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Adherence

Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s

Evidence review N

NICE Guideline, No. 202

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4229-9

1. Adherence

1.1. Review question: What support improves adherence to CPAP or other interventions?

1.2. Introduction

Adherence to interventions such as CPAP/non-invasive ventilation/oral devices/positional modifiers for obstructive sleep apnoea/hypopnoea syndrome (OSAHS), obesity hypoventilation syndrome (OHS) or COPD-OSAHS overlap syndrome is essential in order for these interventions to be effective. Optimal adherence to CPAP therapy is conventionally considered to be four or more hours per night or use for an average of more than 4 hours per night for 70% or more nights. There is some evidence suggesting that increased CPAP use of more than 5 hours a night in OSAHS benefits other aspects of health such as control of blood pressure and cardiovascular risk. However, it is recognised that use of CPAP for four hours per night or more is an arbitrary figure not based on good quality evidence and that people can gain some benefit from a shorter period of use. People should be encouraged to maximise their CPAP use to achieve optimal control of their symptoms, underlying conditions, sleep quality and quality of life. Adherence to other devices is thought to be equally important to gain any benefit.

An evidence review was conducted to assess interventions designed to inform participants about improving adherence of CPAP/non-invasive ventilation, positional modifiers and oral devices, to support them in using these interventions and to modify their behaviour in improving their use.

1.3. PICO table

For full details see the review protocol in appendix A.

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.4. Clinical evidence

1.4.1. Included studies

OSAHS
CPAP

Total of 46 studies reviewing educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea were included in the review. This included one Cochrane review5 with 41 studies and 5 additional studies identified in re-runs12,34,43,57,61 these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).

Studies were categorised into the following comparisons:

  • Behavioural vs. Control - interventions employing psychotherapeutic techniques deriving from behavioural, cognitive or cognitive-behavioural models of health behaviour change (e.g., specific models within this broad genre include motivational enhancement therapy [Miller], Transtheoretical/Stages of Change Model [Prochaska and DiClemente], CBT [Beck]). By definition, behavioural interventions under any of these related models involves at least a minimal degree of direct participant engagement or interaction (as opposed to purely educational, in which information is merely imparted to participants, even if the educational content or style of presentation was based on a cognitive/behavioural model). The objectives of such interventions included enhancing motivation for change, self-efficacy, outcome expectations and/or decisional balance in favour of CPAP. There were a broad range of interventions included in this category such as myofunctional therapy, progressive muscle relaxation training, audiotaped music along with softly spoken directions on relaxation techniques and habit-promoting instructions for using CPAP nightly, motivational interviewing, one to one sessions with a clinical psychologist, motivational enhancement which is devised on the principles of motivational interviewing, motivational enhancement therapy and telephone-linked communications.
  • Educational vs. Control – interventions imparting information about CPAP treatment or about OSAHS more generally, delivered through video format, face-to-face didactic sessions, group educational sessions, written materials, or any combination of these. Interventions that did not involve a component of active engagement from the participants other than reading written materials or observing a presentation or demonstration, even if the content derived from a behavioural change model, were classified as educational.
  • Supportive vs. Control - interventions in which participants were provided with additional clinical follow-up (e.g., additional office or home-based visits or phone check-ins by clinical staff) or with telemonitoring equipment that facilitated self-monitoring of CPAP usage or that facilitated monitoring by clinical staff to prompt as needed clinical follow-up (e.g., a phone call made to participants when CPAP usage fell below a predetermined threshold) for the purpose of addressing barriers or difficulties with CPAP usage in a timely manner (e.g. telemedicine systems, digitised phone calls or audio messages, and/or home visits)
  • Mixed vs. Control – interventions that combined elements of the three previously listed intervention-types (e.g. educational video and material provided + telemedicine follow-up)

In cases where studies used a mixed combination of intervention-types (behavioural, educational or supportive), but had multiple active intervention arms that had distinct elements of one type of intervention (e.g. intervention 1 supportive vs. intervention 2 educational vs. control), the active interventions groups were separated and included in the appropriate comparison subcategory for meta-analysis.

Studies had people with moderate and severe OSAHS; however, the majority of the studies were in people with severe sleep apnoea.

No evidence was identified for the critical outcome mortality.

Oral devices

No studies identified educational, supportive and behavioural interventions to improve usage of oral devices in adults with obstructive sleep apnoea, OHS and COPD-OSAHS overlap syndrome.

Positional modifiers

No studies identified educational, supportive and behavioural interventions to improve usage of positional modifiers in adults with obstructive sleep apnoea, obstructive sleep apnoea/OHS and COPD-OSAHS overlap syndrome.

OHS

No evidence identified for improving adherence of CPAP and non-invasive ventilation (NIV) in OHS.

COPD-OSAHS overlap syndrome

No evidence identified for improving adherence of CPAP and non-invasive ventilation (NIV) in COPD-OSAHS overlap syndrome.

See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E and GRADE tables in appendix F.

1.4.2. Excluded studies

See the excluded studies list in appendix H.

1.4.3. Summary of clinical studies included in the evidence review

Table 2. Summary of studies included in the evidence review for CPAP.

Table 2

Summary of studies included in the evidence review for CPAP.

See appendix D for full evidence tables.

1.4.4. Quality assessment of clinical studies included in the evidence review

Table 3. Clinical evidence summary: Behavioural therapy + CPAP versus control + CPAP- Severe OSAHS.

Table 3

Clinical evidence summary: Behavioural therapy + CPAP versus control + CPAP- Severe OSAHS.

Table 4. Clinical evidence summary: Educational interventions + CPAP versus usual care + CPAP- Severe OSAHS.

Table 4

Clinical evidence summary: Educational interventions + CPAP versus usual care + CPAP- Severe OSAHS.

Table 5. Clinical evidence summary: Increased practical support and encouragement during follow-up + CPAP versus usual care + CPAP - Severe OSAHS.

