A Pilot Study of CPAP Adherence Promotion by Peer Buddies With Sleep Apnea
A Pilot Study of CPAP Adherence Promotion by Peer Buddies With Sleep Apnea
Obstructive sleep apnea (OSA) is a highly prevalent condition in veterans with some estimates
 as high as 47%. Poor adherence to the primary treatment of OSA -- continuous positive airway
 pressure (CPAP) therapy - is associated with increased risk for heart attacks, strokes and
 even death. The investigators plan to improve CPAP adherence in veterans through their
 interactions with peers who have successfully adopted CPAP therapy.

 Such "peer-buddies" may promote the well-being of veterans while remaining highly
 cost-effective when compared to healthcare providers. Our strategy is grounded on the
 rationale that veterans as a group are ecoculturally more homogenous than expected for the
 given level of differences in age, gender, ethnicity, or socioeconomic strata. Our long-term
 objectives are to initiate a larger, multi-site, research study for enhancing CPAP adherence
 in veterans with OSA. The ultimate goal of this research is to develop a cheap, effective and
 exportable system of care to promote CPAP adherence in patients with OSA.
Project background: Obstructive sleep apnea (OSA) is a prevalent condition that is most
 frequently treated with continuous positive airway pressure (CPAP) therapy. Non-adherence to
 such therapy, however, afflicts a high proportion of adults with sleep apnea (46-83%).
 Moreover, such non-adherence to CPAP is associated with increased risk for fatal and
 non-fatal cardiovascular events. There remains a paucity of reliable and cost-effective
 interventions that could promote CPAP adherence. Promoting adherence to therapy through
 peer-driven intervention is cheap and has met with modest success in other chronic conditions
 such as HIV, heart failure and diabetes mellitus. Whether such a peer-driven ("buddy") system
 can improve adherence to CPAP therapy is unknown.

 Project Objectives: Our overall aim is to assess the feasibility and acceptability of a CPAP
 adherence program driven by trained "peer-buddies" with sleep apnea. Specific Objective #1:
 To evaluate patient ratings of the acceptability of the peer buddy system (PBS) in veterans
 receiving CPAP therapy for OSA. Specific Objective #2: To obtain preliminary data on the
 effectiveness of PBS on sleep-specific HR-QOL (Functional outcomes in sleep questionnaire
 [FOSQ]) in veterans receiving CPAP therapy for OSA. Specific Objective #3: To obtain
 preliminary data on the effect of PBS on CPAP adherence, vigilance, patient activation, and
 self-efficacy in veterans receiving CPAP therapy for OSA.

 Project Methods: In order to address these aims, we will recruit recently diagnosed patients
 with OSA who have not been initiated on CPAP therapy and randomly assign them to the
 peer-buddy system to promote adherence to CPAP therapy (intervention group) or be assigned to
 usual care (control group). In the PBS intervention group, trained peers with sleep apnea
 will be paired with the newly diagnosed patients over a 3- month period. During this time the
 trained peers will share experiences on coping strategies with CPAP device and equipment
 (promote self efficacy), share their positive experiences (motivational effects and outcome
 expectancies), share their knowledge of perceived vulnerabilities due to untreated sleep
 apnea (promote risk perception), share methods for improving efficacy of CPAP equipment and
 interface (patient education) and prepare their subjects for upcoming physician or
 respiratory therapist appointments (patient activation). The interaction will occur during
 supervised "in-person" sessions and during telephonic conversations over the 3-month period.
 Subjects from both groups will be reassessed at the end of 3 months in order to determine
 objective measures of CPAP adherence, sleep-specific HRQOL Functional outcomes of sleep
 questionnaire [FOSQ]), vigilance (psychomotor vigilance testing), measures of self-efficacy
 (outcome expectancy, treatment self-efficacy, and risk perception [SEMSA questionnaire]) and
 patient activation (Patient Activation Measure [PAM]).
Inclusion Criteria:

 1. Obstructive Sleep Apnea (defined by Apnea-hypopnea index [AHI] > 5 per hour; with
 hypopneas defined as greater than 30% reduction in airflow with 4 or greater drop in
 oxygen saturation). AHI will be determined by full night or split-night
 polysomnography.

 2. Age range 21 - 85 years old.

 3. Stable medical history and no change in medications, including anti-hypertensive and
 thyroid replacement, in the previous 4 months.

 4. No regular use (> 3 times/week) of sedative or hypnotic medications in the last 4
 months.

 Exclusion Criteria:

 1. Central sleep apnea (central apnea index > 5 per hour and >50% of Apnea-hypopnea index
 constituted by central apneas and non-obstructive hypopneas).

 2. Complex sleep apnea or CPAP emergent central apnea (Central apnea index > 5 per hour
 during CPAP titration with >50% of Apnea-hypopnea index constituted by central apneas
 and non-obstructive hypopneas).

 3. Requiring oxygen or bi-level positive airway pressure for treatment of OSA or
 hypoventilation.

 4. Decompensated cardiac (heart failure or angina) or pulmonary (severe COPD or
 uncontrolled asthma) disease

 5. Chronic narcotic use

 6. Nasal obstruction (nasal congestion score > 15) or enlarged tonsils

 7. Diagnosis of another sleep disorder in addition to OSA based on PSG (e.g., periodic
 limb movement disorder [ 15 limb movements/hour of sleep with arousal], central sleep
 apnea [ 50% of apneas on diagnostic PSG are central apneas], insomnia, obesity
 hypoventilation syndrome, or narcolepsy).

 8. Previous treatment with positive airway pressure, home oxygen therapy, tracheotomy,
 uvulopalatopharyngoplasty, or other surgery for OSA.

 9. Night shift workers in situations or occupations where they regularly experience jet
 lag, or have irregular work schedules by history over the last 6 months.

 10. Routine consumption of more than 2 alcoholic beverages per day.

 11. Recent or recurring history of recreational drug use leading to tolerance or
 dependence.

 12. Unable to perform tests due to inability to communicate verbally, inability to write
 and read in English; less than a 5th grade reading level; visual, hearing or cognitive
 impairment (e.g. previous head injury); or upper extremity motor deficit (e.g.,
 previous stroke that prevents patient from using CPAP treatment).