imprecision (‐1): Low number of participants contribute data to this outcome.
5Imprecision (‐1): Confidence intervals were compatible with reduction and increase in likelihood of study withdrawal.

Figures and Tables -
Summary of findings 3. Behavioural therapy for adults with sleep apnoea who are using CPAP
Table 1. Number screened, entered and completed

Study

N Screened

Entered

Completed

% Screened

% Entered

Aloia 2001

NA

12

12

NA

100

Aloia 2012a, Aloia 2012b

339

227

149

44

66

Basoglu 2011

246

133

133

54

100

Chervin 1997

NA (75% of those approached agreed to participate)

40

33

NA

82.5

DeMolles 2004

NA

30

30

NA

100

Epstein 2000

NA

50

43

NA

86

Fox 2012

NA

75

54

NA

72

Hoy 1999

NA

80

75

NA

94

Hui 2000

NA

108

108

NA

100

Lewis 2006

74

72

55

74

76

Meurice 2007a, Meurice 2007b, Meurice 2007c, Meurice 2007d

133

112

91

68

81

Olsen 2012

132

100

73

55

73

Parthasarathy 2012

49

39

37

76

95

Richards 2007

109

100

79

72

79

Roecklein 2010

NA

30

28

NA

93

Schiefelbein 2005

NA

51

51

NA

100

Smith 2006

NA

19

19

NA

100

Smith 2009

NA

97

73

NA

75

Sparrow 2010

423

250

115

27

46

Stepnowsky 2007

91

45

40

44

88

Taylor 2006

160

132

114

71

86

Wang 2011a, Wang 2011b, Wang 2011c, Wang 2011d

NA

152

130

NA

86

Wiese 2005

NA

93

56

NA

60

Figures and Tables -
Table 1. Number screened, entered and completed
Table 2. Study characteristics

Intervention group

Study

Intervention

Control

Study duration

(weeks)

Increased support and reinforcement components

Increased educational components

Behavioural therapy

Increased support and reinforcement

Chervin 1997

Weekly telephone calls to monitor progress and troubleshoot

Written information on OSA and CPAP

Usual care

Eight

DeMolles 2004

Computer‐based telecommunication system allowing for monitoring and reinforcing compliance

Education provided by the computer‐based telecommunication system

Usual care

Eight

Fox 2012

Telecomunication system allowing for daily monitoring of CPAP usage, timely detection and troubleshooting of problems

Usual care

12

Hoy 1999

2 additional titration nights in hospital, 4 additional visits at home by sleep nurses

Initial education at home with partner

Usual care

24

Hui 2000

2 additional early reviews by sleep physician and frequent telephone calls by sleep nurses

Videotape and additional education session

Usual care

12

Lewis 2006

1 additional early review by sleep physician and 1 early telephone interview with sleep nurse

Educational video

Usual care

52

Meurice 2007a

4 additional home visits in the first 3 months by sleep practitioner for problem solving

Written information and detailed explanation by the prescriber, additional education during home visits

Written information and detailed explanation by the prescriber + usual care

52

Meurice 2007b

4 additional home visits in the first 3 months by sleep practitioner for problem solving

Additional education during home visits

Usual care

52

Parthasarathy 2012

2 individual sessions and 8 telephone conversations with trained peer CPAP users providing support and sharing their positive experience with CPAP

Peers shared their knowledge on CPAP and OSA

Interventions delivered by peer contained elements of promoting self‐efficacy, risk perception, participant activation and motivation

Usual care

12

Schiefelbein 2005

Internet‐based application aimed at encouraging CPAP use and problem solving

Internet‐based application similar in format to intervention but directed activities in neutral health topics (vitamin intake)

16

Smith 2006

Home video‐link sessions delivered by nurse, who guided correct CPAP use and provided problem solving

Nurse provided education on CPAP and OSA

Home video‐link sessions similar in form to intervention but directed activities in neutral health topics (vitamin intake)

12

Smith 2009

Audiotaped music along with softly spoken directions on relaxation techniques and habit‐promoting instructions for using CPAP, user reminder placard

Handouts on benefits of CPAP adherence and health consequences of poor compliance

Audiotaped music along with spoken information about vitamins. Information packet similar in format to intervention, but content was on vitamins

24

Stepnowsky 2007

Wireless telemonitoring of compliance and treatment efficacy on daily basis and acting on the data via prespecified clinical pathways

Usual care

Eight

Taylor 2006

Internet‐based application aimed at monitoring self‐reported compliance, acting on the information in timely fashion

Usual care

Four

Wang 2011b

Progressive muscle relaxation

Usual care

12

Wang 2011c

Progressive muscle relaxation + 2 additional nights of CPAP titration

4hour group education session, written information, video CD

Two additional nights of CPAP titration + four‐hour group education session, written information, video CD + usual care

12

Increased education

Aloia 2012a

Two 45‐minute individual didactic sessions and one booster phone call by sleep nurse

Usual care

52

Basoglu 2011

10‐Minute educational video session on OSA and CPAP

Usual care

24

Epstein 2000

Educational and desensitisation course

Usual care

24

Meurice 2007c

4 additional home visits in the first 3 months by sleep practitioner for problem solving

Written information and detailed explanation by the prescriber, additional education during home visits

Four additional home visits in the first three months by sleep practitioner for problem solving and additional education + usual care

52

Meurice 2007d

Written information and detailed explanation by the prescriber

Usual care

52

Wang 2011a

2 additional nights of CPAP titration

Four‐hour group education session, written information, video CD

Usual care

12

Wang 2011d

Progressive muscle relaxation + 2 additional nights of CPAP titration

Four‐hour group education session, written information, video CD

Progressive muscle relaxation + usual care

12

Wiese 2005

15‐Minute educational video addressing misconception about OSA and barriers to effective CPAP treatment

