4

September 2016

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420 

Prepared by:

Evidence-based Synthesis Program (ESP) 

Minneapolis VA Health Care System

Minneapolis, MN 

Timothy J. Wilt, MD, MPH, Director 

Nancy Greer, PhD, Program Manager 

Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program

The Comparative Effectiveness, 

Harms, and Cost of Care Models 

for the Evaluation and Treatment 

of Obstructive Sleep Apnea (OSA): 

A Systematic Review

Investigators:

Principal Investigators: 

Ken M. Kunisaki, MD, MS 

Wajahat Khalil, MD

Co-Investigators: 

Erin Koffel, PhD 

Loretta Pfannes, MD

Research Associates: 

Eva Koeller, BA

Roderick MacDonald, MS 

4
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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PREFACE

The VA Evidence-based Synthesis Program (ESP) was established in 2007 to provide timely and 

accurate syntheses of targeted healthcare topics of particular importance to clinicians, managers, and 

policymakers as they work to improve the health and healthcare of Veterans. QUERI provides funding 

for four ESP Centers, and each Center has an active University affiliation. Center Directors are 

recognized leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based 

Practice Centers. The ESP is governed by a Steering Committee comprised of participants from VHA 

Policy, Program, and Operations Offices, VISN leadership, field-based investigators, and others as 

designated appropriate by QUERI/HSR&D.

The ESP Centers generate evidence syntheses on important clinical practice topics. These reports help: 

Develop clinical policies informed by evidence;

Implement effective services to improve patient outcomes and to support VA clinical practice

guidelines and performance measures; and

Set the direction for future research to address gaps in clinical knowledge.

The ESP disseminates these reports throughout VA and in the published literature; some evidence 

syntheses have informed the clinical guidelines of large professional organizations. 

The ESP Coordinating Center (ESP CC), located in Portland, Oregon, was created in 2009 to expand the 

capacity of QUERI/HSR&D and is charged with oversight of national ESP program operations, program 

development and evaluation, and dissemination efforts. The ESP CC establishes standard operating 

procedures for the production of evidence synthesis reports; facilitates a national topic nomination, 

prioritization, and selection process; manages the research portfolio of each Center; facilitates editorial 

review processes; ensures methodological consistency and quality of products; produces “rapid response 

evidence briefs” at the request of VHA senior leadership; collaborates with HSR&D Center for 

Information Dissemination and Education Resources (CIDER) to develop a national dissemination 

strategy for all ESP products; and interfaces with stakeholders to effectively engage the program. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP CC Program 

Manager, at Nicole.Floyd@va.gov. 

Recommended citation: Kunisaki KM, Khalil W, Koffel E, Pfannes L, Koeller E, MacDonald R, Greer, 

N, Wilt TJ. The Comparative Effectiveness, Harms, and Cost of Care Models for the Evaluation and 

Treatment of Obstructive Sleep Apnea (OSA): A Systematic Review. VA ESP Project #09-009; 2016.

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at 

the Minneapolis VA Health Care System, Minneapolis, MN, funded by the Department of Veterans Affairs, 

Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. 

The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the 

findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the 

United States government. Therefore, no statement in this article should be construed as an official position of the 

Department of Veterans Affairs. No investigators have any affiliations or financial involvement (eg, employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or 

royalties) that conflict with material presented in the report.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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TABLE OF CONTENTS

ABSTRACT ................................................................................................................................... 1

EXECUTIVE SUMMARY

Introduction ................................................................................................................................. 3

Methods....................................................................................................................................... 4

Data Sources and Searches ..................................................................................................... 4

Study Selection ....................................................................................................................... 4

Data Abstraction and Risk of Bias Assessment ...................................................................... 5

Data Synthesis and Analysis ................................................................................................... 5

Results ......................................................................................................................................... 5

Results of Literature Search .................................................................................................... 5

Summary of Results for Key Questions.................................................................................. 5

Discussion ................................................................................................................................... 7

Key Findings and Strength of Evidence (Executive Summary Table) ................................... 7

Limitations .............................................................................................................................. 9

Applicability and Implementation ........................................................................................ 10

Research Gaps/Future Research ........................................................................................... 11

Conclusions ........................................................................................................................... 11

Executive Summary Table. Strength of Evidence ...................................................................... 9

Abbreviations Table .................................................................................................................. 12

INTRODUCTION

PICOTS and Analytic Frameworks (Figures 1a, 1b) ................................................................ 16

METHODS

Topic Development ................................................................................................................... 19

Search Strategy ......................................................................................................................... 19

Study Selection ......................................................................................................................... 19

Data Abstraction ....................................................................................................................... 20

Risk of Bias Assessment ........................................................................................................... 20

Data Synthesis ........................................................................................................................... 20

Rating the Body of Evidence .................................................................................................... 20

Peer Review .............................................................................................................................. 21
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RESULTS

Literature Flow.......................................................................................................................... 22

Key Question #1: For adults with suspected OSA, what are the effectiveness/harms/

resource utilization of case finding and care provided by practitioners who are not sleep 

physicians (including PCPs, PAs, NPs, technologists, nurses, and respiratory therapists), 

compared to case finding and care provided by sleep specialist physicians? ........................... 23

Summary of Findings for Key Question #1 .......................................................................... 23

Case Finding ......................................................................................................................... 24

Care ....................................................................................................................................... 25

Key Question #1A: Do effectiveness/harms/resource utilization vary by 

patient characteristics: a. Unexplained daytime sleepiness/fatigue; b. AHI severity;

c. Other risk factors or coexisting conditions associated with OSA (eg, obesity, neck

circumference, treatment-resistant hypertension, diabetes, age, sex, race); d. Symptoms 

(eg, nocturia, loss of libido, snoring, witnessed sleep “apnea”)? ............................................. 31

A. Unexplained Daytime Sleepiness/Fatigue ....................................................................... 31

B. AHI Severity .................................................................................................................... 31

C. Other Risk Factors or Coexisting Conditions Associated with OSA ............................... 31

D. Symptoms......................................................................................................................... 32

Strength of Evidence for Key Question 1 (Table 4, Appendix D)........................................ 32

Key Question #2: For adults with suspected OSA, what are the effectiveness/

harms/resource utilization of electronic consultation versus interactive 

(eg, in-person, telephone) consultation? ................................................................................... 34

Key Question #2A: Do effectiveness/harms/resource utilization vary by 

patient characteristics ................................................................................................................ 34

Key Question #3: For adults diagnosed with OSA, what are the effectiveness/

harms/resource utilization (including cost avoidance) of using in-home autotitrating 

continuous positive airway pressure (APAP) technology compared to standard 

continuous positive airway pressure (CPAP) titrated by in-lab PSG? ...................................... 35

Summary of Findings for Key Question 3 ............................................................................ 35

Titration................................................................................................................................. 35

Treatment .............................................................................................................................. 40

Key Question #3A: Do effectiveness/harms/resource utilization vary by 

patient characteristics ................................................................................................................ 48

A. Unexplained Daytime Sleepiness/Fatigue ....................................................................... 48

B. AHI Severity .................................................................................................................... 48

C. Other Risk Factors or Coexisting Conditions Associated with OSA ............................... 48

D. Symptoms......................................................................................................................... 49

Strength of Evidence for Key Question 3 (Table 4, Appendix D)........................................ 49
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SUMMARY AND DISCUSSION

Limitations ................................................................................................................................ 53

Applicability and Implementation of Findings ......................................................................... 54

Research Gaps/Future Research ............................................................................................... 55

Conclusions ............................................................................................................................... 56

REFERENCES ............................................................................................................................ 57

FIGURES

Figure 1a. Analytic Framework – Key Questions 1 and 2 ........................................................ 17

Figure 1b. Analytic Framework – Key Question 3 ................................................................... 18

Figure 2. Literature Flow Chart ................................................................................................ 22

Figure 3. SF 36 Mental Health and Vitality Scores, Standardized Mean Differences 

in Mean Change from Baseline, Non-sleep Specialist versus Sleep Specialista

 ....................... 27

Figure 4. Compliance, Weighted Mean Difference for Hours per Night, Non-sleep 

Specialist versus Sleep Specialista ............................................................................................ 29

Figure 5. Epworth Sleepiness Scores, Standardized Mean Differences for Mean 

Change from Baseline, Non-sleep Specialist versus Sleep Specialista ..................................... 30

Figure 6. SF 36 Scores, Standardized Mean Differences in Mean Change from 

Baseline, Titration Studiesa ....................................................................................................... 38

Figure 7. Epworth Sleep Scores, Standardized Mean Difference for Mean Change 

from Baseline, Titration Studiesa

 .............................................................................................. 40

Figure 8. Compliance, Weighted Mean Difference for Hours per Night, Titration Studiesa ... 40

Figure 9. Epworth Sleepiness Scores, Standardized Mean Difference for Mean 

Change from Baseline from Parallel Group RCTs, Treatment Studiesa ................................... 47

Figure 10. Compliance, Weighted Mean Difference for Hours per Night from 

Parallel Group RCTs, Treatment Studiesa

 ................................................................................ 47

TABLES

Table 1. Key Question 1: Study Characteristics ....................................................................... 24

Table 2. Clinical Outcomes Comparing Non-sleep Specialists to Sleep Specialists ................ 26

Table 3. Intermediate Outcomes Comparing Non-sleep Specialists to Sleep Specialists ........ 28

Table 4. Strength of Evidence for Outcomes, Key Question 1 ................................................. 33

Table 5. Key Question 3, Titration: Study Characteristics ....................................................... 36

Table 6. Clinical Outcomes Comparing APAP to CPAP, Titration Studies ............................ 37

Table 7. Intermediate Outcomes Comparing APAP to CPAP, Titration Studies ..................... 39

Table 8. Key Question 3, Treatment: Study Characteristics ..................................................... 41
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Table 9. Clinical Outcomes Comparing APAP to CPAP, Treatment Studies .......................... 43

Table 10. Intermediate Outcomes Comparing APAP to CPAP, Treatment Studies ................ 45

Table 11. Strength of Evidence for Outcomes, Key Question 3 ............................................... 50

Appendix A. Search Strategies .................................................................................................... 62

Appendix B. Peer Review Comments/Author Responses ........................................................... 64

Appendix C. Evidence Tables ..................................................................................................... 70

Table 1. Study Characteristics for KQ1 .................................................................................... 70

Table 2. Clinical Outcomes for KQ1 ........................................................................................ 76

Table 3. Clinical Outcomes for KQ1, Continued ..................................................................... 79

Table 4. Intermediate Outcomes for KQ1 ................................................................................. 83

Table 5. Intermediate Outcomes for KQ1, Continued .............................................................. 87

Table 6. Intermediate outcomes for KQ1, Continued ............................................................... 92

Table 7. Study Characteristics for KQ3 .................................................................................... 94

Table 8. Clinical Outcomes for KQ3 ...................................................................................... 111

Table 9. Clinical Outcomes for KQ3, Continued ................................................................... 113

Table 10. Intermediate Outcomes for KQ3 ............................................................................. 122

Table 11. Intermediate Outcomes for KQ3, Continued .......................................................... 132

Table 12. Intermediate Outcomes for KQ3, Continued .......................................................... 135

Appendix D. Strength of Evidence ............................................................................................ 144
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ABSTRACT

BACKGROUND

Rising requests for obstructive sleep apnea (OSA) diagnostic and treatment services may make 

traditional in-person evaluation processes unnecessarily expensive and inefficient. 

PURPOSE 

To assess the comparative effectiveness, harms, and costs of care models for OSA evaluation and 

treatment. 

DATA SOURCES

MEDLINE (Ovid) and CINAHL searched for studies published in English language between 

January 2000 and May 2016 with hand searching of reference lists of related systematic reviews 

and included studies. 

STUDY SELECTION

Four randomized controlled trials (RCTs) and 4 observational studies evaluated case-finding and 

care provided by nonsleep specialist practitioners versus sleep specialist physicians (SSP). No 

reports evaluated electronic versus interactive (eg, in-person or telephone) consultation. Twentyseven reports (3 RCTs for titration, 22 RCTs for treatment and 2 cohort studies) assessed inhome autotitrating continuous positive airway pressure (APAP) technology versus standard 

continuous positive airway pressure (CPAP) titrated by in-lab polysomnogram (PSG) as options 

for PAP titration or treatment. 

DATA EXTRACTION

Two investigators independently extracted study data, rated individual study risk of bias, and 

assessed overall strength of evidence. 

DATA SYNTHESIS/RESULTS

No studies assessed the diagnostic accuracy of non-sleep-specialist nurses for case finding and 

referral. One retrospective study reported good agreement between a primary care pulmonologist 

and a SSP on what sleep test to order for patients referred by their family physician. Patientcentered outcomes were infrequently and inconsistently reported. When reported there was no 

significant difference in clinical outcomes between OSA treated by primary care/nurses and 

SSPs (moderate strength of evidence for quality of life). Sleep symptom scores were similar 

between groups (moderate strength of evidence). Treatment compliance was similar between 

patients treated by SSPs and those not (moderate strength of evidence). Strength of evidence for 

access to care and adverse events was insufficient.

Few studies compared patient-centered outcomes between in-lab CPAP titration and at-home 

APAP titration. In limited reporting, study groups were generally similar on quality of life 

(moderate strength of evidence) and cognitive symptoms. Some differences were noted for 

resource utilization and patient preference. Sleep measures, blood pressure, adverse events, and 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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compliance/adherence were generally similar (moderate strength of evidence for Epworth 

Sleepiness Scale (ESS) scores and low strength of evidence for compliance). 

Twenty-three studies compared treatment with CPAP versus APAP. Few studies reported 

patient-centered outcomes other than quality of life and patient preference for one treatment 

approach over another. Quality of life, assessed with the SF-36, was generally similar (moderate 

strength of evidence). Patient preference was generally similar or favored APAP. Strength of 

evidence was insufficient for access to care. Post-treatment ESS scores were generally similar for 

the 2 treatment approaches (moderate strength of evidence). Adverse events were mild and 

similar for APAP and CPAP (low strength of evidence). Compliance was similar (moderate 

strength of evidence). 

LIMITATIONS

Studies were limited to English language and those published in the United States, Canada, 

Western Europe, Australia, or New Zealand. Few studies assessed non-sleep specialist casefinding or care and none assessed electronic consultations. Clinical outcomes were infrequently 

reported. 

CONCLUSIONS

Among patients suspected of having OSA, primary care providers and sleep-specialist nurses 

provide similar outcomes to SSPs, although many outcomes were inconsistently reported. Athome APAP provides similar outcomes to CPAP titrated in the PSG laboratory. No evidence 

addressed electronic consultation for the management of known or suspected OSA. Future 

studies are needed to determine which patients derive the most benefit from treatment and should 

be prioritized for testing and treatment, whether newer models of care with less reliance on SSP 

time (either through utilization of other types of providers or electronic consultation) result in 

similar outcomes to traditional models, and, if effective, how such models should be 

implemented. 
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EXECUTIVE SUMMARY

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic condition that results from repeated closure of the 

upper airway during sleep resulting in reduced airflow (hypopnea) or complete airflow cessation 

(apnea) leading to cyclic sleep disruption. Patients with OSA frequently experience excessive 

daytime sleepiness and decreased quality of life. However, not all individuals have excessive 

daytime sleepiness and symptoms are not required to make a diagnosis or obtain treatment. OSA 

has also been associated with a higher risk of myocardial infarction, heart failure, stroke, and 

cognitive decline. Continuous positive airway pressure (CPAP) effectively reduces apneas and 

hypopneas in most patients with OSA, improves blood pressure, and – particularly in those with 

symptoms of excessive daytime sleepiness – improves quality of life and sleep symptoms. CPAP 

use is also associated with a reduced risk of motor vehicle accidents. 

