Motivational Enhancement for Increasing Adherence to CPAP: A Randomized Controlled Trial

Abstract

Background: Motivational enhancement (ME) shows promise as a means of increasing adherence to CPAP for OSA.

Methods: We performed an open-label, parallel-arm, randomized controlled trial of CPAP only or CPAP + ME, recruiting individuals 45 to 75 years with moderate or severe OSA without marked sleepiness and with either established cardiovascular disease (CVD) or at risk for CVD. All participants received standardized CPAP support from a sleep technologist; those randomly assigned to CPAP + ME also received standardized ME delivered by a psychologist during two appointments and six phone calls over 32 weeks. Mixed-effect models with subject-specific intercepts and slopes were fitted to compare objective CPAP adherence between arms, adjusting for follow-up duration, randomization factors, and device manufacturer. All analyses were intention-to-treat.

Results: Overall, 83 participants (n = 42 CPAP only; n = 41 CPAP + ME) contributed 14,273 nights of data for 6 months. Participants were predominantly male (67%) and had a mean ± SD age of 63.9 ± 7.4 years, a BMI of 31.1 ± 5.2 kg/m(2), and an apnea-hypopnea index of 26.2 ± 12.9 events/h. In our fully adjusted model, average nightly adherence for 6 months was 99.0 min/night higher with CPAP + ME compared with CPAP only (P = .003; primary analysis). A subset of 52 participants remained in the study for 12 months; modeling these data yielded a consistent difference in adherence between arms of 97 min/night (P = .006) favoring CPAP + ME.

Conclusions: ME delivered during brief appointments and phone calls resulted in a clinically significant increase in CPAP adherence. This strategy may represent a feasible approach for optimizing management of OSA.

Trial registry: ClinicalTrials.gov; No.: NCT01261390; URL: www.clinicaltrials.gov.

Keywords: CPAP; OSA; adherence; behavioral therapy; randomized controlled trial.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Trial flow-chart. As part of the larger Best Apnea Interventions in Research trial, 169 participants were randomly assigned to conservative therapy, sham CPAP, CPAP only, or CPAP + ME. Participants in the CPAP-only and CPAP + ME arms were included in the current analyses (n = 83). Any nights of non-CPAP usage, including all nights for participants who refused CPAP set-up, were included in the data set as 0.0 hours; hence, data completeness was 100%. Primary outcome was adherence at 6 months; 12-month adherence data were included in a secondary analysis. ME = motivational enhancement.

Figure 2

CPAP adherence for 6 months in the CPAP-only and CPAP + motivational enhancement (ME) arms. Each data point represents the mean adherence for each 7-day period. Each line is a fitted LOESS (local regression) curve, with the shaded area representing the 95% CI for the curve. Timing of the face-to-face ME visits are marked as “F”; timing of the phone-based ME visits are marked as “P.”

Figure 3

Significant effect modification by cardiovascular disease status. Mean adherence (with 95% CI) is depicted for those randomly assigned to the CPAP-only and CPAP + motivational enhancement arms, by CVD subgroup (established vs risk factors). The interaction term for CVD status was P = .03. CVD = cardiovascular disease.