Table 5

Clinical evidence summary: Increased practical support and encouragement during follow-up + CPAP versus usual care + CPAP - Severe OSAHS.

Table 5. Clinical evidence summary: Mixed (SUP/EDU/BEH) Intervention + CPAP versus Usual Care + CPAP - Severe OSAHS.

Table 5

Clinical evidence summary: Mixed (SUP/EDU/BEH) Intervention + CPAP versus Usual Care + CPAP - Severe OSAHS.

See appendix F for full GRADE tables.

1.5. Economic evidence

1.5.1. Included studies

No health economic studies were included.

1.5.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in appendix G.

1.5.3. Health economic modelling

Original modelling was not prioritised for this question.

1.5.4. Health economic evidence statements

No relevant economic evaluations were identified.

1.6. The committee’s discussion of the evidence

1.6.1. Interpreting the evidence

1.6.1.1. The outcomes that matter most

The committee considered the outcomes of proportion adherent >4hrs/night for CPAP/non-invasive ventilation, adherence in hours/night for CPAP and oral devices, self-reported adherence, quality of life and mortality as critical outcomes for decision making. Other important outcomes included , sleepiness scores (e.g. Epworth), apnoea-Hypopnoea index (AHI) or respiratory disturbance index, oxygen desaturation index , mood or anxiety, withdrawals, treatment related withdrawals, CO2 control, minor adverse effects of treatment, driving outcomes, neurocognitive outcomes and impact on co-existing conditions:HbA1c for diabetes, cardiovascular events for cardiovascular disease and systolic blood pressure for hypertension.

No evidence was identified for the outcomes of mortality, mood or anxiety, neurocognitive outcomes and impact on co-existing conditions: HbA1c for diabetes, cardiovascular events for cardiovascular disease and systolic blood pressure for hypertension for the OSAHS population.

1.6.1.2. The quality of the evidence
OSAHS
CPAP

The quality of the evidence for interventions to improve usage of CPAP in adults with OSAHS varied from moderate to very low quality; majority of the evidence was downgraded due to risk of bias, inconsistency, indirectness and imprecision. Risk of bias was most commonly due to selection bias. Studies were downgraded for indirectness if they included mixed severity OSAHS. The committee also acknowledged that some uncertainty existed across the effect sizes seen within the evidence, with some confidence intervals crossing the MID thresholds or line of no effect. The committee took into account the quality of the evidence, including the uncertainty in their interpretation of the evidence.

The committee considered the clinical importance for AHI on a case by case basis, taking into consideration the baseline AHI and the improvement in severity of sleep apnoea.

There was evidence from 46 studies evaluating educational, supportive and behavioural interventions to improve use of continuous positive airway pressure in adults with obstructive sleep apnoea. Interventions in the review were classified as: educational interventions, behavioural interventions, supportive interventions and mixed interventions. There was a huge variation in the specific type of interventions used in all the categories.

Educational interventions included imparting information about CPAP treatment or about OSAHS more generally, delivered through video format, face-to-face didactic sessions, group educational sessions, written materials, or any combination of these.

There were a broad range of behavioural interventions, with a huge variation in the type (motivational interviewing, oropharyngeal exercises, audio tape with CPAP information and relaxation techniques), delivery (by psychologists, nurses/nurse counsellors) and timing of interventions (after the first session of CPAP/1 week after CPAP/1 month after CPAP).

Supportive interventions included where participants were provided with additional clinical follow-up (e.g. additional office or home-based visits, video or phone check-ins by clinical staff) or with telemonitoring equipment that facilitated self-monitoring of CPAP usage or that facilitated monitoring by clinical staff to prompt ‘as needed’ clinical follow-up.

Mixed interventions combined elements of the three previously listed intervention-types.

Most of the studies included people who are new to CPAP, and there was very little evidence available on people who have difficulty using CPAP. Studies included people with moderate and severe OSAHS.

The committee recognised the lack of evidence in people with mild sleep apnoea and in people who have difficulty using CPAP.

Positional modifiers

There was no evidence for educational, supportive and behavioural interventions to improve usage of positional modifiers in adults with OSAHS.

Oral devices

There was no evidence for educational, supportive and behavioural interventions to improve usage of oral devices in adults with OSAHS.

OHS

No evidence was identified for improving adherence of CPAP and non-invasive ventilation (NIV) in OHS.

COPD-OSAHS overlap syndrome

No evidence was identified for improving adherence of CPAP and non-invasive ventilation (NIV) in COPD-OSAHS overlap syndrome.

1.6.1.3. Benefits and harms
OSAHS
CPAP
Behavioural therapy + CPAP versus control + CPAP

The evidence suggested that there was clinically important benefit with behavioural therapy + CPAP compared to control + CPAP for the outcomes CPAP device usage (hours/night) and number of participants deemed adherent (≥ four hours/night), although there was some uncertainty around the effect estimates. The evidence suggested that there was no clinically important difference between behavioural therapy + CPAP and control + CPAP for the outcomes of withdrawal, Epworth Sleepiness Scale, AHI on treatment, and quality of life.

Educational interventions + CPAP versus usual care + CPAP

The evidence suggested that there was clinically important benefit with educational interventions + CPAP compared to usual care + CPAP for the outcomes CPAP device usage (hours/night) and number of participants deemed adherent (≥ four hours/night), although there was some uncertainty around the effect estimates. The evidence suggested that there was no clinically important difference between educational interventions + CPAP and usual care + CPAP for the outcomes of withdrawal and Epworth Sleepiness Scale.

Increased practical support and encouragement during follow-up + CPAP versus usual care + CPAP

The evidence suggested that there was clinically important benefit with supportive interventions + CPAP compared to control + CPAP for the outcomes CPAP device usage (hours/night) , , number of participants deemed adherent (≥ four hours/night), mean adherence all days (min per day) , days CPAP used > 4 hours at 3 months and systolic and diastolic blood pressure, although there was some uncertainty around the effect estimates. The evidence suggested that there was no clinically important difference between supportive interventions + CPAP and control + CPAP for the outcomes of days CPAP used > 4 hours at 12 months, CPAP use (min/night), withdrawal, Epworth Sleepiness Scale, AHI on treatment. The evidence for quality was life was inconsistent, with no difference between supportive interventions + CPAP and control + CPAP for quality of life scales SF-36, SAQLI, FOSQ and benefit for increased practical support for quality life FOSQ-10.

