Welcome to the educational webcast, Improving Positive Airway Pressure or PAP Adherence, sponsored by the American Academy of Sleep Medicine and brought to you by the Advanced Practice Provider for the APP Assembly. We have Anne Batson from Community Health Network SleepWake Services East in Indianapolis, Indiana, and Sarah Freeman from North Texas Institute of Neurology and Headache in Frisco, Texas to narrate the presentation on this timely topic. Several APP Assembly members were contributors to this presentation. In accordance with the updated Accreditation Council for Continuing Medical Education Standards for Commercial Support, the AASM has implemented a process requiring each speaker to disclose and resolve all conflicts of interest with any commercial entity. We have reviewed the disclosures and resolutions and believe that the submitted citations comply with the ACCME standards. The disclosures and resolutions provided by each speaker are included in the slide presentation for the participant's information. Now, allow me to introduce the narrators. Thank you for joining us, Anne Batson and Sarah Freeman. Hi, my name is Anne Batson. I'm a nurse practitioner working full-time in a sleep disorder clinic in Indianapolis, Indiana. I have no conflicts to disclose. Hi, I'm Sarah Freeman. I'm a physician assistant. I work in the Dallas area at North Texas Institute of Neurology and Headache, and I have no conflicts of interest to disclose. For this presentation, we have five learning objectives. We will review the scope of the problem of untreated obstructive sleep apnea, review current research on PAP non-adherence, and explore possible reasons for this problem among patients. We will also discuss interventions that can be implemented in the practice setting to prevent non-adherence, and then go over some case studies to demonstrate how these interventions can be personalized for individual PAP users. As you may well know, obstructive sleep apnea can lead to significant health problems if it is left untreated or inadequately treated. It can cause and exacerbate cardiac conditions such as atrial fibrillation and congestive heart failure. It can also severely impair patients by increasing daytime sleepiness and reducing their cognitive function. This places patients at higher risk for accidents, such as car crashes and workplace injuries. This in turn contributes to higher health care and societal costs. Consequently, health care resources are diverted towards a problem where an effective treatment exists but is being underutilized. Close to 30 million Americans are affected by obstructive sleep apnea, but only 20 percent are diagnosed, leaving the majority of people suffering from OSA untreated. For those who have been diagnosed, positive airway pressure remains the gold standard for treatment. But unfortunately, adherence is greatly lacking. On average, only 50 percent of patients use it at least four hours nightly, and that number drops down to just 34 percent when we look at patients who use PAP at least seven hours nightly. A 2020 study on a cohort of Medicare patients demonstrated another problem with long-term adherence. Encouraging 75 percent of these patients met the initial insurance requirements and use their machines for a minimum four hours daily, at least 70 percent of the nights in the first 90 days after starting therapy. However, there was a decline in long-term adherence after the initial compliance period, with less than 60 percent of the patients continuing to use their PAP consistently in the first year. Despite myriad research studies that have tried to identify a single or simple reason for PAP non-adherence, we have failed to move the needle that is stuck at the 50 percent adherence rate over the past 20 years. Investigators have realized that there are multifaceted reasons for non-adherence to PAP therapy, and they needed to consider more than just the biomedical and technical aspects of care to identify all the barriers to PAP adherence. In other words, it is not just a matter of mask fit and pressure intolerance. It is more complex, and researchers knew they had to turn their attention towards psychological and motivational predictors of PAP usage. We now recognize that PAP use is above all else, behavior change. Let's talk for a minute about what the term adherence means in the medical context. I would like to point out that in the present day medical profession, the word compliance has been replaced by the more acceptable term adherence. This change in medical terminology came about during the 1990s as certain negative connotations were linked to the term compliance. It suggested a lack of patient autonomy and a passivity to the patient treatment process. On this slide, you'll see two definitions of adherence. The extent to which a person's behavior, taking medication, following a diet, and or executing lifestyle changes corresponds with agreed recommendations from a health care provider. And stickiness, the extent to which a patient's behavior coincides with medical advice. Throughout this webinar, you'll discover how the concept of adherence, combined with theory-driven research, provides