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Original Research: SLEEP DISORDERS |

The Impact of Sleep Consultation Prior to a Diagnostic Polysomnogram on Continuous Positive Airway Pressure AdherenceSleep Consultation and Treatment Adherence Sleep Consultation and Treatment Adherence FREE TO VIEW

Sushmita Pamidi, MD; Kristen L. Knutson, PhD; Farbod Ghods, MD; Babak Mokhlesi, MD, FCCP
Author and Funding Information

From the Sleep Disorders Center, Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL.

Correspondence to: Babak Mokhlesi, MD, FCCP, Sleep Disorders Center and Sleep Fellowship Program, Section of Pulmonary and Critical Medicine, Department of Medicine, 5841 S Maryland Ave, MC 6076/Room M630, Chicago, IL 60637; e-mail: bmokhles@medicine.bsd.uchicago.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Funding/Support: The authors have reported to CHEST that no funding was received for this study.


© 2012 American College of Chest Physicians


Chest. 2012;141(1):51-57. doi:10.1378/chest.11-0709
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Published online

Background:  Polysomnograms (PSGs) are routinely ordered by nonsleep specialists. However, it is unknown whether a sleep specialist consultation prior to a diagnostic PSG influences adherence to continuous positive airway pressure (CPAP) therapy.

Methods:  This study was done at the University of Chicago Sleep Disorders Center and included 403 patients with obstructive sleep apnea who had CPAP adherence data available. CPAP was set up at home, and objective adherence was remotely monitored during the first 30 days of therapy. Physicians who ordered PSGs were divided into two groups: sleep specialists and nonsleep specialists.

Results:  Patients were aged 52.5 ± 14 years, 47% were men, and 54% were African American. Mean daily CPAP use was greater in patients who were referred by sleep specialists (n = 105, 279 ± 179 min/d) than in patients referred by nonsleep specialists (n = 298, 219 ± 152 min/d, P = .005). In the linear regression model adjusting for several covariates, only two predictors were significantly associated with CPAP adherence. A sleep specialist consultation prior to the diagnostic PSG was associated with 58.2 min more per day (P = .002), and African American race was associated with 56.0 min less per day (P = .002) of CPAP use.

Conclusions:  In this cohort study, CPAP adherence was significantly higher with a sleep specialist consultation prior to the diagnostic PSG. In addition, African American race was associated with worse adherence to therapy. A better understanding of predictors of CPAP adherence may be useful in identifying patients who may benefit from a sleep specialist consultation prior to ordering a diagnostic PSG.

Figures in this Article

Although the most effective treatment of obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP) therapy, poor patient adherence is the major limitation to this treatment modality. Despite the long-term neurocognitive, cardiovascular, and metabolic consequences of untreated OSA,13 only 46% to 83% of patients adhere to CPAP treatment of at least 4 h/d.4,5 Although 4 h/d usage is the minimum acceptable threshold for adherence in clinical practice, Weaver and colleagues6 demonstrated that CPAP use longer than 4 h provides additional benefit for certain outcomes. Thus, given the valuable health benefits of CPAP, identifying predictors of CPAP adherence may help to create strategies to maximize treatment benefit.

Reasons for poor adherence to CPAP therapy are complex and not well understood. Severity of sleep apnea based on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) have been variable in predicting CPAP adherence.3,4,7 Patient education and interventions following initiation of CPAP therapy also have had varying degrees of benefit in affecting adherence to therapy.813 Patients at our institution often are directly referred for diagnostic polysomnograms (PSGs) by nonsleep specialists without a sleep specialist consultation prior to the PSG. However, it is unknown whether a sleep specialist consultation prior to the diagnostic PSG affects CPAP adherence. Therefore, our goal was to quantify the impact of having a sleep specialist consultation prior to the diagnostic PSG on initial CPAP adherence.

Patients

Between July 2007 and June 2008, we evaluated the medical records of 1,126 consecutive adults who were CPAP naive and were referred for their first in-laboratory PSG for suspicion of OSA to the University of Chicago Sleep Laboratory. Patients who received a diagnosis of OSA and were referred for CPAP therapy had CPAP set up in their homes by a durable medical equipment (DME) provider. Exclusion criteria for these analyses were previous CPAP use, requirement for bi-level PAP or adaptive servoventilation, central sleep apnea, and lack of adherence data due to a lack of or faulty wireless modem transmission device. The Institutional Review Board of the University of Chicago approved the study, and ethical standards were observed during the investigation (IRB protocol 16167A). Given the chart review nature of the study, the need for informed consent was waived.

