Sleep Medicine 6 (2005) 171–174 www.elsevier.com/locate/sleep
CPAP compliance: video education may help! H. Jean Wiesea,*, Carl Boethelb, Barbara Phillipsb, John F. Wilsona, Jane Petersa, Theresa Viggianoa a
Behavioral Science, University of Kentucky College of Medicine, 107 College of Medicine Office Building, Lexington, KY 40536-0086, USA b Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536-0086, USA Received 28 May 2004; received in revised form 29 July 2004; accepted 3 August 2004
Abstract Background: CPAP remains the treatment of choice for Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS), but compliance with CPAP is poor. Of many interventions tried to improve CPAP compliance, only education and humidification have been shown to be of benefit. Our purpose was to develop and pilot test a video to enhance patient understanding of obstructive sleep apnea and of the purpose, logistics, and benefits of CPAP use in patients newly diagnosed with OSAHS. A patient’s CPAP compliance in the first few weeks after starting its use is predictive of long-term compliance with CPAP treatment. It is imperative that patients grasp at the outset both the severity of OSAHS and the effectiveness of CPAP therapy. Methods: An educational video script was written based on recommendations for patient educational video materials and covering identified misconceptions about OSAHS and perceived barriers to CPAP use. The videotape is 15 min in length and features two middle-aged males, one African-American and one Euro-American, discussing OSAHS and CPAP in a factory break room. Results: In a randomized two-group design with a control group, patients with newly diagnosed OSAHS, and who viewed the CPAP educational video on their first clinic, were significantly more likely to use their machine and to return for a 1-month clinic visit than were those in the control group. Conclusion:Viewing of a patient education video at the initial visit was found to significantly improve the rate of return for the follow-up visit. q 2004 Elsevier B.V. All rights reserved. Keywords: Obstructive sleep apnea; CPAP; Patient education; Compliance; Educational videotapes
1. Introduction The Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) is believed to be present in the adult population ages 30–60 years in the US at a rate of 4% in men and 2% in women and even higher in minority groups and in the elderly [1–3]. Obesity is the single most important risk factor for OSAHS . Therefore, given that the 65Cage group is the most rapidly growing segment of the US adult population, that rates of obesity are rising, and that screening for OSAHS is becoming more common, the reported prevalence of obstructive sleep apnea can be expected to rise. The potential health consequences of sleep apnea are serious, including hypertension, cardiovascular problems, excessiveness daytime sleepiness, and cognitive * Corresponding author. Tel.: C1 606 323 5771; fax: C1 859 323 5350. E-mail address: [email protected]
(H. Jean Wiese). 1389-9457/$ - see front matter q 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.sleep.2004.08.006
deficits which contribute to social dysfunction and vehicular accidents [5,6]. In those cases where obesity is a contributing factor, weight loss is the only ‘cure’ for OSAHS. Since its introduction in 1981, however, the standard treatment for OSAHS is continuous positive airway pressure (CPAP) . Compliance with this treatment is estimated in the US to be between 29 and 89% . This is a compliance rate better than that for regimens of many other chronic conditions, but is surprisingly low since regular CPAP use has consistently demonstrated significant improvement in daytime sleepiness and general quality of life even in those patients with mild OSAHS [9–11]. Therefore, increasing compliance with CPAP is critical . Improvements in CPAP technology have addressed patient complaints about the machine and mask, but the level of compliance with CPAP is still a clinically significant problem. Compliance appears to depend on the severity of the disease as well as on the initial inpatient
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and holiday effects. During an initial visit, all patients received explanations of OSAHS and CPAP by both a physician and a respiratory therapist. After completion of informed consent and agreement to participate in the study, two questionnaires, the Epworth and the Sleep Apnea Quality of Life Index (SAQLI) [18,19], were administered to all research participants. One randomly assigned group of patients viewed an instructional videotape developed for this project. The approximately 15-min videotape depicted two male blue-collar workers discussing their sleep problems, with one describing what sleep apnea was in common language, what CPAP was, what CPAP felt like on a sensory basis, and how it had helped them. If a member of the patient’s household accompanied the patient, whenever possible, that individual viewed the videotape with the patient. The control group of patients was interviewed and completed questionnaires during the initial visit. All patients were given a return visit 4 weeks after viewing the videotape. At the return visit, all patients again completed the Epworth Sleepiness Scale and the SAQLI.
management session. The first few weeks are critical to compliance [13–15]. An alarming finding was that many OSAHS patients mistakenly believe that CPAP use will ‘cure’ their sleep disorder, at which time they can discontinue its use . Improving CPAP compliance in the US, especially among patients with mild OSAHS, rests on improved patient education because just as with other chronic conditions, hospital stays in the US are becoming shorter and less frequent. Patients, therefore, must have an accurate understanding of their condition and its treatment and be motivated to carry it out at home without medical supervision . CPAP patient education research has identified several characteristics essential to a successful educational instrument. Both patients and staff prefer video format to either text or oral staff-delivered information. The video message remains standardized and can be self-administered by the patient, thus freeing staff as well as giving patients privacy. Within the video message, there is a preference for culturally appropriate actors speaking in lay vocabulary about OSAHS and addressing practical suggestions for adjusting to CPAP therapy. The running time of such a tape should be short, optimally about 8 min . The specific target issues identified by literature review and patient interviews were the following: precisely what is OSAHS and what causes it? How serious is OSAHS? What is a CPAP machine? Will CPAP cure it? Will insurance pay for it? How best can one normalize CPAP use within the household? If one has problems using CPAP, how can help be obtained? Given the recommended content and parameters, a 15-min CPAP educational videotape was developed. It features two factory workers conversing in their break room. One has just been diagnosed with OSAHS while the other has been using CPAP successfully for about 2 years. The latter delivers the educational information in the form of replies to questions by the former, all delivered in common vernacular.
