Originalien
Somnologie
DOI 10.1007/s11818-016-0098-9
Received: 13 September 2016
Accepted: 16 December 2016
© The Author(s) 2017. This article is available at
SpringerLink with Open Access.

Holger Woehrle1,2 · Joachim H. Ficker3,4 · Andrea Graml2 · Ingo Fietze5 ·Peter Young6 · Helmut Teschler7 · Michael Arzt8
1

Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
ResMed Science Center, ResMed Germany, Martinsried, Germany
3
Department of Respiratory Medicine, Allergology and Sleep Medicine, General Hospital Nuremberg,
Nuremberg, Germany
4
Paracelsus Medical University, Nuremberg, Germany
5
Centrum für Herz-Kreislauf- und Gefäßmedizin, Interdisziplinäres Schlafmedizinisches Zentrum, Charité– Universitätsmedizin Berlin, Berlin, Germany
6
Klinik für Schlafmedizin und Neuromuskuläre Erkrankungen, Universitätsklinikum Münster, Münster,Germany2

7

Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen,
University Duisburg-Essen, Essen, Germany
8
Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany

Telemedicine-based proactive
patient management during
positive airway pressure therapy
Impact on therapy termination rate

Introduction
Continuous positive airway pressure(CPAP) is the most eﬀective treatment
for obstructive sleep apnoea (OSA) andis mandated by current guidelines [1].
However, the beneﬁts of treatment cannot be realised if patients do not adhere
to prescribed therapy.
A number of diﬀerent approaches toimprove compliance with CPAP therapy have been assessed in clinical trials, including patient education [2–5],
peer support [6, 7], behavioural interventions [3, 4], clinical support [8] andchoice of equipment [9–12]. In addition, features of the healthcare systemand service/treatment delivery can havean impact on adherence [13]. Despite
this, health stakeholders have not traditionally focussed on addressing adherence issues, and there are relatively few
data on interventions to improve adherence, which in turn could improve patient
outcomes [13].
Regular follow-up by clinicians andobjective assessment of device data havebeen suggested to be essential in facilitating good compliance with CPAP therapy

for OSA [14]. However, current management of CPAP compliance is reactive.
Patients who are experiencing challenges
or diﬃculties during CPAP therapy haveto contact their healthcare provider to request assistance. Alternatively, less motivated patients might just stop using therapy altogether if there is a problem, or ifthey perceive there to be a problem.
Telemedicine is a term used todescribe the use of information andcommunications technology to deliver
healthcare at a distance [15]. It also oﬀers
the opportunity to provide quality carewithout dramatically escalating healthcare costs [16]. It is especially suited tothe management of chronic diseases that
require long-term monitoring to ensure
successful therapy [17]. Having remote
access to CPAP therapy data creates anopportunity for healthcare professionals
to intervene proactively and provide appropriate support to individual patientswith the aim of having them continue to
use PAP therapy. Remote data are usefulfor tracking CPAP adherence and canalso provide information on mask leakand residual apnoea–hypopnoea index(AHI), but there are few data on how useof these systems impacts on outcomesin OSA patients [18].
This study used data from a large German homecare provider to investigate theimpact of a proactive patient management programme supported by remote
access to PAP therapy data on therapy termination compared with standard care.

Methods
Study data were obtained from ResMed
Germany Healthcare, a German homecare provider. German data protection
law allows for the use of such data,
if anonymised, for scientiﬁc purposes.
Therefore, patient informed consent was
not necessary in this study.

Subjects
Patients who started PAP therapy for theﬁrst time between 1 September 2009 and
30 April 2014 and were being treatedwith CPAP, automatic continuous positive airway pressure (APAP), bilevel PAP
or adaptive servo-ventilation (ASV) devices, administered via a nasal mask,

Somnologie

Originalien
Table 1

Patient demographic and clinical characteristics at baselineStandard management
Proactive strategy(n = 3401)(n = 3401)

p-value

Male, n (%)

2543 (75)2527 (74)0.680

Age, years

59 ± 1359 ± 130.254

Age group, n (%)<30 years

46 (1)

44 (1)

0.920

30–40 years

210 (6)215 (6)0.840

40–50 years

601 (18)608 (18)

0.850

50–60 years

963 (28)962 (28)

1.000

60–70 years

816 (24)800 (24)0.670

70–80 years

670 (20)676 (20)0.880>80 years

95 (3)

96 (3)