Baseline PSG and CPAP Titrations

Patients either underwent an in-laboratory full-night PSG followed by a full-night CPAP titration or a split-night PSG. Split-night PSGs were performed in patients who had 2 to 3 h of baseline sleep with an AHI ≥ 30 if there was at least 3 to 4 h of titration time remaining. The only CPAP education that patients received from the Sleep Disorders Center staff was on the night of the CPAP titration or split-night PSG and involved the selection of the most comfortable mask by the patient.

PSGs were scored according to the standards issued by the American Academy of Sleep Medicine.14 All the diagnostic and titration PSGs were interpreted by a board-certified sleep specialist who recommended the final CPAP pressure. The Sleep Disorders Center then communicated the final PSG report to the referring physician. It was left at the discretion of the referring physician to discuss the results of the PSG with his or her patients and to decide whether an in-laboratory CPAP titration was appropriate.

Covariates

On the night of the PSG, patients completed a routine questionnaire, which included demographics, medical history, extensive sleep history, the ESS,15 and the Center for Epidemiologic Studies Depression Scale (CES-D).16 Race was self-reported, and it was categorized into African American, non-African American, and unknown. Education level was categorized into high school degree or less, more than a high school degree, and unknown. Age, sex, and medical insurance type were obtained from the medical record. Medical insurance was categorized into Medicaid and non-Medicaid.

CPAP Adherence

At our institution, CPAP adherence was routinely determined objectively through wireless modem technology that enabled remote daily downloading of data from the CPAP unit during the first 30 days of use. CPAP was set up in patients’ homes by a DME provider after receiving a request from a physician. During the first 30 days of treatment, education on CPAP setup and troubleshooting was performed only by the DME provider. The data obtained from each CPAP unit included hours of usage per night at the prescribed pressure, residual daily AHI, and average mask leak.

Referring Physicians and CPAP Set-up

We categorized patients into two groups based on the specialty of the physician ordering the initial diagnostic PSG: nonsleep specialists or board-certified sleep specialists. The nonsleep specialists in our study included 59.7% primary-care physicians, 7.7% otolaryngologists, 7.4% pulmonologists, 6% neurologists, 6% endocrinologists, 5.4% cardiologists, 3.4% surgeons, and 4.3% other (psychiatrists, hematologists, nephrologists, and rheumatologists).

At our institution, both sleep specialists and nonsleep specialists can order diagnostic, split-night, or CPAP titration PSGs. Irrespective of the ordering physician, all PSG and CPAP titration orders were reviewed by a sleep specialist to ensure that instructions were clear to the sleep technologists. Sleep technologists were trained to educate all patients on CPAP use and mask fit. Sleep specialists did not meet with any patients on the night or morning of the diagnostic or CPAP titration PSGs. The PSG or CPAP titration reports were generated within 48 h by the sleep specialists and were sent to all referring physicians, who were then responsible for ordering CPAP devices through a DME provider. Sleep specialists did not contact their patients to review results of the PSG or CPAP titration prior to the follow-up clinic visit, which was typically 6 to 8 weeks after CPAP set-up at home. To avoid delay in starting CPAP therapy, sleep specialists routinely ordered CPAP through the DME provider for the patients they had seen in the clinic soon after the final sleep report was generated.

The initial sleep specialists’ consultation with patients occurred during outpatient clinic visits prior to the PSG. There were only four sleep specialists (two neurologists and two pulmonologists) at our sleep center during this study, all of whom were board certified in sleep medicine. Although the sleep specialists did not use a standard handout or script during the outpatient consultation, all routinely discussed the symptoms of OSA and gave a description of the PSG and procedure for sleeping in the laboratory, including the possibility of a CPAP titration. In addition, patients were educated on the pathophysiology of OSA, the long-term consequences of untreated OSA, the benefits of CPAP therapy, and the importance of adherence to CPAP prior to the follow-up clinic visit 6 to 8 weeks after initiating CPAP therapy. Patients also were told to call the DME provider about any problems relating to the CPAP device, mask, or other CPAP-related issues before the follow-up clinic visit. The initial sleep specialist consultation typically lasted 45 to 60 min. There was no further interaction provided by the sleep specialist or the Sleep Disorders Center during the initial 30 days of CPAP therapy. Patients referred by nonsleep specialists did not interact with the sleep specialists or the sleep laboratory personnel between the time of the PSG or CPAP titration, during the home CPAP set-up, or during the first 30 days of CPAP therapy.