Usual care

Four

Behavioural therapy

Aloia 2001

Elements of education on consequences of OSA and efficacy of CPAP

Two 45‐minute sessions of cognitive‐behavioural therapy interventions

Two 45‐minute sessions involving discussion on sleep architecture and sleep clinic

12

Aloia 2012b

Two 45‐minute sessions of Motivational Enhancement Therapy, one booster phone call

Usual care

52

Olsen 2012

45‐Minute individual education session

Three 30‐minute sessions of Motivational Interviewing Therapy

45‐Minute educational session + usual care

52

Richards 2007

Slide presentation and written information on OSA and CPAP

Two one‐hour group sessions of cognitive‐behavioural therapy

Usual care

Four

Roecklein 2010

Written personalised feedback report framed according to Motivational Enhancement Theory

Written information from the American Academy of Sleep Medicine

12

Sparrow 2010

Side effects management module incorporated in the automated telephone‐linked communication system

Information exchange on OSA and CPAP incorporated in the automated telephone‐linked communication system

Automated telephone‐linked communication system designed around the concept of Motivational Interviewing, which allowed one to assess and enhance CPAP compliance

General education on unrelated health topics via automated telephone‐linked communication system

52

Figures and Tables -
Table 2. Study characteristics
Comparison 1. Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Machine usage (hours/night) Show forest plot

13

803

Mean Difference (IV, Random, 95% CI)

0.82 [0.36, 1.27]

2 Machine usage, sensitivity analysis: excluding participants aware of machine usage monitoring Show forest plot

6

378

Mean Difference (IV, Fixed, 95% CI)

1.07 [0.61, 1.52]

3 Machine usage, sensitivity analysis: adherence in control group < four hours/night Show forest plot

8

471

Mean Difference (IV, Fixed, 95% CI)

1.36 [0.96, 1.76]

4 N deemed adherent (≥ four hours/night) Show forest plot

4

268

Odds Ratio (M‐H, Fixed, 95% CI)

2.06 [1.22, 3.47]

5 Epworth Sleepiness Scale scores Show forest plot

8

501

Mean Difference (IV, Random, 95% CI)

‐0.60 [‐1.81, 0.62]

6 Quality of life: Functional Outcomes of Sleep Questionnaire Show forest plot

2

70

Mean Difference (IV, Fixed, 95% CI)

0.98 [‐0.84, 2.79]

7 Quality of life: Sleep Apnoea Quality of Life Index (SAQLI) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

8 Mood Show forest plot

3

312

Mean Difference (IV, Fixed, 95% CI)

‐0.94 [‐1.55, ‐0.33]

8.1 HAD Scale for Anxiety

1

80

Mean Difference (IV, Fixed, 95% CI)

‐1.10 [‐2.95, 0.75]

8.2 HAD Scale for Depression

3

232

Mean Difference (IV, Fixed, 95% CI)

‐0.93 [‐1.57, ‐0.28]

9 Withdrawals Show forest plot

12

903

Odds Ratio (M‐H, Fixed, 95% CI)

0.65 [0.44, 0.97]

10 AHI on treatment Show forest plot

2

115

Mean Difference (IV, Fixed, 95% CI)

‐0.07 [‐1.62, 1.48]

11 Maintenance of Wakefulness Test (MWT) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 1. Increased practical support and encouragement during follow‐up + CPAP versus usual care + CPAP
Comparison 2. Educational interventions + CPAP versus usual care + CPAP

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Machine usage (hours/night) Show forest plot

7

508

Mean Difference (IV, Fixed, 95% CI)

0.60 [0.27, 0.93]

2 N deemed adherent (≥ four hours/night) Show forest plot

3

285

Odds Ratio (M‐H, Fixed, 95% CI)

1.80 [1.09, 2.95]

3 Epworth Sleepiness Scale scores Show forest plot

5

336

Mean Difference (IV, Fixed, 95% CI)

‐1.17 [‐2.07, ‐0.26]

4 Quality of life: Sleep Apnoea Quality of Life Index (SAQLI) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 HAD Scale for Depression Show forest plot

2

152

Mean Difference (IV, Fixed, 95% CI)

‐0.52 [‐1.25, 0.22]

6 Withdrawal Show forest plot

8

683

Odds Ratio (M‐H, Fixed, 95% CI)

0.67 [0.45, 0.98]

Figures and Tables -
Comparison 2. Educational interventions + CPAP versus usual care + CPAP
Comparison 3. Behavioural therapy + CPAP versus control + CPAP

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Machine usage (hours/night) Show forest plot

6

584

Mean Difference (Random, 95% CI)

1.44 [0.43, 2.45]

2 Sensitivity analysis: excluding participants aware of machine usage monitoring Show forest plot

5

Mean Difference (Fixed, 95% CI)

1.54 [0.99, 2.09]

3 N deemed adherent (≥ four hours/night) Show forest plot

3

358

Odds Ratio (M‐H, Fixed, 95% CI)

2.23 [1.45, 3.45]

4 Epworth Sleepiness Scale score Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 Quality of life: Functional Outcomes of Sleep Questionnaire Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

6 Withdrawal Show forest plot

5

609

Odds Ratio (M‐H, Fixed, 95% CI)

0.85 [0.57, 1.25]

Figures and Tables -
Comparison 3. Behavioural therapy + CPAP versus control + CPAP