1.000

Nasal

1653 (49)1659 (49)0.900

Nasal pillows

462 (14)451 (13)0.720

Full face

1286 (38)1291 (38)

0.920

CPAP

1283 (38)1272 (37)

0.800

APAP

1834 (54)1855 (55)

0.630

ASV

158 (5)157 (5)1.000

Bilevel126 (4)117 (3)0.600

Public2902 (85)2904 (85)0.970

Private499 (15)497 (15)0.970

First mask, n (%)

First device, n (%)

Insurance, n (%)*Pairwise testing was performed, level of significance p < 0.05
Values are mean ± standard deviation, or number of patients (%)
APAP automatic continuous positive airway pressure, ASV adaptive servo-ventilation, Bilevel bilevel
positive airway pressure, CPAP continuous positive airway pressure, PAP positive airway pressure
Table 2

Therapy termination rates at 1 year
Risk of therapy termination, n (%)

Overallp-valueStandard
management

Proactive strategy

Reduction in risk oftherapy termination forproactive vs. standard
management (%)

373/3401 (11.0)

185/3401 (5.4)

50.4<0.001<0.001

Male

262/2543 (10.3)

130/2527 (5.1)

50.1

Female111/858 (12.9)

55/874 (6.3)

51.4<0.001

APAP/CPAP

350/3117 (11.2)

177/3127 (5.7)

49.6<0.001

ASV/Bilevel

23/284 (8.1)

8/274 (2.9)

63.9

0.011

Public335/2902 (11.5)

163/2904 (5.6)

51.3<0.001

Private38/499 (7.6)

22/497 (4.4)

42.1

0.034

APAP automatic continuous positive airway pressure, ASV adaptive servo-ventilation, Bilevel bilevel
positive airway pressure, CPAP continuous positive airway pressure

nasal pillows or full face mask interface,were eligible for inclusion in this analysis.
Patients who had started PAP therapy ≥1 year previously were included.
Those who were managed using a proactive, telemedicine-based strategy werematched with PAP users managed using
Somnologie

standard care. Patients were excluded
from the analysis if they had terminated
PAP therapy for a reason that was not
related to PAP compliance (e. g. theirinsurer refused to cover PAP therapy,
patient death, transfer to ventilation device). The proactive and standard carecohorts were matched for gender, insurance (public versus private), age (10-year
bands), ﬁrst device used (CPAP, APAP,
bilevel PAP or ASV), therapy start date,initial interface (nasal mask, nasal pillows or full face mask) and introduction
to device and interface (in sleep laboratory, at home by the homecare provider
or at the homecare provider’s service
centre).

Patient management
Standard care for each patient varied depending on their health insurance, but
generallyincluded polygraphyafterabout
6 months and when clinically necessary
thereafter, and or patient contact withquestions about device usage. If issues
arose during PAP therapy the patient
was advised to contact his/her healthcare
provider, sleep laboratory and/or treating
physician. Depending on their insurer,
standard care patients might be contacted
at 6 months to provide device usage data.
The proactive management strategy was facilitated by data obtained
via AirView™, a cloud-based remotemonitoring system that connects wirelessly with the PAP therapy devices
used by ResMed Germany Healthcare.
If AirView™ data showed that compliance during the ﬁrst 2 weeks of PAP
therapy did not meet the required level(average <4 h/day), patients received
a telephone call from the homecare
provider. For the period from 2 weeks
to 6 months, average usage was checked
every 14 days and patients were calledagain each time continued periods of noor low (<4 h/day) usage were identiﬁed
from AirView™ data. From 6 months oftherapy onwards, patients were notiﬁed
via telephone call or letter if AirView™
data showed that PAP device usage
dropped signiﬁcantly or did not reachthe required threshold (based on theinsurance-speciﬁed usage criteria forreimbursement [approximate average of
4 h/night]). When contacted, patientswere proactively provided with detailed
information on use of their PAP therapy
device and management of side eﬀects(e. g. upper airway dryness, pressure,ulcers).

