TABLE VIII.A.5.b.

Supportive interventions for PAP adherence

Study	Year	LOE	Study design	Study groups	Clinical endpoint	Conclusion
Wozniak et al.1134	2014	1a	Systematic review 30 RCTs	RCTs examining the effectiveness of educational, supportive, or behavioral strategies in encouraging CPAP usage	CPAP usage	Low- to moderate-quality evidence that all three types of interventions led to increasing machine use. Supportive interventions increased machine usage aby 50 min per night. Educational interventions increased machine usage by 35 min per night. Behavior therapy increased machine usage by 1.44 h per night.
Chervin et al.1135	1997	1b	RCT N = 33 Duration: 8 weeks	1. Intervention 1: telephone call each week during trial; N = 12 2. Intervention 2: two printed documents; N = 14 3. Control: no additional support; N = 7	Machine usage at 1–2 months; dropouts/lost-to-follow-up	There were no significant differences in CPAP adherence between intervention groups and control.
DeMolles et al.1143	2004	1b	RCT N = 30 Duration: 8 weeks	1. Usual care (UC): usual medical care, patient education, and demonstration of equipment use; N = 15 2. Telephone-linked communication technology (TLC): UC + computerized digitized human speech program. TLC asks questions designed to elicit information from participant regarding adherence, education, and reinforcement; N = 15	CPAP usage at 2 months; sleep-related symptoms	There was no difference in average nightly CPAP use between the groups, but the TLC group had fewer sleep-related symptoms.
Fox et al.1140	2012	1b	RCT N = 75 Duration: 12 weeks	1. Telemedicine intervention: physiologic information (adherence, air leak, residual AHI) was transmitted daily to a website that could be reviewed. If problems were identified, the patient was advised over the phone or visited the PAP coordinator; N = 39 2. Standard care	Machine usage, adherence after 3 months, subjective sleep quality, any side effects	PAP adherence was significantly greater in the telemedicine group compared with the standard group. An additional 65 min of technician time was spent on patients in the telemedicine group.
Hoet et al.1144	2017	1b	RCT N = 46	1. Usual care: group education session 1 month after CPAP initiation, and medical visit at 1.5 and 3 months; N = 23 2. Telemonitoring: telemonitoring device attached to CPAP, through which participant data was analyzed and patients were contacted in the case of air leak, residual AHI>10/h, or CPAP use less than 3 h in 3 consecutive days); N = 23	CPAP usage at 3 months; time to delay to first technical intervention after CPAP initiation	Compliance at 3 months was significantly better in the telemonitoring group. Telemedicine reduces delay to first technical intervention in CPAP-treated patients.
Hoy et al.1141	1999	1b	RCT N = 80 Duration: 6 months	1. Standard support: video education, titration of CPAP pressure overnight, nurses telephoned on days 2, 21, reviewed in hospital at 1, 3, 6 months; N = 40 2. Intensive support: standard support + initial education at home with partner, 2 extra nights in hospital, sleep nurses’ home visits to participant and partner at 7, 14, 28 days, and 4 months after starting CPAP; N = 40	Machine usage at 6 months	Intensive support group had higher CPAP usage than those in the usual care group.
Hwang et al.1137	2017	1b	Four-arm, randomized, factorialdesign clinical trial N = 1455 Duration: 90 days	1:1:1:1 to one of four arms: 1. Web-based OSA education (Tel-Ed); N = 380 2. Telemonitoring and automated feedback (Tel-TM); N = 375 3. Tel-ed + tel-TM (Tel-both); N = 346 4. Usual care; N = 354	CPAP usage at 90 days	Tel-TM and Tel-both groups showed significant increase in average usage at 90 days. Tel-ed had no significant effect on CPAP usage at 90 days.
Mendelson et al.1145	2014	1b	RCT N = 107	1. Standard care: baseline evaluation, patients were contacted at day 2 to ask about adherence and to troubleshoot, met with sleep specialist at 4 weeks and at 4 months; N = 53 2. Telemedicine: standard care + smart phone for uploading BP measurements, CPAP adherence, sleepiness, and QOL data; participants received daily pictograms containing health-related messages; N = 54	Home self-measured BP, CPAP usage, cardiovascular risk evolution, sleepiness, QOL, fatigue, dyspnea, withdrawals	CPAP adherence did not differ between the groups. Self-measured BP did not improve in either group.
Munafo et al.1146	2016	1b	RCT N = 122 Duration: 3 months	1. Standard of care 2. SOC + telehealth messaging program: patients and providers were messaged based on CPAP device data	CPAP usage, sleepiness, residual AHI, resource use	Adherence rates were similar in both groups. There was a significant reduction in the mean aggregate time required to coach a patient in the telehealth group versus standard of care group.
Parthasarathy et al.1142	2013	1b	RCT N = 39 Duration: 90 days	1. Usual care: educational brochures regarding OSA and CPAP therapy; N = 17 2. Peer buddy system: trained peers with OSA and good CPAP adherence record were paired with newly diagnosed participants and participated in two face to face sessions and 8 telephone conversations; N = 22	Participant ratings of acceptability of peer-buddy system; CPAP adherence	Weekly CPAP adherence was greater in the intervention group.
Pepin et al.1147	2019	1b	RCT N = 306 Duration: 6 months	1. Usual care; N = 149 2. Multimodal telemonitoring: CPAP related factors, BP, physical activity recorded by connected devices. Symptoms and QOL recorded via electronic questionnaires. Patients received demonstration home telemonitoring use and explanation of why monitoring these physiological variables was relevant; N = 157	SBP, CPAP usage at 6 months, sleepiness, QOL, physical activity	Self-measured BP did not differ significantly between groups. There was a significant increase in CPAP adherence and an improvement in daytime sleepiness and QOL in favor of the multimodal telemonitoring.
Stepnowsky et al.1148	2007	1b	RCT N = 45 Duration: 2 months	1. Usual care: telephone call from staff at 1 week, office visit at 1 month; N = 21 2. Telemonitoring: Compliance and efficacy data garnered as objective compliance data and subjective reports of usage. Follow up tailored to how CPAP used by participants; N = 24	CPAP usage, % nights with CPAP use >4h	There were no statistically significant differences in CPAP compliance.
Stepnowsky et al.1149	2013	1b	RCT N = 241 Duration: 4 months	1. Telemonitoring: allow both the patient and provider access to telemonitored adherence and efficacy data on a daily basis and act on the data collaboratively to guide CPAP management and troubleshoot problems, emphasize ways for patient to express their preferences and needs; N = 126 2. Usual care: CPAP instruction and setup by a healthcare provider, follow up at 1 week and 1 month; N = 115	CPAP usage at 2 and 4 months	There was higher CPAP adherence at 2- and 4-months in the telemonitoring group compared to control.
Turino et al.1150	2017	1b	RCT N = 100	1. Standard management: a short instruction session on CPAP device use and 1-month was less visit; N = 48 2. Telemonitoring program: daily information on CPAP adherence, pressures, mask leak, and respiratory events were sent to the database; automatic alarms for the provider were generated if mask leak >30 L/min for >30% of the night or usage <4 h/night on 2 consecutive nights. Provider contacted the patient, providing case by case problem solving; N = 52	Machine usage at 1, 3 months; cost-effectiveness	No significant difference in CPAP compliance between the groups. Telemedicine was less expensive than standard management and was cost-effective.