Mixed (educational/supportive/behavioural) intervention + CPAP versus usual care + CPAP

The evidence suggested that there was clinically important benefit with mixed interventions + CPAP compared to control + CPAP for the outcomes CPAP device usage (hours/night) and number of participants deemed adherent (≥ four hours/night), although there was some uncertainty around the effect estimates. The evidence suggested that there was no clinically important difference between mixed interventions + CPAP and control + CPAP for the outcomes of withdrawal, Epworth Sleepiness Scale, and AHI on treatment. The evidence for quality was life was inconsistent, with no difference between mixed interventions + CPAP and control + CPAP for quality of life scale FOSQ and benefit for mixed interventions for quality life FOSQ-10 and SF-36 (physical health).

Interventions to improve adherence of interventions for OSAHS- committee’s consideration of the evidence

The overall evidence suggested that all types of interventions (educational, behavioural, supportive and mixed) increased CPAP usage to varying degrees in CPAP‐naive participants with moderate to severe OSAHS. However, it was unclear from the evidence whether any of these interventions also led to meaningful improvement of daytime symptoms or quality of life. There was no evidence of harm associated with these interventions. Although there was uncertainty around the effect estimates for some of the outcomes, the committee agreed that the direction of effect on the whole was positive and the evidence base was large enough to justify a recommendation. The evidence did not show which category of interventions is best suited for individual patients. Also, optimum duration/intensity and long‐term effectiveness of these interventions were not clear from the evidence. However, the committee did not make a research recommendation on this as they did not consider it to be a priority for research recommendation.

In current practice some form of educational interventions is offered, however the content and delivery of these interventions is not consistent across all centers.

Based on the evidence and their knowledge of current practice, the committee agreed that educational or supportive interventions or a combination of these, provided by specialist staff, would help to improve adherence to CPAP. Educational interventions include providing information about OSAHS, its treatment and outcomes, which can be delivered using a variety of different sessions and formats, whereas supportive interventions involve additional clinical follow-up (for example, extra clinic visits, teleconsultations, video consultations or use of telemonitoring) to provide support. Due to the lack of standardised content of behavioural interventions, delivery of interventions (psychologists or nurses or nurse counsellors) and the difficulty in identifying the effective components within these interventions, the committee agreed not to make a make recommendation for any specific behavioural intervention.

The committee discussed that though CPAP therapy is considered as the first line treatment of moderate and severe OSAHS and for symptomatic mild OSAHS if other management such as weight loss has not been effective (see discussion of evidence for CPAP in evidence reports E and F), the uptake and adherence can be low which limits its clinical effectiveness in patients with OSAHS. The committee from their experience stated that adhering to regular use of CPAP treatment has multiple benefits including improving the quality of sleep, reducing sleepiness during waking hours, preventing vehicle accidents, improving blood pressure control and reducing the risk of cardiovascular events. Therefore, they agreed that educational/supportive interventions to improve adherence of CPAP should be offered to all patients at initiation of therapy and as required at follow-up.

Optimal adherence to CPAP therapy is conventionally considered to be 4 hours or more per night or use for an average of more than 4 hours per night for 70% or more nights. Early adherence studies focused on control of sleepiness but there is evidence that increased CPAP use of more than 5 hours a night in OSAHS benefits other aspects of health such as control of blood pressure and cardiovascular risk. However, it is recognised that people can gain some benefit from a shorter period of use and individual response is variable. People should be encouraged to maximise their CPAP use to achieve optimal control of their symptoms, underlying conditions, sleep quality and quality of life.

Although evidence was available only for moderate and severe OSAHS, the committee agreed that the recommendations would be applicable to all severities, including people with mild OSAHS.

The committee stated that the choice of these interventions should be tailored to match individual patient needs. The committee agreed it is more helpful to focus on the content of the intervention rather than the specific type of intervention.

The committee highlighted the importance of timing of the delivery of CPAP education and support; they agreed that the initial contact and information session is a critical component in CPAP uptake and adherence.

The committee agreed that the recommendations reflect best practice, but current provision varies across NHS settings. Therefore, the recommendations will involve a change of practice for some providers.

The committee also discussed the importance of staff being appropriately trained to offer these interventions. They discussed that a low ratio of patients to staff should be maintained to allow individualised input but agreed that staffing issues are outside the remit of this guideline.

There was no evidence available for improving adherence for oral devices and positional modifiers in OSAHS; however, the committee agreed that the educational/supportive interventions for improving adherence for CPAP could be generalised for oral devices and positional modifiers as well.

There was no evidence for improving adherence in people who have difficulty using CPAP. The committee hence made a research recommendation for people who continue to find CPAP difficult to use despite having received some education from trained sleep professionals, access to support in the early adaptation period and/or clinical review to optimise aspects such as machine pressure, mask fit and humidification (Appendix I).

OHS

The committee agreed that the interventions to improve use of CPAP/non-invasive ventilation could be offered in people with OHS as the evidence for OSAHS population could be extrapolated to this population. The committee noted that the recommendations reflect best practice but are currently implemented to varying degrees across NHS settings and will involve a change of practice for some providers.

COPD-OSAHS overlap syndrome

The committee agreed that the interventions to improve use of CPAP/non-invasive ventilation could be offered in people with COPD-OSAHS overlap syndrome as the evidence for OSAHS population could be extrapolated to this population. The committee noted that the recommendations reflect best practice but are currently implemented to varying degrees across NHS settings and will involve a change of practice for some providers.