Abstract · Zusammenfassung
Somnologie DOI 10.1007/s11818-016-0098-9© The Author(s) 2017. This article is available at SpringerLink with Open Access.
H. Woehrle · J. H. Ficker · A. Graml · I. Fietze · P. Young · H. Teschler · M. Arzt

Telemedicine-based proactive patient management during positive airway pressure therapy. Impact
on therapy termination rate
Abstract
Background. Adherence to positive airway
pressure (PAP) therapy is essential for the
beneﬁts of therapy to be realised. Telemedicine-based strategies provide a new option
for enhanced monitoring and intervention topromote adherence during PAP. This study
investigated the impact of telemedicinebased proactive patient management on PAP
therapy termination rates versus standard
care.
Methods. Observational data were obtained
from ResMed Germany Healthcare, a German
homecare provider. Patients were undergoingroutine homecare using either a standard
or proactive management strategy. The
proactive strategy used data from AirView™,a cloud-based remote monitoring system,

to prompt patient contact and information
sharing/education. Patients receiving theirﬁrst PAP therapy were included and analysedin matched pairs.
Results. In all, 3401 patients were includedin each group. In the ﬁrst year of PAP
therapy, overall therapy termination rate
was signiﬁcantly lower (5.4% vs 11.0%; p <0.001) and time to therapy termination
was signiﬁcantly longer (348 ± 58 vs 337 ±76 days; p < 0.05) in the proactive versus
standard care group. Cox proportional hazard
analysis revealed a signiﬁcantly reduced riskof PAP termination in the proactive versus
the standard care group (hazard ratio 0.48,
95% conﬁdence interval 0.4–0.57). Findings
were consistent in subanalyses according togender, type of device and insurance status,
and in patients aged ≥40 years. However,in the subgroup of patients aged younger
than 40 years, the risk of PAP termination was
similar in the proactive and standard groups.
Conclusion. A telemedicine-based proactive
management strategy compared withstandard care of PAP patients was associatedwith a lower long-term therapy termination
rate.
Keywords
Monitoring, ambulatory · Health behavior ·Patient adherence · Obstructive sleep apnea ·Patient compliance

Telemedizinbasierte proaktive Versorgung von Patienten während der Positivdrucktherapie.
Auswirkungen auf die Abbruchrate
Zusammenfassung
Hintergrund. Eine ausreichende Therapieadhärenz ist erforderlich, um das therapeutische
Potenzial einer Positivdrucktherapie (PAP)
auszuschöpfen. Telemedizinbasierte
Strategien ermöglichen durch Therapiemonitoring proaktive individuelle und zeitnaheInterventionen, um die PAP-Adhärenz zu
steigern. Diese Studie untersuchte den
Einﬂuss der telemedizinbasierten proaktiven
Versorgung von Patienten mit Schlafapnoe
auf die Abbruchrate der PAP-Therapie.
Methoden. Beobachtungsdaten wurden
durch den Deutschen Homecare Provider
ResMed Healthcare bereitgestellt. Im Rahmeneines Fall-Kontroll-Designs wurden Patienten,
die erstmalig auf eine PAP-Therapie eingestellt
wurden, mit PAP-Standardversorgung undAssessments
Patient characteristics, therapy termination rates and time to therapy termination were calculated for the standard careand proactive strategy groups based ondata extracted from patient records held
by ResMed Germany Healthcare, a German homecare provider. Therapy termination was then described as compliancerelated if it occurred as the result of pa-

proaktiver PAP-Versorgung verglichen. Die
proaktive PAP-Versorgung erfolgte mit Hilfeder AirView™-Technologie, einem Cloudbasierten automatisierten Monitoringsystem,das bei Therapieproblemen einen zeitnahenproaktiven Patientenkontakt und Informationsaustausch bzw. eine Patientenschulung
einleiten kann.
Ergebnisse. In beide Gruppen wurden jeweils
3401 Patienten eingeschlossen. Innerhalb desersten Jahres nach der Einstellung auf eine
PAP-Therapie war in der Gruppe mit proaktiver
PAP-Versorgung im Vergleich zu einer PAPStandardversorgung die Abbruchrate der
PAP-Therapie signiﬁkant niedriger (5,4 % vs.
11,0 %; p < 0,001) und die durchschnittliche
Zeit bis zum Therapieabbruch signiﬁkant

tient decision or behavior, was related tocomplaints by the patient, or was related
to the PAP interface (i. e. not accepting
or tolerating PAP therapy). Terminations that were not compliance related
occurred when a patient was lost to follow-up, transferred toa ventilation device
or died, or were related to insurance coverage issues or patient transfer to anotherhomecare provider.

