Methods of PAP Therapy Intervention and Support
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Methods of PAP Therapy Intervention and Support
Adherence to PAP-therapy treatment continues to be a problem despite considerable efforts by clinicians and public health advocates around the world. With adherence rates still lagging between 30 and 60 percent, medical professionals are emphasizing new ways to provide ongoing support beyond the initial adjustment period. While there are many reasons for adherence issues, including comfort concerns, feelings of claustrophobia, difficulties with breathing, or technical problems, it is common for patients to abandon treatment too early to experience its benefits, which for many patients outweighs any initial problems of adjustment. Records also show that patients who abandon therapy during the early adjustment period are less likely to give the treatment another try at a later date. But this has not discouraged health professionals from expanding their resources to help patients in need. In order to save lives and improve the health and well-being of millions of sleep apnea sufferers all over the world, medical professionals have developed a number of intervention strategies with one goal in mind: to promote the use of CPAP therapy and raise the rate of treatment compliance.
Difficulties Adjusting to Treatment
PAP-therapy device companies are constantly researching patient needs and improving the technology of their products, but there remains a persistently high percentage of patients who have difficulties adjusting to the lifestyle changes required for the devices to be effective. In addition, new patients may not realize that problems with therapy can have quite simple solutions, such as a different setting or choice of mask. Studies show that even basic interventions involving explanations of sleep test results and the importance of therapy can improve adherence among CPAP patients, especially in the short term, but for long-term adherence goals, ongoing support in the form of periodic interventions is often needed to make a substantial difference.
Psychosocial interventions for PAP therapy adherence have a specific focus on the role of psychosocial factors such as social support, marriage or relationship status, work environment, home environment, or any other social conditions that may affect therapy. This approach, based primarily on social learning and social cognitive theories, involves the observance of social ties as positive influences on target behavior. In studies related to the social aspects of CPAP, researchers have discovered a positive correlation between social ties and high rates of adherence, which then leads to improved health, a more optimistic view of life, and less exhaustion or burnout in the workplace. In the longer term, strong social ties are also linked to lower mortality rates, providing further incentives for the advocacy of patient support outside of the clinical setting.
In order to be effective, psychosocial interventions often require an ongoing process with continued emphasis on team-oriented problem solving. While this is also the case for some other forms of intervention, psychosocial approaches are highly social in nature, demanding continued efforts by the patient to embrace social support and make use of social resources in daily life.
Behavioral Interventions such as cognitive behavioral therapy (CBT) are also considered to be psychosocial approaches, but with much more emphasis on personal challenges, coping mechanisms, and the development of problem-solving strategies. Through one-on-one or group therapy sessions, behavioral interventions help to eliminate cognitive distortions such as unhealthy thoughts, beliefs, and attitudes that reinforce unwanted behavior patterns. In one study, cognitive behavioral interventions led to an average of over three hours of nightly increases in CPAP usage rates.
The majority of intervention studies published in recent years, behavioral Interventions have shown the most positive results of any intervention type to date. But this doesn’t mean that behavioral approaches should be used exclusively. What researchers have found is that a combined approach using all available resources is the most effective in providing the support needed for sustained adherence and continued support.
Another highly effective behavioral intervention strategy is motivational learning. Also referred to as motivational interviewing, this approach involves counseling sessions aimed at behavior change through the resolution of ambivalence. This concept of ambivalence is what arises when an individual considers both the benefits and consequences of a behavioral choice. For CPAP, this could be seen as a patient who has difficulties using the device, but still wants to experience the benefits of continued therapy. Motivational counseling helps to direct the patient in the most beneficial and least harmful direction. The term “interviewing” is used because motivational learning is most effective when therapists use guided questioning to help clients make their own decisions.