The estimated prevalence of mild to severe OSA in the United States (2007-2010 data) among 

30- to 70-year-olds is 34% for men and 17% for women. Despite the data associating OSA with 

consequences to health and quality of life and the conclusions from other guideline groups, many 

persons with OSA remain undiagnosed. In 2010, among 1.8 million US Veterans receiving 

outpatient care at 136 Veterans Affairs (VA) facilities, 37.4% had a body mass index (BMI) ≥ 30 

kg/m2

. Given the strong relationship between high BMI and OSA, these data suggest that a 

substantial portion of US Veterans are at high risk for OSA. A recent analysis of Veterans 

Administration Informatics and Computing Infrastructure (VINCI) data between 2000 and 2010 

showed that among 9.8 million Veterans, the age-adjusted prevalence of diagnosed sleep apnea 

was 0.4% in 2000 and had increased to 3.0% in 2010 (a relative increase of 650%). As awareness 

of OSA by patients and providers continues to increase, and as BMI continues to increase in the 

US and globally, healthcare systems such as the VA need to develop strategies to manage the 

increasing demand for sleep services. One strategy is to target screening and testing to those 

most likely to derive benefit from OSA treatment (eg, those with significant unexplained daytime 

sleepiness), as suggested by the American College of Physicians (ACP). Another strategy is to 

improve efficiency within healthcare systems by implementing innovative, less resource-intense 

models of care for OSA.

The traditional model of OSA evaluation and care relies upon primary care providers to refer 

patients with suspected OSA to a sleep specialist physician (SSP) for consultation. After an 

initial consultative visit, the SSP can order formal, in-lab polysomnogram (PSG) for diagnostic 

purposes and for those with confirmed OSA, a PSG for titration of CPAP pressures. The SSP 

would typically initiate CPAP at the pressure suggested by the titration PSG, and then the patient 

would follow up with the SSP at regular intervals for assessment of treatment compliance and 

efficacy. Given the rapidly rising requests for OSA diagnostic and treatment services, this 

traditional model is increasingly viewed as unnecessarily expensive and inefficient for the 

evaluation and treatment of patients at high risk of OSA. Recent data also indicate a decreasing 

supply of SSPs to care for patients with known or suspected OSA. 

Therefore, new models of OSA care have been proposed and implemented. These new models 

include home sleep testing (HST) for diagnostic purposes, followed by treatment with an 

autotitrating CPAP (APAP) device which has internal algorithms to adjust CPAP pressure to 

keep the airway open during sleep. These models reduce PSG-associated costs and logistical 
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barriers, yet typically still include consultation and follow up with a SSP. Other proposed models 

would reduce reliance on SSPs by including non-SSP providers such as nurses or primary care 

physicians to provide the bulk of OSA diagnosis and treatment. 

Although several studies have been conducted to test some of these new models, systematic 

reviews are lacking. The Minneapolis VA’s Evidence-based Synthesis Program (ESP) Center, in 

partnership with topic nominators and a Technical Expert Panel (TEP), was commissioned to 

systematically review the evidence regarding the comparative effectiveness, harms, and cost of 

these new models of OSA evaluation and treatment. 

We addressed the following key questions (KQs): 

Key Question 1. For adults with suspected OSA, what are the effectiveness/harms/resource 

utilization of case finding and care provided by practitioners who are not sleep physicians 

(including PCPs, PAs, NPs, technologists, nurses, and respiratory therapists), compared to case 

finding and care provided by sleep specialist physicians? 

Key Question 2. For adults with suspected OSA, what are the effectiveness/harms/resource 

utilization of electronic consultation versus interactive (eg, in-person, telephone) consultation? 

Key Question 3. For adults diagnosed with OSA, what are the effectiveness/harms/resource 

utilization (including cost avoidance) of using in-home autotitrating continuous positive airway 

pressure (APAP) technology compared to standard continuous positive airway pressure (CPAP) 

titrated by in-lab PSG?

METHODS

Data Sources and Searches 

We searched MEDLINE (Ovid) and CINAHL for articles published between 2000 and May 

2016. We obtained additional articles by hand searching the reference lists of related systematic 

reviews and included studies. 

Study Selection

Abstracts were independently reviewed in duplicate by investigators and research associates. We 

included studies of any design, published in English, that reported on OSA care or case finding 

in adults with suspected or diagnosed OSA and took place in North America, Europe, Australia, 

or New Zealand. For KQ1 we excluded studies that did not include a comparison of a supervised 

practitioner or non-specialist licensed independent practitioner (eg, primary care physician, 

physician’s assistant, nurse, technologist, or respiratory therapist) to a SSP. We excluded studies 

evaluating the role of dentists and anesthesiologists. For KQ2 we excluded studies that did not 

compare an electronic initial consultation without patient contact to an interactive initial 

consultation. For KQ3 we excluded studies that did not compare the use of APAP to CPAP for 

titration or treatment of OSA. Furthermore, in studies of titration we only included articles in 

which the APAP was used at home and CPAP was manually titrated in a lab. We also excluded 

studies if they did not report any of our outcomes of interest. 
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Full-text reports of studies identified as potentially eligible based on abstract review were 

obtained for further review. Each article was independently reviewed by 2 investigators or 

research associates with disagreements settled by a third. 

Data Abstraction and Risk of Bias Assessment 

Study characteristics (location, setting, intervention groups, follow-up, aim of study, treatments, 

inclusion/exclusion criteria, and patient characteristics) as well as intermediate and clinical 

outcomes were extracted onto evidence tables by one investigator or research associate and 

verified by another. Trained research methodologists rated the risk of bias of individual studies 

as low, moderate, or high risk. 

We assessed strength of evidence for the following outcomes: access to care, quality of life, 

compliance (hours of use per night), and adverse events. Strength of evidence was rated as high, 

moderate, low, or insufficient based on precision, consistency, directness, and risk of bias of the 

individual studies. 

Data Synthesis and Analysis

We summarized findings by Key Question. We were able to pool data for quality of life (SF-36 

scores), Epworth Sleepiness Scale (ESS) scores, and compliance (hours per night of use) for 

KQ1 and KQ3 (titration and treatment studies). 

RESULTS 

Results of Literature Search

We reviewed 2,847 abstracts, 2,252 from MEDLINE, and 595 from CINAHL. We excluded 

2,493 abstracts and reviewed the full-text of 354 references. During full-text review we excluded 

323 articles, leaving 31 eligible for inclusion. Hand searching reference lists of pertinent trials 

and systematic review identified an additional 3 references. 

Summary of Results for Key Questions 

Key Question 1

Eight studies (n = 1,401; 4 randomized controlled trials [RCTs]) reported results for KQ1. Sleep 

physician care was compared to management by primary care in 4 studies (n = 564), sleepspecialist nurses in 3 studies (n = 434), and other non-sleep physicians in one study (n = 403). 

Patients were generally middle-aged and moderately obese with mild sleepiness and severe sleep 

apnea as determined by apnea-hypopnea index (AHI). 

Case Finding 

One retrospective study reported on the ability of a primary care pulmonologist to order the 

proper sleep test. There was good agreement between the primary care pulmonologist and SSP

(kappa = .74) and 93% (89/96) of the referred patients were diagnosed with OSA. 
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Care 

Seven studies reported treatment outcomes in patients being managed by providers other tha 

SSPs. Three of these studies compared SSP care to primary care (n = 468, 1 RCT), 3 to sleep 

specialist nurses (n = 434; 3 RCTs), and one compared SSP care to management by a variety of 

physicians who were not sleep specialists. 

Three studies reported quality of life; all found that SF-36 scores were similar between patients 

being treated by primary care (k = 1) or sleep-specialist nurses (k = 2) as compared to SSPs. Two

studies reporting patient satisfaction found overall satisfaction was similar between groups. 

CPAP compliance was reported in 7 studies. Six of the 7 studies found no difference in 

compliance, regardless of measure used, when comparing patients receiving SSP care to those 

receiving care from non-SSPs. The final study found that patients who were referred for a sleep 

study by non-SSPs were significantly less compliant, with fewer hours per night and less regular 

use, than those patients who were referred by SSPs. Cost was reported, in various ways, by 5 of 

the studies. Three did not report the significance of cost differences between SSP and non-SSP 

care. Two studies, however, found that nurse-led OSA care was associated with significantly 

lower costs per patient and within-trial costs. 

Five studies reported ESS scores; all found scores were similar between groups receiving care 

from different providers. AHI was reported by one study. Residual AHI on CPAP was 

significantly lower in patients referred for PSG by non-SSPs than in patients referred by SSPs 

(P<.001). 

Occurrence of adverse events was similar in the SSP and nurse/primary care groups. Time to 

initiation of therapy was reported in 2 studies. One found that significantly fewer patients in the 

primary care group received CPAP within one month of PSG when compared to patients in the 

SSP group (P = .012). The other reported that while there was no significant difference between 

groups for satisfaction with time waiting (P = .706), patients receiving nurse-led care were more 

satisfied with their impression of wait time (P = .004). 

Key Question 2

No articles were identified that met inclusion criteria for this question. 

Key Question 3

Twenty-seven studies addressed KQ3 and KQ3a, including 4 that compared titration with APAP 

to titration with CPAP and 23 that compared treatment with APAP to treatment with CPAP. The 

mean age of patients enrolled was 52 years, 80% were male, baseline BMI was 33 kg/m2

, 

baseline ESS was 13, and baseline AHI was 44 events/hour. 

Titration

Of the 4 studies comparing titration in-lab with CPAP to titration at home with APAP, 3 were 

RCTs and one was an observational study. Mean ESS scores at baseline ranged from 14.0 to 

15.5. 
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Few studies reported clinical outcomes. Most frequently reported was quality of life with 2 

studies finding CPAP titration and APAP titration to be similar while another found mixed 

results for different subscales of the SF-36. No study reported access to care.

Intermediate outcomes were more commonly reported. ESS scores and compliance were

generally similar for the CPAP titration and APAP titration groups. 

Treatment

Among the 23 studies comparing treatment with CPAP to treatment with APAP, there were 22 

RCTs (15 using a crossover design) and one retrospective cohort study. Baseline ESS scores 

ranged from 6.4 to 17.4. 

The most commonly reported clinical outcomes were quality of life (specifically SF-36 scores) 

and patient preference for one treatment over another. Quality of life was similar for the 2 

treatment groups in 7 of 9 studies reporting that outcome. In 7 of 12 studies reporting treatment 

preference, APAP was preferred. No study reported a significantly higher preference for CPAP.

Intermediate outcomes, including ESS scores and compliance (hours per night and proportion of 

nights used) were generally similar for the CPAP and APAP treatment group. Adverse events, 

reported in 6 studies, were generally similar between groups. 

DISCUSSION 

Key Findings and Strength of Evidence (Executive Summary Table)

Key Question 1

Case Finding 

• No studies assessed the diagnostic accuracy of non-sleep-specialist nurse for case finding 

and referral.

• One retrospective study reported good agreement between a primary care pulmonologist 

and a SSP on what sleep test to order for patients referred by their family physician.

Care 

• Clinical (ie, patient-centered) outcomes were infrequently and inconsistently reported. 

When reported there was no significant difference in clinical outcomes between OSA 

treated by primary care/nurses and SSPs. The strength of evidence for quality of life was 

moderate.

• Intermediate outcomes were more commonly reported. Sleep symptom scores were 

similar between groups (moderate strength of evidence). 

• There was little evidence that treatment compliance differed between patients treated by 

SSPs and those not, including the proportion of patients with 4 hours or more of CPAP 

use on 70% or more of nights (moderate strength of evidence). 
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• Very few studies reported other intermediate outcomes. One reported a significantly 

lower residual AHI on CPAP in patients referred for PSG by non-sleep specialists and 

another found that the proportion of patients receiving CPAP within one month of their 

PSG was significantly higher in patients cared for by a SSP. Strength of evidence for 

access to care and adverse events was insufficient. 

Key Question 3

Titration

• Few studies compared clinical (ie, patient-centered) outcomes between in-lab CPAP 

titration and at-home APAP titration. In limited reporting, study groups were generally 

similar on measures of quality of life (moderate strength of evidence) and cognitive 

symptoms. Some differences were noted for resource utilization and patient preference.

• Intermediate outcomes (ie, sleep measures, blood pressure, adverse events, and 

compliance/adherence) were more commonly reported and generally similar. Strength of 

evidence for ESS was moderate and strength of evidence for compliance was low. 

Strength of evidence for adverse events was insufficient. 

Treatment

• Twenty-three studies compared treatment with CPAP to treatment with APAP. The 

studies enrolled patients with a broad range of baseline AHI values. 

• Few studies reported clinical (ie, patient-centered) outcomes other than quality of life and 

patient preference for one treatment approach over another. Quality of life, assessed with 

the SF-36, was generally similar between the CPAP and APAP groups (moderate 

strength of evidence). Patient preference was also generally similar or favored APAP in 

studies reporting statistical significance. Strength of evidence was insufficient for access 

to care.

• Intermediate outcomes including post-treatment ESS scores were frequently reported and 

generally similar for the 2 treatment approaches (moderate strength of evidence). 

Adverse events were mild and similar for APAP and CPAP (low strength of evidence). 

• Compliance, reported as either hours per night or the proportion of nights the device was 

used, was also similar for the CPAP and APAP treatment groups (moderate strength of 

evidence).
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Executive Summary Table. Strength of Evidence

Comparison Outcome of interest Strength of

evidencea Direction

KQ1: Sleep 

physician care 

compared to 

management by 

primary care, sleepspecialist nurses, or 

other non-sleep 

physicians

Access to care Insufficient

Epworth Sleepiness Score Moderate SIMILAR

Quality of life Moderate SIMILAR

Compliance, hours per 

night Moderate SIMILAR

Adverse events Insufficient

KQ3: Home APAP

technology versus 

standard in-center 

manual CPAP 

titration

Access to care Insufficient

Epworth Sleepiness Score Moderate SIMILAR

Quality of life Moderate SIMILAR

Compliance Low SIMILAR

Adverse events Insufficient

KQ3: APAP versus 

CPAP treatment

Access to care Insufficient

Epworth Sleepiness Score Moderate SIMILAR

Quality of life Moderate SIMILAR

Compliance Moderate SIMILAR

Adverse events Low

APAP = Auto-adjusted (autoregulated) continuous positive airway pressure; CPAP = continuous positive airway 

pressure

a

Strength of Evidence Definitions (Owens, DK et al, J Clin Epidemiol. 2010;63(5):523-523) 

• High: Very confident that estimate of effect lies close to true effect. Few or no deficiencies in body of evidence, 

findings believed to be stable.

• Moderate: Moderately confident that estimate of effect lies close to true effect. Some deficiencies in body of 

evidence; findings likely to be stable, but some doubt.

• Low: Limited confidence that estimate of effect lies close to true effect; major or numerous deficiencies in body of 

evidence. Additional evidence necessary before concluding that findings are stable or that estimate of effect is close 

to true effect. 

• Insufficient: No evidence, unable to estimate an effect, or no confidence in estimate of effect. No evidence is 

available or the body of evidence precludes judgment.

Limitations

We limited inclusion to English language studies and those performed in the United States, 

Canada, Western Europe, Australia, or New Zealand. This likely increases applicability of our 

findings to the VA healthcare system, but may reduce generalizability of our findings to other 

health settings. We also chose to exclude studies of dentists and anesthesiologists due to our 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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uncertainty whether or not these persons truly represent “Non-Sleep-Specialist Physicians” given 

that many dentists and anesthesiologists have substantial practices or background in sleep 

medicine. We also did not assess the role of surgery or mandibular assist devices for OSA 

treatment including referral of patients who may be more interested in or better candidates for 

these options. 