the evidence that steers the interventions that are used to encourage behavior change. Now that we've covered what medical adherence means in a broader sense, we can discuss what it means specifically in relation to PAP therapy. The measure of PAP adherence evolved from several studies that demonstrated that PAP for at least four hours helped normalize levels of daytime sleepiness and functioning. Adherence to PAP also improved cardiovascular outcomes and reduced cardiovascular morbidity and mortality. These findings led to the current consensus that the minimum threshold of PAP usage that is effective in achieving improvements in clinical outcomes is at least four hours or more of therapy for 70% or more of nights measured. Data suggests there seems to be a linear relationship between increased hours of PAP use and greater improvement in clinical outcomes. Several studies demonstrated that users who averaged seven hours a night on PAP had the most improvement in the measured outcome, such as hospital readmission, survival rates in patients with COPD, and overall mortality. This suggests a dose-dependent response to PAP therapy and that monitoring not only adherence, but hours used is important in clinical practice. Patients should be encouraged to use their PAP therapy throughout their total sleep time. We can think about the predictors of non-adherence in three major categories. Patient-related factors, health professional factors, and biomedical factors. This webinar focuses on patient-related and health professional-related factors that affect adherence. This webinar is not going to spend time on the biomedical component because there is an excellent webinar on the AASM website called PAP Therapy Troubleshooting that Loretta Colvin and Anne Cartwright produced in 2019. Listed here are the common biomedical factors that can predict PAP non-adherence, and their webinar covers these problems well and is worth a watch. So our next category is patient-related factors. High-risk groups for non-adherence include certain demographics, such as low socioeconomic status, addiction, younger age and or single, and Black and Latino patients. Realizing which patients are subjected to healthcare disparities and are more vulnerable to non-adherence to PAP can guide the treatment approach. The literature tells us that there are several patient-related factors of PAP non-adherence. Take a look at the list above and realize how often we run into these issues in clinic. There are some factors that may be considered fixed or unchanging, such as the sleep apnea severity or the presence of depression. Some characteristics, however, should be considered more fluid or malleable and may be influenced by our interaction with our patients. For example, we can listen and explore their doubts about therapeutic benefits of PAP therapy and work to improve that significantly. Recognizing the factors that we can change may just help the patient succeed with PAP treatment. We may not want to acknowledge the shortcomings of the medical community, but the above issues have been identified as barriers to PAP adherence. Some of these items are access to medical care, but others may be a result of a suboptimal culture of care at a clinic or durable medical equipment company. Some items might be the consequence of poor customer service or a poorly managed team of PAP therapy providers, whatever the reason, deficient patient care does exist and we need to address it where and when we can. As we know, adopting and adhering to PAP therapy requires a behavior change. Providers can approach a non-adherent patient from this angle and help guide their interaction to encourage new habits. Three such theoretical models, the trans-theoretical model, the health belief model, and social cognitive theory can help a healthcare provider understand the patient's perspective of readiness for change. The trans-theoretical model recognizes that change unfolds through a series of stages over time. The health belief model suggests that a person's belief in the personal threat of an illness or disease, together with their belief in the effectiveness of the recommended health change, will predict the likelihood that that person will adapt to a new behavior. In social cognitive therapy, behavior is held to be determined by four factors, goals, outcome expectancies, self-efficacy, and social structural variables. You will notice that self-efficacy is a shared construct among all three theoretical models. Self-efficacy refers to the level of a person's confidence or belief in their own ability to successfully perform a behavior. Studies specific to PAP users suggest that self-efficacy is a robust predictor of PAP adherence for new starts, as well as long-term users. Self-efficacy is characterized by a person's degree of confidence to perform tasks successfully and attain positive outcomes from treatment. The stronger the perceived self-efficacy, the firmer the person's commitment to achieving their goals. Levels of perceived self-efficacy also determine how impediments are viewed. Individuals with poor self-efficacy are easily influenced or convinced of the futility of their efforts. When