Interventions to improve use of continuous positive airway pressure for obstructive sleep apnoea

Ian Smith; Toby J Lasserson; Muzlifah Haniffa

doi:10.1002/14651858.CD003531.pub2

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Figure 1

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

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Figure 2

Forest plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.1 Compliance (nightly usage: hours) ‐ 1st arm/parallel studies.

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Figure 3

Forest plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.2 Compliance (nightly usage) ‐ crossover studies.

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Figure 4

Forest plot of comparison: 2 Bi‐level PAP versus fixed CPAP, outcome: 2.1 Compliance (nightly usage: hours) ‐ 1st arm/parallel studies.

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Analysis 1.1

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 1 Compliance (nightly usage: hours) ‐ 1st arm/parallel studies.

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Analysis 1.2

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 2 Compliance (nightly usage) ‐ crossover studies.

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Analysis 1.3

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 3 Compliance (frequency of usage as % of days) ‐ crossover studies.

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Analysis 1.4

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 4 Compliance (frequency of usage as % of days) ‐ 1st arm/parallel studies.

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Analysis 1.5

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 5 Compliance (% of nights of > 4 hours of use) ‐ crossover studies.

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Analysis 1.6

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 6 Number of participants who applied CPAP therapy >4 hrs day/5 days/week ‐ 1st arm/parallel studies.

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Analysis 1.7

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 7 Withdrawals (Parallel group trials/first arm crossover trials).

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Analysis 1.8

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 8 Patient preference (auto CPAP/not auto CPAP).

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Analysis 1.9

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 9 Epworth Sleepiness Score ‐ 1st arm/parallel studies.

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Analysis 1.10

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 10 Epworth Sleepiness Score ‐ crossover studies.

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Analysis 1.11

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 11 Arousals(events/hour) ‐ 1st arm/parallel studies.

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Analysis 1.12

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 12 Arousals (events/hr) ‐ crossover studies.

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Analysis 1.13

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 13 Apnoea Hypopnoea Index (events/hr) ‐ 1st arm/parallel studies.

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Analysis 1.14

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 14 Apnoea Hypopnoea Index (events/hr) ‐ crossover studies.

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Analysis 1.15

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 15 Number of subjects where AHI reduced to <10 events/hour.

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Analysis 1.16

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 16 Pressure of CPAP treatment.

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Analysis 1.17

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 17 Vitality (SF‐36) ‐ crossover studies.

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Analysis 2.1

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 1 Compliance (nightly usage: hours) ‐ 1st arm/parallel studies.

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Analysis 2.2

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 2 Compliance (nightly usage: hours) ‐ crossover studies.

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Analysis 2.3

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 3 Withdrawals ‐ 1st arm/parallel studies.

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Analysis 2.4

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 4 Patient preference ‐ BiPAP/No preference or CPAP.

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Analysis 2.5

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 5 Epworth Sleepiness Score ‐ 1st arm/parallel studies.

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Analysis 3.1

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 1 Compliance (nightly usage: hours) ‐ crossover studies.

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Analysis 3.2

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 2 Compliance (% days when CPAP used) ‐ crossover studies.

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Analysis 3.3

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 3 Compliance (% nights when CPAP used for >4 hours) ‐ crossover studies.

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Analysis 3.4

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 4 Withdrawals ‐ 1st arm/parallel studies.

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Analysis 3.5

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 5 Apnoea Hypopnoea Index (events/hr) ‐ crossover studies.

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Analysis 3.6

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 6 Epworth Sleepiness scores.

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Analysis 3.7

Comparison 3 Patient‐titrated CPAP versus fixed CPAP, Outcome 7 Quality of life (SAQLI score) ‐ crossover studies.

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Analysis 4.1

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 1 Compliance (hours per night) ‐ 1st arm parallel studies.

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Analysis 4.2

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 2 Nasal symptoms.

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Analysis 4.4

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 4 AHI.

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Analysis 5.1

Comparison 5 Cognitive behavioural therapy + CPAP versus control education + CPAP, Outcome 1 Compliance (hours/night).

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Analysis 5.2

Comparison 5 Cognitive behavioural therapy + CPAP versus control education + CPAP, Outcome 2 Number of participants deemed 'compliant'.

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Analysis 6.1

Comparison 6 Telephone call each week + CPAP versus verbal explanation + CPAP, Outcome 1 Compliance (mean hours per night) ‐ 1st arm/parallel studies.