länger (348 ± 58 vs. 337 ± 76 Tage; p <0,05). Diese Verbesserung war unabhängig
von Geschlecht, Gerätetyp und Art der
Krankenversicherung sowie bei Patienten
im Alter von >40 Jahren nachweisbar. In derGruppe der Patienten unter 40 Jahren war kein
Vorteil einer proaktiven Strategie nachweisbar.
Schlussfolgerung. Ein telemedizinbasiertes
proaktives PAP-Versorgungsmodell ist mit
einer signiﬁkant geringeren Abbruchrate alsbei einer konventionellen PAP-Versorgung
assoziiert.
Schlüsselwörter
Ambulantes Monitoring · Gesundheitsverhalten · Patientenadhärenz · Obstruktive
Schlafapnoe · Patientencompliance

Data analysis
Descriptive statistics are shown as absolute and relative frequency or mean ±standard deviation (SD), as appropriate.
Numerical diﬀerences between groups
were analysed using t-tests because thesample size allows for this approximation. For categorical data, diﬀerences inproportions were analysed using Z-tests.

Somnologie

Originalien

HR = 0.48 ( 0.4 , 0.57 )Proactive
Standardp < 0.001

80

On therapy (%)

90

100

Discussion//

70

Proactive vs. Standard

0

90

180

270

360

Observation time (days)

N at risk
Standard

3401

3292

3150

2982

2906

Proactive

3401

3348

3288

3125

3083

Matching was used to eliminate the inﬂuence of unequal distributions of risk
factors on diﬀerences in compliance between the proactive care and standard
care groups. Propensity score matching
was conducted based on the following
factors: gender, insurance, age (10-year
bands), ﬁrst device, therapy start date,ﬁrst mask and therapy set up. Time totherapy termination was analyzed using
Coxproportional hazards regressionwith
standard vs. proactive care included as
an explanatory factor. The results for
marginal times to termination were visualized using Kaplan–Meier plots. A pvalue of <0.05 was considered statisticallysigniﬁcant. All statistical analyses were
performed using IBM SPSS Statistics 22
and R version 3.0.2.

Results
A total of 3401 patients who were managed using the proactive strategy and
3401 matched patients receiving standard care were included in the analysis. There were no signiﬁcant diﬀerences
between the matched groups at baseline(. Table 1).

PAP termination
The overall therapy termination rate
was more than halved by the proactive
strategy compared with standard care
(5.4% vs 11.0%, respectively) (. Table 2).
Mean time to therapy termination in
the ﬁrst year was 348 ± 58 days in
the proactive strategy group comparedwith 337 ± 76 days in the standard caregroup. Cox proportional hazard analysis
Somnologie

Fig. 1 9 Kaplan–
Meier plot showing risk of therapy
termination in positive airway pressure
users managed using a proactive strategy versus standard
care

revealed a signiﬁcantly reduced risk of
PAP termination in the proactive versus
the standard care group (hazard ratio
0.48, 95% conﬁdence interval 0.4–0.54)(. Fig. 1).

Subanalyses according to potential
modiﬁers
Therapy termination rates with the standard and proactive strategies were similar
in males and females (. Table 2), andfor both genders the proactive strategy
signiﬁcantly reduced the risk of therapy
termination compared with standard
management. The risk of therapy termination was signiﬁcantly reduced by
the proactive strategy versus standard
care in patients aged ≥40–69 years and≥70 years, but there was no signiﬁcantdiﬀerence between the two management strategies in younger patients (age<40 years) (. Fig. 2). Therapy termination risk reduction with proactive
management was the greatest (63.9%) inpatients receiving bilevel PAP or ASV,
although the risk of therapy termination
did not diﬀer signiﬁcantly based on thetype of device used (. Table 2). The overall signiﬁcant beneﬁt of the proactive
strategy compared with standard careon therapy termination was the same inpatients whose ﬁrst device was APAP or
CPAP, or bilevel or ASV. The proactive
strategy was also eﬀective in reducing
the therapy termination rate in patientswith either public or private insurance,with a slightly greater beneﬁcial eﬀect inthose with public insurance.

