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The effectiveness of continuous positive airway pressure (CPAP) is dependent on the degree of use, so adherence is essential. Cognitive components (eg, self-efficacy) and support during treatment have been found to be important in CPAP use. Video consultation may be useful to support patients during treatment. So far, video consultation has rarely been evaluated in thorough controlled research, with only a limited number of outcomes assessed.
The aim of the study was to evaluate the superiority of video consultation over face-to-face consultation for patients with obstructive sleep apnea (OSA) on CPAP use (minutes per night), adherence, self-efficacy, risk outcomes, outcome expectancies, expectations and experiences with video consultation, and satisfaction of patients and nurses.
A randomized controlled trial was conducted with an intervention (video consultation) and a usual care group (face-to-face consultation). Patients with confirmed OSA (apnea-hypopnea index >15), requiring CPAP treatment, no history of CPAP treatment, having access to a tablet or smartphone, and proficient in the Dutch language were recruited from a large teaching hospital. CPAP use was monitored remotely, with short-term (weeks 1 to 4) and long-term (week 4, week 12, and week 24) assessments. Questionnaires were completed at baseline and after 4 weeks on self-efficacy, risk perception, outcome expectancies (Self-Efficacy Measure for Sleep Apnea), expectations and experiences with video consultation (covering constructs of the unified theory of acceptance and use of technology), and satisfaction. Nurse satisfaction was evaluated using questionnaires.
A total of 140 patients were randomized (1:1 allocation). The use of video consultation for OSA patients does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. A significant difference in change over time was found between groups for short-term (
Support of OSA patients with video consultation does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. The findings of this research suggest that self-efficacy is an important factor in improving CPAP use and that video consultation may be a feasible way to support patients starting CPAP. Future research should focus on blended care approaches in which self-efficacy receives greater emphasis.
Clinicaltrials.gov NCT04563169; https://clinicaltrials.gov/show/NCT04563169
Telemedicine is increasingly used to support self-management in chronic diseases and is defined as the use of information and communication technology to deliver health care at a distance [
Video consultation may be a useful way to support patients [
Only a limited number of randomized controlled trials (RCTs) were conducted [
Video consultation is often found to be as effective as face-to-face consultation in terms of CPAP use [
Therefore, the objective of this paper is to evaluate the superiority of video consultation versus face-to-face consultation for patients with OSA on CPAP use (minutes per night), CPAP adherence, self-efficacy, risk perception, outcome expectancy, video consultation expectations and experiences with technology, and the satisfaction of patients and nurses.
We conducted a nonblinded RCT with an intervention group (video consultation) and a usual care group (face-to-face consultation), with 1:1 allocation.
Patients were recruited from a large teaching hospital (Rijnstate, Arnhem). To be eligible to participate, patients had to be older than 18 years, be diagnosed with moderate or severe OSA (AHI >15), require CPAP treatment, have no history of CPAP treatment, have access to a tablet or smartphone, and be proficient in the Dutch language. Exclusion criteria were having a psychiatric or cognitive disorder.
Prior to the study, a letter was sent to patients to confirm their appointments (eg, sleep study and consultation with the pulmonologist) including information about the study. During the first face-to-face consultation with the pulmonologist, patients received their treatment plan and information about the study (including information letter and informed consent form). This was followed by instruction about their CPAP treatment. After this consultation, the researcher provided patients with additional information about the study, and they were asked to sign the informed consent form. For reasons of clinical necessity, patients started treatment the same day.
After patients signed informed consent and completed the baseline questionnaire, they were randomized by the researcher to the intervention or usual care group using the software program Research Manager (Cloud9 Software) with block size of 10. The researcher informed the patients about their allocation, and the intervention group received additional information about the video consultation app (Facetalk, Qconferencing) [
The video consultation app Facetalk [
The usual care group followed the same care process but with face-to-face consultation instead of video consultation. Patients received a confirmation letter with the day and time of their next consultation.
The primary outcome was CPAP use (minutes per night), monitored remotely with Encore Anywhere (Philips). Conforming to the initial protocol, CPAP use was assessed during the first 4 weeks (short-term). Additionally, we assessed CPAP use after week 4, week 12, and week 24 (long-term).
CPAP adherence was defined as CPAP use for at least 5 nights per week for at least 4 hours per night [
The Self-Efficacy Measure for Sleep Apnea (SEMSA) [
The relations between CPAP use and self-efficacy, risk perception, and outcome expectancies were assessed. Also, the differences between the intervention and usual care group were analyzed.