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Analysis 7.1

Comparison 7 Short course education + CPAP versus standard physician follow‐up + CPAP, Outcome 1 Compliance (mean hour per night; short‐term outcome <4 weeks) ‐ 1st arm/parallel studies.

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Analysis 7.2

Comparison 7 Short course education + CPAP versus standard physician follow‐up + CPAP, Outcome 2 Compliance (mean hour per night ‐ long term outcome ‐ >6 months) ‐ 1st arm/parallel studies.

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Analysis 8.1

Comparison 8 Two printed documents + CPAP versus verbal information + CPAP, Outcome 1 Compliance (mean hrs/night) ‐ parallel studies.

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Analysis 9.1

Comparison 9 Augmented support + CPAP versus basic support + CPAP, Outcome 1 Compliance‐objective (hours/night) ‐ 1st arm/parallel studies.

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Analysis 9.2

Comparison 9 Augmented support + CPAP versus basic support + CPAP, Outcome 2 Compliance rate, %‐ objective (at least 4 hrs CPAP use/night for at least 70% of nights /week).

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Analysis 9.3

Comparison 9 Augmented support + CPAP versus basic support + CPAP, Outcome 3 Epworth Sleepiness Score (change from baseline) ‐ 1st arm/parallel.

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Analysis 9.4

Comparison 9 Augmented support + CPAP versus basic support + CPAP, Outcome 4 Quality of life (total SAQLI score) ‐ 1st arm/parallel studies.

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Analysis 9.5

Comparison 9 Augmented support + CPAP versus basic support + CPAP, Outcome 5 Mean pressure of CPAP for treatment (cmH2O) ‐ 1st arm/parallel studies.

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Analysis 10.1

Comparison 10 Active reinforcement + CPAP versus control reinforcement + CPAP, Outcome 1 Compliance(hours/night) ‐ 1st arm/parallel studies.

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Analysis 10.2

Comparison 10 Active reinforcement + CPAP versus control reinforcement + CPAP, Outcome 2 Compliance (hours/night) ‐ crossover studies.

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Analysis 11.1

Comparison 11 Intensive support + CPAP versus basic support + CPAP, Outcome 1 Compliance (hrs/night).

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Analysis 11.2

Comparison 11 Intensive support + CPAP versus basic support + CPAP, Outcome 2 Cognitive Function.

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Analysis 11.3

Comparison 11 Intensive support + CPAP versus basic support + CPAP, Outcome 3 Quality of Life.

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Analysis 11.4

Comparison 11 Intensive support + CPAP versus basic support + CPAP, Outcome 4 Maintenance of wakefulness test (MWT) ‐ Parallel studies.

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Analysis 11.5

Comparison 11 Intensive support + CPAP versus basic support + CPAP, Outcome 5 Mood.

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Analysis 11.6

Comparison 11 Intensive support + CPAP versus basic support + CPAP, Outcome 6 Epworth Sleepiness Score (ESS) ‐ Parallel studies.

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Table 1. Sensitivity analyses

Outcome	Study(ies) removed	Reason	Result	Heterogeneity	Type of study
Compliance ‐ parallel studies/1st arm data	Ficker 2002	FOT (forced oscillation technique)	WMD ‐0.06 [‐0.61 to 0.74]	Chi2 = 10.30; df = 4 I2 = 61.1%	Parallel
Mean treatment pressure ‐ parallel studies/1st arm data	Ficker 2002	FOT (forced oscillation technique)	SMD ‐0.52 [‐1.06 to 0.01]	Chi2 = 11.36; df = 4; I2 = 64.8%	Parallel

Table 1. Sensitivity analyses

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Table 2. Numbers entering and completing studies