faced with difficulties or obstacles, they might stop trying, whereas individuals with high levels of perceived self-efficacy will view the same obstacles as surmountable and increase their efforts to stay the course. Let's apply the social cognitive theory to PAP usage specifically. According to psychologist Dr. Emerson Wickwire's model, social cognitive theory suggests that our behavior is influenced by three core constructs, perceived environment, outcome expectancies, and self-efficacy. The perceived environment includes personal experience such as bed partner's attitudes towards PAP or social support from the family, friends, and healthcare providers. Outcome expectancies are the perceived costs and benefits of using PAP versus not using it and the risk an individual associates with sleep apnea. The final component of social cognitive therapy is self-efficacy, which, according to Wickwire, includes both how an individual perceives their ability to use PAP as well as their overall personal self-efficacy and coping skills when facing other life's challenges. There are a few instruments that are used in PAP adherence research. The SEMSA, self-efficacy measures for sleep apnea, effectively measures perception about PAP and demonstrates that more than 60% of the subjects indicated they would use PAP despite the obstacles. The apnea belief scale helped to identify predictors for PAP adherence such as spousal involvement, immediate social support for treatment, and troubleshooting and psychological factors such as self-efficacy. When administered at two weeks and six months post-PAP treatment, the ACTI, attitude towards CPAP inventory tool, provided a sensitivity of 93% and specificity of 44% for PAP termination within six months. The INAP, index for non-adherence, showed 87% sensitivity and 63% specificity for identifying non-adherence at one month. These instruments are grounded in psychosocial theory and help guide research, but are not necessarily practical to administer in the clinic. If we do not yet have a valid and reliable instrument that can predict PAP adherence that is easy to use in the clinic setting, how else can we discover or screen our patients who may be at high risk for PAP failure? We need to use other educational and behavioral strategies that focus on readiness and self-efficacy with timely initial intervention and follow-up. One such approach is to simply assess the patient's readiness for PAP treatment. Let's review the readiness ruler, a concept introduced by Dr. Emerson-Wickwire. Two key elements of readiness are patient self-selection of PAP treatment and timing of treatment. Patients who have self-selected PAP therapy as their preferred treatment are most likely to be long-term users. Patients may resist or abandon PAP therapy if they feel rushed into making their treatment decision. By asking the patients to rate their level of readiness, the provider can measure the patient's level of motivation and ability to process the information and skills needed for success. Ask the three questions. Number one, do you agree that PAP is the best option to treat your sleep apnea? Number two, on a scale of 1 to 10, how important do you think it is for you to use PAP? Number three, on a scale of 1 to 10, how confident are you in your ability to use PAP from now until the next time we meet? If their scores are less than 8 on any item, you can use a technique called motivational interviewing to examine their position, and then you can work to modify the modifiable. If healthcare providers focus on highlighting the modifiable barriers to PAP adherence, our interactions could influence their attitudes and behaviors towards PAP use. Listed here in the left column are common reasons a patient might struggle with PAP use. On the right side are responses or tactics that healthcare providers can use to modify that behavior. So let's look at some examples on the left side. We now have some tools such as the readiness ruler to identify at-risk patients, and early intervention might be the best choice. If a person is skeptical of the benefits of PAP therapy, we can focus on the discussion on education about the pathophysiology of untreated sleep apnea. If they are claustrophobic, we need to offer desensitization strategies, and so on. The rest of this talk will dig further into these care options. Obstructive sleep apnea results in most patients being unaware of events occurring during their sleep. Pulling up a hypnogram allows patients to have a visual representation of what occurs during their sleep and often gives another layer of perspective on both the underlying condition as well as what one might expect during treatment. For some patients, this makes their diagnosis feel more concrete, and many patients will recall this data, thus demonstrating that they really understand the impact of their sleep apnea. This is particularly nice to see when you have a split-night study and can show the unresolved and resolved oxygen tracings. Patients benefit from hearing some of the risk reduction associated with treating OSA. Be careful not to set expectations that treatment will improve associated conditions but that