Exploring Nurse Practitioner Students' Perceptions of a Sleep e-Learning Program.

AIM: The aim of this study was to explore nurse practitioner (NP) students' perceptions of a sleep e-learning program. BACKGROUND: Sleep assessment is uncommon as nursing curricula lack sleep education. By preparing NPs to conduct sleep assessment and screening and understand basic sleep diagnostics, sleep health is more likely to be part of the differential diagnosis. METHOD: The study is a qualitative descriptive study utilizing two focus groups. A directed content analysis, guided by the Kirkpatrick model, was used for analysis. RESULTS: Twenty-four students participated in focus groups. Two overarching themes emerged: perceptions of course design and content. Asynchronous, case-based scenarios and quizzes were favorable. Students spoke of content relevance to themselves and patients and intentions to adopt sleep assessment practices. CONCLUSION: NP students embraced sleep education and declared intention to apply learned skills in practice. This study highlights the feasibility of increasing curricular exposure to sleep education and ensuring NPs have skills to recognize implications of poor and disordered sleep in patients.

Sleep and hypoglycaemia symptom perception in adults with type-1 diabetes mellitus: A mixed-methods review.

AIMS: The study aims to review, synthesize and integrate primary research on the relationship between sleep and hypoglycaemia symptom perception in adults with type-1 diabetes. DESIGN: This mixed-methods review follows a convergent segregated approach to synthesis and integration of qualitative and quantitative evidence. DATA SOURCES: With assistance of a biomedical librarian, a search of four databases was conducted (PubMed, CINAHL, Embase and PsycINFO) in June 2020. The review included primary research measuring sleep and hypoglycaemia symptom perception in adults (age ≥ 18 years) with type-1 diabetes in English. Studies that exclusively addressed children, type-2 diabetes or outcomes unrelated to sleep and hypoglycaemia symptom perception were excluded. REVIEW METHODS: Screening focused on title and abstract review (n = 624). Studies not excluded after screening (n = 35) underwent full-text review. References of each study selected for inclusion (n = 6) were hand searched with one study added. All studies included in the review (n = 7) were critically appraised with JBI Critical Appraisal tools, and then data were extracted with systematic evaluation. RESULTS: Quantitative synthesis found sleep reduces the magnitude of detectable symptoms and one's capacity to detect them. Qualitative synthesis found that individuals with type-1 diabetes perceive unpredictable severity, frequency and awareness of symptoms while asleep as an oppressive, lingering threat. Integration of findings highlights the troublesome duality of sleep's relationship with hypoglycaemia symptom perception. CONCLUSIONS: Sleep presents a challenging time for individuals with type-1 diabetes. Further research examining the relationship between sleep and hypoglycaemia symptom perception is recommended as the number of studies limits this review. IMPACT: Symptom perception is the main physiologic defense against severe hypoglycaemia in type-1 diabetes. This review found that sleep's relationship with hypoglycaemia symptoms has unique physiological and psychological components to address when providing comprehensive care. This review may inform future lines of inquiry that develop into interventions, improvements in practice and risk reduction for hypoglycaemia-related complications.

Coping Processes, Self-Efficacy, and CPAP Use in Adults With Obstructive Sleep Apnea.

Background: Coping strategies are predictive of 1 week CPAP use. Coping strategies may predict longer-term CPAP use among adults with obstructive sleep apnea (OSA). Objectives: To investigate the influence of two coping styles (active and passive) and individual coping processes on CPAP use at 1 week and 1 month; and explore the association between self-efficacy and coping on CPAP use. Participants: CPAP-naïve adults (52.3% male, 90.9% White) newly diagnosed with OSA (AHI ≥ 5 events/hr) from two U.S. clinical sleep centers (n = 66). Methods: A post-hoc analysis from a prospective, longitudinal study that examined influential factors on CPAP use among CPAP-naïve patients with newly diagnosed OSA. The Ways of Coping Questionnaire and the Self-Efficacy Measure for Sleep Apnea were completed immediately after CPAP titration polysomnography. Objective 1 week and 1 month CPAP use (mean hr/night) were the primary outcomes. Descriptive analyses and stepwise multiple linear regression analyses modeling for CPAP use (mean hr/night). Results: Active coping was significantly associated with greater CPAP use (mean hr/night) at 1 week, but not at 1 month (p = 0.0397; p = 0.0556, respectively). Higher Planful Problem Solving was significantly associated with greater average CPAP use at 1 week and 1 month (p = 0.0117, p = 0.0378, respectively). Self-efficacy was significantly associated with greater average CPAP use at 1 week (p = 0.0056) and 1 month (p = 0.0056). Conclusions: Self-efficacy and Planful Problem Solving coping are promising behavioral intervention targets to promote CPAP use in newly diagnosed OSA.