Study	Screened	Entered	Completed	% screened	% entered	Duration	Intervention type
Aloia 2003	Not reported	12	12	N/A	100	12 weeks	Support
Chervin 1997	Not reported	40	33	N/A	82.5	4‐8 weeks	Support
d'Ortho 2000	Not reported	25	25	N/A	100	8 weeks	Auto‐CPAP
Ficker 2002	Not reported	100	95	N/A	95	Two nights (data are reported in the review from unpublished abstract reporting 8 week data for both treatment groups)	Auto‐CPAP
Fitzpatrick 2003	28	24	18	64.3	75	10 weeks	Self‐adjusting CPAP
Fletcher 1991	Not reported	11	10	N/A	90.90	24 weeks	Support
Hoy 1999	Not reported	80	73	N/A	91.25	24 weeks	Support
Hudgel 2000	Not reported	53	39	N/A	73.58	12 weeks	Auto‐CPAP
Hui 2000	Not reported	108	108	N/A	100	12 weeks	Support
Kendrick 2002	Not reported	41	27	N/A	65.85	4 weeks	Auto‐CPAP
Konermann 1998	Not reported	50	48	N/A	96	12‐24 weeks	Auto‐CPAP
Massie 2003	Not reported	46	44	N/A	95.6	12 weeks	Auto‐CPAP
Meurice 1996	Not reported	16	16	N/A	100	3 weeks	Auto‐CPAP
Meurice 1998	Not reported	23	18	N/A	78.26	3 weeks	Auto‐CPAP
Randerath 2001	Not reported	52	47	N/A	90.38	12 weeks	Auto‐CPAP
Reeves‐Hoché 1995	Not reported	83	62	N/A	74.7	52 weeks	Bi‐PAP
Rostig 2003	Not reported	30	30 (assumed)	N/A	100 (assumed)	4 weeks	Auto‐CPAP
Senn 2003	Not reported	31	29	N/A	93.55	12 weeks	Auto‐CPAP
Sériès 1997	39	36	36	92.3	100	3 weeks	Auto‐CPAP
Teschler 2000	Not reported	10	10	N/A	100	16 weeks	Auto‐CPAP
Torvaldsson 2003	Not reported	11 (assumed)	11	N/A	100 (assumed)	3 weeks	Auto‐CPAP
Gay 2004	Not reported	40	27	N/A	67.5	30 days	Bi‐PAP
Muir 1998	Not reported	16	16 (assumed)	N/A	100 (assumed)	16 weeks	Bi‐PAP
Worsnop 2003	Not reported	54	54 (assumed)	N/A	100 (assumed)	12 weeks	Humidification + CPAP

Table 2. Numbers entering and completing studies

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Comparison 1. Auto‐CPAP versus fixed CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (nightly usage: hours) ‐ 1st arm/parallel studies Show forest plot	5	237	Mean Difference (IV, Random, 95% CI)	0.32 [‐0.26, 0.90]

2 Compliance (nightly usage) ‐ crossover studies Show forest plot	8	492	Mean hrs/night (Fixed, 95% CI)	0.29 [0.06, 0.51]

3 Compliance (frequency of usage as % of days) ‐ crossover studies Show forest plot	4	176	% (Fixed, 95% CI)	3.15 [‐0.97, 7.27]

4 Compliance (frequency of usage as % of days) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Compliance (% of nights of > 4 hours of use) ‐ crossover studies Show forest plot	1		% (Fixed, 95% CI)	Totals not selected

6 Number of participants who applied CPAP therapy >4 hrs day/5 days/week ‐ 1st arm/parallel studies Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7 Withdrawals (Parallel group trials/first arm crossover trials) Show forest plot	4	142	Odds Ratio (M‐H, Fixed, 95% CI)	0.59 [0.12, 2.88]

8 Patient preference (auto CPAP/not auto CPAP) Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

9 Epworth Sleepiness Score ‐ 1st arm/parallel studies Show forest plot	4	178	Mean Difference (IV, Fixed, 95% CI)	‐0.52 [‐1.77, 0.73]

10 Epworth Sleepiness Score ‐ crossover studies Show forest plot	5	308	ESS (Fixed, 95% CI)	‐0.36 [‐1.67, 0.96]

11 Arousals(events/hour) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

12 Arousals (events/hr) ‐ crossover studies Show forest plot	1		Events/hr (Fixed, 95% CI)	Totals not selected

13 Apnoea Hypopnoea Index (events/hr) ‐ 1st arm/parallel studies Show forest plot	6	277	Mean Difference (IV, Fixed, 95% CI)	‐0.34 [‐1.20, 0.52]

14 Apnoea Hypopnoea Index (events/hr) ‐ crossover studies Show forest plot	6	380	Events/hr (Fixed, 95% CI)	0.20 [‐0.96, 1.35]

15 Number of subjects where AHI reduced to <10 events/hour Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

15.1 Parallel studies	0		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.2 Crossover studies	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Pressure of CPAP treatment Show forest plot	12		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

