Amy M. Sawyer

A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions.

Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.

Differences in Perceptions of the Diagnosis and Treatment of Obstructive Sleep Apnea and Continuous Positive Airway Pressure Therapy Among Adherers and Nonadherers

Obstructive sleep apnea (OSA) patients’ consistent use of continuous positive airway pressure (CPAP) therapy is critical to realizing improved functional outcomes and reducing untoward health risks associated with OSA. We conducted a mixed methods, concurrent, nested study to explore OSA patients’ beliefs and perceptions of the diagnosis and CPAP treatment that differentiate adherent from nonadherent patients prior to and after the first week of treatment, when the pattern of CPAP use is established. Guided by social cognitive theory, themes were derived from 30 interviews conducted postdiagnosis and after 1 week of CPAP use. Directed content analysis, followed by categorization of participants as adherent/nonadherent from objectively measured CPAP use, preceded across-case analysis among 15 participants with severe OSA. Beliefs and perceptions that differed between adherers and nonadherers included OSA risk perception, symptom recognition, self-efficacy, outcome expectations, treatment goals, and treatment facilitators/ barriers. Our findings suggest opportunities for developing and testing tailored interventions to promote CPAP use.

Claustrophobic tendencies and continuous positive airway pressure therapy non-adherence in adults with obstructive sleep apnea

OBJECTIVES (1) Determine claustrophobia frequency in adults with obstructive sleep apnea (OSA) after first CPAP night; (2) determine if claustrophobia influences CPAP non-adherence. BACKGROUND Claustrophobia is common among CPAP-treated OSA adults yet few studies have examined the problem. METHODS Secondary analysis of prospective, longitudinal study of OSA adults (n = 97). CPAP-Adapted Fear and Avoidance Scale (CPAP-FAAS) collected immediately after CPAP titration polysomnogram. PRIMARY OUTCOME objective CPAP use at 1 week and 1 month. RESULTS Sixty-three percent had claustrophobic tendencies. Females had higher CPAP-FAAS scores than males. FAAS ≥ 25, positive score for claustrophobic tendencies, was influential on CPAP non-adherence at 1 week (aOR = 5.53, 95% CI 1.04, 29.24, p = 0.04) and less CPAP use at 1month (aOR = 5.06, 95% CI 1.48, 17.37, p = 0.01) when adjusted for body mass index and CPAP mask style. CONCLUSION Claustrophobia is prevalent among CPAP-treated OSA adults and influences short-term and longer-term CPAP non-adherence. Interventions are needed to address this treatment-related barrier.

Is Inconsistent Pre-Treatment Bedtime Related to CPAP Non-Adherence?

Lack of adherence to continuous positive airway pressure therapy (CPAP) limits the effectiveness of treatment of obstructive sleep apnea (OSA). We hypothesized that an irregular bedtime would be negatively related to regular use of CPAP treatment. If so, modifying bedtime schedule may address the persistent problem of inconsistent CPAP use in adults with OSA. In a prospective longitudinal study, we examined whether inconsistent self-reported bedtime before initiation of CPAP treatment, operationalized as bedtime variability, was (1) different among those adherent (≥4 hours per night) and non-adherent to CPAP treatment at 1 week and 1 month; and/or (2) was related to 1-week and 1-month CPAP use when other variables were accounted for. Consecutively recruited newly diagnosed OSA adults (n = 79) completed sleep diaries prior to CPAP treatment. One-week and 1-month objective CPAP use data were collected. Pre-treatment bedtime variability was different among CPAP non-adherers and adherers at 1 month and was a significant predictor of non-adherence at 1 month in multi-variable analyses. The odds of 1-month CPAP non-adherence were 3.5 times greater in those whose pre-treatment bedtimes varied by >75 minutes. Addressing sleep schedule prior to CPAP initiation may be an opportunity to improve CPAP adherence.

What it takes: perspectives from developing nurse scientists.