there are studies that show it can. But we can make it personal and need to make it matter. Here are some hard facts you can share with your patient. Those with untreated OSA are more likely to be readmitted to the hospital after discharge. They are two and a half times more likely to be involved in a motor vehicle accident and twice as likely to be involved in workplace accidents. If a patient has a certain underlying health condition, the healthcare provider can be disease-specific. We can let them know that 70% of patients with resistant hypertension have OSA and that treatment with CPAP can be seen to lower blood pressure. Patients with atrial fibrillation and OSA are two times more likely to have a recurrence of their atrial fibrillation after cardioversion. For those with type 2 diabetes, treatment with CPAP can lower A1C levels. Education is not completed in a single visit. Patient education should be addressed in layers, beginning with an initial foundation of understanding of the condition and how it's connected to the patient's current health condition and symptoms, then both the status of the patient's health, adaptation to treatment, and symptom response should be reassessed and followed by reeducation in a cycle that continues throughout the patient's treatment. There is a lack of consensus about appropriate follow-up time for new PAP users. The Center for Medicare Services requires an in-person visit within 90 days of initiating therapy. The American Academy of Sleep Medicine recommends follow-up in the first two weeks to evaluate and manage nonadherence. The research tells us that patients will make up their minds about PAP therapy very quickly, and long-term adherence to PAP can be predicted in as early as three days. Patients who skip more than two nights in the first week of treatment are also at risk for non-adherence. Up to 50% of patients new to PAP will discontinue use in the first week. While insurers do not require a clinical follow-up visit until at least 30 days after beginning PAP, earlier follow-ups may be more effective in reducing non-adherence. This allows an opportunity to intervene sooner if patients feel like their symptoms are not improving or they're having problems acclimating. The goal here is to get them before they abandon treatment. Telemedicine can be an excellent way to increase access for patients during this critical initiation phase. For instance, we can schedule a telephone call in the first two weeks of therapy to check in on their progress and see where they need further guidance. After that, and if they're showing consistency with their PAP use, we can gradually extend the interval between subsequent follow-up visits, typically three months, six months, and then one year out if they're doing well. You may already be using telemonitoring in clinic, which is great because research studies have shown that it can significantly improve PAP adherence. These services are offered through PAP manufacturers as well as through online companies and smartphone applications that patients can enroll in by themselves. These platforms can remotely monitor a patient's PAP machine usage and have the ability to connect them with sleep coaches who will help motivate and guide them as they acclimate to therapy. If a patient is experiencing problems, some of these services will even connect them with a respiratory therapist to troubleshoot issues. We are already seeing promising data that patients who participate have higher adherence rates. For example, 78% of patients who used an accompanying smartphone app with their machine reached compliance within 90 days versus 56% who did not use the app. We encourage our patients to actively engage in their treatment by letting them know about these resources that can provide real-time feedback and additional support and education. Telemonitoring platforms can help improve adherence at the beginning of treatment by identifying patients who may be struggling with PAP in the first week or two of therapy. Remember, the first week of therapy can already signal whether a patient will be non-adherent to treatment. So focusing on this crucial timeframe may impact outcomes. On this screen, you'll see an example of one manufacturer's platform, which shows a weekly overview of PAP usage for patients who are still in their first 30 days of therapy. This gives us a quick snapshot of each patient's usage patterns and can be a really useful tool for monitoring patients at the onset of therapy and intervening before these patients have reached their insurance-mandated follow-up visit. The platform can be easily monitored by support staff in the clinic, who can then reach out to patients to provide further assistance if they see that a problem is developing. Here's another PAP company's telemonitoring platform that allows us to quickly pull up a report to see which patients are still adherent with therapy after their initial 90-day compliance window has passed. This report shows that about 87% of these patients met their initial minimum usage requirement, but none of them have maintained adherence since their compliance window ended. As you can see, these platforms can