1.6.2. Cost effectiveness and resource use

There were no economic evaluations identified for this review question.

There was clinically important benefit for educational, supportive, behavioural and a mixture of these strategies for improving device usage (hours per night). There was also some evidence of better blood pressure control. The evidence for improvement in quality of life was mixed but from their experience, the committee explained that quality of life gains associated with using CPAP and other interventions could only be achieved and sustained if the device was used regularly. Poor adherence could lead to interventions no longer being cost-effective. The committee therefore agreed that providing education and support was reasonable because they can improve adherence and contribute to the cost-effectiveness of the intervention.

The provision of education and support is current practice for people who are newly provided with CPAP. This has traditionally been provided in the form of sleep specialist (usually nurse or physiologist)-led outpatient appointments but is now most likely to be conducted remotely. People receive their first outpatient appointment for CPAP when collecting the device. During this appointment people requiring CPAP receive advice and are educated on how to use their new device e.g. cleaning, plus are fitted with an appropriate mask and taught how to ensure the mask is on properly to avoid leaks. They have reminders of the importance of using the device regularly. This appointment when initiating people with CPAP is deemed to be important by the committee because they explained early encouragement and successful adherence is an important factor on whether people will be compliant over a longer time horizon. The provision of information is then typically provided again during a follow-up sleep specialist outpatient appointment 1 month after initiation with CPAP and then per annum thereafter. It is important to note that provision of education and advice are incorporated into these appointments, but they are not exclusively for providing education and support. For example, during the same appointment sleep specialist would explore whether people with OSAHS have adequate control of their symptoms and whether further assistance is required to improve symptoms (e.g. changing mask types, increasing machine pressure) and download data on adherence from the CPAP machine.

The provision of education and support is consistent with the minimum level of care all people should expect as explained in the Patient experiences guideline (CG138). It was therefore agreed provision of education and support should also be extended to people receiving positional modifiers or oral devices for OSAHS and CPAP or non-invasive ventilation for (COPD-OSAHS overlap syndrome and OHS). As these recommendations are consistent with what occurs in current practice, a significant resource impact is not expected due to these recommendations.

The committee noted that providing intensive behavioural interventions as described in some of the clinical studies would be quite costly. Due to the lack of cost effectiveness evidence and a concern that behavioural interventions could be interpreted in different ways (which would increase variation in practice) the committee opted to not make a recommendation for this intervention. Finally, in those people who have difficulty with using the device, the committee decided to make a research recommendation to explore a range of strategies (including behavioural strategies) that could be utilised to improve adherence.

