APAP Treatment Acceptance Rate and Cost-Effectiveness of Telemedicine in Patients with Obstructive Sleep Apnea: A Randomized Controlled Trial

Figures & data

Figure 1 Study flowchart.

Abbreviations: HST, Home Sleep Apnea Test; OSA, Obstructive sleep apnea; APAP, Auto-adjusted positive airway pressure.

Table 1 Baseline Characteristics

	Control (N=31)	Telemedicine (N=26)	P
Age (years)	42.02±10.98	37.85±12.39	0.182
BMI (kg/m^2)	26.29±3.85	28.69±4.64	0.037
Home address			0.452
City	22 (71%)	16 (61.5%)
Outside the city	9 (29%)	10 (38.5%)
Type of medical insurance expense			0.054
At one’s own expense	20 (66.7%)	23 (88.5%)
Medical insurance	10 (33.3%)	3 (11.5%)
Route of visit			0.624
Take the initiative to see a doctor	17 (54.8%)	15 (57.7%)
Family members urge them to see a doctor	9 (29%)	8 (30.8%)
Friend’s suggestion	2 (6.5%)	0
Other department doctors recommend	3 (9.7%)	3 (11.5%)
Male	24 (77.4%)	23 (88.5%)	0.275
Educational level			0.582
Below junior high school	2 (6.5%)	0
Secondary school level	8 (25.8%)	6 (23.1%)
Junior college	6 (19.4%)	5 (19.2%)
Bachelor’s degree or above	15 (48.4%)	15 (57.7%)
Working state			0.345
On the job	26 (83.9%)	23 (95.8%)
Retired	4 (12.9%)	1 (4.2%)
Unfixed work	1 (3.2%)	0
Per capita monthly household income (yuan)			0.324
<2000	0	2 (8%)
2000–3999	3 (9.7%)	1 (4%)
4000–5999	4 (12.9%)	2 (8%)
>6000	24 (77.4%)	19 (76%)
Smoking	12 (38.7%)	9 (34.6%)	0.75
Drinking alcohol	17 (54.8%)	17 (65.4%)	0.419
Drinking tea	25 (80.6%)	21 (80.8%)	0.991
Systemic hypertension	12 (38.7%)	8 (30.8%)	0.532
Diabetes mellitus	0	4 (15.4%)	0.024
Rhinitis / Sinusitis	8 (25.8%)	7 (26.9%)	0.924

Abbreviation: BMI, body mass index.

Table 2 Acceptance Rate of APAP Treatment and Home Stress Titration

	Control	Telemedicine	P
Receive a home stress titration	19 (61.3%)	15 (57.7%)	0.783
Receive APAP treatment	17 (54.8%)	15 (57.7%)	0.829

Abbreviation: APAP, Auto-adjusted positive airway pressure.

Table 3 Comparison of Change from Baseline in Questionnaire Scores Between the Telemedicine and Control Groups

	Control		Telemedicine		LS mean Difference*,^†	95% CI		P
	Baseline N=31	Follow-Up N=17	Baseline N=26	Follow-Up N=14	(Telemedicine Minus Control)	Lower	Upper
PSQI	7.23±3.06	4.27±0.29	6.46±2.70	3.82±0.32	−0.446	−0.449	1.34	0.316
ISI	5.68±4.92	2.71±0.48	4.81±4.46	3.06±0.54	0.347	−1.143	1.837	0.637
ESS	8.94±4.94	2.76±0.38	9.23±4.44	2.94±0.42	0.179	−0.984	1.342	0.755
FSS	36.97±15.33	23.48±1.49	37.38±14.04	24.99±1.64	1.513	−3.051	6.077	0.503
Short SAQLI	20.87±16.03	8.75±1.25	26.23±14.66	8.02±1.37	−0.736	−4.534	3.061	0.694
EQ-5D
EQ-5D	0.83±0.08	0.87±0.11	0.81±0.07	0.85±0.12	−0.03	−0.09	0.03	0.42
EQ VAS	70.28±11.23	71.32±20.2	76.38±10.22	81.23±12.21	−6.23	−17.32	1.72	0.133

Notes: *Analysis is based on an ANCOVA model for change from baseline in the adherence to continuous positive airway pressure (CPAP) treatment variables as response and with treatment group as a factor along with baseline adherence to CPAP treatment variables as covariates. ^†LS mean: least square mean for the change from baseline in the adherence to CPAP treatment variables in the ANCOVA model.

Abbreviations: ANCOVA, analysis of covariance; PQSI, Pittsburgh Sleep Quality Index; ISI, Insomnia Severity Index; ESS, Epworth Sleepiness Scale; FSS, Fatigue Severity Scale; short SAQLI, short Sleep Apnea Quality of Life Index; EQ-5D, EuroQol five-dimensional health scale; EQ VAS, EuroQol Visual Analogue Scale.

