Original Title: Intervenciones para mejorar la adherencia al tratamiento con CPAP en pacientes con apnea obstructiva del sueño

Authors' objectives: 1. To analyse the factors that cause low CPAP treatment adherence in patients with OSAS (adults and children). 2. To determine the effects of different interventions on improving CPAP treatment adherence and the health status in patients with OSAS.

Authors' results and conclusions: Factors that had an influence on CPAP treatment adherence were identified, including those that were related to the patient and the disease, technological factors, factors related to side effects, as well as psychological and social factors. Several studies revealed the multifactorial nature of CPAP adherence. Studies conducted in children showed that maternal education and social support to families were the most important factors influencing treatment adherence. Likewise, certain features of the patients such as, race and age may have an influence on adherence behaviours in children. The scientific literature regarding interventions to improve CPAP treatment adherence in paediatric populations is very limited and currently only two studies have been published on this specific population. Evidence on the effectiveness of interventions to improve CPAP treatment adherence was obtained from 14 studies that met the established criteria (which included: two systematic reviews, nine RCTs, two non-randomised controlled trials and one randomised pilot study). Six of the studies included were classified as high quality, three as medium quality, one as medium-to-low quality and four as low quality. Five RCTs and two non-randomized controlled trials were included for the analysis of the effectiveness of educational interventions, recruiting a total of 6,108 patients. Due to the great variability among the interventions applied, the differences in sample sizes, monitoring times and quality of the different studies, the data from the included studies were not metaanalysed. Available evidence on educational interventions was mainly based on one good quality RCT performed on 3,100 patients. The intensive educational intervention increased the use of CPAP by approximately 1 hour and 40 minutes (95% CI: 1.56 to 1.84) compared with the usual care, and the percentage of patients who were adherent to the treatment (with ≥4 h use/night for at least 70% of the nights) increased from 79.8% to 92.8% (Odds ratio (OR) 3.25; 95% CI: 2.58 to 4.08). The study showed improvements in symptoms derived from OSAS (daytime somnolence and depression symptoms), and it had a positive effect on the patient’s quality of life. Likewise, lower cardiovascular mortality rates and fewer hospital admissions associated with cardiovascular disease were observed in the group that received the educational intervention. Cognitive-behavioural interventions increased the use of CPAP by approximately 1 extra hour (mean difference 1.07; 95% CI: 0.43 to 1.72; 11 studies; 1,190 patients; moderate quality evidence) compared with the usual care, and the percentage of patients who used CPAP for ≥4h/night increased from 38% to 53% (OR 2.61; 95% CI: 1.21 to 5.63; 774 patients; six studies, low-to-moderate quality evidence). However, a high degree of heterogeneity was observed in the results (I2 = 81%). Moderate quality evidence indicated an improvement in daytime somnolence symptoms in patients that received cognitive-behavioural interventions (ESS score of –0.80; 95% CI: –1.70 to 0.10; 667 patients; five studies). However, the clinical significance of the magnitude of this difference is questionable. Depression was measured in one of the studies using the DASS questionnaire and despite the scores improved in both groups compared to baseline measurements, there were no differences between the intervention group (IG) and the control group (CG). No significant differences between IG patients and CG patients were observed in any of the three studies that evaluated the effect of cognitive-behavioural interventions on quality of life. Low quality evidence showed that supportive interventions increased the use of CPAP by approximately 50 minutes every night (0.80 hours; 95% CI; 0.40 to 1.19; 14 studies; 1,044 patients). Such interventions also increased the number of patients who used their devices for more than 4 hours a night from 59% to 75% (OR 2.06, 95% CI: 1.22 to 3.47; N = 268, four studies) compared with normal care. Evidence on the effect of supportive interventions on daytime somnolence was statistically inaccurate and did not reach statistical significance (ESS score –0.27; 95% CI: –1.53 to 0.99; 742 patients, nine studies, very low quality evidence). Depression was measured in one study using the CES-D questionnaire, but no differences were observed between the IG and the CG. No significant differences were observed in terms of quality of life between patients who received supportive interventions and those who received normal care. CONCLUSIONS With a low to moderate evidence level, it was observed that all three types of interventions studied (educational, cognitive-behavioural and supportive), increased the use of CPAP in varying degrees in patients with moderate-to-severe OSAS over a limited time. The results of this review show that the different types of educational and cognitive-behavioural interventions resulted in greater increases in the hours of use of CPAP. Very little evidence has been published on the improvement of the health status as a result of increased hours of CPAP use. However, a high quality study has recently been published, which analysed the effect of a greater use of CPAP on OSAS symptoms, quality of life and cardiovascular disease on a sufficiently large sample of 3,100 patients, for a long follow-up period (24 months). The study showed a significant improvement in all the outcome measures analysed. A specific type of intervention may not be equally suitable for all patients. Thus, the characteristics of each individual patient must be taken into account, personalising the interventions and, therefore, contributing to improving the effectiveness.

Authors' methods: Objective no. 1 was addressed through an overview, by conducting a narrative review of the scientific literature. Objective no. 2 was addressed through a systematic review of the scientific literature. The following databases were searched: Medline (PubMed), Embase (OVID), Cochrane Library (Wiley) and Centre for Reviews and Dissemination (CRD). The process was completed by searching meta-search engines such as, TripDatabase and Emergency Care Research Institute (ECRI Institute). The electronic searches were supplemented by manually scanning the reference lists from included articles to identify additional studies that may have been missed during the search of databases. The ClinicalTrials.gov and the Spanish Clinical Trials Register databases were examined to identify studies in progress or pending publication. Randomised controlled trials (RCTs) (crossover or parallel), systematic reviews, meta-analyses, clinical practice guidelines, health technology assessment reports, non-randomised controlled studies and pilot studies with an adequate design were selected. The methodological quality of the included studies was assessed using the FLC 2.0 software, developed by the Basque Office for Health Technology Assessment (Osteba). In turn, the internal validity of the studies was assessed using the Risk of Bias of the Cochrane Collaboration with some modifications proposed by the GRADE methodology. The level of evidence was classified following the method proposed by the Scottish Intercollegiate Guidelines Network (SIGN). When judged appropriate, data were meta-analysed.

Project Status: Completed

Year Published: 2016

URL for published report: https://www.ogasun.ejgv.euskadi.eus/r51-catpub/es/k75aWebPublicacionesWar/k75aObtenerPublicacionDigitalServlet?R01HNoPortal=true&N_LIBR=051915&N_EDIC=0001&C_IDIOM=es&FORMATO=.pdf

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government</p>