A significant limitation is the paucity of high-quality literature regarding key questions 1 and 2. 

Although we are aware of the existence of clinical care models utilizing sleep respiratory 

therapists and behavioral sleep medicine providers to provide varying degrees of OSA care, we 

did not find any studies to address these particular type of practitioners. We also note that, 

importantly, the providers in many of these “primary care” studies were persons who had 

substantial experience in sleep medicine. Therefore, the generalizability of these findings to 

primary care providers with less experience in sleep medicine is not clear.

Applicability and Implementation

Most patients enrolled in studies were obese, middle-aged men, with severe OSA based on both 

high AHI levels and the presence of excessive daytime sleepiness. Our findings are most 

applicable to these individuals. We found only one study that was performed in a VA population 

for Key Question 3. One study was performed at Walter Reed Army Medical Center for key 

questions 1 and 3. While most studies were not specifically conducted in VA or military 

populations, because the patients enrolled in these studies were generally older, overweight men 

with OSA, we believe the findings of our systematic review should be applicable to the 

population of Veterans served by VA facilities. 

Many of the study providers who were not SSPs had prior sleep training and therefore the results 

may not be fully generalizable to all primary care providers. While data are not conclusive, 

because our findings indicated similar Epworth Sleepiness Scores, quality of life, and treatment 

compliance scores among patients evaluated and treated by non-SSPs compared to SSPs it may 

be reasonable to consider expanded use of non-SSP providers who have received training in 

sleep medicine, especially where SSPs are in limited supply and demand for OSA services is 

high. Similarly, greater use of at-home APAP may lessen dependence on backlogged PSG 

laboratories, as most health outcomes were similar between groups.

Our report focused on methods that might improve the ‘supply’ side of OSA evaluation and 

treatment, through use of non-SSPs, electronic consultation, and at-home APAP titration and 

treatment. However, healthcare systems struggling to match supply to demand might also 

consider whether the ‘demand’ is truly appropriate. We found little to no data in screen-detected 

patients (ie, those found to have abnormal AHI either through direct referral to sleep laboratories 

or based on results of screening questionnaires such as the Berlin questionnaire but without 

excessive daytime sleepiness). The evidence to date indicates that the main benefit of OSA 

detection and treatment is improvement in patient-reported sleepiness symptoms among those 

with unexplained daytime somnolence. Therefore, VA healthcare providers and decision-makers 

could potentially achieve the highest value care, including resource use, by targeting case finding 

approaches and subsequent evaluation and treatment to individuals with unexplained daytime 

somnolence and who express interest in further evaluation and treatment. Theorectically, this 

referral approach could be readily be implemented by developing and using electronic medical 

record templates that describe the evidence-based rationale for the referral recommendations 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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while requesting that referring providers include information specifically about daytime 

somnolence and the patient’s willingness for further evaluation and treatment in the consult.

Research Gaps/Future Research

Comparative effectiveness trials were lacking for all key questions. Key questions 1 and 2 would 

particularly benefit from trials to address the outcomes resulting from non-SSP care of sleep 

apnea patients (Key Question 1) and electronic consultation (Key Question 2). Limited available 

data suggest that care led by non-SSPs may potentially provide equivalent outcomes to care led 

by SSPs. Comparative effectiveness trials are needed in order to determine whether such results 

can be achieved in routine practice, outside of controlled research settings. The available data 

suggest that with some appropriate training, non-SSPs can potentially provide equivalent 

outcomes, but the operationalization of such training is unclear. Therefore, future comparative 

effectiveness trials should describe their training programs. Such trials should also collect 

clinical outcomes where possible. 

As more healthcare systems implement comprehensive electronic medical records (EMRs), we 

anticipate Key Question 2 will become more feasible to study. In the current climate of 

increasing numbers of sleep referrals, yet a declining number of SSPs, EMR-based electronic 

consultation holds significant promise to provide equivalent outcomes in a more cost-effective, 

time-efficient manner. Although many systems have already implemented electronic consultation 

systems, evidence supporting this practice is largely lacking and further studies should be

conducted. We think comparative effectiveness study designs such as stepped-wedge 

randomization (where sites are randomly assigned to the time point at which they implement 

electronic consultation) would allow the creation of good-quality evidence to quantify the risks, 

benefits, and economic impacts of electronic consultation for patients with known or suspected 

OSA.

We also note that blinding the intervention is not feasible in many of these randomized trials. 

However, we recommend that future studies make efforts to assess outcomes by persons blinded 

to treatment assignment and thereby mitigate the potential for biased assessments.

A large gap in evidence is related to the effectiveness of treatment for individuals without 

excessive daytime sleepiness (screen detected or case-finding in at-risk asymptomatic 

individuals) and on outcomes other than daytime sleepiness. For example, a recently published 

multi-site randomized trial showed that CPAP was not effective for secondary prevention of 

cardiovascular events in those with established cardiovascular disease and moderate to severe 

OSA. Additional information gaps include the effectiveness of treatment in those with mild AHI 

regardless of symptoms. These gaps are supported by recent evidence reports and accompanying 

clinical practice recommendations by the ACP and US Preventive Services Task Force

(USPSTF) and described in greater detail in the introduction to the main report. These are 

critically important gaps to fill due to the dramatic increase in patients with, or suspected to have, 

OSA and thus being referred for evaluation and treatment. 

Conclusions

Among patients suspected of having OSA, evidence suggests that primary care providers and 

sleep-specialist nurses might provide similar outcomes to SSPs, although the strength of this 

evidence was only moderate and many outcomes were inconsistently reported. Likewise, among 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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patients diagnosed with OSA, evidence suggests that at-home APAP titration and treatment

provides similar outcomes to fixed pressure CPAP titrated in the PSG laboratory, although the 

strength of evidence was generally low to moderate. 

We found no evidence addressing the topic of electronic consultation for the management of 

known or suspected OSA. 

Future studies are needed to determine which patients derive the most benefit from treatment and 

should be prioritized for testing and treatment, whether newer models of care with less reliance 

on SSP time (either through utilization of other types of providers or electronic consultation) 

result in similar outcomes to traditional models, and if effective, how such models should be 

implemented. 

ABBREVIATIONS TABLE

AHI Apnea-Hypopnea Index

APAP Auto-adjusting Positive Airway Pressure

BMI Body Mass Index

CI Confidence Interval

CPAP Continuous Positive Airway Pressure

ESS Epworth Sleepiness Scale

FOSQ Functional Outcomes of Sleep Questionnaire

HbA1c Hemoglobin A1c

HST Home Sleep Testing

LIP Licensed Independent Practitioner

MeSH Medical Subject Heading

MID Minimally Important Difference

ODI Oxygen Desaturation Index

OSA Obstructive Sleep Apnea

PSG Polysomnogram/Polysomnography

PSQI Pittsburgh Sleep Quality Index

RCT Randomized Controlled Trial

RDI Respiratory Disturbance Index

RR Risk Ratio

SAQLI Sleep Apnea Quality of Life Index

SASQ Sleep Apnea Symptom Questionnaire

SF-36 Short Form-36, quality of life scale

SSP Sleep Specialist Physician

US United States

USPSTF United States Preventive Services Task Force

VA Department of Veterans’ Affairs

VAS Visual Analogue Scale

VINCI Veterans Administration Informatics and Computing Infrastructure

VSQ-9 Visit-specific Satisfaction Instrument
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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EVIDENCE REPORT

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic condition that results from repeated closure of the 

upper airway during sleep resulting in reduced airflow (hypopnea) or complete airflow cessation 

(apnea) leading to cyclic sleep disruption. Subsequently, patients with OSA frequently 

experience excessive daytime sleepiness and decreased quality of life. However, not all 

individuals have excessive daytime sleepiness and symptoms are not required to make a 

diagnosis or obtain treatment. OSA has also been associated with a higher risk of myocardial 

infarction,

1,2 heart failure,3 stroke,4,5 and cognitive decline.6,7 The severity of OSA can be 

categorized as mild, moderate, or severe based on the number of apnea and hypopnea events per 

hour (known as the apnea-hypopnea index [AHI]). An AHI of 5/hour to fewer than 15/hour is 

considered mild, 15/hour to fewer than 30/hour is considered moderate, and 30/hour or greater is 

considered severe. Continuous positive airway pressure (CPAP) effectively reduces AHI in most 

patients with OSA, improves blood pressure, and particularly in those with symptoms of 

excessive daytime sleepiness, improves quality of life and sleep symptoms.

8 CPAP use is also 

associated with a reduced risk of motor vehicle accidents.

9

The estimated prevalence of mild to severe OSA based on AHI thresholds (AHI ≥ 5/hour) in the 

United States (2007-2010 data) among 30- to 70-year-olds regardless of symptom status is 34% 

for men and 17% for women.10 The corresponding values for moderate to severe OSA (AHI ≥ 

15/hour) are 13% for men and 6% for women. The prevalence of 30-70 year olds with AHI ≥ 

5/hour and daytime sleepiness (Epworth Sleepiness Scale score > 10) is 14% for men and 5% for 

women. Current prevalence of abnormal AHI may be higher due to rising rates of obesity and 

increased testing for OSA due to heightened awareness of the condition. The proportion of 

persons with OSA who are asymptomatic or have unrecognized symptoms is unknown but a 

recent review estimated that 80% of individuals with AHI ≥ 5/hour may be undiagnosed.11 The 

cost burden of diagnosing and treating OSA in the US in 2015 was estimated to be $12.4 billion 

while the cost burden of undiagnosed OSA in the US in 2015 was estimated to be $149.6 billion 

when costs of comorbidities and mental health, motor vehicle accidents, workplace accidents, 

and lost productivity were considered.11 The authors acknowledged the difficulty of determining 

exact costs.

A prior evidence report and accompanying clinical practice guideline by the American College 

of Physicians (ACP) recommends that clinicians should target their assessment of OSA to 

individuals with unexplained daytime sleepiness.12-14 This is largely because evidence is lacking 

on the effect of CPAP on improving many other outcomes, including diabetes, coronary heart 

disease events, and mortality, especially among individuals without daytime sleepiness. 

Furthermore, the ACP concluded that assessment of OSA in the absence of daytime sleepiness 

and treatment of persons with low AHI are both low-value care because evidence to date 

indicates that neither improves clinical outcomes. 

A draft evidence report and recommendation statement from the US Preventive Services Task 

Force (USPSTF) indicated that evidence was insufficient to assess the net benefit of screening 

for and treatment of asymptomatic OSA.15
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Specifically, the most evidence was available on CPAP and found that compared to sham 

intervention, CPAP reduced AHI, ESS score, and blood pressure. Although studies generally 

showed that treatment with CPAP reduced AHI to near-normal levels, the clinical significance of 

the small reductions in ESS score and blood pressure is uncertain. Further, given that most of the 

trials were conducted in referred patients or patients of sleep clinics, the applicability of this 

evidence to a screen-detected population (ie, detection of abnormal AHI in asymptomatic 

individuals or those without excessive daytime somnolence, including based on findings from 

"screening” questionnaires) is limited. Despite the consistent observational findings of an 

association between severe OSA and increased mortality, the USPSTF identified no studies that 

reported on change in AHI and associated change in mortality. Thus, it is unclear whether 

treatments that improve AHI would also improve mortality. The USPSTF found inadequate 

evidence on the link between change in the intermediate outcome (AHI) and reduction in the 

health outcome (mortality). While the USPSTF found evidence that treatment with CPAP can 

improve general and sleep-related quality of life in populations referred for treatment, the 

applicability of this evidence to screen-detected populations is unknown. The USPSTF also 

found inadequate evidence on whether treatment with CPAP improves other health outcomes 

(mortality, cognitive impairment, motor vehicle accidents, and cardiovascular or cerebrovascular 

events). Following release of the USPSTF report, results from a multi-site randomized trial were 

published and showed that CPAP was not effective for secondary prevention of cardiovascular 

events in those with established cardiovascular disease and moderate to severe OSA.

16

Despite the data associating OSA with consequences to health and quality of life and the 

conclusions from other guideline groups, many persons with OSA remain undiagnosed. In 2005, 

the National Sleep Foundation administered the Berlin sleep apnea risk questionnaire (a 

questionnaire commonly used for OSA screening and/or case finding) by phone to a random 

sample of 1,506 US adults who agreed to complete the questionnaire and found that 31% of men 

and 21% of women met criteria for high OSA risk.

17 Obesity is a major risk factor for OSA and 

among those with a body mass index (BMI) of ≥ 30 kg/m2 (25% of the sample), 57% had high 

risk for OSA.

In 2010, among 1.8 million US Veterans receiving outpatient care at 136 Veterans Affairs (VA) 

facilities, 37.4% had a BMI ≥ 30 kg/m2

, suggesting that a substantial portion of US Veterans are 

at high risk for OSA.

18 A recent analysis of Veterans Administration Informatics and Computing 

Infrastructure (VINCI) data between 2000 and 2010 showed that among 9.8 million Veterans, 

the age-adjusted prevalence of diagnosed sleep apnea was 0.4% in 2000 and had increased to 

3.0% in 2010 (a relative increase of 650%).

19 As awareness of OSA by patients and providers 

continues to increase, and as BMI continues to increase in the US and globally,

20 healthcare

systems such as the VA need to develop strategies to manage the increasing demand for sleep 

services. One strategy is to target screening and testing to those most likely to derive benefit 

from OSA treatment (eg, those with significant unexplained daytime sleepiness), as suggested by 

the ACP. Another strategy is to improve efficiency within healthcare systems by implementing 

innovative, less resource-intense models of care for OSA.

The traditional model of OSA evaluation and care relies upon primary care providers to refer 

patients with suspected OSA to a sleep specialist physician (SSP) for consultation. After an 

initial consultative visit, the SSP can order formal, in-lab polysomnogram (PSG) for diagnostic 

purposes and for those with confirmed OSA, a PSG for titration of CPAP pressures. The SSP 

would then typically initiate CPAP at the pressure suggested by the titration PSG, and then the 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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patient would follow up with the SSP at regular intervals for assessment of treatment compliance 

and efficacy. Given the rapidly rising requests for OSA diagnostic and treatment services, this 

traditional model is increasingly viewed as unnecessarily expensive and inefficient for the 

evaluation and treatment of patients at high risk of OSA. Recent data also indicate a decreasing 

supply of SSPs to care for patients with known or suspected OSA.

21

Therefore, new models of OSA care have been proposed and implemented. These new models 

include home sleep testing (HST) for diagnostic purposes,

22 followed by treatment with an 

autotitrating CPAP (APAP) device,

23 which has internal algorithms to adjust CPAP pressure to 

keep the airway open during sleep. These models reduce PSG-associated costs and logistical 

barriers, yet typically still include consultation and follow up with a SSP. Other proposed models 

would reduce reliance on SSPs by including non-SSP providers such as nurses or primary care 

clinics to provide the bulk of OSA diagnosis and treatment.

Although several studies have been conducted to test some of these new models, systematic 

reviews are lacking. The Minneapolis VA’s Evidence-based Synthesis Program (ESP) Center, in 

partnership with topic nominators and a Technical Expert Panel (TEP), was commissioned to 

systematically review the evidence regarding the comparative effectiveness, harms, and cost of 

these new models of OSA evaluation and treatment.

We addressed the following key questions:

Key Question 1. For adults with suspected OSA, what are the effectiveness/harms/resource 

utilization of case finding and care provided by practitioners who are not sleep physicians 

(including PCPs, PAs, NPs, technologists, nurses, and respiratory therapists), compared to case 

finding and care provided by sleep specialist physicians?