Questions covering constructs of the unified theory of acceptance and use of technology (UTAUT) model [
Patient satisfaction was evaluated with questions about the consultations and information received. Additionally, the intervention group answered questions about the video consultation system. All questions were rated on a 5-point scale (from 1=totally disagree to 5=totally agree). Nurses’ experiences were evaluated using a questionnaire with questions about the video consultation system, satisfaction, and organizational benefits (eg, time and efficiency).
Patient age, marital status, education, experience with internet and internet use, tablet or smartphone skills, and support (with tablet or smartphone use) were assessed via a questionnaire at baseline. Data about comorbidities, AHI, number of consultations, symptoms, and results of the Epworth Sleepiness Scale [
Since there is no determined clinically relevant difference for CPAP use [
Data analysis was performed using SPSS (version 22.0, IBM Corp). Descriptive statistics were used to report the baseline characteristics, experiences, expectations, and satisfaction. Linear mixed models were used to analyze differences in CPAP use over time for the intervention and usual care group (interaction term: time × group). All available CPAP use data were used in the analysis, according to the intention-to-treat principle. Differences in adherence over time between groups was analyzed using generalized estimating equations. The relation between CPAP use and risk perception, outcome expectancies, and self-efficacy was analyzed with a linear regression. Normally distributed variables were reported as mean and standard deviation, and statistical differences were tested using an independent samples
All participants signed a written informed consent form prior to inclusion in the study. The study was approved by the regional medical research ethics committee Commissie Mensgebonden Onderzoek Arnhem–Nijmegen and registered at Clinicaltrials.gov [NCT04563169].
Patients were included from January 2, 2019, until June 26, 2019. In total, 222 patients were screened for eligibility, and 50 patients did not meet the inclusion criteria: no tablet or smartphone (n=17), no proficiency in the Dutch language (n=10), AHI <15 (n=10), history of CPAP treatment (n=5), no OSA (n=4), psychiatric or cognitive disorder (n=3), and age <18 years (n=1). In total, 28 patients declined to participate, and 4 patients were not informed about the study for other reasons: 2 patients were not referred to the researcher due to logistical errors, 1 patient followed a different care process (there was no consultation with the pulmonologist that same day), and 1 patient had had CPAP for try out for a short period.
In total, 140 patients were randomized, and 70 patients were allocated to the intervention group and 70 patients to the usual care group. During the intervention period, 2 patients discontinued the intervention: 1 preferred face-to-face consultation, and 1 had no working device. Four patients stopped CPAP treatment during the intervention period (first 4 weeks). In total, 10 patients were lost to follow-up in the intervention group (n=9 stopped CPAP treatment and n=1 died) and 3 in the usual care group (n=3 stopped CPAP treatment). See
CONSORT flow diagram.
Both groups had similar baseline characteristics (
Baseline characteristics (n=140).
Characteristics | All patients (n=140) | Intervention (n=70) | Usual care (n=70) | ||
Gender, women, n (%) | 29 (21) | 12 (17) | 17 (24) | .30 | |
Age (years), mean (SD) | 53.3 (12.1) | 52.3 (12.4) | 54.3 (11.9) | .40 | |
AHIa, median (IQR) | 31.0 (21.5-45.0) | 31.0 (22.0-46.0) | 30.5 (20.0-42.0) | .96 | |
Living with a partner, n (%) | 110 (79) | 59 (84) | 51 (73) | .10 | |
|
—b | — | — | .22 | |
|
Low | 8 (6) | 3 (4) | 5 (7) | — |
|
Middle | 89 (64) | 41 (59) | 48 (69) | — |
|
High | 43 (31) | 26 (37) | 17 (24) | — |
|
— | — | — | >.99 | |
|
<6 months | 3 (2) | 1 (1) | 2 (3) | — |
|
1-2 years | 1 (1) | 1 (1) | 0 (0) | — |
|
>2 years | 1 (1) | 1 (1) | 0 (0) | — |
|
>3 years | 135 (96) | 67 (96) | 68 (97) | — |
|
— | — | — | .31 | |
|
(almost) every day | 128 (91) | 66 (94) | 62 (89) | — |
|
Multiple days per week | 9 (6) | 4 (6) | 5 (7) | — |
|
≤1 day per week | 3 (2) | 0 (0) | 3 (4) | — |
|
— | — | — | .91 | |
|
Quite bad or bad | 5 (4) | 2 (3) | 3 (4) | — |
|
Not good or not bad | 23 (16) | 11 (16) | 12 (17) | — |
|
Quite good | 27 (19) | 14 (20) | 13 (19) | — |
|
Good | 55 (39) | 26 (37) | 29 (41) | — |
|
Very good | 30 (21) | 17 (24) | 13 (19) | — |
Expects to need help with tablet or smartphone use, n (%) | 26 (19) | 11 (16) | 15 (22) | .41 | |