Statistical Analyses

Means or proportions of all variables were calculated for the entire cohort and then separately by referring physician specialty groups. We used the natural log of AHI in our analyses because of nonnormal distribution. Differences between the physician specialty groups were analyzed using Student t test for continuous variables that were normally distributed, Mann-Whitney test for continuous variables that were not normally distributed, or χ2 test for categorical variables.

We performed a univariate analysis to compare associations between CPAP adherence and physician specialty group as well as important demographic variables such as age, sex, race, education level, Medicaid insurance status, and BMI. In addition, we examined variables that have been previously described in the literature to affect CPAP adherence, including AHI (either as a continuous variable or as categories of OSA severity), ESS, and CES-D. We performed a linear regression model to adjust for all possible confounding variables in order to identify independent predictors of CPAP adherence. An α ≤ .05 was considered statistically significant. All analyses were performed using PASW Statistics, version 18.0 (SPSS, Inc) software.

Patient Characteristics

Of the 1,126 patients who had PSGs for suspicion of OSA between July 2007 and July 2008, 786 (76%) were given a diagnosis of OSA, and CPAP titration was performed; 403 CPAP-naive patients were available for analysis (Fig 1). A comparison of the patients included and excluded from the analyses is available in e-Table 1.

Figure Jump LinkFigure 1. Study flow diagram illustrating how the final cohort of patients were obtained. CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnogram.Grahic Jump Location

Table 1 shows the patients for the entire sample and separately by physician specialty group. The majority of the cohort was obese and middle-aged, and more than one-half were women. African Americans constituted 54% of all patients, and a greater proportion of patients in the nonsleep specialist group were African American than in the sleep specialist group (P = .01). For all participants, 58% of patients received a diagnosis of severe OSA (AHI ≥ 30). In unadjusted analyses, patients referred by sleep specialists had a significantly higher average nightly CPAP use, higher percentage of days used ≥ 4 h per night, and a higher percentage achieving a minimum of 70% of the nights ≥ 4 h per night during the initial 30 days of therapy (Table 2). Patients referred by nonsleep specialists had a significantly higher 3% oxygen desaturation index (Table 2). In univariate analyses, only two variables demonstrated a significant difference in mean daily CPAP usage: sleep specialists vs nonsleep specialists (279 ± 179 min/d vs 219 ± 152 min/d, P = .001) and African Americans vs non-African Americans (212 ± 154 min/d vs 264 ± 156 min/d, P = .001).

Table Graphic Jump Location
Table 1 —Characteristics of Study Cohort

Data are presented as mean ± SD or No. (%). CES-D = Center of Epidemiology Study Depression Scale; ESS = Epworth Sleepiness Scale.

a 

P value comparing sleep specialists to nonsleep specialists.

b 

Data missing on 11 patients.

c 

Student t test, all other categorical values were compared using χ test.

d 

Data missing on 16 patients.

Table Graphic Jump Location
Table 2 —Polysomnographic, CPAP Titration, and CPAP Adherence Data

Data are presented as median (interquartile range), mean ± SD, or No. (%). Average mask leakage and average residual AHI were estimated daily by the CPAP device over the initial 30-day period. AHI = apnea-hypopnea index; CPAP = continuous positive airway pressure; ODI = oxygen desaturation index based on 3% oxygen desaturations; OSA = obstructive sleep apnea; PSG = polysomnogram; Spo2 = oxygen saturation as measured by pulse oximetry; T90 = percentage of total sleep time spent with oxygen saturation < 90%.

a 

P value comparing sleep specialists to nonsleep specialists.

b 

Mann-Whitney nonparametric test; all other P values were obtained by a Student t test. Categorical values were compared using χ test.

In the linear regression analysis, only two variables were independently associated with CPAP adherence after adjusting for the covariates (Table 3). Mean CPAP adherence was ∼ 58 min higher per day when there was a sleep specialist consultation prior to the initial PSG, even after adjustment for age, sex, race, BMI, Medicaid insurance, AHI, ESS, CES-D, and education level. African Americans averaged 56 min/d less CPAP use than non-African Americans after adjusting for all other variables. In an additional linear regression model, type of PSG (split night vs full night of titration) and the DME provider (only two DME providers) were not significant predictors of CPAP adherence and did not influence the regression coefficient for specialty of the referring physician and race.