KQ1A. Do effectiveness/harms/resource utilization vary by patient characteristics:

a. Unexplained daytime sleepiness/fatigue

b. AHI severity

c. Other risk factors or coexisting conditions associated with OSA (eg, obesity, 

neck circumference, treatment-resistant hypertension, diabetes, age, 

sex, race)

d. Symptoms (eg, nocturia, loss of libido, snoring, witnessed sleep “apnea”)?

Key Question 2. For adults with suspected OSA, what are the effectiveness/harms/resource 

utilization of electronic consultation versus interactive (eg, in-person, telephone) consultation?

KQ2A. Do effectiveness/harms/resource utilization vary by patient characteristics:

a. Unexplained daytime sleepiness/fatigue

b. AHI severity

c. Other risk factors or coexisting conditions associated with OSA (eg, obesity, 

neck circumference, treatment-resistant hypertension, diabetes, age, 

sex, race)

d. Symptoms (eg, nocturia, loss of libido, snoring, witnessed sleep “apnea”)?

Key Question 3. For adults diagnosed with OSA, what are the effectiveness/harms/resource 

utilization (including cost avoidance) of using in-home autotitrating continuous positive airway 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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pressure (APAP) technology compared to standard continuous positive airway pressure (CPAP) 

titrated by in-lab PSG?

KQ3A. Do effectiveness/harms/resource utilization vary by patient characteristics:

a. Unexplained daytime sleepiness/fatigue

b. AHI severity

c. Other risk factors or coexisting conditions associated with OSA (eg, obesity, 

neck circumference, treatment-resistant hypertension, diabetes, age, 

sex, race)

d. Symptoms (eg, nocturia, loss of libido, snoring, witnessed sleep “apnea”)?

PICOTS AND ANALYTIC FRAMEWORKS (FIGURES 1A, 1B)

Population: 

KQ1, KQ2: Adults with suspected obstructive sleep apnea (OSA) to include:

KQ3: Adults with diagnosed OSA

Intervention

KQ1: supervised practitioner or non-specialist licensed independent practitioner-led care (ie, 

PCP, PA, NP, nurse, technologist, or respiratory therapist) (for case finding or treatment)

KQ2: Electronic initial consultation (chart review or algorithm) (for case finding)

KQ3: Home auto-titrating continuous positive airway pressure (APAP)

Comparator

KQ1: Sleep specialist-led care (for case finding or treatment)

KQ2: Interactive (eg, in-person, telephone) initial consultation (case finding)

KQ3: In-center manual CPAP titration

Outcomes

Intermediate Outcomes: time to initiation of therapy; compliance; apnea-hypopnea index (AHI); 

oxygen saturation; continuous or scale score measures of sleep symptoms, urinary symptoms, 

cognitive ability, weight, BMI, libido, blood pressure, or HBA1c; harms (false 

positives/negative, overdiagnosis, patient safety/adverse events); costs

Clinical Outcomes: mortality; resource utilization; access to care; minimally important 

differences in sleep symptom scores, urinary symptom scores, libido, weight change, BMI, blood 

pressure, or HbA1c; quality of life; diagnosis of cognitive impairment; sleep symptom score 

below threshold; patient satisfaction

Timing: Any

Setting: Study done in North America, Europe, or Australia/New Zealand
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Figure 1a. Analytic Framework – Key Questions 1 and 2

Solid Arrow = Linkage; Dotted Arrow = Association; Curved Arrow leads to Harms (Ovals); AHI = Apnea Hypoxia Index; LIP = licensed independent 

practitioner; OSA = obstructive sleep apnea; PSG = polysomnography; SSP = sleep specialist physician

Adults with unexplained 

daytime sleepiness or at 

risk for OSA (ie, risk 

factors, coexisting 

conditions, or other 

symptoms)

Harms (Case 

Finding)

False positives/ 

negatives

Overdiagnosis 

Case Finding

KQ1: Supervised practitioner or 

non-specialist LIP-led 

evaluation vs SSP

KQ2: Electronic consultation vs 

interactive

OSA 

diagnosis

No OSA

Intermediate 

Outcomes

Case finding/

diagnostic accuracy

Time to initiation of 

therapy

Compliance

AHI

Oxygen saturation

Continuous 

measures of sleep 

and urinary 

symptom scores, 

cognitive ability, 

weight, BMI, libido, 

blood pressure, 

HbA1c

Clinical Outcomes

Mortality

Resource utilization 

(eg, hospitalizations)

Access to care

Minimally important 

differences in sleep 

symptom scores

Normalization of AHI

Quality of life

Diagnosis of cognitive 

impairment

Sleep symptom score 

below threshold

Patient satisfaction

Harms

(Intervention)

Patient safety/ 

adverse events

Costs

Intervention

KQ1: Supervised practitioner 

or non-specialist LIP-led care

vs SSP

PSG
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Figure 1b. Analytic Framework – Key Question 3

Solid Arrow = Linkage; Dotted Arrow = Association; Curved Arrow leads to Harms (Ovals); AHI = Apnea Hypoxia Index; APAP = Auto-adjusting Positive 

Airway Pressure; CPAP = C Positive Airway Pressure OSA = obstructive sleep apnea

Adults with 

diagnosed OSA

Intermediate 

Outcomes

Compliance

AHI

Oxygen saturation

Continuous 

measures of sleep 

and urinary 

symptom scores, 

cognitive ability, 

weight, BMI, libido, 

blood pressure, 

HbA1c

Clinical Outcomes

Mortality

Resource utilization 

(eg, hospitalizations)

Minimally important 

differences in sleep 

symptom scores

Normalization of AHI

Quality of life

Diagnosis of cognitive 

impairment

Sleep symptom score 

below threshold

Patient satisfaction

Harms

(Intervention)

Patient safety/ 

adverse events

Costs

Intervention

Home APAP vs CPAP

(titration, treatment)
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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METHODS

TOPIC DEVELOPMENT

This topic was nominated by Kathleen Sarmiento, MD, MPH, Director of Pulmonary Sleep 

Medicine, VA San Diego and W. Claibe Yarbrough, MD, National Program Director, 

Pulmonary/Critical Care/Sleep, on behalf of the Specialty Care Services (10P4E) –

Pulmonary/Critical Care/Sleep National Program office. The evidence review examines the 

effectiveness and harms associated with different care models aimed at increasing access to care 

for Veterans who have obstructive sleep apnea.

SEARCH STRATEGY

We searched MEDLINE (Ovid) and CINAHL for articles published from 2000 through May

2016. Our search was limited to studies enrolling adults and published in the English language. 

The search for KQs 1 and 2 included the MeSH terms sleep apnea syndromes; sleep apnea, 

obstructive; health personnel; and remote consultation. The search for KQ3 included the MeSH 

terms home care services, continuous positive airway pressure, and calibration. The full search 

strategies are presented in Appendix A. We obtained additional articles by hand searching the 

reference lists of related systematic reviews and relevant studies.

STUDY SELECTION

All abstracts were independently reviewed by 2 trained investigators and research associates. We 

included studies of any design that reported results in adults with suspected or diagnosed OSA 

and were conducted in North America, Europe, Australia, or New Zealand. For KQ1 we 

excluded studies that did not include a comparison of a supervised practitioner or non-specialist 

licensed independent practitioner (eg primary care physician, physician’s assistant, nurse, 

technologist, or respiratory therapist) to a SSP. We excluded studies evaluating the role of

dentists or anesthesiologists. We also excluded studies in which the goal of the intervention was 

not case finding or care for OSA. For KQ2 we excluded studies that did not compare an 

electronic initial consultation, without patient contact, to an interactive initial consultation. For 

KQ3 we excluded studies that did not compare the use of APAP to CPAP for titration or 

treatment of OSA. We also excluded studies that used different diagnostic methods in those 

treated with APAP versus CPAP. In studies of titration we only included articles in which the 

APAP was used for titration at home and CPAP was manually titrated in a lab. We also excluded 

studies if they did not report any of our outcomes of interest (see PICOTS, above). There was no 

minimum follow-up duration.

Full-text reports of studies identified as potentially eligible were obtained for further review 

using the inclusion and exclusion criteria described above. Each article was independently 

reviewed by 2 investigators or research associates. Reasons for excluding a study at full-text

review were noted and disagreements were decided by a third reviewer.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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DATA ABSTRACTION

Study characteristics (location, setting, intervention groups, follow-up, aim of study, treatments, 

inclusion/exclusion criteria, and patient characteristics) as well as intermediate and clinical 

outcomes (time to initiation of therapy, compliance, AHI, oxygen saturation, sleep symptoms, 

urinary symptoms, cognitive ability, weight, BMI, libido, blood pressure, HbA1c, harms, 

overdiagnosis, adverse events, costs, mortality, resource utilization, access to care, quality of life, 

and patient satisfaction) were extracted onto evidence tables by one investigator or research

associate and verified by another. 

RISK OF BIAS ASSESSMENT

Trained research methodologists rated the risk of bias of individual studies as low, moderate, or 

high risk. One methodologist rated risk of bias and the rating was verified by a second

investigator trained in risk of bias assessment. Discrepancies were resolved by discussion. For 

randomized controlled trials (RCTs), risk of bias ratings were based the following criteria:

allocation sequence generation, allocation concealment, blinding, incomplete outcome data, and 

selective outcome reporting – a modification of the Cochrane approach to determining risk of 

bias.24

For observational studies, risk of bias was rated using criteria suggested in the Agency for 

Healthcare Research and Quality (AHRQ) Methods Guide: selection bias (use of appropriately 

comparable control group, design/analysis accounted for important confounding and modifying 

variables); masking of the outcome assessment (outcome assessor); use of intention-to-treat 

principles (ie, inclusion of all comparison group participants in outcomes analyses); attrition bias 

(if overall or differential dropout/loss to follow-up or exclusions a concern, missing data 

appropriately handled); and selective reporting of pre-specified outcomes.25 Observational 

studies were considered high risk of bias unless all 5 criteria were addressed by the study 

authors. Studies that addressed all 5 criteria were considered medium or low risk of bias 

depending on how completely the criteria were addressed.

DATA SYNTHESIS

We created separate evidence tables for each KQ. We described and qualitatively compared the 

characteristics and findings of included studies. For KQ1 and KQ3, data were analyzed in 

Comprehensive MetaAnalysis Version 3 (Biostat, Englewood, New Jersey) using DerSimonian 

and Laird random effects models to calculate weighted mean differences (WMD) for compliance 

and standardized mean differences (SMD) for changes from baseline for Epworth Sleepiness 

Scale (ESS) and quality of life (SF-36) scores with corresponding 95% confidence intervals (CI). 

SMDs can be interpreted by using Cohen's definition of small (0.2), medium (0.5), and large 

(0.8) effect sizes.

26 Statistical heterogeneity among trials was assessed by using the I2 test.27 A 

score of 75% or greater may indicate considerable heterogeneity.

RATING THE BODY OF EVIDENCE

We assessed strength of evidence using the method described by Owens et al for the following 

outcomes: access to care, ESS, quality of life, compliance (hours of use per night), and adverse 

events. Strength of evidence for an outcome was rated as high, moderate, low, or insufficient. 

This rating was based on precision (degree of certainty in the estimate of effect), consistency
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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(direction of effect across included studies), directness (whether evidence links intervention 

directly to health outcomes), and risk of bias of the individual studies (as described above).28

One methodologist rated strength of evidence and the rating was verified by a second. 

Discrepancies were resolved by discussion.

PEER REVIEW

A draft version of this report was reviewed by content experts as well as clinical leadership. 

Reviewer comments and our responses are presented in Appendix B and the report was modified 

as needed.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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RESULTS

We reviewed 2,847 abstracts, 2,252 from MEDLINE and 595 from CINAHL. We excluded

2,493 abstracts and reviewed the full text of 354 references. During full-text review we excluded 

323 articles leaving 31 eligible for inclusion. Hand searching pertinent trials and systematic 

review identified an additional 3 references. Figure 2 details the process. 

LITERATURE FLOW 

Figure 2. Literature Flow Chart

Search Results

Ovid: 2,252 abstracts

CINAHL: 595 abstracts

2,847 abstracts

Abstracts excluded:

2,493

Full-text Review:

354 references Excluded: 323

Population: 11

Intervention: 84

Comparator: 48

No outcomes: 3

Inappropriate Setting: 13

Study Design: 164 

Included:

34 references* 

KQ1: 8 papers

KQ2: 0 papers 

KQ3: 27 papers

*1 paper included for both 

KQ1 and KQ3

Hand Search: 

3 references 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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KEY QUESTION #1: For adults with suspected OSA, what are the 

effectiveness/harms/resource utilization of case finding and care 

provided by practitioners who are not sleep physicians (including 

PCPs, PAs, NPs, technologists, nurses, and respiratory therapists), 

compared to case finding and care provided by sleep specialist 

physicians?

Summary of Findings for Key Question #1 

Case Finding

• No studies assessed the diagnostic accuracy of non-sleep-specialist nurse for case finding 

and referral.

• One retrospective study reported good agreement between a primary care pulmonologist 

and a SSP on what sleep test to order for patients referred by their family physician.

Care

• Clinical (ie, patient-centered) outcomes were infrequently and inconsistently reported. 

When reported there was no significant difference in clinical outcomes between OSA 

treated by primary care/nurses and SSPs. The strength of evidence for quality of life was 

moderate.

• Intermediate outcomes were more commonly reported. Sleep symptom scores were 

similar between groups (moderate strength of evidence).

• There was little evidence that treatment compliance differed between patients treated by 

SSPs and those not, including the proportion of patients with 4 hours or more of CPAP 

use on 70% or more of nights (moderate strength of evidence). 

• Very few studies reported other intermediate outcomes. One reported a significantly 

lower residual AHI on CPAP in patients referred for PSG by non-sleep specialists and 

another found that the proportion of patients receiving CPAP within one month of their 

PSG was significantly higher in patients cared for by a SSP. Strength of evidence for 

access to care and adverse events was insufficient.

Overview of Studies – Table 1

Eight studies (n = 1,401; 4 RCTs) reported results for KQ1.

29-36 Study characteristics are 

summarized in Table 1 with more details in Appendix C, Table 1. Sleep physician care was 

compared to management by primary care in 4 studies (n = 564),31-33,36 sleep-specialist nurses in 

3 studies (n = 434),29,30,34 and other non-sleep physicians in one study (n = 403).35 The weighted 

mean age was 52 years and roughly half of the participants (54%) had hypertension. The mean 

BMI was 34 kg/m2

, ESS was 11.5, and AHI was 32/hour. Three studies (n = 678) reported that 

their patients had moderate or severe OSA (mean AHI ≥ 15/hour)

29,33,35 and 5 studies (n = 721) 

reported that their patients had mild OSA (mean ESS 11-14)30-32 or moderate (mean ESS > 14)

sleepiness.29,33 Three studies (n = 415) required all participants to have symptoms of sleepiness

(ie, ESS ≥ 830,31 or ESS ≥ 1229), and participants in these studies had a mean baseline ESS of 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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13.6 (mild sleepiness). Participants in the remaining 4 studies that reported ESS but did not 

require sleepiness had a mean baseline ESS of 10.5 (normal sleepiness). Three studies took place 

in Europe, 3 in North America, and 2 in Australia/New Zealand. Of the 4 RCTs, one was low 

risk of bias30 and 3 were medium risk of bias. Of the 4 observational studies, 3 were medium risk 

of bias and one was high risk of bias.32

Table 1. Key Question 1: Study Characteristics 

Characteristic

Weighted Mean 

(range)

Unless otherwise 

noted

Number of 

studies 

reporting

Total number enrolled/randomized 1,401 (65-403) 8

Randomized controlled trials, total n 589 (65-195) 4

Other, total n 812 (96-403) 4

Primary care, total n 564 (96-210) 4

Sleep-specialist nurse, total n 434 (65-195) 3

Other non-sleep physician provider, total n 403 1

Age of subjects (years) 52.2 (47.7-58.7) 8

Percent Male 67% (47-85.5) 8

Baseline BMI, kg/m2 34 (30.2-36.6) 7

Baseline ESS 11.5 (8.5-15.7) 7

Baseline AHI (events/hour) 32 (21-43) 3

Percent with hypertension (%)* 54 (38-58.5) 4

Location – North America, total n 716 (103-403) 3

Location – Europe, total n 335 (65-174) 3

Location – Australia/New Zealand, total n 350 (155-195) 2

Required participants to have daytime sleepiness, total n 415 (65-195) 3

*as defined by study

Case Finding

One retrospective study reported on the ability of a primary care pulmonologist to order the 

proper sleep test.