|
— | — | — | — | |
|
Obesity (BMI >30) | 97 (69) | 51 (73) | 46 (66) | .36 |
|
Hypertension | 48 (34) | 24 (34) | 24 (34) | >.99 |
|
Hypercholesterolemia | 21 (15) | 8 (11) | 13 (19) | .24 |
|
Heart disease | 20 (14) | 11 (16) | 9 (13) | .63 |
|
Diabetes | 14 (10) | 7 (10) | 7 (10) | >.99 |
|
— | — | — | .19 | |
|
Total score ≤10 | 105 (79) | 56 (84) | 49 (74) | — |
|
Total score >10 | 28 (21) | 11 (16) | 17 (26) | — |
|
— | — | — | — | |
|
Outcome expectancies, mean (SD) | 2.78 (0.62) | 2.88 (0.57) | 2.67 (0.65) | .048 |
|
Self-efficacy, median (IQR) | 3.00 (2.56-3.56) | 3.00 (2.56-3.33) | 3.00 (2.56-3.67) | .40 |
|
Risk perception, median (IQR) | 2.00 (1.54-2.50) | 2.31 (1.63-2.63) | 1.88 (1.50-2.31) | .02 |
aAHI: apnea-hypopnea index.
bNot applicable.
cESS: Epworth Sleepiness Scale.
dSEMSA: Self-Efficacy Measure for Sleep Apnea.
The use of video consultation does not lead to superior results on CPAP use compared with face-to-face consultation. A significant difference in change over time was found between groups for short-term (weeks 1 through 4) CPAP use (
No significant difference in change over time for long-term CPAP use (week 4, week 12, and week 24) was found between groups (
Long-term continuous positive airway pressure use (minutes per night).
Weeka | Intervention | Usual care | ||
|
EMMb (SE) | 95% CI | EMM(SE) | 95% CI |
Week 4 | 334.3 (16.3) | 302.1-366.5 | 371.4 (15.8) | 340.1-402.7 |
Week 12 | 311.5 (16.8) | 278.4-344.6 | 348.6 (16.2) | 316.5-380.7 |
Week 24 | 295.2 (17.8) | 260.0-330.4 | 332.7 (17.3) | 298.1-366.5 |
aLinear mixed model.
bEMM: estimated marginal mean.
Long-term continuous positive airway pressure use: change over time.
The use of video consultation does not lead to superior results on CPAP adherence compared with face-to-face consultation. No significant difference was found between both groups for short-term (
No significant difference between groups was found for the SEMSA constructs: outcome expectancies (
After 4 weeks, a relation was found between CPAP use and self-efficacy (
Patients expressed positive expectations for the use of video consultation. After 4 weeks, 76% (48/63) indicated that video consultation had a positive effect on control over their treatment, and 75% (47/63) indicated that it positively affected the treatment itself. The majority (58/63, 92%) implied it did not cost them effort, 95% (60/63) reported that they had enough skills to use a tablet or smartphone and that they received enough support (53/63, 84%). Although, 64% (44/69) expected to be stimulated by people in their direct environment to use video consultation, only 25% (16/63) were actually stimulated. Almost all patients (60/63, 95%) intended to keep using video consultation. See
Patients in both groups were satisfied with the consultations. On average, the intervention group rated the consultations with an 8.5 and the usual care group with an 8.3 on a scale of 1 to 10 (1=not at all satisfied to 10=very satisfied). Patients indicated (intervention group versus usual care group) that health care professionals understood their problems (59/63, 94%, vs 58/68, 85%) and listened to them (60/63, 95%, vs 61/68, 90%). Almost all patients understood the content of the consultation (61/63, 97%, vs 62/68, 91%), could easily express their feelings (59/63, 94%, vs 62/68, 91%), and were satisfied with the information they received (58/63, 92%, vs 60/68, 88%). However, more patients with video consultation reported that they did not miss important information (56/63, 89%, vs 43/68, 63%). See
The majority (56/63, 89%) of the patients were very satisfied with video consultation, the quality of the video (50/63, 79%), and sound of the system (45/63, 71%). It also saved them time (61/63, 97%) and provided better access to health care professionals (43/63, 68%). Almost all patients felt safe about their privacy and confidentiality (61/63, 97%) and preferred a video consultation over a face-to-face consultation (51/63, 81%). According to almost half (28/63, 44%) the patients, face-to-face consultation can be replaced by video consultation. See
Nurses (n=3) rated the use of video consultation on average with a 7.3 (SD .57) on a scale of 1 to 10 (1=not at all satisfied to 10=very satisfied). They were all satisfied with privacy and confidentiality and quality of the sound and video and would recommend its use to colleagues and patients. Two nurses agreed that its use fits in their work process. However, only one nurse was completely satisfied with the information she could provide. They did not think that the use of video consultation helped them save time or work more efficiently.