The need for nurse scientists has never been greater, given the complexity of health problems facing our world and the rising cost of providing care to prevent and treat them. The development of nurse researchers is critical to preserve and advance the scientific foundation of the discipline. In this article, two successful doctoral students present their personal views about the cognitive and behavioral transformation they experienced during their program of study, highlighting what they believe to be important resources that enhance doctoral education and sharing how they overcame the challenges encountered. The framework of transformational leadership is used to highlight important aspects of their development as nurse scientists. Action steps for attracting a greater number of nurses to a career in science are recommended.

Sleep and CKD in Chinese Adults: A Cross-Sectional Study

BACKGROUND AND OBJECTIVES To assess the association between self-reported sleep duration and quality and odds of having CKD in Chinese adults on the basis of a community study. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this cross-sectional study, we included 11,040 Chinese adults who participated in an ongoing prospective study, the Kailuan cohort. Survey questionnaire items addressed insomnia, daytime sleepiness, snoring, and sleep duration during their 2012 interview. Overall sleep quality was evaluated by summarizing these four sleep parameters. Fasting blood samples and single random midstream morning urine samples were collected in 2012 and analyzed for serum creatinine and proteinuria. CKD was defined by eGFR<60 ml/min per 1.73 m2 or proteinuria >300 mg/dl. We also examined those at high or very high risk of having CKD, on the basis of the Kidney Disease Improving Global Outcomes recommendations. The association between sleep quality and CKD was assessed using logistic regression model. RESULTS Worse overall sleep quality was associated with higher likelihood of being high or very high risk for CKD (multiadjusted odds ratio, 2.69; 95% confidence interval, 1.30 to 5.59 comparing two extreme categories; P trend <0.01), but not overall CKD (multiadjusted odds ratio, 1.58; 95% confidence interval, 0.89 to 2.80 comparing two extreme categories; P trend =0.46), after adjusting for potential confounders. Specifically, individuals with worse sleep quality were more likely to have proteinuria (multiadjusted odds ratio, 1.95; 95% confidence interval, 1.03 to 3.67 comparing two extreme categories; P trend =0.02), rather than lower eGFR level (multiadjusted mean eGFR levels were 96.4 and 93.6 ml/min per 1.73 m2 in the two extreme sleep categories, respectively; P trend =0.13). However, there was no statistically significant association between individual sleep parameters and CKD status. CONCLUSIONS Worse overall sleep quality was associated with higher odds of being high or very high risk for CKD and proteinuria in Chinese adults.

Management of Obstructive Sleep Apnea by Continuous Positive Airway Pressure

Obstructive sleep apnea (OSA) is a common problem, with 9% to 28% of women and 24% to 26% of males having apneic events at a treatable level, making this syndrome a serious public health issue. This article describes the outcomes associated with continuous positive airway pressure treatment, significance of the issue of poor adherence in OSA, discusses evidence regarding the optimal duration of nightly use, describes the nature and predictors of nonadherence, and reviews interventions that have been tested to increase nightly use and suggests management strategies.

A Tailored Intervention for PAP Adherence: The SCIP-PA Trial.