32 Patients (n = 96) were referred to the primary care pulmonologist by their 

family physician. An SSP reviewed the sleep tests ordered by the primary care pulmonologist. 

There was good agreement between the primary care pulmonologist and SSP (kappa = .74) and 

93% (89/96) of the referred patients were diagnosed with OSA. 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Care

Seven studies reported treatment outcomes in patients being treated by providers other tha SSPs. 

Three of these studies compared SSP care to primary care (n = 468; 1 RCT), 3 compared SSP 

care to sleep specialist nurses (n = 434; 3 RCTs), and one compared SSP care to management by 

a variety of physicians who were not sleep specialists. The nature of care provided by different 

professionals was varied and often inconsistently reported. Two of the studies (n = 506) were 

retrospective and gave few details regarding the care given by each practitioner.

35,36 Three 

studies (n = 560; 2 RCTs and one cohort study) described interventions in which the SSP had 

much more autonomy than the non-SSP provider, who was generally giving protocol-driven care 

that followed clinical guidelines.

30,31,33 Two RCTs compared patients who received similar care 

delivered by different providers and at different locations (home versus a hospital/clinic).29,34

Many of the articles only described the care given to patients in non-specific terms and often 

details were only given for one study arm. 

Clinical Outcomes – Table 2; Appendix C, Tables 2-3

Clinical outcomes were only reported sporadically. The most commonly reported clinical 

outcome was resource utilization (k = 5). Two studies reported receipt of treatment finding no 

significant difference in the proportion of patients using CPAP at follow-up.

31,36 One study found 

that patients whose follow-up appointments were at the hospital, as opposed to at home, often 

needed additional help from a specialist nurse for practical problems, although the significance 

and impact of this finding was not reported.

34 Three studies reported provider contact. One RCT 

found that patients being managed by a sleep specialist nurse had significantly more scheduled 

nursing time than patients being managed by a SSP (153 minutes vs 103 minutes, P<.001, effect 

size 1.25, 95% CI 0.94, 1.56) and patients managed by SSPs had significantly more physician 

visits than patients receiving nurse-led care (2.4 vs 0.2; P<.001, effect size 2.24, 95% CI 1.88, 

2.60).

30 A second RCT compared the time nurse-managed patients spent with a nurse to the time 

SSP-managed patients spent with a SSP and found groups were similar (effect size 0.32, 95% CI

-0.13, 0.66).

34 A third study reported extra visits and calls required by patients but without a 

measure of statistical significance.29 We had difficulty determining what would constitute 

improved resource utilization and ultimately, OSA management by a non-SSP had no significant 

effect on any measure of resource utilization as compared to SSP care. 

Three studies reported quality of life and all found that SF-36 scores were similar for patients 

being managed by primary care (k = 1)

31 or sleep-specialist nurses (k = 2)30,34 compared to SSPs. 

The pooled standard mean differences in change from baseline for the mental health and vitality 

components of the SF-36 are presented in Figure 3.

The 2 studies reporting patient satisfaction both found no significant difference in overall 

satisfaction between groups.30,31 One study reported significant differences on several VSQ-9 

items but cautioned that the effect sizes were all small and may not be clinically significant.31 No 

study reported all-cause mortality, access to care, minimally important differences in symptom 

scores, cognitive outcomes, libido, or percent of patients achieving physiological targets.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Table 2. Clinical Outcomes Comparing Non-sleep Specialists to Sleep Specialists

a

subjective symptom improvement, bHADS = Hospital Anxiety and Depression Scale

MID = minimally important difference; ESS = Epworth Sleepiness Scale; BMI = body mass index; SF-36 = 36 item 

short form survey; SAQLI = Calgary Sleep Apnea Quality of Life Index; VAS = visual analogue scale; VSQ-9 = 

Visit-Specific Satisfaction Instrument; HbA1c = hemoglobin A1c; retro = retrospective; Obs = observational

↑ = significantly better with non-SSP than with usual care SSP including less resource utilization, ↔ = nonsignificant difference between non-SSP and SSP care, ↓ = significantly better with SSP than non-SSP, ↕ = mixed 

results comparing non-SSP and SSP care, X = between provider significance not reported; number before symbol 

indicates number of studies

Light gray shading in a cell indicates measure of significance was calculated, not reported by the study. 

Author, Year

Enrolled/

Randomized (n)

Study Design

All-cause Mortalityy

Normalization of AHI

MID Quality 

of Life

Patient 

SatisfactionResource Utilization

Access to 

Care

Libido

% 

Achieving 

Target

Cognitive 

Symptoms

Other

ESS

Urinary 

Symptom 

Scores

SF-36

SAQLI

VAS

VSQ-9 

Hospitalization

Treatment

Contact

Provider 

Referrals

Weight 

Loss

BMI

Blood 

Pressure

HbA1c

Primary Care 3 studies (n = 468)

Chai-Coetzer 2013 31

(n = 155); RCT ↔ ↕ ↔

Lettieri 201133 (n =

210); Obs. cohort 

Scharf 200436 (n =

103); Retro 

survey/chart review 

↔ ↔a

Nurse 3 studies (n = 434)

Andreu 201229 (n =

65); RCT X 

Antic 200930 (n =

195); RCT ↔ ↔ ↕

Palmer 200434 (n =

174); RCT ↔ ↔ X ↔b

Not specified 1 study (n = 403)

Pamidi 201235 (n =

403); Retro chart 

review

Total 0 0 0 0 3↔ 0 0 1↔

1↕ 0 2↔

1↔

1↕

1X

1X 0 0 0 0 0 0 0 2↔
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Figure 3. SF 36 Mental Health and Vitality Scores, Standardized Mean Differences in 

Mean Change from Baseline, Non-sleep Specialist versus Sleep Specialista

 

Mental Health

Vitality

a

Lower and upper limits represent 95% confidence intervals

PCP = primary care physician

Intermediate Outcomes – Table 3; Appendix C, Tables 4-6 

The most frequently reported intermediate outcome was compliance with therapy, reported by 7 

studies with some reporting multiple indicators of compliance. The majority of studies reported 

adherence as hours of use per night (k = 6).29-31,33-35 Several reported the proportion of patients 

with regular use (k = 4), defined as ≥ 4 hours of CPAP use on ≥ 70% of nights, a compliance 

threshold often used to define minimally acceptable compliance for payment 

reimbursement.

29,33,35,36 One reported the proportion of nights with any use.33 Six of the 7 studies 

found no difference in compliance, regardless of measure used, when comparing patients 

receiving SSP care to those receiving care from non-SSPs. The pooled mean difference from the 

RCTs was -0.25 (95% CI -0.72, 0.22; I

2

 = 21%) (Figure 4). The final study found that patients 

who were referred for a sleep study by non-SSPs were significantly less compliant, with fewer 

hours per night and less regular use, than those patients who were referred by SSPs.

35 Cost was 

reported, in various ways, by 4 of the studies.29-31,34 Two did not report the significance of 

differences between SSP and non-SSP care for OSA.31,34 Two studies, however, found that 

nurse-led OSA care was associated with significantly lower costs per patient29 and within-trial 

costs.

30 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Table 3. Intermediate Outcomes Comparing Non-sleep Specialists to Sleep Specialists

a

decreased costs

b

maintenance of wakefulness

c ≥ 4h of use on ≥ 70% of nights

AHI = apnea-hypopnea index; ODI = oxygen desaturation index; ESS = Epworth Sleepiness Scale; FOSQ = 

Functional Outcomes of Sleep Questionnaire; SASQ = Sleep Apnea Symptom Questionnaire;TST = total sleep time; 

PSQI = Pittsburgh Sleep Quality Index; BMI = body mass index; retro = retrospective; Obs = observational

↑ = significantly better with non-SSP than with usual care SSP including less resource utilization, ↔ = nonsignificant difference between non-SSP and SSP care, ↓ = significantly better with SSP than non-SSP, ↕ = mixed 

results comparing non-SSP and SSP care, X = between provider significance not reported; number before symbol 

indicates number of studies

Light gray shading in a cell indicates measure of significance was calculated, not reported by the study. 

Author, Year

Enrolled/

randomized (n)

Study design

AHI

Oxygen 

SaturationSleep Symptom Scores

Weight 

Loss

BMI

Blood Pressure

HbA1c

Time to Initiation of 

Therapy

Adverse Events

Cost

Compliance/ 

Adherence

Mean

Time <90%

ODI

Minimum

ESS

FOSQSASQ

Arousals

TST

PSQI

Snoring

Other

Hrs/night

Proportion of 

Nights

Regular 

Usec

Other

Primary Care 3 studies (n = 468)

Chai-Coetzer, 

2013 31 (n = 

155); RCT 

↔ ↔ ↔ ↔ ↔ X ↔

Lettieri, 201133

(n = 210); Obs. 

cohort 

↔ ↔ ↔ ↔ ↔

Scharf, 200436

(n = 103); Retro 

survey/chart 

review 

↓ ↔

Nurse 3 studies (n = 434)

Andreu, 201229

(n = 65); RCT ↔ ↕ X ↑

a ↔ ↔

Antic, 200930 (n

= 195); RCT ↔ ↔ ↔b ↕ ↑ ↔

Palmer, 200434

(n = 174); RCT ↔ ↔ X ↔

Not specified 1 study (n = 403)

Pamidi, 201235

(n = 403); Retro 

chart review

↑ ↓ ↓

Total 1↑ 5↔ 2↔

1↕

1

↔

2

↔

1

↔

1

↔

1↓

1↕

1

↔

1

X

2

↑

2

X

5

↔

1↓

1↔

3

↔

1↓
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Figure 4. Compliance, Weighted Mean Difference for Hours per Night, Non-sleep Specialist

versus Sleep Specialista

 

a

Lower and upper limits represent 95% confidence intervals

PCP = primary care physician

Sleep symptom scores were reported by 5 studies.29-31,33,34 All 5 reported ESS scores and all 

found similar results for groups receiving care from different providers. For the RCTs, the SMD 

for improvement from baseline was 0.06 (95% CI -0.11, 0.24; I2 = 2%) (Figure 5) and the 

weighted mean difference (WMD) was 0.30 (95% CI -0.50, 1.10). Three studies also reported 

FOSQ and one reported SASQ scores; 2 reported no significant between group differences in 

either score.30,31 The third study, which used a 3-arm design, found that patients with sleep unit 

nurse-led follow-up care had lower (ie, worse) FOSQ scores than one of the 2 groups of patients 

with sleep pulmonologist follow-up.29 The difference was small (one point) but statistically 

significant. There was no difference between the nurse-followed group and the other 

pulmonologist group. AHI was reported by one study, which found that residual AHI on CPAP 

was significantly lower in patients referred for PSG by non-SSPs than in patients referred by 

SSPs (P<.001).35

One RCT reported dryness (54%), nasal congestion (40%), and abrasions (25%) but did not 

provide separate data for the 2 study groups.29 An observational study reported no significant 

differences between groups in the percentages of patients who discontinued therapy although 

reasons for discontinuing were not reported.33 In one study, changes in weight loss and blood 

pressure were similar with primary care management of OSA as compared to SSP care.31 Time 

to initiation of therapy was reported in 2 studies. One found that significantly fewer patients in 

the primary care group received CPAP within one month of PSG when compared to patients in 

the SSP group (P = .012).36 The other reported that while groups were similar in satisfaction with 

time waiting (P = .71), patients receiving nurse-led care were more satisfied with their 

impression of wait time (P = .004).30 No studies reported oxygen saturation, HbA1c, or BMI. 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Figure 5. Epworth Sleepiness Scores, Standardized Mean Differences for Mean Change 

from Baseline, Non-sleep Specialist versus Sleep Specialista

 

a

Lower and upper limits represent 95% confidence intervals

PCP = primary care physician
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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KEY QUESTION #1A: Do effectiveness/harms/resource utilization vary 

by patient characteristics:

a. Unexplained daytime sleepiness/fatigue

b. AHI severity

c. Other risk factors or coexisting conditions associated with OSA 

(eg, obesity, neck circumference, treatment-resistant hypertension, 

diabetes, age, sex, race)

d. Symptoms (eg, nocturia, loss of libido, snoring, witnessed sleep 

“apnea”)?

Few studies provided information to address KQ1A. 

A. Unexplained Daytime Sleepiness/Fatigue

Of the studies eligible for KQ1, 2 required patients to have at least mild daytime sleepiness (ESS

≥ 8)30,31 and one required an ESS ≥ 12.29 Another study did not report ESS but noted that 68% of 

patients reported excessive sleepiness at baseline.36 No study reported results for subgroups of 

patients based on daytime sleepiness. In addition, with sporadic outcome reporting, it was not 

possible to determine whether results were different in studies that required a measure of 

sleepiness for study inclusion versus those that did not.

B. AHI Severity

Four studies reported baseline AHI. Values ranged from 21/hour

33 to 68/hour.30 In one of the 

studies, 55% were diagnosed with severe OSA (AHI ≥ 30/hour).35 Similar to the finding for 

daytime sleepiness, no study reported results for subgroups of patients based on AHI and it was 

not possible to determine whether results were different in the studies with higher baseline AHI 

values.

C. Other Risk Factors or Coexisting Conditions Associated with OSA 

Each of the 7 studies with newly evaluated/diagnosed patients reported BMI. Values ranged from 

30 kg/m233 to 36 kg/m2

.

35 One study reported neck circumference (mean of 45.5 cm).29 No study 

reported treatment resistant hypertension but 4 reported percentages of study participants with 

hypertension ranging from 38%32 to 58%.

35 Three reported percentages of participants with 

diabetes (14% to 26%).

32,35,36 As noted previously, mean age in the 8 studies was 52 years with 

little variation across studies (range 48 to 59 years). The mean percentage of male study 

participants was 67% but values ranged from 47% to 85%. No study reported results for 

subgroups of patients based on obesity, neck circumference, hypertension, diabetes, age, or 

gender.

One study from the US (Chicago) reported race with 54% African American and 46% nonAfrican American.35 In a model adjusted for age, sex, BMI, Medicaid insurance, AHI, ESS, 

Center for Epidemiologic Studies Depression Scale, and education level, African Americans 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

32

used CPAP an average of 56 minutes/day less than non-African Americans (P = .002) It was not 

reported whether there was an interaction with physician specialty.

D. Symptoms

Four studies addressed snoring. In 2 studies, snoring was an inclusion criterion with “habitual 

snoring” being a high-risk feature in one study33 and history of snoring “most” or “every” night 

being a factor in patient referral in another study.

30 Two studies reported the percentage of 

patients with snoring at baseline: 100%29 and 83%.

36 None of the studies reported results for 

subgroups of patients based on snoring as an inclusion criterion or a baseline factor. 

Strength of Evidence for Key Question 1 (Table 4, Appendix D)

There was insufficient evidence for access to care and adverse events. Strength of evidence for 

quality of life, ESS, and CPAP compliance (hours of use per night) was rated as moderate. 