One form of motivational learning, called motivational enhancement therapy, or MET, was originally developed as a therapy model for substance abuse and addiction problems, but was later adopted as a way to coach new patients in treatments such as CPAP, which have low adherence rates. MET has been used by a number of clinics with substantially positive results in heightening PAP-therapy adherence, using cognitive-behavioral strategies to guide patients through the problem-solving process. The primary goal of this strategy is to help patients establish inward motivations for change. This is done primarily with standard counseling models, but with much of the focus dedicated to guided troubleshooting in a clinical setting.
The Health Belief Model
The Health Belief Model (HBM), like the MET, uses social psychological and behavioral approaches to treat disease by changing people's personal habits and attitudes. HBM remains one of the most popular and widely used theories in health behavior intervention and research. Specifically, the HBM approach is based on the premise that people's beliefs about the potential costs or benefits of a treatment will determine their level of engagement (or lack thereof). But HBM differs from MET in that it emphasizes lasting, internal changes that can improve patient attitudes and eventually lead to a happier, healthier lifestyle.
Most intervention strategies involve education on some level, whether it is achieved with verbal education during counseling sessions or by providing materials to patients for later reading and reference. Larger public education campaigns also aim to broaden awareness and improve health throughout entire communities, both locally and globally. In the clinical setting, doctors often take steps to assess patient health literacy and use methods of communication such as patient teach-back to assure that the information is received. The teach-back method is a way of confirming communication by having patients explain what they have learned. It is also important to use patient-preferred formats. This is often accomplished by providing multiple formats, or by using a variety of strategies such as slide presentations, videos, general discussion, demonstrations, printed materials, or online resources. This is where health technology becomes extremely important. In regard to PAP therapy, timing of the delivery of CPAP education is also very important, as the patient may seek further information once the titration process is complete and the first therapy session is attempted. Records also show that initial contact with a sleep specialist is highly significant for the uptake, acceptance, and continuation of therapy. First impressions mean a lot in the medical world, especially for patients who are unsure or uninformed about their treatment options.
Telemonitoring and Telehealth
While telemonitoring refers specifically to remote capabilities, often used for the purposes of follow-up support and communications, telehealth refers to a wide range of clinical and non-clinical services. Telehealth services, for example, may include guidance and training, remote meetings, medical assessments, data tracking, and health education. For CPAP in particular, telehealth is a major component of treatment. Nearly all modern PAP therapy devices include remote monitoring capabilities, therapy data applications, and convenient cloud platforms for real-time access by patients and medical providers. These applications are highly informative from a clinical standpoint, notifying both patients and providers of apnea-hypopnea index results, mask leaks, and various flow signals that track changes in breathing patterns. At the same time, therapy starting and stopping times are recorded, which give providers a clear and accurate assessment of patient compliance.
Studies assessing the impact of telemonitoring on PAP-therapy adherence have found an average increase of nearly two hours per night, when compared to standard care models without telemonitoring support. After just 30 days of therapy, patients monitored with wireless communications systems have shown steady increases in nightly therapy hours as well as the total number of days used. Expansion of these capabilities into broader telehealth systems of intervention not only show promise in higher adherence rates, but can even be more cost-effective in terms of investment.
These interventions used in combination offer a highly effective means of providing tailored support strategies for CPAP patients with adherence problems. By combining the above theories in the interest of best-practice protocols, for example, behavioral interventions with ongoing telehealth support, may at last provide a viable solution for the improvement of CPAP adherence in an expanding patient population.
In the American Academy of Sleep Medicine’s extensive 2016 report on the hidden cost of untreated sleep apnea, lack of education and limited support structures were cited as primary reasons for CPAP failure. Continued research in this area has highlighted, again and again, the need for substantial increases in treatment resources, as well as a more diversified approach that could serve the needs of a growing population of patients. As reported by the AASM, the cost of treating individuals with sleep apnea would remain significantly less than the consequences of leaving the disorder untreated. This includes the additional costs of expanding current resources to reach an unacceptable number of individuals suffering from sleep apnea conditions that, for whatever reasons, they are no longer treating.
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