Table 4 Comparison of Typical OSA Symptoms Between the Telemedicine and Control Groups

	Control		Telemedicine		OR (Telemedicine Group Data were Reference Values)	95% CI for the OR		p value
	Baseline N(%)(N=31)	Follow-Up N(%)(N=17)	Baseline N(%)(N=26)	Follow-Up N(%)(N=14)		Lower	Upper
Snoring	31 (100)	3 (17.6)	26 (100)	1 (7.1)	0.36	0.03	3.9	0.4
Nocturnal awakening	22 (71)	6 (35.3)	20 (76.9)	4 (28.6)	0.31	0.07	1.38	0.13
Witnessed apnea	25 (80.6)	1 (5.9)	20 (76.9)	1 (7.1)	2.59	0.49	13.61	0.26
Nocturia	19 (61.3)	7 (41.2)	18 (69.2)	4 (28.6)	0.41	0.09	1.92	0.26
Daytime sleepiness	24 (77.4)	6 (35.3)	26(100)	2 (14.3)	0.19	0.03	1.11	0.04
Dry mouth in the morning	27 (87.1)	6 (35.3)	24 (92.3)	4 (28.6)	1.02	0.23	4.47	0.98
Fatigue	24 (77.4)	6 (35.3)	22 (84.6)	3 (21.4)	0.67	0.16	2.77	0.58

Table 5 Follow-Up of APAP Treatment

	1 week		P	1 month		P	3 months		P	6 months		P
	Control N=17	Telemedicine N=15		Control N=17	Telemedicine N=15		Control N=17	Telemedicine N=15		Control N=16	Telemedicine N=15
Actual usage time (days)	7.00±0.35	6.53±0.99	0.079	28.94±2.82	27.27±4.20	0.191	84.76±7.66	80.79±9.33	0.202	166.88±14.49	156.86±24.07	0.162
The number of days of use ≥ 4 h	6.76±0.56	6.13±1.51	0.118	26.82±4.35	25.00±5.75	0.316	77.38±12.91	72.71±14.47	0.359	151.00±24.83	138.21±33.78	0.235
Average time spent per night (h)	6.42±0.97	5.99±1.34	0.306	6.31±1.00	5.74±1.35	0.178	5.93±1.27	5.60±1.29	0.486	5.92±1.30	5.34±1.30	0.228
Average nightly usage time over days of use (h)	6.42±0.97	6.57±0.81	0.635	6.47±0.98	6.34±0.89	0.682	6.30±1.04	6.31±0.79	0.977	6.23±1.13	6.09±1.02	0.732
AHI after treatment (times/h)	4.1±2.1	3.3±2.5	0.293	3.7±2.1	3.2±2.5	0.581	3.7±2.2	2.6±1.5	0.132	2.8±1.4	2.5±1.4	0.536
95% pressure (cmH2O)	10.91±2.95	11.76±2.36	0.38	11.08±2.50	11.83±2.36	0.391	10.98±2.31	12.05±2.85	0.255	10.70±2.23	11.55±2.31	0.305
95% air leakage (L/min)	17.00±4.07	17.49±5.32	0.77	15.77±3.09	17.12±5.67	0.401	15.52±4.95	18.96±5.06	0.069	15.85±2.73	18.82±5.53	0.061

Abbreviation: AHI, Apnea-Hypopnea Index.

Table 6 Factors Influencing Adherence to APAP Therapy

	Adherence
	β	95% CI	P
Grouping	−8.10	(−56.06, 39.85)	0.732
Age	0.94	(−2.51, 4.40)	0.577
Gender	−33.28	(−129.79, 63.24)	0.486
BMI	−1.35	(−8.30, 5.60)	0.692
Baseline PSQI score	−7.26	(−22.73, 8.21)	0.341
Baseline ISI score	2.76	(−7.22, 12.73)	0.57
Baseline ESS score	4.46	(−2.52, 11.45)	0.02
Baseline FSS score	−1.20	(−3.36, 0.96)	0.261
Baseline short SAQLI score	0.56	(−1.92, 3.03)	0.646
AHI	−0.22	(−1.64, 1.21)	0.757

Abbreviations: BMI, body mass index; AHI, Apnea-Hypopnea Index; PQSI, Pittsburgh Sleep Quality Index; ISI, Insomnia Severity Index; ESS, Epworth Sleepiness Scale; FSS, Fatigue Severity Scale; short SAQLI, short Sleep Apnea Quality of Life Index.