Quality of life, ESS, and compliance were similar for patients managed by practitioners who are 

not sleep physicians compared to patients managed by SSPs.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Table 4. Strength of Evidence for Outcomes, Key Question 1

Comparison Outcome of 

Interest

Strength of

Evidence Direction Findings

KQ1: Sleep 

physician care 

compared to 

management by 

primary care, sleepspecialist nurses or 

other non-sleep 

physicians

Access to care Insufficient We found no evidence for this outcome.

Epworth Sleepiness 

Scale (ESS) Moderate Similar

Based on 4 RCTs (n = 568) with aggregate moderate risk of bias, we found 

improvement from baseline in ESS scores was similar for patients being managed by 

primary care/sleep-specialist nurses compared to SSPs (SMD = 0.06 [95% CI -0.11, 

0.24]). One observational study also found ESS scores were similar between groups.

Quality of life Moderate Similar

Based on 3 RCTs (n = 524) with aggregate moderate risk of bias, we found quality of life 

measures were similar for patients being managed by primary care/ sleep-specialist 

nurses compared to SSPs. SMDs for SF-36 Vitality and Mental Health scores were -0.04 

[95% CI -0.22, 0.15]) and -0.04 [95% CI -0.22, 0.14], respectively.

Compliance, 

hours per night Moderate Similar

Based on 4 RCTs (n = 568) with aggregate moderate risk of bias, we found compliance 

was similar for patients being managed by primary care/sleep-specialist nurses 

compared to SSPs (WMD = -0.25 [95% CI -0.72, 0.22]). One observational cohort study 

also found compliance was similar between groups but one study based on 

retrospective chart review reported compliance was greater in the SSP group compared 

to the non-sleep specialist group.

Adverse events Insufficient Based on the findings of one RCT (n = 65) that did not report adverse events by 

treatment arm, the evidence is insufficient to draw conclusions.

APAP = Auto-adjusted (autoregulated) continuous positive airway pressure; CPAP = continuous positive airway pressure; RCT = randomized controlled trial; 

SAQLI = Sleep Apnea Quality of Life Index; SF-36 = Short Form-36; SMD = standardized mean difference; WMD = weighted mean difference. a

Strength of Evidence Definitions;28 See Appendix D for more details

• High: Very confident that estimate of effect lies close to true effect. Few or no deficiencies in body of evidence, findings believed to be stable.

• Moderate: Moderately confident that estimate of effect lies close to true effect. Some deficiencies in body of evidence; findings likely to be stable, but some 

doubt.

• Low: Limited confidence that estimate of effect lies close to true effect; major or numerous deficiencies in body of evidence. Additional evidence necessary 

before concluding that findings are stable or that estimate of effect is close to true effect. 

• Insufficient: No evidence, unable to estimate an effect, or no confidence in estimate of effect. No evidence is available or the body of evidence precludes 

judgment.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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KEY QUESTION #2: For adults with suspected OSA, what are the 

effectiveness/harms/resource utilization of electronic consultation 

versus interactive (eg, in-person, telephone) consultation?

Key Question #2A: Do effectiveness/harms/resource utilization vary 

by patient characteristics:

a. Unexplained daytime sleepiness/fatigue

b. AHI severity

c. Other risk factors or coexisting conditions associated with OSA 

(eg, obesity, neck circumference, treatment-resistant hypertension, 

diabetes, age, sex, race)

d. Symptoms (eg, nocturia, loss of libido, snoring, witnessed sleep 

“apnea”)?

We found no studies that addressed KQ2 or KQ2a.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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KEY QUESTION #3: For adults diagnosed with OSA, what are the 

effectiveness/harms/resource utilization (including cost avoidance) of 

using in-home autotitrating continuous positive airway pressure 

(APAP) technology compared to standard continuous positive airway 

pressure (CPAP) titrated by in-lab PSG?

Summary of Findings for Key Question 3

Titration

• Few studies compared clinical (ie, patient-centered) outcomes between in-lab CPAP 

titration and at-home APAP titration. In limited reporting, study groups were generally 

similar on measures of quality of life (moderate strength of evidence) and cognitive 

symptoms. Some differences were noted for resource utilization and patient preference.

• Intermediate outcomes (ie, sleep measures, blood pressure, adverse events, and 

compliance/adherence) were more commonly reported and generally similar. Strength of

evidence for ESS was moderate and strength of evidence for compliance was low. 

Strength of evidence for adverse events was insufficient.

Treatment

• Twenty-three studies compared treatment with CPAP to treatment with APAP. The 

studies enrolled patients with a broad range of baseline AHI values. 

• Few studies reported clinical (ie, patient-centered) outcomes other than quality of life and 

patient preference for one treatment approach over another. Quality of life, assessed with 

the SF-36, was generally similar between the CPAP and APAP groups (moderate 

strength of evidence). Patient preference was also generally similar or favored APAP in 

studies reporting statistical significance. Strength of evidence was insufficient for access 

to care.

• Intermediate outcomes including post-treatment ESS scores were frequently reported and 

generally similar for the 2 treatment approaches (moderate strength of evidence). Adverse 

events were mild and similar for APAP and CPAP (low strength of evidence).

• Compliance, reported as either hours per night or the proportion of nights the device was 

used, was also similar for the CPAP and APAP treatment groups (moderate strength of 

evidence).

Titration

Overview of Studies – Table 5; Appendix C, Table 7

Four studies compared titration of positive airway pressure using in-lab CPAP versus at-home 

APAP to determine a final long-term CPAP pressure setting.

33,37-39 Three were RCTs conducted 

in Canada,

39 Australia,38 and Spain.37 The fourth study, a cohort study, was done in the US.33

Follow-up periods ranged from 4 to 12 weeks. Sample sizes ranged from 6839 to 24537 at 

baseline but at least 10% of the sample was not included in the final analysis of each study. Each 

of the studies was rated medium risk of bias.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

36

Table 5. Key Question 3, Titration: Study Characteristics

Characteristic

Weighted Mean 

(range)

Unless otherwise 

noted

Number of 

studies 

reporting

Total number enrolled/randomized 622 (68-245) 4

Randomized controlled trials, total n 482 (68-245) 3

Other, total n 140 1

Age of subjects (years) 50 (46-54) 4

Percent Male 76 (67-88) 4

Baseline BMI (kg/m2) 33 (29.3-38.5) 4

Baseline ESS 14.7 (14.0-15.6) 3

Baseline AHI (events/hour) 43 (21.2-62.3) 3

Percent with hypertension (%)* 45 (32-56) 2

Location - North America, total n 208 (68-140) 2

Location - Europe, total n 213 1

Location - Australia/New Zealand, total n 169 1

*as defined by study

In 3 of the studies, all of the study participants had a diagnostic PSG. In the cohort study, 

those diagnosed with OSA (defined as an AHI > 5/hour with compatible symptoms) and eligible 

for the home sleep study program (having at least 2 high-risk features such as habitual snoring 

and daytime fatigue) were included.33 The RCT from Australia required patients to have 

symptomatic OSA, defined as ESS ≥ 8 and AHI ≥ 15/hour.38 The RCT from Spain also required 

patients to have symptomatic OSA, defined as ESS ≥ 12 and AHI ≥ 30/hour.37 

In the remaining RCT, patients with clinical suspicion of moderate to severe OSA were 

evaluated using a diagnostic algorithm. Patients with ESS ≥ 10, Sleep Apnea Clinical Score 

(SACS) ≥ 15, and RDI ≥ 15/hour (respiratory disturbance index, a measure similar to AHI) were 

eligible for the study.

39 The group assigned to in-lab CPAP titration underwent PSG to evaluate 

the performance of the diagnostic algorithm and 34 of 36 patients had an AHI ≥ 15/hour 

(probability of moderate to severe OSA 0.94 (95% CI 0.81, 0.99)). 

Baseline ESS scores were similar in all 4 studies, ranging from 14.0 to 15.5 with the highest 

score in the study requiring an AHI ≥ 30/hour.37 Baseline AHI values ranged from 21/hour33 to 

62/hour.37

Clinical Outcomes - Table 6, Appendix C Tables 8-9 

None of the studies reported all-cause mortality; minimally important differences in AHI, ESS, 

or urinary symptom scores; patient satisfaction; hospitalizations; access to care; libido; or percent 

achieving targets for weight loss, BMI, blood pressure, or HbA1c. Quality of life measures were 

most commonly reported including SF-36 (2 RCTs) and the Sleep Apnea Quality of Life 

(SAQLI) (1 RCT).

In the study from Spain, SF-36 scores were reported as change from baseline. There was a 

significant (P<.01) improvement from baseline for both groups in the physical score while the 

33,37,38
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

37

mental score improved from baseline only for the in-lab CPAP titration group. The Australian 

study found CPAP and APAP titration resulted in similar scores at the 4-week follow-up for both 

the physical and mental components of the SF-36.38 Standard mean difference for the change 

from baseline in the mental and physical health components of the SF-36 are depicted in Figure 

6. 

One RCT reported several resource utilization outcomes.38 During the 4-week study period, there 

were more humidifiers issued to the home APAP group but fewer chin straps. Technologist staff 

time for education was similar in the 2 groups as was the time required for follow-up clinics and 

telephone calls. Technologist time was significantly higher for the home APAP group compared 

to the in-lab titration group on titration morning. Technologist time for the home APAP group 

included time needed to download data from the home device. Physician time for titration study 

reporting was significantly higher in the in-lab titration group compared to the home APAP 

group as the physician analyzed the manual titration results to determine the fixed pressure for 

CPAP therapy. Physician time for follow-up clinics was similar.

The same study reported cognitive outcomes.38 Baseline and 4-week scores on the Trails A and 

Trails B cognitive function tests were similar in the in-lab CPAP and home APAP groups. 

One study reported patient preference.39 Sixty-two percent in the in-lab study group would have 

preferred home management while 6% of the home groups would have preferred in-lab 

management.

Table 6. Clinical Outcomes Comparing APAP to CPAP, Titration Studies

37

Author, Year

Enrolled/

Randomized (n)

Study Design

All-cause 

Mortality

Normalization of AHI

MID Quality 

of Life

Patient 

Satisfaction

Resource 

Utilization

Access to 

Care

Libido

% Achieving 

Target

Cognitive Symptoms

Patient Preference

Other

ESS

Urinary 

Symptom 

Scores

SF-36

SAQLI

VAS

VSQ-9 

Hospitalization

Treatment

Provider 

Contact

Referrals

Weight 

Loss

BMI

Blood 

Pressure

HbA1c

Lettieri 201133 (n = 140) 

Obs. Cohort

McArdle 201038 (n = 169) 

RCT ↔ ↕ ↓ ↔

Mulgrew 200739 (n = 68) 

RCT ↔ X 

Masa 200437 (n = 245) 

RCT ↕

Total 4 studies 

(n = 622) 0 0 0 0 1↔

1↕ 1↔ 0 0 0 1↕ 1↓ 0 0 0 0 0 0 0 1↔ 1X 0 

MID = minimally important difference; AHI = apnea-hypopnea index; ESS = Epworth Sleepiness Scale; BMI = 

body mass index; SF-36 = 36 item short form survey; SAQLI = Sleep Apnea Quality of Life Index; VAS = visual 

analogue scale; VSQ-9 = Visit-Specific Satisfaction Instrument; HbA1c = hemoglobin A1c; Obs = observational
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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↑ = significantly better with APAP than CPAP, ↔ = non-significant difference between APAP and CPAP, ↓ = 

significantly better with CPAP than APAP, ↕ = mixed results comparing APAP and CPAP, X = between group

significance not reported; number before symbol indicates number of studies

Figure 6. SF 36 Scores, Standardized Mean Differences in Mean Change from Baseline, 

Titration Studiesa 

a

Lower and upper limits represent 95% confidence intervals

Intermediate Outcomes – Table 7; Appendix C, Tables 10-12

Changes in sleep measures were commonly reported with the in-lab CPAP titration and home 

APAP titration groups, and found to be similar at follow-up. Three RCTs reported AHI values on 

PAP were similar at 4 weeks38 and 12 weeks.37,39 Two RCTs reported oxygen saturation 

outcomes finding the groups to be similar at 4 weeks38 and 12 weeks.37 All 4 studies reported 

ESS scores and found the titration groups were similar at follow-up. For the 2 RCTs reporting 

mean ESS scores, the SMD in change in ESS scores from baseline was 0.00 (95% CI -0.22, 0.21; 

I

2

 = 0%) (Figure 7) and the WMD was -0.01 (95% CI -1.11, 1.10).37,38

Other sleep symptom measures included the FOSQ,37 Arousal Index,37,38 and total sleep time;

38

these were also similar at follow-up for the in-lab CPAP and home APAP groups. 

One study reported blood pressure.38 At 4 weeks follow-up, the in-lab CPAP and home APAP 

groups had similar systolic and diastolic blood pressures. No studies reported on weight loss, 

BMI, or HbA1c.

The cohort study reported on discontinuation of therapy during the 4-6 week follow-up and 

found similar discontinuation rates – 8.6% of the in-lab CPAP group and 10% of the home 

APAP groups discontinued treatment.33 The RCT from Spain reported “secondary effects” (eg, 

oral dryness, mask intolerance, noise, headache, claustrophobia, smothering sensations, bed 

partner intolerance) noting that there were no important differences between the in-lab CPAP 

and home APAP groups.37

One study reported staff costs per patient and capital equipment and consumable costs per 

patient. Both were higher for the in-lab CPAP group but the statistical significance of the 

findings was not reported.38
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Each of the studies reported on PAP use (ie, hours per night). Three studies reported that the inlab CPAP and home APAP groups were similar33,37,38 while one reported significantly (P = .02) 

more hours per night (median 6.0 vs 5.4) in the home APAP group.39 Mean differences from the 

RCTs are presented in Figure 8. The pooled mean difference was 0.02 (95% CI -0.41, 0.45). 

Other reported adherence/compliance measures were similar for the 2 groups including 

percentage of nights used,33 use of device for more than 4 hours per night for more than 70% of 

nights,33 and percentage of patients continuing to use device at 4 week follow-up.38

One study reclassified participants into “adherent” and “non-adherent” groups based on use of 

the device for more than 4 hours per night for more than 70% of nights.33 Age, gender, BMI, 

AHI, and baseline sleepiness did not influence use of the PAP device. 

Table 7. Intermediate Outcomes Comparing APAP to CPAP, Titration Studies

Author, Year

Enrolled/Randomize

d (n)

Study Design

AHI

Oxygen 

Saturation Sleep Symptom Scores

Weight 

Loss

BMI

Blood Pressure

HbA1c

Adverse Events

Costs

Compliance/

Adherence

Mean

Time <90%

ODI

Minimum

ESS

FOSQ

SASQ

Arousals

Total 

Sleep Time

PSQI

Snoring

Other

Hrs/night

Proportion of 

Nights

Regular 

Usea

Other

Lettieri, 201133

(n = 140) Obs. 