Table Graphic Jump Location
Table 3 —Significant Predictors From a Fully Adjusted Multiple Linear Regression Model Predicting Mean CPAP Adherence Over the First 30 Days of Therapy in Minutes

Nonsignificant covariates in this model were age, sex, BMI, education, AHI, ESS, CES-D, and Medicaid insurance status. Because of missing values, the sample size in the regression model was decreased to 379 patients. See Table 1 and 2 legends for expansion of abbreviations.

Among 403 adult patients with OSA who had available CPAP adherence data during the first 30 days of use, only two variables independently predicted CPAP adherence in a fully adjusted regression model: sleep specialist consultation prior to the initial PSG and African American race. Patients who had a consultation with a sleep specialist used CPAP an average of 58 min/night more than patients who did not after adjusting for all covariates. In addition, our results indicated that African American race was associated with reduced CPAP adherence after adjusting for other important covariates.

At our institution, nonsleep specialists often evaluate patients for sleep apnea and order PSGs. However, no studies have specifically looked at the effect of a sleep specialist consultation prior to the initial PSG on objective CPAP adherence. We were able to demonstrate that objectively measured CPAP adherence in patients with OSA was strongly associated with a consultation with a sleep specialist prior to undergoing a diagnostic PSG. The higher CPAP adherence occurred despite the fact that there was no contact between the patient and sleep specialists or the Sleep Disorders Center staff between the time of CPAP titration and the first 30 days of treatment.

Although it remains unclear which aspect of the consultation with the sleep specialist led to higher CPAP adherence, we speculate that it may be related to the increased time spent discussing and educating the patient on OSA, including the neurocognitive, cardiovascular, and metabolic consequences of untreated OSA and the importance of adhering to CPAP therapy. Sleep specialists dedicated the entire clinic visit (45-60 min at our institution) to sleep symptoms and, therefore, have sufficient time to educate the patient about OSA prior to treatment. Additionally, the patients seeing sleep specialists often were referred by another physician and, therefore, had an additional physician interaction prior to the PSG that may have reiterated the importance of diagnosing and treating OSA. In fact, increased physician interaction may partially explain the higher percentage of self-reported hypertension in patients referred by sleep specialists despite no significant differences in age, sex, BMI, and OSA severity.

Although other studies have demonstrated improved adherence with education interventions after CPAP is initiated, we are not aware of any studies that have investigated the effect of a sleep specialist consultation prior to the diagnostic PSG on CPAP adherence. Prior research has demonstrated that primary-care physicians have a suboptimal understanding of the issues and complications of OSA.17 In a retrospective study of patients with OSA, patients treated by physicians with an expertise in sleep disorders had greater awareness of their disease process than those whose care was provided by community-based physicians without formal expertise in sleep medicine.18 One previous study that used a Web-based questionnaire found that patients with OSA managed by certified sleep specialists at accredited sleep centers had significantly higher self-reported CPAP adherence and decreased likelihood of discontinuing use of CPAP compared with patients managed by noncertified sleep physicians and nonaccredited centers.19 This national Web-based survey did not include objective CPAP adherence. Another study, however, saw no significant differences in objectively measured CPAP adherence after 3 months of treatment between nurse-led and physician-led care for patients with OSA. However, the nurses were highly trained in sleep medicine, with an average of 8.3 years of experience in sleep disorders and CPAP therapy.20

We also observed reduced CPAP adherence among African Americans. It has been shown that African Americans have decreased sleep duration compared with whites,21 which may affect the number of hours CPAP is used among this group compared with non-African Americans. Other investigators also have reported lower CPAP adherence in African Americans.7,18,22,23 In our study, African American race had a persistent effect on lower CPAP adherence, even when adjusted for other potential confounders. Therefore, it would be important to better understand the health beliefs surrounding CPAP therapy among African Americans in order to improve long-term adherence.