Increasing nursing research capacity: The roles and contributions of nurse scientists within healthcare systems in the Greater Philadelphia region.

PhD prepared nurse scientists within healthcare systems are uniquely positioned to advance nursing science through research and evidence-based practice (EBP) initiatives due to their ability to closely collaborate with nurses and other healthcare professionals in the clinical setting. The purpose of this paper is threefold: 1) to describe the roles and contributions of Nurse Scientists, from their perspectives, in four different health care systems in the Greater Philadelphia area, three of which are Magnet® designated hospitals; 2) to highlight organizational approaches to increase nursing research and EBP capacity; and 3) to explore strategies that Nurse Scientists used to overcome barriers to build nursing research capacity. Nurse Scientists employed in these healthcare systems share many of the same essential roles and contributions focused on developing nursing research and EBP initiatives through education and mentorship of clinical nurses, conduct and oversight of independent research, and dissemination activities. With supportive executive nurse leadership, the Nurse Scientists within each healthcare system employed different strategies to overcome barriers in building nursing research and EBP capacity. Nurse scientists within healthcare settings have potentially powerful positions to generate and apply new knowledge to guide nursing practice and improve outcomes.

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

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.

Modelling Adherence Behaviour for the Treatment of Obstructive Sleep Apnoea.

Continuous positive airway pressure therapy (CPAP) is known to be the most efficacious treatment for obstructive sleep apnoea (OSA). Unfortunately, poor adherence behaviour in using CPAP reduces its effectiveness and thereby also limits beneficial outcomes. In this paper, we model the dynamics and patterns of patient adherence behaviour as a basis for designing effective and economical interventions. Specifically, we define patient CPAP usage behaviour as a state and develop Markov models for diverse patient cohorts in order to examine the stochastic dynamics of CPAP usage behaviours. We also examine the impact of behavioural intervention scenarios using a Markov decision process (MDP), and suggest a guideline for designing interventions to improve CPAP adherence behaviour. Behavioural intervention policy that addresses economic aspects of treatment is imperative for translation to clinical practice, particularly in resource-constrained environments that are clinically engaged in the chronic care of OSA.

Risk assessment for CPAP nonadherence in adults with newly diagnosed obstructive sleep apnea: preliminary testing of the Index for Nonadherence to PAP (I-NAP).

PURPOSE: Identification of risk for continuous positive airway pressure therapy (CPAP) nonadherence prior to home treatment is an opportunity to deliver targeted adherence interventions. Study objectives included the following: (1) test a risk screening questionnaire to prospectively identify CPAP nonadherence risk among adults with newly diagnosed obstructive sleep apnea (OSA), (2) reduce the questionnaire to a minimum item set that effectively identifies 1-month CPAP nonadherence, and (3) examine the diagnostic utility of the screening index. METHODS: A prospective, longitudinal study at two clinical sleep centers in the USA included adults with newly diagnosed OSA (n=97; AHI≥5 events/h) by polysomnogram (PSG) consecutively recruited to participate. After baseline participant and OSA characteristics were collected, a risk screening questionnaire was administered immediately following CPAP titration polysomnogram. One-month objective CPAP use was collected. RESULTS: Predominantly, white (87%), males (55%), and females (45%) with obesity (BMI 38.3 kg/m2; SD 9.3) and severe OSA (AHI 36.8; SD 19.7) were included. One-month CPAP use was 4.25 h/night (SD 2.35). Nineteen questionnaire items (I-NAP) reliably identified nonadherers defined at <4 h/night CPAP use (Wald X2[8]=34.67, p<0.0001) with ROC AUC 0.83 (95% CI 0.74-0.91). Optimal score cut point for the I-NAP screening questionnaire were determined to maximize sensitivity (87%) while maintaining specificity>60% (63%). CONCLUSION: A risk screening questionnaire employed immediately after titration PSG may reliably identify CPAP nonadherers and permit the delivery of targeted interventions to prevent or reduce nonadherence. This novel approach may enhance cost-effectiveness of care and permit appropriate allocation of resources for CPAP adherence.