Cohort

↔ ↔ ↔ ↔ ↔

McArdle, 201038 

(n = 169) RCT ↔ ↔ ↔ ↔ ↔ ↔ ↔ X ↔ ↔b

Mulgrew, 200739 

(n = 68) RCT ↔ ↔ ↑

Masa, 200437 

(n = 245) RCT ↔ ↔ ↔ ↔ ↔ ↔ ↔

Total 4 studies 

(n = 622) 3↔ 1↔ 2↔ 0 0 4↔ 1↔ 0 2↔ 1↔ 0 0 0 0 0 1 0 2↔ 2X 1↑3↔ 1↔1↔1↔

a

as defined by study

b

percentage of patients continuing to use CPAP

AHI = apnea-hypopnea index; ODI = oxygen desaturation index; ESS = Epworth sleepiness scale; FOSQ = 

functional outcomes of sleep questionnaire; PSQI = Pittsburgh sleep quality index; BMI = body mass index

↑ = significantly better with APAP than CPAP, ↔ = non-significant difference between APAP and CPAP, ↓ = 

significantly better with CPAP than APAP, ↕ = mixed results comparing APAP and CPAP, X = between group 

significance not reported; number before symbol indicates number of studies
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Figure 7. Epworth Sleep Scores, Standardized Mean Difference for Mean Change from 

Baseline, Titration Studiesa 

a

Lower and upper limits represent 95% confidence intervals

Figure 8. Compliance, Weighted Mean Difference for Hours per Night, Titration Studiesa 

a

Lower and upper limits represent 95% confidence intervals

Treatment

Overview of Studies –Table 8; Appendix C, Table 7

We included 23 studies (with 1,260 patients) comparing CPAP to APAP for treatment of OSA.40-

62 Most of the studies included an in-lab CPAP titration study, but 4 of the 23 studies put patients 

on APAP without a titration study.43,56,59,62 In 2 of those 4 studies, the CPAP fixed pressure was 

based on a 1-week62 or 2-week59 adaptation period of APAP (rather than an in-lab titration 

study). Three studies were rated low risk of bias52,54,61 and the remaining studies medium risk of 

bias.
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Table 8. Key Question 3, Treatment: Study Characteristics

Characteristic

Weighted Mean 

(range)

Unless otherwise 

noted

Number of 

studies 

reporting

Total number enrolled/randomized 1260 (10-200) 23

Randomized controlled trials, total n 486 (21-109) 7

Crossover studies, total n 600 (10-200) 15

Other, total n 174 1

Age of subjects (years) 53 (45-57) 23

Percent Male 87 (75-100) 22

Baseline BMI 33 (29.3-49.9) 22

Baseline ESS 11.8 (6.4-17.4) 20

Baseline AHI (events/hour) 44 (14.7-75.8) 19

Percent with hypertension (%)* 28 (20-55) 2

Location - North America, total n 119 (10-109) 2

Location - Europe, total n 1,018 (20-200) 17

Location - Australia/New Zealand, total n 77 (12-55) 3

Location - Multi-national, total n 46 1

*as defined by study

There were 22 RCTs (15 of which used a crossover design) and one retrospective cohort study.58. 

One study was conducted in the US with a VA population.43 Of the remaining studies, one was 

conducted in Canada, 3 in Australia or New Zealand, and 17 in Europe. 

Individual study sample sizes ranged from 1047 to 200.61 Among the non-crossover RCTs, 

treatment periods ranged from one43 to 650,62 months. In the crossover studies, treatment phases 

ranged from 6 nights40 to 2 months/8 weeks.42,45,46,51,53,60 Several of the crossover studies 

reported either a washout period between study arms or exclusion of data collected during an 

initial period of use following a change to a different protocol. 

Patient inclusion criteria varied in the 23 studies. All but 3 studies enrolled patients based on 

AHI. Minimum AHIs for enrollment were 5/hour,46,51,58 10/hour,42,45,54,57,59 15/hour,40,41,47,49,61

20/hour,53,55,60 and 30/hour.48,50,56 One study included patients with a home sleep test AHI above 

10/hour or a laboratory PSG AHI above 20/hour.44 Three studies did not specify a minimum 

AHI. In one, patients were referred for PSG based on the Berlin Questionnaire.43 Another 

included patients based on excessive daytime sleepiness and an ESS above 9.62 The third study 

enrolled patients who were already being treated with CPAP.52 Of the studies specifying an AHI, 

11 also required clinical symptoms: sleepiness in 444,54,59,61 and daytime symptoms in 2.41,58

Baseline values for AHI ranged from 15/hour51 (a study that required participants to have AHI 

values between 5/hour to 30/hour) to 76/hour40 (a study that required participants to have an AHI 

of 15/hour or higher with morbid obesity). The baseline value was below 20/hour in one study, 

between 31 and 40/hour in 3 studies, between 41 and 50/hour in 8 studies, and 51/hour or higher 

in 7 studies. No studies had baseline values between 21 and 30/hour; 4 did not report baseline 

AHI.
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Baseline ESS scores ranged from 6.458to 17.440 in 21 studies. Two studies did not report baseline 

ESS scores. 

Clinical Outcomes – Table 9; Appendix C, Table 8-9

The most frequently reported clinical outcomes were patient preference (12 studies) and quality 

of life assessed with the SF-36 (9 studies). In 7 of the 12 studies reporting preference, patients 

preferred APAP over CPAP. The difference was reported to be statistically significant in 3 

studies.

45,54,57 Four studies did not report statistical significance.40,42,48,53 The percentage of 

patients expressing a preference for APAP or CPAP was similar in 5 studies with 2 reporting the 

statistical significance for the comparison.47,61 No study reported a significantly higher patient 

preference for CPAP. In 4 studies reporting, between 10% and 72% of patients did not express a 

preference.48,51,59,61

Seven of the 9 studies reporting SF-36 quality of life found the APAP and CPAP groups to be 

similar post-intervention.

44,46,52,54,59,61,62 One study reported a significantly higher mental health 

composite score in the APAP group.49 The remaining study did not report statistical significance 

for between group comparisons.50 One study also reported groups were similar for the SAQLI.62

All-cause mortality was reported in 3 studies with no or few events.43,58,61 One study reported 

that a minimally important difference in ESS scores was achieved in both study groups.59 The 

minimally important difference was 2 points. Patient satisfaction (2 studies) was similar for the 

APAP and CPAP groups.46,58 Four studies reported measures of resource utilization including 

hospitalization for chest pain,

43 seeking help from the sleep center,61 extra calls or visits with 

sleep nurses,

62 or unplanned contacts and duration of unplanned contacts.46 finding the groups 

were similar or not reporting statistical significance. 

No study reported minimally important differences in urinary symptom scores, access to care, or 

diagnosis of cognitive impairment.
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Table 9. Clinical Outcomes Comparing APAP to CPAP, Treatment Studies

Author, Year

Enrolled/Randomized 

(n)

Study Design

All-cause 

Mortality

Normalization of 

AHI

MID Quality 

of Life

Patient 

Satisfaction

Resource 

Utilizatio

n

Access to Care

Diagnosis of 

Cognitive 

Impairment

Patient 

Preference

Other

ESS

S

Urinary 

ympto

m 

Scores

SF-36

SAQLI

VAS

VSQ-9 

Hospital

i-zation

C

Provider 

ontact

Bakker 201140

(n = 12) crossover

X 

Drummond 201043

(n = 109) RCT X X 

Vennelle 201061

(n = 200) crossover X ↔ ↔ ↔

Damjanovic 200941

(n = 100) RCT

Galetke 200845

(n = 20) crossover ↑

Fietze 200744

(n = 21) RCT ↔

Meurice 200750

(n = 83) RCT X 

Nolan 200751

(n = 29) crossover X 

Patruno 200755

(n = 40) RCT

Richard 200758

(n = 174) retro cohort X ↔

Nolan 200652

(n = 27) crossover ↔ X 

Nussbaumer 200654

(n = 34) crossover ↔ ↑

West 200662

(n = 98) RCT ↔ ↔ X 

Hukins 200446

(n = 55) crossover ↔ ↔ ↔

Hussain 200447

(n = 10) crossover ↔

Marrone 200448

(n = 22) crossover X 

Noseda 200453

(n = 27) crossover X 

Massie 200349

(n = 46) crossover ↑

Planes 200356

(n = 35) RCT ↔a 

Senn 200359

(n = 31) crossover ↔ ↔ X 
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Randerath 200157

(n = 52) crossover ↑

D’Ortho 200042

(n = 25) crossover X 

Teschler 200060

(n = 10) crossover

Total 23 studies 

(n = 1,260) 3X 0 1↔ 0 

1↑

7↔

1X

1↔ 2↔ 0 1X 2↔

1X 0 0 

3↑

2↔

7X

1↔

a

tolerance

↑ = significantly better with APAP than CPAP, ↔ = non-significant difference between APAP and CPAP, ↓ = 

significantly better with CPAP than APAP, ↕ = mixed results comparing APAP and CPAP, X = between group

significance not reported

Intermediate Outcomes – Table 10; Appendix C, Tables 10-12

Intermediate outcomes were more frequently reported. Seventeen studies reported AHI after the 

treatment periods with 12 finding APAP and CPAP resulted in similar AHI values, one reporting 

significantly better results with CPAP compared to APAP, and 4 not reporting the significance of 

the findings. Oxygen saturation measures were reported in 11 studies with most finding APAP 

and CPAP to be similar. 

Sleep symptom scores were also generally similar. The most frequently reported score was the 

ESS (reported in 20 of the 23 studies). Sixteen studies found the CPAP and APAP groups to be 

similar, 2 reported the scores were statistically significantly better for the APAP groups, and 2 

did not report significance. For the 4 pooled parallel group RCTs, the SMD in improvement from 

baseline was 0.18 (95% CI -0.06, 0.43; I2 = 0%) (Figure 9) and the WMD was 0.85 (95% CI -

0.28, 1.99). We included data from the longest follow-up time reported. Findings for other sleep 

measures including the FOSQ, arousals, total sleep time, PSQI, and snoring were similar 

between the CPAP and APAP groups. 

Few studies measured changes in weight, BMI, or blood pressure with none reporting a 

significant difference between groups.41,51,55,56,62 One study reported statistically significant 

decreases in systolic and diastolic blood pressure in the CPAP group but not the APAP group but 

did not report the significance of the difference between study groups.55 No study reported 

changes in HbA1c.

One study reported time to initiation of therapy follow diagnosis.56 Mean time in the APAP 

group was 12 days compared to 27 days in the CPAP group (P <.01). The difference was 

attributed to wait time for PSG.

Adverse events were reported in 6 studies. Three found similar frequency of events (dry mouth, 

blocked/runny nose, skin irritation, nasal irritation, pressure feeling too high, claustrophobia) in 

the CPAP and APAP groups.51,57,59 One found incidence of nasal and throat/mouth symptoms

was similar for different APAP devices but did not compare findings to CPAP.52 One study 

reported mixed results (ie, no difference in nasal irritation/obstruction, pressure intolerance, or 

partner dislike but fewer total side effects [P = .02] in the APAP group).46 One reported no side 

effects requiring alteration of treatment.54 In this study, the incidence of nasal and mouth/throat 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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side effects was similar for the CPAP and APAP groups while discomfort with air pressure was 

significantly higher in the CPAP group. 

One study reported costs during a 2-month treatment period.

56 Hospital costs were significantly 

lower in the APAP group while telecommunication costs (to transmit data from home to sleep 

laboratory) were significantly higher (both P <.001). Costs for equipment and home nurse visits 

were similar for the APAP and CPAP groups. Total cost per patient of the 2-month treatment 

was lower in the APAP group (€1,264 vs €1,720; P <.01). 

Table 10. Intermediate Outcomes Comparing APAP to CPAP, Treatment Studies 

Author, Year

Enrolled/Randomized 

(n)

Study Design

AHI

Oxygen 

Saturation Sleep Symptom Scores

Weight Loss

BMI

Blood Pressure

HbA1c

Time to Initiation 

of Therapy

Adverse Events

Costs

Compliance/

Adherence

Mean

Time <90%

ODI

Minimum

ESS

FOSQ

SASQ

Arousals

Total Sleep 

Time

PSQI

Snoring

Other

Hrs/night

Proportio

n of 

Regular

Use

Other

Bakker 201140

(n = 12) crossover ↔ ↓ ↔ ↔ ↔ ↔ ↔

Drummond 201043

(n = 109) RCT ↔ ↔

Vennelle 201061

(n = 200) crossover ↔ ↑ ↑

Damjanovic 200941

(n = 100) RCT ↔ ↔ ↔ ↔ X ↔ ↔ ↔a

Galetke 200845

(n = 20) crossover ↔ ↔ ↔ ↔ ↔ ↔

Fietze 200744

(n = 21) RCT ↔ ↔ ↔ ↔

Meurice 200750

(n = 83) RCT X ↔ ↔ ↔ X ↔

Nolan 200751

(n = 29) crossover ↔ ↔ ↔ ↑ ↔ ↔ X X X ↔ ↔

Patruno 200755

(n = 40) RCT ↓ ↔ ↓ X X ↔

Richard 200758

(n = 174) retro cohort ↔ ↔ X 

Nolan 200652

(n = 27) crossover ↔ X ↕ ↕

Nussbaumer 200654

(n = 34) crossover ↔ ↔ ↔ ↕ ↔ ↔

West 200662

(n = 98) RCT ↔ ↔ ↔b ↔ ↔ ↔

Hukins 200446

(n = 55) crossover ↔ ↑ ↔ ↔

Hussain 200447

(n = 10) crossover ↔ ↔ ↓ ↔ ↔ ↔ ↔
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Marrone 200448

(n = 22) crossover ↔ ↔ ↔

Noseda 200453

(n = 27) crossover ↑ ↔ ↔ ↔ ↔

Massie 200349

(n = 46) crossover ↔ ↔ ↑ ↔

Planes 200356

(n = 35) RCT ↔ ↔ ↔ X ↑ ↑ ↔ ↔

Senn 200359

(n = 31) crossover ↔ ↔ ↔ ↔ ↔ ↔

Randerath 200157

(n = 52) crossover X X X X X ↔ X X 

D’Ortho 200042

(n = 25) crossover X X X ↔ X 

Teschler 200060

(n = 10) crossover X ↔ ↔

Total 23 studies 

(n = 1,260)

12

↔

1↓

4X

3↔

1↓

1X

4↔4↔

1↓

1↓

1↔

2↑

16↔

2X

1↔ 0

1↑

4↔

1X

3↔

2X 1↔ 2↔

1X 1↔1X3X1↔2X 0 1↑

1↑

2↔

1↕

2X

1↑

a

hours use/sleep time

b maintenance of wakefulness

↑ = significantly better with APAP than CPAP, ↔ = non-significant difference between APAP and CPAP, ↓ = 

significantly better with CPAP than APAP, ↕ = mixed results comparing APAP and CPAP, X = between group

significance not reported

Twenty-two of the 23 included studies reported hours per night of use with 19 of 22 reporting the 

CPAP and APAP groups were similar. Of the remaining 3 studies, 2 noted significantly higher 

use with APAP49,61 and one reported mixed results for different APAP devices.52 The differences 

in means for the 5 non-crossover RCTs are presented in Figure 10. Using data from the longest 

reported follow-up time, the pooled difference was -0.08 (95% CI -0.55, 0.38; I2 = 14%).

The results for proportion of nights used were similar; 10 of 12 studies found the CPAP and 

APAP groups to be similar, one reported mixed results,52 and one did not report statistical 

significance.57 “Regular use,” as defined by the study, was similar in 3 of the 5 studies reporting 

(with 2 not reporting significance). 
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Figure 9. Epworth Sleepiness Scores, Standardized Mean Difference for Mean Change

from Baseline from Parallel Group RCTs, Treatment Studiesa 

a

Lower and upper limits represent 95% confidence intervals

Figure 10. Compliance, Weighted Mean Difference for Hours per Night from Parallel 

Group RCTs, Treatment Studiesa 

a

Lower and upper limits represent 95% confidence intervals
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KEY QUESTION #3A: Do effectiveness/harms/resource utilization vary 

by patient characteristics:

a. Unexplained daytime sleepiness/fatigue

b. AHI severity

c. Other risk factors or coexisting conditions associated with OSA 

(eg, obesity, neck circumference, treatment-resistant hypertension, 

diabetes, age, sex, race)

d. Symptoms (eg, nocturia, loss of libido, snoring, witnessed sleep 

“apnea”)?