The results of this study showed thata telemedicine-based proactive strategy
for the management of patients receiving
PAP therapy reduced the rate of therapy termination over time, irrespectiveof gender, device used and the type of
insurance. The ﬁnding that the proactive strategy was eﬀective irrespective ofthe type of PAP device used might suggest that therapy acceptability (e. g. interface comfort) may play a bigger role
than the type of device being used. Interestingly, the positive eﬀects of proactive
care were seen in all age groups except
those aged <40 years. One possible explanation for this may be that the youngest
patients are more comfortable with using
information technology to better informthemselves about their condition.
To the best of our knowledge, thisstudy is the ﬁrst to investigate the impactof a telemedicine-based strategy on longterm continuation of PAP therapy. The
main outcome measure in many previous studies has been compliance in termsof hours of device usage per night, andthere is a lack of data on therapy termination rates. The majority of thesestudies have focussed only on CPAP inpatients with OSA, used a variety of different telemedicine-based strategies, andreported inconsistent results. In addition, the majority were small, single-centre and/or short-term studies [19–24].
Interface problems and side eﬀects are
the most common causes of CPAP intolerance and an important potential beneﬁt
of telemedicine-based strategies is early
identiﬁcation of these issues and the implementation of strategies to resolve themin a timely fashion. Other beneﬁts oftelemonitoring strategies have been reported, such as reduced labour time forhealthcare staﬀ, allowing the same levelsof adherence and eﬃcacy to be achieved
with fewer staﬀ resources [17, 25]. This isimportant in the context of a projected increase in the number of patients presenting with sleep-disordered breathing due
to the aging population and the growing
rates of comorbidities such as obesity anddiabetes that will increase demand for already stretched healthcare services. The
ability to utilise telemedicine to provide

100
90

//

//
0

90

180

270

360

0

Observation time (days)

N at risk

90

180

270

360

Observation time (days)

N at risk

Standard

256

255

247

230

226

Standard

601

586

564

534

518

Proactive

259

256

251

228

221

Proactive

608

600

591

559

553

b

Proactive
Standardp < 0.001

Proactive
Standard90

p < 0.001
Proactive vs. Standard

//

//

70

70

Proactive vs. Standard

HR = 0.51 ( 0.35 , 0.76 )80

On therapy (%)

HR = 0.43 ( 0.3 , 0.62 )80

On therapy (%)

90

100

100

a

0

90

180

270

0

360

Observation time (days)

N at risk

90

180

270

360

Observation time (days)

N at risk

Standard

963

935

894

854

837

Standard

816

795

768

732

718

Proactive

962

954

937

899

889

Proactive

800

787

776

736

726

d

90
Proactive vs. Standard

Proactive
Standard////0

HR = 0.34 ( 0.16 , 0.74 )p = 0.006

70

Proactive vs. Standard

80

Proactive
Standardp < 0.001

70

On therapy (%)

HR = 0.39 ( 0.27 , 0.57 )80

On therapy (%)

90

100

100

c

90

180

270

360

0

Observation time (days)

N at riskeProactive
Standard

p = 0.003
Proactive vs. Standard

70

70

Proactive vs. Standard

HR = 0.53 ( 0.34 , 0.81 )80

On therapy (%)

90

100

Proactive
Standard

p = 0.999

80

On therapy (%)

HR = 1 ( 0.55 , 1.83 )

90

180

270

360

Observation time (days)

N at risk

Standard

670

635

602

561

541

Standard

95

86

75

71

66

Proactive

676

660

645

621

614

Proactive

96

91

88

82

80

f

Fig. 2 8 Kaplan–Meier plot showing risk of therapy termination in positive airway pressure users managed using a proactive
strategy versus standard care based on patient age (a Age <40 years. b Age 40–49 years. c Age 50–59 years. d Age 60–69 years.
e Age 70–79 years. f Age ≥80 years)

patient-focussed, proactive and intensive
management of patients using PAP therapy facilitates the management of large
patient populations, as well as signiﬁcantly improving therapy continuation
rates and usage. Telemedicine also appears to be a cost eﬀective strategy for

managing CPAP treatment in patientswith OSA [16].
Improved patient engagement is another potential advantage of telemedicine
strategies, which in turn could contributeto additional gains in terms of PAP adherence and outcomes. The positive impact of patient involvement in therapy

was highlighted in a recent study whichshowed that providing patients with webbased access to their personal PAP usage
data increased device usage in the ﬁrst
week of therapy and over 3 months offollow-up compared with usual care [26].
According tothe World HealthOrganisation (WHO), it is important that healthSomnologie