be very valuable, a very valuable tool that allows us to efficiently monitor patients at regular intervals and identify those who might be having a problem with PAP sooner so that we can intervene before they totally abandon therapy or risk having their device returned to the DME company if they cannot meet criteria. Artificial intelligence is an emerging technology that is now being applied to healthcare platforms to improve PAP adherence. These platforms utilize algorithms and predictive analytics to estimate the risk of a patient becoming non-adherent and can help identify which patients are most likely to become adherent with intervention. They can automatically perform downloads from machines on regular intervals and then assign patients to different risk categories based on their PAP usage. Artificial intelligence has the potential to improve workflow efficiency and help us target our efforts on the patients at highest risk for non-adherence. The path towards PAP treatment has several opportunities for medical providers to interact with patients. Typically, the patient starts with a discussion of the need for testing with their medical provider and from there, the patient may meet a sleep technician, a sleep coach, a patient navigator, a respiratory therapist, and their mental health counselor if they have one. Everyone has a different skillset and if they are motivated professionals, they can use their expertise to provide something along the way. Each interaction could contribute to the overall success of the patient if that provider uses motivational language. It is said that, quote, poor relationships with medical providers, close quote, was found to be a barrier to PAP adherence and we all should work harder to make a difference. As healthcare providers in sleep medicine, we have additional knowledge and an increased understanding of who may be at risk for non-adherence and how to identify and intervene early in their struggles with PAP inflammation. We also have some insight into what we can do to encourage attitude and behavior change. We tend to ignore the thinking that people do that goes into whether or not people will use their PAP device. Understanding their rationale and thought process is important and we must remember to not take a blaming attitude towards the ones who struggle. So it's time to look at some case studies. We've got three. The first is Harriet High Risk, a 61-year-old obese female with atrial fibrillation. Her AHI is 32 and her O2 Nader 72% according to her home sleep study. One foreseeable challenge to initiating treatment is that Harriet is subjectively asymptomatic. She denies having classic symptoms of sleep apnea during her initial visit. What should we already be thinking about as we meet Harriet for the first time? How do we approach a patient like Harriet and how can we prepare for the likelihood of her being resistant to PAP treatment? Harriet could benefit from reviewing her sleep study and learning the pathophysiology of sleep apnea as well as the consequences of untreated sleep apnea. If the provider wanted to make the discussion specific to her, they should include the natural connection between sleep apnea and atrial fibrillation. The provider could make it matter more by reminding Harriet that her cardiologist referred her. Harriet might have more trust in what her cardiologist recommends than in the sleep professional sitting in front of her. The provider could prepare her for the PAP experience and set some realistic expectations for her. We can do all of these things and that would seem to be enough and still Harriet remains steadfast in her reluctance to use PAP. In the next few slides, we'll discuss how we can incorporate a behavioral intervention called motivational enhancement therapy into our patient education process for Harriet. Let's demystify motivational enhancement therapy a little. The good news is that we probably already practice some of these techniques in clinic without knowing it. Imagine if we hone our skills a little more, we could become comfortable enough to add motivational enhancement therapy to our toolkit. Motivational enhancement therapy is a behavioral intervention based on the principles of motivational interviewing. Therapy is delivered in a nonjudgmental, supportive and collaborative approach to help patients ready themselves for behavior change and empower patient's confidence. Motivational enhancement therapy is patient focused, meaning that you meet the patients where they are using an empathetic and non-threatening manner. It is well suited to CPAP users who are ambivalent about their CPAP early in treatment. Motivational enhancement therapy is a patient focused and collaborative effort between the provider and the patient. Healthcare providers can use the techniques of motivational enhancement therapy to help them identify barriers as well as benefits to behavior changes. These interventions can be delivered through brief in-person visits, via telehealth and or telephone calls. Patients are encouraged to set realistic goals based on their readiness and their confidence levels. Achieving attainable goals in turn helps strengthen their