Table 7 Cost Analysis

	Control	Telemedicine	P
Registration fee	40.0±16.9	37.0±7.0	0.421
Scale evaluation fee, HSAT, pressure titration fee	1682.5±50.2	1701.5±38.2	0.452
Transportation, room, and lodging fee (yuan)	497.7±887.0	104.2±144.7	0.047
Leave time (h)	10.1±12.5	3.9±6.4	0.027
Lost time expenses incurred by leave (yuan)	578.7±719.7	225.6±365.8	0.027
Doctor’s time spent (h)	2.2±0.9	7.2±27.1	0.019
Cost of doctor’s work (yuan)	166.6±74.8	542.3±2031.7	0.019

Abbreviation: HSAT, Home Sleep Apnea Test.

Table 8 Cost-Effectiveness Analysis

	Control		Telemedicine		Difference
	Mean(SD)	95% CI	Mean(SD)	95% CI	Mean(SD)	95% CI
Cost	2558.09(1520.69)	(2000.29,3115.88)	2100.25(2260.82)	(1187.08,3013.42)	−457.84(503.50)	(−551.19,1466.87)
OSA-related cost	1841.85(1108.38)	(1435.29,2248.41)	1781.42(2241.89)	(875.90,2686.94)	−60.42(457.11)	(−855.65,976.50)
QALYs	0.0893(0.0059)	(0.0828,0.0899)	0.0872(0.0056)	(0.0832,0.0895)	−0.0021(0.0029)	(−0.0024,0.0025)

Abbreviations: OSA, Obstructive sleep apnea; QALYs, quality-adjusted life years.

Table 9 Additional Interventions of Two Groups

	Control	Telemedicine	P
Number of additional interventions	0.06±0.25	0.38±0.75	0.03
Additional intervention time (min)	0.16±0.64	5.08±14.13	0.048

Table 10 Characteristics of Subjects Receiving APAP Treatment in the Telemedicine Group

	Treated	Untreated	P
Age (years)	42.53±12.60	31.45±9.14	0.021
BMI (kg/m^2)	29.87±4.78	27.09±4.11	0.134
Home address			0.031
City	8 (53.3%)	8 (72.7%)
Outside the city	7 (46.7%)	3 (27.3%)
Type of medical insurance expense			0.364
At one’s own expense	14 (93.3%)	9 (81.8%)
Medical insurance	1 (6.7%)	2 (18.2%)
Route of visit			0.85
Take the initiative to see a doctor	9 (60.0%)	6 (54.5%)
Family members urge them to see a doctor	4 (26.7%)	4 (36.4%)
Friend’s suggestion	2 (13.3%)	1 (9.1%)
Gender			0.032
Male	15 (100%)	8 (72.7%)
Female	0	3 (27.3%)
Educational level			0.035
Secondary school level	3 (33.3%)	1 (9.1%)
Junior college	2 (13.3%)	3 (27.3%)
Bachelor’s degree or above	10 (66.7%)	7 (63.6%)
Working state			0.388
On the job	13 (92.9%)	10 (100%)
retire	1 (7.1%)	0
Smoking			0.5
Yes	9 (60.0%)	8 (72.7%)
No	6 (40.0%)	3 (27.3%)
Drinking alcohol			0.873
Yes	5 (33.3%)	4 (36.4%)
No	10 (66.7%)	7 (63.6%)
Drinking tea			0.907
Yes	3 (20.0%)	2 (18.2%)
No	12 (80.0%)	9 (81.8%)
Systemic hypertension			0.234
Yes	9 (60.0%)	9 (81.8%)
No	6 (40.0%)	2 (18.2%)
Diabetes mellitus			0.735
Yes	13 (86.7%)	9 (81.8%)
No	2 (13.3%)	2 (18.2%)
Fatty liver			0.014
Yes	5 (33.3%)	9 (81.8%)
No	10 (66.7%)	2 (18.2%)
PSQI score	6.53±2.48	6.36±3.11	0.047
ISI score	5.27±4.77	4.18±4.14	0.021
ESS score	9.60±4.39	8.73±4.67	0.63
FSS score	34.13±15.27	41.82±11.35	0.173
Short SAQLI score	23.40±15.18	30.09±13.64	0.258
AHI	49.13±25.28	22.64±16.09	0.006
Mean oxygen saturation	90.20±5.12	94.00±1.89	0.028
Minimum oxygen saturation	66.93±16.70	78.45±11.18	0.049
SaO2<90% of the time(min)	95.13±92.41	21.73±30.27	0.019

Abbreviations: BMI, body mass index; AHI, Apnea-Hypopnea Index; PQSI, Pittsburgh Sleep Quality Index; ISI, Insomnia Severity Index; ESS, Epworth Sleepiness Scale; FSS, Fatigue Severity Scale; short SAQLI, short Sleep Apnea Quality of Life Index.

Data Sharing Statement

The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.