References

1.
Aardoom JJ, Loheide-Niesmann L, Ossebaard HC, Riper H. Effectiveness of eHealth interventions in improving treatment adherence for adults with obstructive sleep apnea: Meta-analytic review. Journal of Medical Internet Research. 2020; 22(2):e16972 [PMC free article: PMC7055847] [PubMed: 32130137]
2.
Aloia M, Harrington J, Cartwright A, Goelz K, Edinger JD, Lee-Chiong T. Personalized video to improve adherence to PAP therapy. Sleep. 2013; 36(Suppl):A407–A408
3.
Aloia MS, Arnedt JT, Strand M, Millman RP, Borrelli B. Motivational enhancement to improve adherence to positive airway pressure in patients with obstructive sleep apnea: A randomized controlled trial. Sleep. 2013; 36(11):1655–1662 [PMC free article: PMC3792382] [PubMed: 24179298]
4.
Aloia MS, Di Dio L, Ilniczky N, Perlis ML, Greenblatt DW, Giles DE. Improving compliance with nasal CPAP and vigilance in older adults with OAHS. Sleep & Breathing. 2001; 5(1):13–21 [PubMed: 11868136]
5.
Askland K, Wright L, Wozniak DR, Emmanuel T, Caston J, Smith I. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD007736. DOI: 10.1002/14651858.CD007736.pub3. [PMC free article: PMC7137251] [PubMed: 32255210] [CrossRef]
6.
Bague-Cruz A, Esteller E. Pneumotoning (oropharyngeal and pulmonary exercises, electrical stimulation and manual therapy) to improve the continuous positive airway pressure’s compliance in patients with obstructive sleep apnea-hipopnea. A pilot study. European Respiratory Journal. 2014; 44(Suppl 58):4678
7.
Bague A. Pneumotoning (oropharyngeal and pulmonary exercises, electrical stimulation and manual therapy) to improve the CPAP compliance in patients with obstructive sleep apnea-hypopnea. A pilot study. Somnologie. 2015; 19(Suppl 1):38
8.
Bakker JP, Wang R, Weng J, Aloia MS, Toth C, Morrical MG et al. Motivational enhancement for increasing adherence to CPAP: A randomized controlled trial. Chest. 2016; 150(2):337–345 [PMC free article: PMC4980541] [PubMed: 27018174]
9.
Bartlett D, Wong K, Richards D, Moy E, Espie CA, Cistulli PA et al. Increasing adherence to obstructive sleep apnea treatment with a group social cognitive therapy treatment intervention: A randomized trial. Sleep. 2013; 36(11):1647–1654 [PMC free article: PMC3792381] [PubMed: 24179297]
10.
Basoglu OK, Midilli M, Midilli R, Bilgen C. Adherence to continuous positive airway pressure therapy in obstructive sleep apnea syndrome: Effect of visual education. Sleep & Breathing. 2012; 16(4):1193–1200 [PubMed: 22167633]
11.
Berger M, Barthelemy J, Hupin D, Labeix P, Donnat M, Iddir H et al. A supervised community physical activity program as an effective treatment in moderate obstructive sleep apnea: A randomized controlled trial. American Journal of Respiratory and Critical Care Medicine. 2018; 197:A4395
12.
Berry RB, Beck E, Jasko JG. Effect of cloud-based sleep coaches on positive airway pressure adherence. Journal of Clinical Sleep Medicine. 2020; 16(4):553–562 [PMC free article: PMC7161456] [PubMed: 32022679]
13.
Bouloukaki I, Giannadaki K, Mermigkis C, Tzanakis N, Mauroudi E, Moniaki V et al. Intensive versus standard follow up to improve continuous positive airway pressure (CPAP) compliance. 2013. Available from: https:​//clinicaltrials​.gov/ct2/show/nct02016339 Last accessed: 12/07/2019.
14.
Cartwright A, Depew A, Burleson A, Vannoni V, Simmons B, Goelz K et al. Use of a personalized video to enhance PAP adherence: Preliminary report from a randomized clinical trial. Sleep. 2017; 40(Suppl 1):A190
15.
Chen C, Wang J, Pang L, Wang Y, Ma G, Liao W. Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials. Therapeutic Advances in Chronic Disease. 2020; 10.1177/2040622320901625 [PMC free article: PMC7065282] [PubMed: 32215196] [CrossRef]
16.
Chen X, Chen W, Hu W, Huang K, Huang J, Zhou Y. Nurse-led intensive interventions improve adherence to continuous positive airway pressure therapy and quality of life in obstructive sleep apnea patients. Patient Prefer Adherence. 2015; 9:1707–1713 [PMC free article: PMC4664526] [PubMed: 26648703]
17.
Chervin RD, Theut S, Bassetti C, Aldrich MS. Compliance with nasal CPAP can be improved by simple interventions. Sleep. 1997; 20(4):284–289 [PubMed: 9231954]
18.
Cotton J, Zarrouf FA. Weekly text messaging to improve CPAP compliance: A randomized prospective trial. Sleep. 2012; 35:A165
19.
Cunali PA, Almeida FR, Santos CD, Valdrichi NY, Nascimento LS, Dal-Fabbro C et al. Mandibular exercises improve mandibular advancement device therapy for obstructive sleep apnea. Sleep & Breathing. 2011; 15(4):717–727 [PubMed: 20967571]
20.
Dantas AP, Winck JC, Figueiredo-Braga M. Adherence to APAP in obstructive sleep apnea syndrome: Effectiveness of a motivational intervention. Sleep & Breathing. 2015; 19(1):327–334 [PubMed: 24989482]
21.
Dawson JD, Yu L, Aksan NS, Tippin J, Rizzo M, Anderson SW. Feedback from naturalistic driving improves treatment compliance in drivers with obstructive sleep apnea. Proceedings of the International Driving Symposium on Human Factors in Driver Assessment, Training, and Vehicle Design. 2015; 2015:30–35 [PMC free article: PMC4673965] [PubMed: 26658275]
22.
De Vries GE, Hoekema A, Claessen J, Stellingsma C, Stegenga B, Kerstjens H et al. Long-term objective compliance with a mandibular advancement device and continuous positive airway pressure in moderate obstructive sleep apnea. European Respiratory Journal. 2018; 52(Suppl 62):OA5373
23.
De Vries GE, Hoekema A, Wijkstra PJ. Objective compliance with oral appliance therapy versus CPAP in moderate obstructive sleep apnea. European Respiratory Journal. 2017; 50(Suppl 61):PA4725
24.
DeMolles DA, Sparrow D, Gottlieb DJ, Friedman R. A pilot trial of a telecommunications system in sleep apnea management. Medical Care. 2004; 42(8):764–769 [PubMed: 15258478]
25.
Deng T, Wang Y, Sun M, Chen B. Stage-matched intervention for adherence to CPAP in patients with obstructive sleep apnea: A randomized controlled trial. Sleep & Breathing. 2013; 17(2):791–801 [PubMed: 22945541]
26.