self-efficacy. Let's discuss some examples now of how motivational enhancement therapy can be utilized in clinic to improve CPAP adherence. For Harriet, acknowledging where she is in processing her sleep study results and the treatment offered might be helpful. Perhaps she says, oh, I can never sleep with that thing on. And the provider just sets an initial goal of two hours per day with rapid and frequent follow-up visits. Highlighting her success of just two hours per night in the first one to two weeks might help improve her self-efficacy. And then the healthcare provider could tap into that process and encourage her to set a new goal of four hours per night. Let's meet Alex. He's a pretty typical patient who presents with personal concerns about job loss due to wrecking the company vehicle and a poor performance review. He claims he has picked up some extra work to please his boss, but he's too tired to continue doing this. He feels like his health is not great after gaining weight and new onset of high blood pressure. He expresses that he's skeptical about whether CPAP will help him or will it fit in with his lifestyle. He mentions that one of his coworkers uses CPAP and loves it but he has met other people who couldn't stand it. Prior to starting treatment, the provider could assess Alex's level of readiness to initiate CPAP and his current understanding of the health risk associated with untreated sleep apnea. Motivational enhancement therapy includes a patient-centered interviewing technique called elicit-provide-elicit. This dialogue style focuses on the patient's perception of the importance of behavior change. The provider asks an open-ended question and then after hearing the patient's response, they can provide information or have a discussion with the patient to fill in any gaps or address misconceptions in the patient's current knowledge. This is then followed by another question to assess their readiness for behavior change. This has been shown to be an effective communication method that is designed to explore the problem from the patient's perspective and encourages patients to start thinking and talking about their intrinsic motivations for change. So let's go to the script. This is an example of a conversation using motivational enhancement therapy, elicit-provide-elicit dialogue. So provider says, sleep apnea leads to frequent disruptions in your sleep and may be the cause of your daytime sleepiness. What do you think about this? Alex, from what I understand, this disruption in my sleep quality is essentially making me sleep deprived, but I really think I just need to get more sleep and stop picking up overtime hours at work. Can you write me a letter to get me out of the mandatory overtime? Provider, let's take another look at your sleep study and I can show you how many times you had an arousal or a sleep disturbance that was caused by sleep apnea. Many people with untreated sleep apnea can sleep longer hours and still wake up feeling unrefreshed and groggy. They can get a full eight to nine hours in bed and still not feel rested the next day. Okay, providing education. Have you ever noticed that? Eliciting. Patient, Alex. Yeah, I don't get it. It makes no sense and I feel I'm just getting older. Explain this to me again so I can wrap my head around this. The provider is pulling Alex along by reframing his complaints and concerns and then checking in to see if Alex's attitude is starting to shift. Another technique to motivational interviewing is the decisional balance exercise. This exercise allows the provider to explore with the patient the pros and cons of PAP therapy. The provider asks the patient to list the negative aspects of using PAP followed by the positive aspects of using PAP. The conversation helps to reveal the reasons for the patient's ambivalence towards PAP therapy as well as what motivates them towards behavior change. The provider can then highlight and address barriers as well as normalize the patient's attitude towards PAP. This exercise allows providers the opportunity to identify the areas of education needed and guide the patient through their ambivalence. Let's look at the example above to better understand the decisional balance exercise. So here we are with the provider and Alex again. Provider says, help me understand your thoughts about using the PAP machine. First, let's start with what you think are the downsides or the cons. Alex, well, it's not sexy, let's be honest, between me looking like an alien and the mask leaking, I do worry that my wife will have a hard time adjusting. I also hate the idea of having to drag this around when I travel. Honestly, I really don't wanna use a PAP machine but I guess nobody does, right? Provider, so you feel it's unattractive and the sight and sounds it makes is off-putting to your wife. You also travel and the PAP machine is just one more thing to pack and lug around. Alex, exactly. Provider, okay, so you can think of the cons, the pros or the upsides of using PAP. Alex, if this will get me through the day without struggling to stay awake, I will get over my appearance at night and the inconvenience when traveling. The biggest