3. Results Ninety-three patients met inclusion criteria and agreed to participate in the study. Potential research subjects were first approached by clinic physicians. Of the patients who agreed to talk with the researcher, only two declined to participate after hearing a description of the study activities. In both cases, low literacy was the problem. Of those subjects who were enrolled in the study, only two notified the clinic of their withdrawal, both because of their insurance company’s decision to disallow coverage for their CPAP machine rental. Table 1 gives the demographic characteristics of the subjects by Treatment (T) and Control (C) groups. On age, sex, marital status and average hours of travel to clinic, there were no significant differences between the two groups. Table 2 gives the relevant health characteristics of the subjects. On the characteristics of BMI, duration of symptoms, use of alcohol, AHI and number of apneas, there were no significant differences between the two groups of subjects. Subjects in the control group were significantly more likely to be smokers than those in the treatment group. Smoking status was therefore used as a covariate in all analyses reported in this paper, and inclusion of smoking as a variable does not alter the results reported for the effects of the educational video on treatment outcome.
2. Methods Patients were recruited at a sleep disorder center. Inclusion criteria are O20 years of age, an RDI of O4 obstructed events per hour of sleep, and new diagnosis of OSAHS. The study used a randomized two-group design, and study packets were randomized in groups of 10 to assure 50% in each condition and to control for the potential effects of season of the year, changes in referral patterns, Table 1 Demographic characteristics of subjects Group
T (51) C (49)
Mean hours traveled
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Table 2 Medical characteristics of subjects Group
Mean duration of symptoms in years
Use alcohol (%)
Mean num of apneas
T (51) C (49)
Dependent variables for the analyses were changes in total scores on the Epworth and SAQLI scales, and subject compliance with CPAP as measured by attendance of the patient at the scheduled 4-week return visit, and by hours of CPAP usage. Continuous variables (Epworth and SAQLI) were assessed using repeated-measures analysis of variance, with the treatment group as the between-subjects independent variable, and time (Clinic Visit One and Two) as the within-subjects variable. Chi-square analysis was used to examine the effect of the treatment video on compliance as measured by completion of the return visit. Rate of compliance with CPAP as measured by return to clinic at 4 weeks was 61.2%. Retention was significantly associated with viewing of the treatment video. Fig. 1 shows the rate of return of each group. In the video treatment group, 72.9% of patients returned for their follow-up visit, in comparison to only 48.9% in the control group. (c2Z5.65, PZ0.0174). CPAP hour usage (MeanZ4.15, SDZ2.38) was not associated with the
Fig. 1. Rate of return by group.
treatment video in the group of patients returning for their 4-week appointment. The usefulness of the hour CPAP usage data, however, is limited, because 13 of the 57 patients who returned for their 1-month clinic visit had unusable machine-recorded data. Epworth Sleepiness scores improved from the initial visit to the 4-week follow-up visit F (1.56)Z30.82, P!0.0001). Mean Epworth improved in the video treatment group from 13.1 (SDZ5.9) to 8.90 (SDZ5.35), and in the control group (Initial XZ12.78 (SDZ6.11) follow-up 8.78, SDZ6.56). Similarly, in both treatment and control groups, SAQLI scores improved from the initial visit to the follow-up: F (1.48)Z21.77, P!0.0001; Video Group PresZ3.82 (SDZ1.38), follow-up 4.85, (SDZ1.62); control preZ4.05 SDZ1.00, follow-up 5.12, (SDZ1.40).
4. Discussion The most important result of this study as a clinical study is the significant reduction in the attrition rate of newly diagnosed OSAHS patients who were randomly assigned to view the treatment video. Almost three-fourths of the video treatment group remained in treatment, whereas fewer than half of the control group returned for their 1-month visit. The first barrier to compliance with treatment for OSAHS is use of the CPAP machine long enough to return for the first 1-month clinic visit. Patients who returned for a 1-month follow-up appointment after initial treatment for sleep apnea with CPAP showed substantial improvement on both the Epworth Sleepiness Scale and the SAQLI. Those patients who never return to clinic are very likely to not be in compliance and are therefore treatment failures in this encounter with the health care system. Since most insurance companies require proof of regular clinic attendance for sustained coverage of CPAP machine rental, patients who do not return to clinic will shortly lose the use of the machine. Viewing of a patient education video at the initial visit was found to significantly improve the rate of return for the follow-up visit, and was therefore a factor in retention of patients in treatment. It is impossible to say from these data the manner in which the patient video decreased the number of patients dropping out of treatment. It is possible that CPAP treatment produces initial problems that causes patients to drop out and that the video’s discussion of problems and eventual positive outcomes helps patients overcome the initial
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difficulties and discomforts of CPAP usage long enough for the positive benefits to become more obvious. It is also possible that a key element of the compliance equation is the involvement of family, perhaps heightened by their participation in the video. In any event, further research could focus on the mechanism of action so that compliance could be enhanced. Although the study is limited in scope, results provide encouragement for improvement in treatment outcome of sleep apnea patients through use of inexpensive and easily administered patient education techniques.
Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.sleep.2004.08. 006
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