Diaferia G, Santos-Silva R, Truksinas E, Haddad FLM, Santos R, Bommarito S et al. Myofunctional therapy improves adherence to continuous positive airway pressure treatment. Sleep & Breathing. 2017; 21(2):387–395 [PubMed: 27913971]
27.
Epstein L, Graham L, Turner A, larkin E, Garshick E, Ayas N. Comparison of two methods for achieving CPAP compliance. American Journal of Respiratory and Critical Care Medicine. 2000; 161:A358
28.
Escourrou P, Durand-Zaleski I, Charrier N, Agostini H, Alfandary D, Orvoen-Frija E et al. Respiradom: A telemedicine system for the follow-up of patients with Sleep Apnea Syndrome. Journal of Sleep Research. 2012; 21(Suppl 1):50
29.
Falcone VA, Damiani MF, Quaranta VN, Capozzolo A, Resta O. Polysomnograph chart view by patients: A new educational strategy to improve CPAP adherence in sleep apnea therapy. Respiratory Care. 2014; 59(2):193–198 [PubMed: 23920211]
30.
Fox N, Hirsch-Allen AJ, Goodfellow E, Wenner J, Fleetham J, Ryan CF et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: A randomized controlled trial. Sleep. 2012; 35(4):477–481 [PMC free article: PMC3296789] [PubMed: 22467985]
31.
Garbuio SA, Dal-Fabbro C, Veloso FB, Zamin LK, Bittencourt LR. Compliance to the continuous positive airway pressure and oral appliances in the same sample of obstructive sleep apnea syndrome patients. Sleep. 2008; 31(Suppl):A183
32.
Gauthier L, Laberge L, Beaudry M, Laforte M, Rompre PH, Heinzer R et al. Follow-up study of two mandibular advancement appliances: Preliminary results. Sleep & Breathing. 2010; 14(3):278–279
33.
Guralnick AS, Balachandran JS, Szutenbach S, Adley K, Emami L, Mohammadi M et al. Educational video to improve CPAP use in patients with obstructive sleep apnoea at risk for poor adherence: A randomised controlled trial. Thorax. 2017; 72(12):1132–1139 [PubMed: 28667231]
34.
Hanger KL. Use of telemedicine to improve CPAP non-adherence in patients with obstructive sleep apnea, a pilot study. 2018; Doctor of Nursing Practice (DNP) Final Clinical Projects. 22
35.
Harris DL, Nielsen DB, Densley A, Caldwell M, Muhlestein J, Bradshaw D. CPAP compliance > 4 hours per night in the CPAP utilization development from directed learning, education and supervision (CUDDLES) study. Sleep. 2014; 37:A119–A120
36.
Hoet F, Libert W, Sanida C, Van den Broecke S, Bruyneel AV, Bruyneel M. Telemonitoring in continuous positive airway pressure-treated patients improves delay to first intervention and early compliance: A randomized trial. Sleep Medicine. 2017; 39:77–83 [PubMed: 29157591]
37.
Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? American Journal of Respiratory and Critical Care Medicine. 1999; 159(4 Pt 1):1096–1100 [PubMed: 10194151]
38.
Hui DS, Chan JK, Choy DK, Ko FW, Li TS, Leung RC et al. Effects of augmented continuous positive airway pressure education and support on compliance and outcome in a Chinese population. Chest. 2000; 117(5):1410–1416 [PubMed: 10807830]
39.
Hwang D, Chang JW, Benjafield AV, Crocker ME, Kelly C, Becker KA et al. Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial. American Journal of Respiratory and Critical Care Medicine. 2018; 197(1):117–126 [PubMed: 28858567]
40.
Isetta V, Leon C, Embid C, Duran-Cantolla J, Campos-Rodriguez F, Galdeano M et al. Telemedicine-based strategy in the management of sleep apnea: A multicenter randomized controlled trial. American Journal of Respiratory and Critical Care Medicine. 2014; 189:A6358
41.
Isetta V, Negrin MA, Monasterio C, Masa JF, Feu N, Alvarez A et al. A bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: A multicentre randomised controlled trial. Thorax. 2015; 70(11):1054–1061 [PubMed: 26310452]
42.
Kataria LV, Sundahl CA, Skalina LM, Shah M, Pfeiffer MH, Balish MS et al. Annie: The veterans health administration’s personalized text message application promotes compliance with positive airway pressure. Sleep. 2017; 40(Suppl 1):A196
43.
Kotzian ST, Saletu MT, Schwarzinger A, Haider S, Spatt J, Kranz G et al. Proactive telemedicine monitoring of sleep apnea treatment improves adherence in people with stroke- a randomized controlled trial (HOPES study). Sleep Medicine. 2019; 64:48–55 [PubMed: 31670004]
44.
Lai A, Fong D, Lam J, Ip M. Long-term efficacy of an education programme in improving adherence with continuous positive airway pressure treatment for obstructive sleep apnoea. Hong Kong Medical Journal. 2017; 23 Suppl 2(3):24–27 [PubMed: 29938667]
45.
Lai AYK. Education programme on continuous positive airway pressure treatment. 2014. Available from: https:​//clinicaltrials​.gov/ct2/show/nct01173406 Last accessed: 12/07/2019.
46.
Lai AYK, Fong DYT, Lam JCM, Weaver TE, Ip MSM. The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: A randomized controlled trial. Chest. 2014; 146(3):600–610 [PubMed: 24810282]
47.
Lewis KE, Bartle IE, Watkins AJ, Seale L, Ebden P. Simple interventions improve re-attendance when treating the sleep apnoea syndrome. Sleep Medicine. 2006; 7(3):241–247 [PubMed: 16564210]
48.
Lopez-Martin S, Sanchez-Munoz G, Gonzalez-Moro JMR, de Miguel-Diez J, Pedraza-Serrano F, de Lucas-Ramos P. CPAP treatment compliance in patients with obstructive sleep apnea syndrome (OSAS) does it improve when the treatment is inhaled under supervision. Proceedings of the American Thoracic Society. 2005; 2:C29
49.
Lugo VM, Garmendia O, Suarez-Giron M, Torres M, Vazquez-Polo FJ, Negrin MA et al. Comprehensive management of obstructive sleep apnea by telemedicine: Clinical improvement and cost-effectiveness of a Virtual Sleep Unit. A randomized controlled trial. PloS One. 2019; 14(10):e0224069 [PMC free article: PMC6812794] [PubMed: 31647838]
50.
Luyster FS, Aloia MS, Buysse DJ, Dunbar-Jacob J, Martire LM, Sereika SM et al. A couples-oriented intervention for positive airway pressure therapy adherence: A pilot study of obstructive sleep apnea patients and their partners. Behavioral Sleep Medicine. 2018:1–12 [PMC free article: PMC6261795] [PubMed: 29388827]
51.