upside is my driving. I cannot risk another car wreck, that was so terrifying. Provider, you make good points about PAP therapy being intrusive in the bedroom and cumbersome when you travel. I won't argue with you there and a lot of patients complain about these things, but you also like the idea of using PAP therapy when you're working and while driving. Alex, I hate knowing I need a machine to breathe at night and I know I need to work on my weight, but right now I need to focus at work and when driving and that trumps the downside, no question. After the elicit, provide elicit and decisional balance exercise, we now have a better understanding of Alex's perception of his symptoms and risk while driving. We also know what he considers to be the pros and cons of using CPAP. This information can help us tailor our patient education for him. For example, he should see the hypnogram to illustrate the sleep fragmentation, but he also may need strategies to manage his sleepiness, for example, a nap prior to driving. Alex may not need to hear about genetic counseling, associated cardiovascular consequences and other treatment options at this stage of the conversation. The education should not be boilerplate stuff, tailor the conversation to the individual. Lastly, we're gonna look at Claude the claustrophobic. He's a 54 year old firefighter that's retired and has been effectively treated for his PTSD, but he still feels he will not be able to use PAP therapy because of the mask. We have all met Claude. Claude is visibly anxious and declares, you don't understand, I cannot even wear hats. I'm so sensitive to having anything around my head and I know I will not feel comfortable if I am in any way trapped or confined. He is also presenting with a chronic insomnia complaint and says he is more concerned about treating his insomnia and nightmares than his sleep apnea. Claude has several issues, including nightmares. What options do we have to help Claude? First and foremost, we should recognize we are dealing with a patient in a threatened state who might perceive that treating his OSA has nothing to do with his insomnia complaint and therefore may feel as if his providers are not listening to him. He's also warning us that he cannot wear a PAP mask because of his PTSD. What might be a good initial technique when caring for Claude? Claude needs education directed at his concerns. How and why does untreated OSA contribute to insomnia and nightmares? What does sleep fragmentation mean? And he would surely benefit from seeing this depicted on a hypnogram. He needs education on his OSA severity and he needs to hear the connection between apnea and hypoxic events causing him not to breathe and that the mask is the remedy that helps him breathe normally. Claude may want to hear alternatives to PAP therapy so that he can make an informed decision on which treatment is his best option. What Claude really needs is a roadmap to acclimation and perhaps weekly or biweekly follow-up appointments to ensure he's making progress, no matter how slowly. Claude needs to approach his PAP therapy in bite-sized pieces and a formal desensitization process is a good strategy. The instruction sheet shown is an example of the steps toward PAP desensitization. The healthcare provider needs to give Claude time and grace and be patient with this process. Claude at first might only be able to hold the mask over his nose for several minutes. It may take a few days before he attaches the straps and a few more days before he can turn on the pressure. This should be practiced in front of the TV or some other distraction and performed while awake. At every stage, once they are comfortable, they can move forward to the next step. In severe cases, mindfulness training or relaxation exercises may help. Working with Claude's psychologist can be very beneficial. There are many variations on desensitization therapy and the provider should be prepared to modify the plan if needed. The American Academy of Sleep Medicine Task Force found that educational, behavioral and troubleshooting interventions prior to or during PAP therapy treatment improves PAP adherence when compared to no intervention. They reviewed 18 randomized controlled trials with some combination of an educational, behavioral or troubleshooting intervention as an adjunct therapy to usual care when initiating PAP. They found clinically significant improvement in PAP adherence with all three types of interventions. Health care providers are using many of these interventions in clinic, but we hope that this webinar demonstrated why they work. We hope that you now have some useful tools and resources that will enable you to help your patients feel more confident and ready to start PAP and improve their adherence to therapy, both in the initial period and in the long run. Thank you, Anne Batson and Sarah Freeman for the presentation and thanks for participating today. Stay tuned for other upcoming webinars offered by the AASM on sleep medicine.

positive airway pressure adherence

obstructive sleep apnea

interventions

case studies

adherence and behavior change

motivational enhancement therapy

telemonitoring