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.

Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea.

STUDY OBJECTIVES: Chronic noncancer pain (CP) commonly co-occurs with obstructive sleep apnea (OSA) and may contribute to greater symptom burden. The study aims were to (1) characterize CP among veterans with OSA and (2) examine differences in sleepiness (Epworth Sleepiness Scale), insomnia symptoms (Insomnia Severity Index), and quality of life (Short Form Health Survey-20) in veterans with OSA with or without pre-existing CP. METHODS: An observational, cross-sectional, study of 111 veterans with newly diagnosed, untreated OSA was conducted. Descriptive statistics characterized the sample and comorbid CP outcomes. Regression analyses were performed to investigate associations between self-reported CP and sleep-related symptoms or quality of life while controlling for potential confounders. RESULTS: CP was reported by 69.5% (95% confidence interval: 61.8%, 76.2%) of participants. Having CP was associated with increased Epworth Sleepiness Scale (12.7 ± 5.5 vs 10.2 ± 5.2; P = .021) and Insomnia Severity Index scores (18.1 ± 6.2 vs 13.7 ± 7.4; P = .002), and worse quality of life across all Short Form Health Survey-20 domains. CONCLUSIONS: There is a high prevalence of CP among veterans with OSA and symptom burden is higher in patients with OSA and CP. Future investigations should address symptom response and burden to OSA treatment in comorbid OSA and CP to guide outcome expectancies and residual OSA symptom treatment plans. CITATION: Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med. 2023;19(6):1121-1132.

Cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure use.

OBJECTIVES: To evaluate the cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure (PAP) use in obstructive sleep apnea (OSA). STUDY DESIGN: A post hoc cost-effectiveness analysis (from US payers' perspective) of data from a 3-month tele-OSA trial, augmented with 33 months of epidemiologic follow-up. METHODS: Cost-effectiveness was compared among 3 groups of participants with an apnea-hypopnea index of at least 15 events/hour: (1) no messaging (n = 172), (2) messaging for 3 months (n = 124), and (3) messaging for 3 years (n = 46). We report the incremental cost (2020 US$) per incremental hour of PAP use and the fraction probability of acceptability based on a willingness-to-pay threshold of $1825 per year ($5/day). RESULTS: The use of 3 years of messaging had similar mean annual costs ($5825) compared with no messaging ($5889; P = .89) but lower mean cost compared with 3 months of messaging ($7376; P = .02). Those who received messaging for 3 years had the highest mean PAP use (4.11 hours/night), followed by no messaging (3.03 hours/night) and 3 months of messaging (2.84 hours/night) (all P < .05). The incremental cost-effectiveness ratios indicated that 3 years of messaging showed lower costs and greater hours of PAP use compared with both no messaging and 3 months of messaging. Based on a willingness-to-pay threshold of $1825, there is a greater than 97.5% chance (ie, 95% confidence) that 3 years of messaging is acceptable compared with the other 2 interventions. CONCLUSIONS: Long-term tele-messaging is highly likely to be cost-effective compared with both no and short-term messaging, with an acceptable willingness-to-pay threshold. Future long-term cost-effectiveness studies in a randomized controlled trial setting are warranted.

Association Between Positive Airway Pressure Adherence and Health Care Costs Among Individuals With OSA.