Our study had some methodologic limitations. First, although we objectively measured CPAP adherence, we were unable to obtain CPAP adherence data on all the patients. However, most of the missing adherence data were due to malfunctioning of the wireless modem devices, which is unlikely to be related to CPAP adherence or physician specialty. In addition, there were no significant differences in the baseline characteristics of excluded vs included patients in the cohort (e-Table 1). Further, because some patients in the sleep specialist group were self-referred, they may possess more motivation to pursue treatment with CPAP therapy than those referred for sleep specialist consultation. However, in our analysis, we did not find any significant difference in adherence between these two groups. Indeed, the patients seen by sleep specialists may have had greater motivation for treating their OSA because they agreed to see an additional physician for their sleep symptoms, suggesting that they recognized it as an important problem and, thus, possibly creating a selection bias in this group. Because of limited resources during the time of the study, interventions that have been proven to improve CPAP adherence, such as daily phone calls during the first week of therapy or cognitive behavioral therapy to improve CPAP adherence, were not implemented.10,13 Other important factors that may influence CPAP adherence, such as patient perception of CPAP treatment, were not examined in the present study. Measuring change in symptoms also may prove to be useful correlates for CPAP adherence. Finally, 30 days of CPAP adherence may not be representative of longer-term adherence despite some studies reporting that early CPAP adherence is reflective of adherence at 1 year.7,24,25 Despite the demonstrated effectiveness of CPAP therapy in improving symptoms and outcomes, a better understanding of the factors that predict poor CPAP adherence may be useful in determining whether certain patients may benefit from a sleep specialist consultation prior to the ordering of a diagnostic PSG.

Author contributions: Dr Mokhlesi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Pamidi: contributed to the study concept and design, data analysis and interpretation, drafting of the manuscript, and review of the manuscript for important intellectual content.

Dr Knutson: contributed to the study concept and design, data analysis and interpretation, drafting of the manuscript, and review of the manuscript for important intellectual content.

Dr Ghods: contributed to the data analysis and interpretation, drafting of the manuscript, and review of the manuscript for important intellectual content.

Dr Mokhlesi: contributed to the study concept and design, data analysis and interpretation, drafting of the manuscript, and review of the manuscript for important intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Mokhlesi has served as a consultant to Philips/Respironics Inc in a role unrelated to the work performed in the submitted research. Drs Pamidi, Knutson, and Ghods have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Table can be found in the Online Supplement at http://chestjournal.chestpubs.org/content/141/1/51/suppl/DC1.

AHI

apnea-hypopnea index

CES-D

Center for Epidemiologic Studies Depression Scale

CPAP

continuous positive airway pressure

DME

durable medical equipment

ESS

Epworth Sleepiness Scale

OSA

obstructive sleep apnea

PSG

polysomnogram

Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;35319:2034-2041 [PubMed] [CrossRef]
 
Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;28314:1829-1836 [PubMed]
 
Gay P, Weaver T, Loube D, Iber C. Positive Airway Pressure Task Force Positive Airway Pressure Task Force Standards of Practice Committee Standards of Practice Committee American Academy of Sleep Medicine American Academy of Sleep Medicine Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;293:381-401 [PubMed]
 
Kohler M, Smith D, Tippett V, Stradling JR. Predictors of long-term compliance with continuous positive airway pressure. Thorax. 2010;659:829-832 [PubMed]
 
Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;52:173-178 [PubMed]
 
Weaver TE, Maislin G, Dinges DF, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007;306:711-719 [PubMed]
 
Budhiraja R, Parthasarathy S, Drake CL, et al. Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep. 2007;303:320-324 [PubMed]
 
Chervin RD, Theut S, Bassetti C, Aldrich MS. Compliance with nasal CPAP can be improved by simple interventions. Sleep. 1997;204:284-289 [PubMed]
 
Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? Am J Respir Crit Care Med. 1999;1594 pt 1:1096-1100 [PubMed]
 
Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep. 2007;305:635-640 [PubMed]
 
Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;6512:1061-1066 [PubMed]
 
Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA. CPAP Promotion and Prognosis-The Army Sleep Apnea Program Trial CPAP Promotion and Prognosis-The Army Sleep Apnea Program Trial Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med. 2009;15110:696-702 [PubMed]
 
Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;1212:430-435 [PubMed]
 
Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM Manual for the Scoring of Sleep and Associated Events: Rules Terminology, and Technical Specifications. 2007; Westchester, IL American Academy of Sleep Medicine
 
Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;146:540-545 [PubMed]
 
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Parthasarathy S, Haynes PL, Budhiraja R, Habib MP, Quan SF. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea. J Clin Sleep Med. 2006;22:133-142 [PubMed]
 
Antic NA, Buchan C, Esterman A, et al. A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea. Am J Respir Crit Care Med. 2009;1796:501-508 [PubMed]
 
Lauderdale DS, Knutson KL, Yan LL, et al. Objectively measured sleep characteristics among early-middle-aged adults: the CARDIA study. Am J Epidemiol. 2006;1641:5-16 [PubMed]
 