16.1 Parallel studies	6	284	Std. Mean Difference (IV, Random, 95% CI)	‐0.81 [‐1.48, ‐0.15]
16.2 Crossover studies	8	432	Std. Mean Difference (IV, Random, 95% CI)	‐0.90 [‐1.47, ‐0.32]
17 Vitality (SF‐36) ‐ crossover studies Show forest plot	3	148	SF‐36 units (Fixed, 95% CI)	3.90 [‐1.83, 9.63]

Comparison 1. Auto‐CPAP versus fixed CPAP

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Comparison 2. Bi‐level PAP versus fixed CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (nightly usage: hours) ‐ 1st arm/parallel studies Show forest plot	2	89	Mean Difference (IV, Fixed, 95% CI)	‐0.08 [‐0.55, 0.38]

2 Compliance (nightly usage: hours) ‐ crossover studies Show forest plot	1		hours/night (Fixed, 95% CI)	Totals not selected

3 Withdrawals ‐ 1st arm/parallel studies Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4 Patient preference ‐ BiPAP/No preference or CPAP Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 Epworth Sleepiness Score ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Bi‐level PAP versus fixed CPAP

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Comparison 3. Patient‐titrated CPAP versus fixed CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (nightly usage: hours) ‐ crossover studies Show forest plot	1		hours/night (Fixed, 95% CI)	Totals not selected

2 Compliance (% days when CPAP used) ‐ crossover studies Show forest plot	1		% (Fixed, 95% CI)	Totals not selected

3 Compliance (% nights when CPAP used for >4 hours) ‐ crossover studies Show forest plot	1		% (Fixed, 95% CI)	Totals not selected

4 Withdrawals ‐ 1st arm/parallel studies Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 Apnoea Hypopnoea Index (events/hr) ‐ crossover studies Show forest plot	1		Events/hr (Fixed, 95% CI)	Totals not selected

6 Epworth Sleepiness scores Show forest plot	1		ESS (Fixed, 95% CI)	Totals not selected

7 Quality of life (SAQLI score) ‐ crossover studies Show forest plot	1		SAQLI (Fixed, 95% CI)	Totals not selected

Comparison 3. Patient‐titrated CPAP versus fixed CPAP

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Comparison 4. Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (hours per night) ‐ 1st arm parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Nasal symptoms Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Withdrawals	0		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
4 AHI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 4. Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone

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Comparison 5. Cognitive behavioural therapy + CPAP versus control education + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (hours/night) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Number of participants deemed 'compliant' Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 5. Cognitive behavioural therapy + CPAP versus control education + CPAP

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Comparison 6. Telephone call each week + CPAP versus verbal explanation + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (mean hours per night) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 6. Telephone call each week + CPAP versus verbal explanation + CPAP

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Comparison 7. Short course education + CPAP versus standard physician follow‐up + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (mean hour per night; short‐term outcome <4 weeks) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Compliance (mean hour per night ‐ long term outcome ‐ >6 months) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 7. Short course education + CPAP versus standard physician follow‐up + CPAP

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Comparison 8. Two printed documents + CPAP versus verbal information + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (mean hrs/night) ‐ parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 8. Two printed documents + CPAP versus verbal information + CPAP

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Comparison 9. Augmented support + CPAP versus basic support + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance‐objective (hours/night) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Compliance rate, %‐ objective (at least 4 hrs CPAP use/night for at least 70% of nights /week) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Epworth Sleepiness Score (change from baseline) ‐ 1st arm/parallel Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Quality of life (total SAQLI score) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Mean pressure of CPAP for treatment (cmH2O) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 9. Augmented support + CPAP versus basic support + CPAP

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Comparison 10. Active reinforcement + CPAP versus control reinforcement + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance(hours/night) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Compliance (hours/night) ‐ crossover studies Show forest plot	1		Hours/night (Fixed, 95% CI)	Totals not selected

Comparison 10. Active reinforcement + CPAP versus control reinforcement + CPAP

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Comparison 11. Intensive support + CPAP versus basic support + CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Compliance (hrs/night) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Cognitive Function Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Quality of Life Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Short Form 36 for Physical Quality ‐ Parallel studies	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Short Form 36 for Mental Quality ‐ Parallel studies	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Nottingham Health Profile Part II (score) ‐ Parallel studies	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Maintenance of wakefulness test (MWT) ‐ Parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Mood Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 HAD Scale for Anxiety ‐ Parallel studies	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 HAD Scale for Depression ‐ Parallel studies	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Epworth Sleepiness Score (ESS) ‐ Parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 11. Intensive support + CPAP versus basic support + CPAP

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