BACKGROUND: The impact of positive airway pressure (PAP) therapy for OSA on health care costs is uncertain. RESEARCH QUESTION: Are 3-year health care costs associated with PAP adherence in participants from the Tele-OSA clinical trial? STUDY DESIGN AND METHODS: Participants with OSA and prescribed PAP in the Tele-OSA study were stratified into three PAP adherence groups based on usage patterns over 3 years: (1) high (consistently ≥ 4 h/night), (2) moderate (2-3.9 h/night or inconsistently ≥ 4 h/night), and (3) low (< 2 h/night). Using data from 3 months of the Tele-OSA trial and 33 months of posttrial follow up, average health care costs (2020 US dollars) in 6-month intervals were derived from electronic health records and analyzed using multivariable generalized linear models. RESULTS: Of 543 participants, 25% were categorized as having high adherence, 22% were categorized as having moderate adherence, and 52% were categorized as having low adherence to PAP therapy. Average PAP use mean ± SD was 6.5 ± 1.0 h, 3.7 ± 1.2 h, and 0.5 ± 0.5 h for the high, moderate, and low adherence groups, respectively. The high adherence group had the lowest average covariate-adjusted 6-month health care costs ± SE ($3,207 ± $251) compared with the moderate ($3,638 ± $363) and low ($4,040 ± $304) adherence groups. Significant cost differences were observed between the high and low adherence groups ($832; 95% CI, $127 to $1,538); differences between moderate and low adherence were nonsignificant ($401; 95% CI, -$441 to $1,243). INTERPRETATION: In participants with OSA, better PAP adherence was associated with significantly lower health care costs over 3 years. Findings support the importance of strategies to enhance long-term PAP adherence.

Strategies to Assess the Effect of Continuous Positive Airway Pressure on Long-Term Clinically Important Outcomes among Patients with Symptomatic Obstructive Sleep Apnea: An Official American Thoracic Society Workshop Report.

Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA). Although CPAP improves symptoms (e.g., daytime sleepiness), there is a lack of high-quality evidence that CPAP prevents many long-term outcomes, including cognitive impairment, myocardial infarction, and stroke. Observational studies suggest that patients with symptoms may be particularly likely to experience these preventive benefits with CPAP, but ethical and practical concerns limited the participation of such patients in prior long-term randomized trials. As a result, there is uncertainty about the full benefits of CPAP, and resolving this uncertainty is a key priority for the field. This workshop assembled clinicians, researchers, ethicists, and patients to identify strategies to understand the causal effects of CPAP on long-term clinically important outcomes among patients with symptomatic OSA. Quasi-experimental designs can provide valuable information and are less time and resource intensive than trials. Under specific conditions and assumptions, quasi-experimental studies may be able to provide causal estimates of CPAP's effectiveness from generalizable observational cohorts. However, randomized trials represent the most reliable approach to understanding the causal effects of CPAP among patients with symptoms. Randomized trials of CPAP can ethically include patients with symptomatic OSA, as long as there is outcome-specific equipoise, adequate informed consent, and a plan to maximize safety while minimizing harm (e.g., monitoring for pathologic sleepiness). Furthermore, multiple strategies exist to ensure the generalizability and practicality of future randomized trials of CPAP. These strategies include reducing the burden of trial procedures, improving patient-centeredness, and engaging historically excluded and underserved populations.

Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students.

STUDY OBJECTIVES: Primary care nurse practitioners (NPs) receive little sleep education in graduate programs but are often first-line providers for patients presenting with sleep-related symptoms. A pre-/postevaluation study was conducted using asynchronous, case-based sleep education modules in a cohort of primary care NP students enrolled in a single academic institution's nursing master's degree program. METHODS: Six virtual, case-based modules addressed adult sleep health and disorders, prioritized based on prevalence and primary care presentation. Kirkpatrick Training Evaluation Model guided outcome selection. Descriptive and paired comparative analyses were conducted. RESULTS: Participants were first-year NP students (n = 149; 88% female; 82% ≤ 35 years of age) in an adult primary care program that included psychiatric/mental health track. Participants reacted positively to course delivery methods and content. Insomnia was endorsed by 87% as most relevant to practice with healthy sleep (88%) and obstructive sleep apnea (50%) also frequently endorsed as practice relevant. Posttest knowledge scores significantly improved for all modules (P < .001). Self-rated confidence for future practice application was high. CONCLUSIONS: This novel asynchronous, virtual curriculum met Kirkpatrick levels 1 and 2 (positive reaction and knowledge transfer) in NP students who predicted an impact on their practice (Kirkpatrick level 3). Studies are needed to assess the benefits of increasing primary care NP knowledge in sleep medicine on quality of care and access to care (Kirkpatrick level 4). Future use of this novel sleep curriculum in other professional curricula, new-to-sleep clinical researchers, and practicing primary care providers may further potentiate care quality and sleep care access. CITATION: Sawyer AM, Saconi B, Lyons MM, et al. Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students. J Clin Sleep Med. 2022;18(10):2367-2376.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Socioeconomic Disparities in Positive Airway Pressure Adherence: An Integrative Review.

