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

Dariusz R Wozniak; Toby J Lasserson; Ian Smith

doi:10.1002/14651858.CD007736.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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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.

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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.

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Figure 5

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

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Figure 6

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

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Figure 7

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

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Analysis 1.1

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

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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.

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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.

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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).

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Analysis 1.5

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

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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.

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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).

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Analysis 1.8

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

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Analysis 1.9

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

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Analysis 1.10

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

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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).

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 2.3

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

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Analysis 2.4

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

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Analysis 2.5

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

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Analysis 2.6

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

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Analysis 3.1

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

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Analysis 3.2

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

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Analysis 3.3

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

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Analysis 3.4

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

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Analysis 3.5

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

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Analysis 3.6

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

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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)	⊕⊕⊝⊝ low^1,2
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)	⊕⊕⊝⊝ low^1,3
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 low^1,4,5
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)	⊕⊕⊝⊝ low^1,6
Quality of life Sleep Apnoea Quality of Life Index (SAQLI)	See comment	See comment		108 (1 study)	⊕⊕⊝⊝ low^1,6	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.

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

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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)	⊕⊕⊝⊝ low^1,2
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 low^1,3	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)	⊕⊕⊝⊝ low^1,4
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.

Summary of findings 2. Educational interventions for adults with sleep apnoea

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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)	⊕⊕⊝⊝ low^1,2	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 low^1,3
Symptoms Epworth scores	See comment	See comment		100 (1 study)	⊕⊕⊝⊝ low^1,4	Single study estimate
Quality of life Functional Outcomes of Sleep Questionnaire	See comment	See comment		100 (1 study)	⊕⊕⊝⊝ low^1,4	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 low^1,2,5
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.

Summary of findings 3. Behavioural therapy for adults with sleep apnoea who are using CPAP

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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

Table 1. Number screened, entered and completed

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Table 2. Study characteristics

Intervention group	Study	Intervention			Control	Study duration (weeks)
Intervention group	Study	Increased support and reinforcement components	Increased educational components	Behavioural therapy	Control	Study duration (weeks)
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

Table 2. Study characteristics

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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

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

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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]

Comparison 2. Educational interventions + CPAP versus usual care + CPAP

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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]

Comparison 3. Behavioural therapy + CPAP versus control + CPAP

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