Marques S, Bento AR, Monteiro S, Gralho A, Silva F, Duarte M et al. The impact of a telemedicine monitoring on positive airway pressure in naive obstructive sleep apnea patients’ outcomes: A randomized controlled trial. Sleep Medicine. 2017; 40(Suppl 1):e83
52.
Marshall MJ, Scammels C, Lowe S. Does proactive intervention influence compliance on continuous positive airway pressure therapy (CPAP)?. Respiratory Care. 2003; 48(11):1094
53.
Mendelson M, Vivodtzev I, Tamisier R, Laplaud D, Dias-Domingos S, Baguet JP et al. CPAP treatment supported by telemedicine does not improve blood pressure in high cardiovascular risk OSA patients: A randomized, controlled trial. Sleep. 2014; 37(11):1863–1870 [PMC free article: PMC4196069] [PubMed: 25364081]
54.
Meurice JC, Ingrand P, Portier F, Arnulf I, Rakotonanahari D, Fournier E et al. A multicentre trial of education strategies at CPAP induction in the treatment of severe sleep apnoea-hypopnoea syndrome. Sleep Medicine. 2007; 8(1):37–42 [PubMed: 17157557]
55.
Moore WR, Olson EJ, Vickers Douglas K, Dierkhising RA, Sikkink VK, Heim-Penokie PC et al. Can video based positive airway pressure (PAP) education impact acceptance, self efficacy and adherence to PAP in the management of obstructive sleep apnea? Sleep. 2012; 35(Suppl):A170
56.
Munafo D, Hevener W, Crocker M, Willes L, Sridasome S, Muhsin M. A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacy when compared to standard of care. Sleep & Breathing. 2016; 20(2):777–785 [PMC free article: PMC4850183] [PubMed: 26754933]
57.
Murase K, Tanizawa K, Minami T, Matsumoto T, Tachikawa R, Takahashi N et al. A randomized controlled trial of telemedicine for long-term sleep apnea CPAP management Annals of the American Thoracic Society. 2020; 17(3):329–337 [PubMed: 31689141]
58.
Murphie P, Paton R, Little S. Non-invasive ventialtion (NIV)-Our experience of telemonitoring in a remote and rural Service. European Respiratory Journal. 2016; 48(Suppl 60):PA3710
59.
Nadeem R, Rishi MA, Srinivasan L, Copur AS, Naseem J. Effect of visualization of raw graphic polysomnography data by sleep apnea patients on adherence to CPAP therapy. Respiratory Care. 2013; 58(4):607–613 [PubMed: 22906794]
60.
National Institute for Health and Care Excellence. Developing NICE guidelines: the manual [Updated 2018]. London. National Institute for Health and Care Excellence, 2014. Available from: http://www​.nice.org.uk​/article/PMG20/chapter​/1%20Introduction%20and%20overview [PubMed: 26677490]
61.
Nilius G, Schroeder M, Domanski U, Tietze A, Schafer T, Franke KJ. Telemedicine improves continuous positive airway pressure adherence in stroke patients with obstructive sleep apnea in a randomized trial. Respiration. 2019; 98(5):410–420 [PubMed: 31390641]
62.
Olsen S, Smith SS, Oei TP, Douglas J. Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: A randomized controlled trial. Journal of Consulting and Clinical Psychology. 2012; 80(1):151–163 [PubMed: 22103957]
63.
Ong JC, Crawford MR, Dawson SC, Fogg LF, Turner AD, Wyatt JK et al. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: Main outcomes from the MATRICS study. Sleep. 2020; 43(1):zsaa041 [PMC free article: PMC7487869] [PubMed: 32170307]
64.
Parthasarathy S, Wendel C, Haynes PL, Atwood C, Kuna S. A pilot study of CPAP adherence promotion by peer buddies with sleep apnea. Journal of Clinical Sleep Medicine. 2013; 9(6):543–550 [PMC free article: PMC3659373] [PubMed: 23772186]
65.
Pengo MF, Czaban M, Berry MP, Nirmalan P, Brown R, Birdseye A et al. The effect of positive and negative message framing on short term continuous positive airway pressure compliance in patients with obstructive sleep apnea. Journal of Thoracic Disease. 2018; 10(Suppl 1):S160–S169 [PMC free article: PMC5803053] [PubMed: 29445540]
66.
Pepin JL, Jullian-Desayes I, Sapene M, Treptow E, Joyeux-Faure M, Benmerad M et al. Multimodal remote monitoring of high cardiovascular risk patients with osa initiating CPAP: A randomized trial Chest. 2019; 155(4):730–739 [PubMed: 30472022]
67.
Pepin JLD, Woehrle H, Liu D, Shao S, Armitstead JP, Cistulli PA et al. Adherence to positive airway therapy after switching from CPAP to ASV: A big data analysis. Journal of Clinical Sleep Medicine. 2018; 14(1):57–63 [PMC free article: PMC5734894] [PubMed: 29198291]
68.
Quintela MM, Uechi CH, Pacheco Filho F. Evaluation of initial patient adherence to use of a trial-appliance for obstructive sleep apnea therapy. Sleep Medicine. 2009; 10:S77
69.
Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: A randomized trial. Sleep. 2007; 30(5):635–640 [PubMed: 17552379]
70.
Rodgers B, Brown LK, Lopez S, Glasser J. Increased engagement and adherence in adults with obstructive sleep apnea. Sleep. 2015; 38:A182
71.
Roecklein KA, Schumacher JA, Gabriele JM, Fagan C, Baran AS, Richert AC. Personalized feedback to improve CPAP adherence in obstructive sleep apnea. Behavioral Sleep Medicine. 2010; 8(2):105–112 [PubMed: 20352546]
72.
Sarac S, Afsar GC, Oruc O, Topcuoglu OB, Salturk C, Peker Y. Impact of patient education on compliance with positive airway pressure treatment in obstructive sleep apnea. Medical Science Monitor. 2017; 23:1792–1799 [PMC free article: PMC5398328] [PubMed: 28406882]
73.
Sawyer AM, King TS, Weaver TE, Sawyer DA, Varrasse M, Franks J et al. A Tailored Intervention for PAP Adherence: The SCIP-PA Trial. Behavioral Sleep Medicine. 2019; 17(1):49–69 [PMC free article: PMC5529283] [PubMed: 28128977]
74.
Scala D, Starace A, Lembo L, de Falco F, Niola M, Lisi R et al. Therapeutic patient education program for patient with Obstructive Sleep Apnea Syndrome (OSAS): Preliminary results. Bollettino della Società Italiana di Farmacia Ospedaliera. 2012; 59(5):195–201
75.
Schiefelbein J. Internet interventions for older persons with obstructive sleep apnea: Preparedness and problem-solving confidence. Kansas, K.S. University of Kansas. 2005
76.
Schoch OD, Baty F, Boesch M, Benz G, Niedermann J, Brutsche MH. Telemedicine for continuous positive airway pressure in sleep apnea: A randomized, controlled study. Annals of the American Thoracic Society. 2019; 16(12):1550–1557 [PubMed: 31310575]