Nonadherence with positive airway pressure (PAP) therapy impedes the effectiveness of treatment and increases risk of mortality. Disparities in PAP adherence as a function of socioeconomic status (SES) are not well understood. A literature search identified 16 original publications meeting inclusion criteria that described effects of SES factors on objective PAP adherence; 69% of these articles found evidence of lower adherence as a function of SES. This integrative review provides a structured summary of the findings, highlights factors that may contribute to disparities among adult PAP users, and identifies future directions to improve equity in the management of OSA.

The influence of sleep disturbances and sleep disorders on pain outcomes among veterans: A systematic scoping review.

Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management.

Intervention Design and Trial Protocol: Mindfulness-based Exposure for PAP-associated Claustrophobia.

Positive airway pressure (PAP) associated claustrophobia is common among obstructive sleep apnea patients and plays a prominent role in low adherence and treatment failure. As there are no evidence-based interventions for PAP-associated claustrophobia, the objective of the present research is to pilot test Mindfulness-based Exposure for PAP-associated Claustrophobia, in sleep apnea adults that present with treatment non-adherence and claustrophobia. This approach combines Mindfulness-based Stress Reduction with exposure-based treatment components to target this treatment-associated claustrophobia. The present article outlines the mindfulness exposure intervention design and methods and reports the pilot trial study protocol. Trial findings are intended to: (a) develop a preliminary effect size of the intervention on PAP-associated claustrophobia; (b) explore differences in treatment adherence by group (intervention vs control); and (c) establish feasibility for expanded protocol implementation, delivery, and participant acceptability of the intervention to support subsequent design of a fully powered randomized controlled trial.

Where to Next for Optimizing Adherence in Large-Scale Trials of Continuous Positive Airway Pressure?

Large-scale randomized trials of positive airway pressure (PAP) efficacy have been largely negative but PAP adherence was notably suboptimal across the trials. To address this limitation, evidence-based PAP adherence protocols embedded within the larger trial protocol are recommended. The complexity of such protocols depends on adequacy of resources, including funding and inclusion of behavioral scientist experts on the scientific team, and trial-specific considerations (eg, target population) and methods. Recommendations for optimizing PAP adherence in large-scale trials are set forth that address rigor and reproducibility.

Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: implications for future interventions.

Adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) is a critical problem. Poor adherence (30-60%) to CPAP is widely recognized as a significant limiting factor in treating OSA, reducing the overall effectiveness of the treatment and leaving many OSA patients at heightened risk for co-morbid conditions, impaired function and quality of life. The extant literature examining adherence to CPAP provides critical insight to measuring adherence outcomes, defining optimal adherence levels, and predicting CPAP adherence. This research has revealed salient factors that are associated with or predict CPAP adherence and may guide the development of interventions to promote CPAP adherence. Over the past 10 years, intervention studies to promote CPAP adherence have incorporated a multitude of strategies including education, support, cognitive behavioural approaches, and mixed strategies. This review of the current status of research on CPAP adherence will (i) synthesize the extant literature with regard to measuring, defining, and predicting CPAP adherence; (ii) review published intervention studies aimed at promoting CPAP adherence; and (iii) suggest directions for future empiric study of adherence to CPAP that will have implications for translational science. Our current understanding of CPAP adherence suggests that adherence is a multi-factorial, complex clinical problem that requires similarly designed approaches to effectively address poor CPAP adherence in the OSA population.

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.