ABSTRACT Objective/Background: Positive airway pressure (PAP) is highly efficacious treatment but nonadherence is prevalent with little improvement over the last 15 years. Tailored interventions show promise for promoting adherence to other treatments. The study objective was to examine feasibility and acceptability of a tailored intervention to promote PAP adherence. Participants: The convenience sample met inclusion criteria: newly diagnosed OSA; treatment-naïve; ≥ 18 years. Exclusion criteria: previous obstructive sleep apnea (OSA) diagnosis and treatment; new psychiatric diagnosis; use of oxygen/bilevel PAP; secondary sleep disorder. Adults (n = 118) were randomized to tailored intervention (TI; n = 61) or usual care (UC; n = 57); application of a priori exclusion criteria resulted in 30 participants per assignment who were middle-aged (51.3 ± 11.1 years) adults (70% male) with severe OSA (apnea hypopnea index [AHI], 35.9 ± 25.2). Methods: Randomized, double-blind, single-site pilot controlled trial. A multiphased tailored intervention targeting social cognitive perceptions of OSA–PAP treatment was delivered at four intervals. Descriptive analysis, group differences, and self-efficacy change scores by t-test, and thematic analysis of acceptability data are reported. Results: One-week PAP use among TI was 35 min greater than UC condition (p = 0.20; Cohen’s d = 0.336). Treatment use decreased at 1 month and 3 months (NS). Per-protocol delivery of face-to-face intervention delivery was 100% but lower for telephone intervention delivery. Personalized approach was valued by participants. Conclusions: A tailored intervention approach is acceptable to participants and feasibly implemented in a clinical sleep center setting. The intervention effect size at 1 week is consistent with other educational PAP adherence interventions but was not sustained; further pilot testing is warranted to address pilot RCT limitations.

Clinical Trial Enrollment Enrichment in Resource-Constrained Research Environments: Multivariable Apnea Prediction (MAP) Index in SCIP-PA Trial

STUDY OBJECTIVES Determine the Multivariable Apnea Prediction (MAP) index predictive utility for enrollment enrichment in a clinical trial wherein enrollment was prior to obstructive sleep apnea diagnosis. METHODS Secondary analysis of screening data (n = 264) from randomized, double-blind, pilot trial. Clinical sleep center patients with complete screening and polysomnography data were included. To determine diagnostic test accuracy of the MAP index using apnea-hypopnea index criterion ≥ 10 events/h (primary) and ≥ 5, ≥ 15, and ≥ 30 events/h (secondary), sensitivity, specificity, negative and positive predictive values, likelihood positive and negative ratios, and receiver operating characteristic curves were calculated. Predictive utility was examined by characteristic variables. RESULTS Middle-aged, overweight or obese, men and women were included. Employing a MAP index threshold ≥ 0.5, sensitivity for obstructive sleep apnea (apnea-hypopnea index ≥ 10 events/h) was 83.6%; specificity was 46.4%; area under the curve = 0.74. Sensitivity was higher in males than females (95.3%, 68.7%, respectively); specificity was lower in males than females (30.4%, 57.6%, respectively) with similar area under the curve (0.74 versus 0.72, respectively). MAP accuracy was higher in younger versus older adults (younger than 50 years, or 50 years or older; area under the curve 0.82 versus 0.63, respectively). Varied apnea-hypopnea index criteria produced stable accuracy estimates. CONCLUSIONS Recruitment/enrollment is a high-cost endeavor. Screening procedures may confer resource savings but careful evaluation prior to study implementation assures effectiveness and efficiency. CLINICAL TRIAL REGISTRATION The secondary analysis reports data from the SCIP-PA Trial (NCT 01454830); study information available at: https://clinicaltrials.gov.

Adherence to positive airway pressure treatment among minority populations in the US: A scoping review

Minority individuals in the United States (US) have an increased prevalence of obstructive sleep apnea (OSA) compared to their white/Caucasian counterparts. In general, adherence to positive airway pressure (PAP) therapy is poor and some studies suggest that PAP use among minority individuals is inferior to that of whites. However, there has not been a review of the evidence that addresses racial-ethnic disparities for PAP adherence in the treatment of OSA, and no review has systematically examined the contributing factors to poor adherence among minority individuals compared to whites. We searched the literature for studies published between January 1990 to July 2016 that included objective PAP use comparisons between adult US minority individuals and whites. Twenty-two studies met the inclusion criteria. All studies compared the PAP adherence of blacks to whites. Seven studies compared the PAP adherence of additional minority groups to that of whites. Sixteen of the 22 studies (73%) showed worse PAP adherence in blacks compared to whites. Four studies found equivalent PAP use in US Hispanics compared to whites. Little is known about the PAP adherence of other US minority groups. We present a framework and research agenda for understanding PAP use barriers among US minority individuals.