The nurses reported that use of video consultation is not suitable for new patients, and they prefer to use it during follow-up:
It is not suitable for a first consultation after starting CPAP because you cannot provide enough information.
Not for new patients because providing information and checking the device and sleep mask is difficult using video consultation.
The nurses also experienced some technical problems:
Sometimes there were log-in problems and I had to call the patient first by phone.
Sometimes it took long before there was a connection. This costs more time.
They also provided suggestions for improvement and described advantages of video consultations:
Plan the video consultations one after the other and not alternating with face-to-face consultations.
It is a good alternative for follow-up consultations. It is more patient friendly than a face-to-face consultation.
Saves time for patients.
In this RCT, we evaluated the superiority of video consultation over face-to-face consultation for newly diagnosed OSA patients. For CPAP use, we found a significant difference in change over time between groups in the short term (
Unfortunately, change over time was not evaluated in previous controlled studies [
Where previous studies mainly focused on CPAP use, adherence, and satisfaction with video consultation [
However, limited evidence was available about the effect of video consultation for newly diagnosed patients starting CPAP. Most previous RCTs were small, with sample sizes varying from 19 to 40 patients [
The assessment of UTAUT components and self-efficacy can also be used to indicate technology use [
The involvement of health care professionals is essential to achieve successful implementation of technology [
Video consultation can be seen as a promising app to support OSA patients during treatment. Still, evidence was lacking and previous research was not strong enough in design or focused on a limited number of outcomes. With the evaluation of a broad range of outcomes affecting CPAP use and implementation of video consultation in clinical practice, this RCT adds value to current knowledge.
However, proper evaluation in this field is challenging because research often lags behind the rapid development of technology [
Several limitations should be considered. Risk perception and outcome expectancies were significantly different at baseline, despite randomization. For a limited number of patients (7/66, 11%, in the intervention group and 6/70, 9%, in the control group), video consultations or face-to-face consultations were replaced with a telephonic consultation due to technical problems in the intervention group and because patients in the control group could not come to the hospital. The protocol process were not strictly followed because patients failed to attend their scheduled appointment (no show, sick, on holiday) or there were organizational inaccuracies such as wrongly scheduled appointments. The percentage of patients that followed the process exactly as described (
Support of OSA patients with video consultation does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. The findings of this research show that a significant difference in change over time was found between groups for short-term CPAP use (but not on specific time points), but not for long-term CPAP use. Levels of self-efficacy were positively related to CPAP use in both groups. Patients were very satisfied with video consultation and reported positive experiences.
Therefore, the findings of this research suggest that self-efficacy is an important factor in improving CPAP use and that video consultation may be a feasible way to support patients starting CPAP. The integration in health care processes and tailoring video consultation use to patient and professional needs is essential to ensure successful use. A blended care setting, in which an initial video consultation is combined with face-to-face consults, may be beneficial. To our knowledge, this is the first RCT that examined the effects of video consultation on CPAP use over time for newly diagnosed OSA patients in combination with cognitive components and experience with technology use. Future research should focus on blended care approaches in which self-efficacy receives greater emphasis.
Study process.
Short-term CPAP use.
Short-term CPAP use: change over time.
Short-term CPAP adherence.
Long-term CPAP adherence.
Self-Efficacy Measure for Sleep Apnea constructs: self-efficacy, risk perception, and outcome expectancies.
Expectations and experiences with video consultation.
Patient satisfaction with consultation.
Patient satisfaction with video consultation.
CONSORT-eHEALTH checklist (V 1.6.1).
apnea-hypopnea index
Consolidated Standards of Reporting Trials
continuous positive airway pressure
obstructive sleep apnea
randomized controlled trial
Self-Efficacy Measure for Sleep Apnea
unified theory of acceptance and use of technology
The authors thank Els Fikkers (nurse practitioner, pulmonology) for her assistance with the study.
None declared.