Originaliensystems evolve to meet new challenges[13]. The introduction of new technologies, such as telemedicine, is one way inwhich healthcare systems and providers
can advance patient care. In the caseof PAP therapy this could contribute tobetter adherence and improved patient
outcomes. WHO has also recognisedthat interventions targeted at improving adherence should provide a significant positive return on investment via
prevention of adverse health outcomes,
and that there are also economic beneﬁts associated with improved quality oflife, including reductions in indirect costs
and increased productivity [13]. In thecontext of CPAP therapy for OSA, theimportance of increasing adherence has
also been recognised by a Cochrane review that emphasised the need for new
strategies to promote CPAP compliance[27].
One of the main limitations of thisanalysis is the lack of speciﬁc data on
device usage in the standard care group.
Thus, we report therapy termination
rates rather than device usage hours,
which made comparison with existingdata more diﬃcult. However, it could beargued that therapy termination is themost important endpoint to assess because once a patient stops therapy getting
them to restart is likely to be diﬃcult. In
contrast, reduced usage provides a cue
for intervention, and there is always thepossibility that hours of device use will
increase. Another potential limitation isthat the ability to accurately determine
therapy termination is diﬀerent in thetwo groups – it is very obvious when
patients in the proactive strategy groupstop PAP therapy based on device data
received, but therapy termination might
be less obvious in the standard caregroup for whom the requirement fora homecare provider visit may be theonly indicator of therapy problems or
termination. Interrogation of big data
allows inclusion of a very large population of patients treated in routine clinicalpractice. However, databases created foradministrative, rather than scientiﬁc,
purposes do not include a full set ofclinical data. In the current analysis, thismeans that we had no data on clinicalfeatures, insomnia and other factors that
Somnologie

might have inﬂuenced the outcomesunder study. Furthermore, these areobservational data and therefore do notprovide proof for a causative relationship between the intervention (proactivecare) and the outcome (reduced therapy
termination). Data from randomised
clinical trials are needed to more clearly
elucidate the eﬀects of a telemedicinebased proactive management strategy
on PAP therapy termination rates. In
addition, future research should further
investigate the potential of telemonitoring-guided proactive care on additional
endpoints, including device usage, resource use and healthcare professionaltime requirements.

Conclusion
This analysis of a large population of PAP
therapy users in Germany showed thatthe long-term rate of therapy termination
was signiﬁcantly lower in patients managed using a telemedicine-based proactive management strategy compared withstandard care. This association was observed in both men and women, acrossa wide range of patient ages, for all PAP
devices and in patients with public or
private insurance. Implementation oftelemedicine-based strategies has the potential to improve adherence and patient
outcomes and may allow more eﬃcient
allocation of scarce healthcare resources.
Randomized, controlled clinical trials areneeded to further assess both therapy termination rates and device usage, which
would complement our large data set
from routine clinical practice.

Corresponding address
H. Woehrle, MD
Sleep and Ventilation Center Blaubeuren,
Respiratory Center Ulm
Olgastr. 83, 89073 Ulm, Germany
hwoehrle@lungenzentrum-ulm.de
Acknowledgements. Medical writing assistance
was provided by Nicola Ryan, independent medical
writer, funded by ResMed.

Compliance with ethicalguidelines
Conflict of interest. H. Woehrle was employed by
ResMed during the conduct of the study. Dr. Ficker
reports personal fees and non-ﬁnancial support from
ResMed, personal fees and non-ﬁnancial support from
Weinmann, outside the submitted work. A. Graml isan employee of ResMed Germany Inc. I. Fietze reports
grants and personal fees from ResMed, grants from
Philips, grants from Fisher&Paykel, grants from Hoffrichter, grants from Heinen&Löwenstein, grants from
Weinmann, outside the submitted work. Dr. Youngreports personal fees from Sanoﬁ Genzyme, personal
fees from Biomarin, personal fees from UCB Pharma,
personal fees from Medice, personal fees from ResMed,
personal fees from Heinen&Löwenstein, personal
fees from Vanda, grants from Löwensteinstiftung,grants from German Ministry of Education and Science(BMBF), outside the submitted work. Dr. Teschler reports grants, personal fees and non-ﬁnancial support
from ResMed, during the conduct of the study; grants,
personal fees and non-ﬁnancial support from ResMed,
outside the submitted work. Dr. Arzt reports grants
and personal fees from ResMed, grants and personal
fees from Philips Respironics, outside the submitted
work.
Study data were obtained from ResMed Germany
Healthcare, a German homecare provider. German
data protection law allows for the use of such data, if
anonymised, for scientiﬁc purposes. Therefore, patient
informed consent was not necessary in this study.
Open Access. Thisarticleisdistributedunderthetermsof the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,and reproduction in any medium, provided you give
appropriate credit to the original author(s) and thesource, provide a link to the Creative Commons license,
and indicate if changes were made.

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