Means MK, Ulmer CS, Edinger JD. Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behav Sleep Med. 2010;84:260-273 [PubMed]
 
Joo MJ, Herdegen JJ. Sleep apnea in an urban public hospital: assessment of severity and treatment adherence. J Clin Sleep Med. 2007;33:285-288 [PubMed]
 
Drake CL, Day R, Hudgel D, et al. Sleep during titration predicts continuous positive airway pressure compliance. Sleep. 2003;263:308-311 [PubMed]
 
Popescu G, Latham M, Allgar V, Elliott MW. Continuous positive airway pressure for sleep apnoea/hypopnoea syndrome: usefulness of a 2 week trial to identify factors associated with long term use. Thorax. 2001;569:727-733 [PubMed]
 

Figures

Figure Jump LinkFigure 1. Study flow diagram illustrating how the final cohort of patients were obtained. CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnogram.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Characteristics of Study Cohort

Data are presented as mean ± SD or No. (%). CES-D = Center of Epidemiology Study Depression Scale; ESS = Epworth Sleepiness Scale.

a 

P value comparing sleep specialists to nonsleep specialists.

b 

Data missing on 11 patients.

c 

Student t test, all other categorical values were compared using χ test.

d 

Data missing on 16 patients.

Table Graphic Jump Location
Table 2 —Polysomnographic, CPAP Titration, and CPAP Adherence Data

Data are presented as median (interquartile range), mean ± SD, or No. (%). Average mask leakage and average residual AHI were estimated daily by the CPAP device over the initial 30-day period. AHI = apnea-hypopnea index; CPAP = continuous positive airway pressure; ODI = oxygen desaturation index based on 3% oxygen desaturations; OSA = obstructive sleep apnea; PSG = polysomnogram; Spo2 = oxygen saturation as measured by pulse oximetry; T90 = percentage of total sleep time spent with oxygen saturation < 90%.

a 

P value comparing sleep specialists to nonsleep specialists.

b 

Mann-Whitney nonparametric test; all other P values were obtained by a Student t test. Categorical values were compared using χ test.

Table Graphic Jump Location
Table 3 —Significant Predictors From a Fully Adjusted Multiple Linear Regression Model Predicting Mean CPAP Adherence Over the First 30 Days of Therapy in Minutes

Nonsignificant covariates in this model were age, sex, BMI, education, AHI, ESS, CES-D, and Medicaid insurance status. Because of missing values, the sample size in the regression model was decreased to 379 patients. See Table 1 and 2 legends for expansion of abbreviations.

References

Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;35319:2034-2041 [PubMed] [CrossRef]
 
Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;28314:1829-1836 [PubMed]
 
Gay P, Weaver T, Loube D, Iber C. Positive Airway Pressure Task Force Positive Airway Pressure Task Force Standards of Practice Committee Standards of Practice Committee American Academy of Sleep Medicine American Academy of Sleep Medicine Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;293:381-401 [PubMed]
 
Kohler M, Smith D, Tippett V, Stradling JR. Predictors of long-term compliance with continuous positive airway pressure. Thorax. 2010;659:829-832 [PubMed]
 
Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;52:173-178 [PubMed]
 
Weaver TE, Maislin G, Dinges DF, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007;306:711-719 [PubMed]
 
Budhiraja R, Parthasarathy S, Drake CL, et al. Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep. 2007;303:320-324 [PubMed]
 
Chervin RD, Theut S, Bassetti C, Aldrich MS. Compliance with nasal CPAP can be improved by simple interventions. Sleep. 1997;204:284-289 [PubMed]
 
Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? Am J Respir Crit Care Med. 1999;1594 pt 1:1096-1100 [PubMed]
 
Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep. 2007;305:635-640 [PubMed]
 
Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;6512:1061-1066 [PubMed]
 
Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA. CPAP Promotion and Prognosis-The Army Sleep Apnea Program Trial CPAP Promotion and Prognosis-The Army Sleep Apnea Program Trial Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med. 2009;15110:696-702 [PubMed]
 
Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;1212:430-435 [PubMed]
 
Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM Manual for the Scoring of Sleep and Associated Events: Rules Terminology, and Technical Specifications. 2007; Westchester, IL American Academy of Sleep Medicine
 
Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;146:540-545 [PubMed]
 
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Means MK, Ulmer CS, Edinger JD. Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behav Sleep Med. 2010;84:260-273 [PubMed]
 
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