77.
Sedkaoui K, Leseux L, Pontier S, Rossin N, Leophonte P, Fraysse JL et al. Efficiency of a phone coaching program on adherence to continuous positive airway pressure in sleep apnea hypopnea syndrome: A randomized trial. BMC Pulmonary Medicine. 2015; 15:102 [PMC free article: PMC4570038] [PubMed: 26370444]
78.
Shapiro AL. Effect of the CPAP-SAVER intervention on adherence. Clinical Nursing Research. 2019; 10.1177/1054773819865875 [PubMed: 31387377] [CrossRef]
79.
Sheets V, Maerz R, Johnston W, Magalang U, Firestone A. Increasing adherence to mandibular advancement devices for obstructive sleep apnea. Sleep. 2019; 42 (Suppl 1):A396–A397
80.
Singhal P, Joshi Y, Singh G, Kulkarni S. Study of factors affecting compliance of continuous positive airway pressure (CPAP) in obstructive sleep apnea-hypopnea syndrome (OSAHS). European Respiratory Journal. 2016; 48(Suppl 60):PA2362
81.
Smith CE, Dauz E, Clements F, Werkowitch M, Whitman R. Patient education combined in a music and habit-forming intervention for adherence to continuous positive airway (CPAP) prescribed for sleep apnea. Patient Education and Counseling. 2009; 74(2):184–190 [PMC free article: PMC2653854] [PubMed: 18829212]
82.
Smith CE, Dauz ER, Clements F, Puno FN, Cook D, Doolittle G et al. Telehealth services to improve nonadherence: A placebo-controlled study. Telemedicine and e-Health. 2006; 12(3):289–296 [PubMed: 16796496]
83.
Soares Pires F, Drummond M, Marinho A, Sampaio R, Pinto T, Goncalves M et al. Effectiveness of a group education session on adherence with APAP in obstructive sleep apnea--a randomized controlled study. Sleep & Breathing. 2013; 17(3):993–1001 [PubMed: 23179140]
84.
Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: A randomised controlled trial. Thorax. 2010; 65(12):1061–1066 [PubMed: 20880872]
85.
Stepnowsky C, Edwards C, Zamora T, Barker R, Agha Z. Patient perspective on use of an interactive website for sleep apnea. International Journal of Telemedicine & Applications. 2013; 2013:239382 [PMC free article: PMC3612462] [PubMed: 23573081]
86.
Stepnowsky CJ, Palau JJ, Marler MR, Gifford AL. Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea. Journal of Medical Internet Research. 2007; 9(2):e14 [PMC free article: PMC1874716] [PubMed: 17513285]
87.
Suarez MC, Garmendia O, Lugo VM, Moraleda A, Farre R, Guerrero G et al. Simple telemedicine intervention to improve CPAP compliance on OSA patients to minimal (>4 h) and optimal (> 5.5 h) use: study design (CPAP-rescue). Sleep Medicine. 2017; 40(Suppl 1):e317
88.
Sweetman A, Lack L, Catcheside PG, Antic NA, Smith S, Chai-Coetzer CL et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019; 42(12):24 [PubMed: 31403168]
89.
Tatousek J, Lacroix J, Visser T, Teuling N. Promoting adherence to CPAP with tailored education and feedback: a randomized controlled clinical trial. Sleep. 2015; 38:A182
90.
Taylor Y, Eliasson A, Andrada T, Kristo D, Howard R. The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome. Sleep & Breathing. 2006; 10(3):132–138 [PubMed: 16565867]
91.
Tolson J, Miles JC, Bartlett DJ, Barnes M, Jackson ML. An intensive CPAP program to improve treatment adherence and self-efficacy in patients with obstructive sleep apnea. Sleep. 2016; 39:A150–A151
92.
Turino C, de Batlle J, Woehrle H, Mayoral A, Castro-Grattoni AL, Gomez S et al. Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea. European Respiratory Journal. 2017; 49(2):1601128 [PubMed: 28179438]
93.
Vanderveken OM, Dieltjens M, De Backer WA, Van De Heyning PH, Braem MJ. Comparison of subjective and objective measures of oral appliance compliance during treatment of sleep-disordered breathing. Sleep & Breathing. 2011; 15(2):259–260
94.
Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van de Heyning PH, Braem MJ. Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax. 2013; 68(1):91–96 [PMC free article: PMC3534260] [PubMed: 22993169]
95.
Wang Y, Gao W, Sun M, Chen B. Adherence to CPAP in patients with obstructive sleep apnea in a Chinese population. Respiratory Care. 2012; 57(2):238–243 [PubMed: 21762553]
96.
Wiese HJ, Boethel C, Phillips B, Peters J, Viggiano T. CPAP compliance: Video education may help!. Chest. 2002; 122:P256
97.
Yoshioka Y, Yamamoto U, Tsuda H, Handa S, Yoshimura C, Tokunoh T et al. The factors that affect to the better compliance of mandibular advancement device when compared with continuous positive airway pressure in the patients with moderate to severe sleep apnea syndrome. Sleep Medicine. 2017; 40(Suppl 1):e357–e358

Appendices

Appendix A. Review protocols

Table 6. Review protocol: adherence (PDF, 415K)

Table 7. Health economic review protocol (PDF, 196K)

Appendix B. Literature search strategies

Sleep Apnoea search strategy 1_adherence

This literature search strategy was used for the following review;

  • What support improves adherence to CPAP or other interventions?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.60

For more information, please see the Methods Report published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy (PDF, 303K)

B.2. Health Economics literature search strategy (PDF, 345K)

Appendix C. Clinical evidence selection

Figure 1. Flow chart of clinical study selection for the review of adherence (PDF, 154K)

Appendix D. Clinical evidence tables

Download PDF (468K)

Appendix E. Forest plots

E.1. Adherence for CPAP (PDF, 521K)

Appendix G. Health economic evidence selection

Figure 31. Flow chart of health economic study for the guideline (PDF, 210K)

Appendix H. Excluded studies

H.2. Excluded health economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2003 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below:

None.

Appendix I. Research recommendations

I.1. Interventions to improve CPAP adherence (PDF, 130K)

Final

Intervention evidence review

Developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2021.
Bookshelf ID: NBK574320PMID: 34613679

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