Few studies reported results by patient characteristics.

A. Unexplained Daytime Sleepiness/Fatigue

No study reported results for subgroups of patients based on unexplained daytime sleepiness or 

fatigue.

B. AHI Severity

One treatment study grouped patients by baseline AHI (< 60/hour or ≥ 60/hour).

42 Duration of 

use (hours/night) of CPAP and APAP was similar in the overall study population. There was 

significantly longer use of both CPAP and APAP in patients with baseline AHI ≥ 60/hour 

compared to those with baseline AHI <60/hour. A second study compared baseline AHI in 

compliant and non-compliant patients (with compliance defined as at least 4 hours per night for 

at least 5 days per week). AHI levels did not differ (51/hour for the compliant group, 47/hour for 

the non-compliant group, P = .40); results were not reported by treatment group.58 A third study 

reported that compliance was similar between CPAP and APAP treatment groups in post-hoc 

subgroup analyses of patients with differing degrees of OSA severity.46

Two treatment studies compared baseline AHI in patients who expressed a preference for CPAP 

or APAP. One found that baseline AHI was a significant predictor of preference for CPAP or 

APAP.48 Patients who preferred APAP had a higher baseline AHI than patients who preferred 

CPAP (73.1 vs 60.0/hour, P<.02). The other found AHI values were similar whether patients 

preferred APAP or CPAP (16.3 vs 14.2/hour, P = .49).51

C. Other Risk Factors or Coexisting Conditions Associated with OSA 

One treatment study included only morbidly obese (BMI ≥ 40 kg/m2) patients.40 Neck 

circumferences was 46.5 (4.0) cm. CPAP and APAP generally produced similar results; patients 

were not stratified by BMI.

Two treatment studies evaluated age and compliance. In both studies, older patients tended to be 

more compliant with therapy but the findings were not statistically significant.45,58 One study 

also reported that baseline BMI and ESS were not associated with compliance.58 Neither study 

reported results by treatment group (CPAP or APAP).
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Two studies reported other factors associated with preference for CPAP or APAP. One found 

that neither age or ESS score at baseline were significant predictors of preference.48 Another 

reported that neither age, BMI, neck circumference, or ESS score were significant predictors.51

D. Symptoms

One titration study reported baseline percentages of patients with habitual snoring (88%), 

observed apneas (61%), and nocturia (27%).37 The study did not report results for subgroups of 

patients based on these characteristics.

Strength of Evidence for Key Question 3 (Table 4, Appendix D)

Titration

For studies comparing in-lab CPAP titration to at-home APAP titration, there was insufficient 

evidence for the outcomes of access to care and adverse events. Strength of evidence was 

moderate for quality of life and low for compliance (hours/night) and ESS with similar findings 

for the 2 study groups.

Treatment

Among studies comparing CPAP to APAP for treatment of OSA, there was insufficient evidence 

for access to care. Strength of evidence was moderate for quality of life, ESS, and compliance 

(hours/night) and low for adverse events. These outcomes were similar in the 2 treatment groups.
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Table 11. Strength of Evidence for Outcomes, Key Question 3

Comparison Outcome of 

Interest

Strength of

Evidence

Direction Findings

KQ3: Home APAP 

technology 

versus standard 

in-center manual 

CPAP titration

Access to care Insufficient We found no evidence for this outcome.

Epworth 

Sleepiness Scale 

(ESS)

Moderate Similar

Based on 2 RCTs (n = 414) with moderate risk of bias, we found improvement 

from baseline in ESS scores was similar for patients allocated to home APAP 

titration compared to patients allocated to in-center CPAP titration (SMD = 0.0 

[95% CI -0.22, 0.21]). One moderate risk of bias RCT (n = 68) found median 

change in EES scores from baseline was also similar between groups (MD 1 

[95% CI -1, 4]). One observational cohort study also found ESS scores were 

similar between groups.

Quality of life Moderate Similar

Based on 2 RCTs (n = 414) with moderate risk of bias, we found quality of life 

measures were similar for patients allocated to home APAP titration compared 

to patients allocated to in-center CPAP titration. The SMDs for SF-36 Mental 

Health and Physical Health scores were 0.08 [95% CI -0.14, 0.29] and -0.21 

[95% CI -0.61, 0.20], respectively. Results for the Physical Health scores were 

imprecise. One moderate risk of bias RCT (n = 68) found median improvement 

from baseline in the SAQLI was similar between groups (median difference = 

0.17 [95% CI -0.6, 0.9])

Compliance,

hours per night Low Similar

Based on 2 RCTs (n = 414) with moderate risk of bias, we found compliance 

was similar for patients allocated to home APAP titration compared to patients 

allocated to in-center CPAP titration (WMD = 0.02 [95% CI -0.41, 0.45]). One 

moderate risk of bias RCT (n = 68) found median compliance was better in the 

APAP group versus the CPAP group (MD -1.1 [95% CI -2.0, -0.2]). One 

observational cohort study found compliance was similar between groups.

Adverse events Insufficient

Based on the findings of one RCT (n = 245) that reported no “important 

differences” in adverse events between the home APAP and in-lab CPAP and 

groups, the evidence is insufficient to draw conclusions.

KQ3: APAP 

versus CPAP 

treatment

Access to care Insufficient We found no evidence for this outcome.

Epworth 

Sleepiness Scale 

(ESS)

Moderate Similar

Based on 4 parallel group RCTs (n = 327) with aggregate moderate risk of 

bias, we found improvement from baseline in ESS scores was similar for 

patients allocated to APAP treatment compared to patients allocated to CPAP 

treatment (SMD = 0.18 [95% CI -0.06, 0.43]). Two parallel group trials not 

pooled (reported as a median or data not shown) also found improvement from 

baseline in ESS scores similar between groups. Ten crossover RCTs (n = 269) 

reported similar improvements between groups and 2 (N = 227) reported 

greater improvement with APAP. 
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Comparison Outcome of 

Interest

Strength of

Evidence

Direction Findings

Quality of life Moderate Similar

Based on 3 parallel group RCTs (n = 202) with aggregate moderate risk of 

bias, we found quality of life measures (SF-36, SAQLI) were similar for patients 

allocated to APAP treatment compared to patients allocated to CPAP 

treatment (data were not pooled due to variation in reporting of results, ie,

reported as medians). Six crossover RCTs (n = 393) also reported no 

differences in most of the quality of life measures between the treatment 

groups.

Compliance, 

hours per night Moderate Similar

Based on 5 parallel group RCTs (n = 279) with aggregate moderate risk of 

bias, we found compliance was similar for patients allocated to APAP 

treatment compared to patients allocated to CPAP treatment (WMD = -0.08 

[95% CI -0.55, 0.38]). One parallel group RCT reporting median compliance, 

most of the remaining crossover RCTs, and one observational study also 

found compliance was similar between groups.

Adverse events Low Similar

Adverse events were infrequently reported. One parallel group RCT (n = 109) 

reported adverse events, chest pain in 12% and 9% of APAP and CPAP 

patients, respectively. Five crossover trials reported adverse events for both 

APAP and CPAP treatments. One trial (n = 55) reported a higher frequency of 

total number of events and another trial (n = 34) reported a higher incidence of 

pressure discomfort with CPAP therapy arm compared with the APAP 

treatment. There trials (n = 112) reported no differences in adverse events 

between the treatment groups.

APAP = Auto-adjusted (autoregulated) continuous positive airway pressure; CPAP = continuous positive airway pressure; RCT = randomized controlled trial; 

SAQLI = Sleep Apnea Quality of Life Index; SF-36 = Short Form-36; SMD = standardized mean difference; WMD = weighted mean difference. a

Strength of Evidence Definitions;28 See Appendix D for more details

• High: Very confident that estimate of effect lies close to true effect. Few or no deficiencies in body of evidence, findings believed to be stable.

• Moderate: Moderately confident that estimate of effect lies close to true effect. Some deficiencies in body of evidence; findings likely to be stable, but some 

doubt.

• Low: Limited confidence that estimate of effect lies close to true effect; major or numerous deficiencies in body of evidence. Additional evidence necessary 

before concluding that findings are stable or that estimate of effect is close to true effect. 

• Insufficient: No evidence, unable to estimate an effect, or no confidence in estimate of effect. No evidence is available or the body of evidence precludes 

judgment.
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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SUMMARY AND DISCUSSION

Our systematic review compared outcomes associated with 3 key questions: 1) use of non-SSP 

providers compared to SSPs; 2) electronic consultation compared to interactive consultation; and

3) in-home APAP compared to in-laboratory CPAP. Overall the evidence was often lacking to 

fully address the key questions and we found no data for Key Question 2. 

For Key Question 1, we found 8 studies, of which 4 were randomized trials. Access to care was 

not reported in any of the studies, so we were unable to determine if use of non-SSP providers 

improves access to OSA diagnosis and treatment. Likewise, adverse events including 

overdiagnosis/overtreatment and underdiagnosis/undertreatment were not reported. We found 

moderate-strength evidence that care provided by non-SSP providers and SSPs resulted in 

similar Epworth Sleepiness Scores, quality of life, and treatment compliance. 

For Key Question 3, we found 4 studies comparing at-home APAP to in-laboratory CPAP for 

titration of CPAP pressures and 23 for treatment. For both titration and treatment, access to care 

was not reported in any of the studies. Adverse events were rarely reported and therefore strength 

of evidence was insufficient to low to determine whether at-home APAP and in-laboratory 

CPAP differ for adverse events. We found moderate-strength evidence in both titration and 

treatment studies that at-home APAP and in-lab CPAP were similar in regards to Epworth 

Sleepiness Scores and quality of life outcomes. For PAP titration, at-home APAP and inlaboratory CPAP resulted in similar treatment compliance, though strength of evidence was low.

For PAP treatment, at-home APAP and in-laboratory CPAP resulted in similar treatment 

compliance (moderate strength of evidence).

Our systematic review was not intended to determine the best OSA screening tools nor in whom

OSA treatments are most effective. However, most of the included studies in our report enrolled 

patients who were generally older, obese, and sleepy, as determined by Epworth Sleepiness 

Scores. Furthermore, 2 recent evidence reports and clinical practice recommendations have 

addressed OSA screening and treatment.12-15 This additional evidence may assist clinicians and 

policymakers when determining referral recommendations and evaluation pathways to target 

individuals with the greatest likelihood of benefiting while minimizing harms, as well as 

financial and opportunity costs associated with diagnosis and treatment of OSA. Specifically, a

prior evidence report and accompanying clinical practice guideline by the ACP recommends that 

clinicians target their assessment of OSA to individuals with unexplained daytime sleepiness.

The ACP concluded that assessment of OSA in the absence of daytime sleepiness or treatment of 

persons with low AHI scores is low-value care because evidence to date indicates that neither 

improves clinical outcomes.14 Additionally, a draft evidence report and recommendation 

statement from the U.S. Preventive Services Task Force indicates that evidence is insufficient to 

assess the net benefit of screening for and treatment of asymptomatic OSA.15 While good 

evidence has established that people with severe OSA are at increased mortality risk compared to 

controls, trials of CPAP and other treatments have not established whether treatment reduces 

mortality or improves most other health outcomes, except possibly for sleep-related quality of 

life. In addition to the findings included in the ACP and USPSTF reports, a recently published 

multi-site randomized trial showed that CPAP was not effective for secondary prevention of 

cardiovascular events in those with established cardiovascular disease and moderate to severe 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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OSA.16 Furthermore, the USPSTF evidence report also found uncertainty about the clinical 

utility of screening tools and that most screening questionnaires had poor diagnostic accuracy.

When redesigning OSA care models we recommend that clinicians and policymakers consider 

the limited data to support some of these newer models (eg, hiring non-SSPs to provide sleep 

care) and the existing evidence used to inform clinical practice recommendations by the ACP 

and USPSTF. While the existing data do not suggest significant harm from these newer care 

models, current data are insufficient to draw firm conclusions.

LIMITATIONS

Inherent to the process of systematic review there are certain general limitations, some related to 

our inclusion criteria, others inherent in the available research. For example, we limited inclusion 

to English language studies and those performed in the United States, Canada, Western Europe, 

Australia, or New Zealand. We did this to target research most likely to be applicable to clinical 

practice in the United States and Veterans Affairs facilities. However, these search criteria also 

mean that our findings may not apply to the evaluation and care of OSA patients in other 

healthcare settings.

We also chose to exclude studies of dentists and anesthesiologists due to our uncertainty whether 

or not these persons truly represent “Non-Sleep-Specialist Physicians” given that many dentists 

and anesthesiologists have substantial practices or background in sleep medicine. Therefore, our 

systematic review does not address the role of these practitioners on sleep apnea care. We also 

did not assess the role of surgery or mandibular assist devices for OSA treatment including 

referral of patients who may be more interested in or better candidates for these options. 

A significant limitation is the paucity of high-quality literature regarding key questions 1 and 2. 

For initial evaluation and treatment of OSA (Key Question 1), we identified 4 randomized trials 

and 4 observational studies. The non-SSP providers were primary care providers in 4 studies, 

nurses in 3 studies, and a pulmonologist in one study. Therefore, although we are aware of the 

existence of clinical care models utilizing sleep respiratory therapists to provide varying degrees 

of OSA care, we did not find any studies to address this particular type of practitioner. Due to 

small sample sizes, we were also unable to directly compare primary care-based models of OSA 

evaluation and treatment to sleep nurse-based models.

We also note that, importantly, the providers in many of these “primary care” studies were 

persons who had substantial experience in sleep medicine. For example, in the randomized trial 

of Chai-Coetzer and colleagues,31 one of the 4 primary care nurses had 15 years of experience at 

a tertiary care sleep medicine center. In the study by Chamorro and colleagues,32 the non-SSP 

provider was a ‘primary care pulmonologist’ – the degree of sleep training and experience of this 

person was unclear. Therefore, the generalizability of these findings to primary care providers 

with less experience in sleep medicine is not clear.

Due to the lack of studies regarding electronic consultation for persons suspected of having OSA 

(Key Question 2), we are unable to determine the effectiveness/harms/resource utilization of this 

evolving practice. 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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We found the most data for Key Question 3, which compared at-home autotitrating continuous

positive airway pressure (APAP) to the more traditional CPAP titrated in the PSG laboratory.

Several studies that compared at-home APAP to in-lab CPAP63-65 were excluded as these studies

also used different methods of diagnostic testing (eg, HST preceded at-home APAP, while PSG 

preceded in-lab CPAP) and we were concerned that the differences in diagnostic testing might 

confound our analysis of outcomes between APAP and CPAP. Although these studies were not 

included in our formal analysis, they reassuringly also further support the notion that APAP and 

CPAP (combined with at-home vs in-laboratory testing, respectively) result in similar outcomes 

in regards to: 1) 6-week ESS and PAP adherence among 106 Veterans in Florida using 2-3 nights 

of APAP for titration,

63 3-month ESS, SF-12, and adherence among 182 Veterans in 

Pennsylvania using 4-5 nights of APAP for titration,

64 and 3-month ESS and SF-36 among 142 

patients at 7 academic sleep centers in the U.S. using 5-7 nights of APAP for titration;

65 this last 

study also found higher 3-month PAP adherence in those assigned to the home study plus APAP 

titration arm.

65

APPLICABILITY AND IMPLEMENTATION OF FINDINGS

Most patients enrolled in studies were obese, middle-aged men, with severe OSA based on both 

high AHI levels and the presence of excessive daytime sleepiness. Our findings are most 

applicable to these individuals. We found only one study that was performed in a VA population

for Key Question 3.43 One study was performed at Walter Reed Army Medical Center for key 

questions 1 and 3.33 While most studies were not specifically conducted in VA or military 

populations, because the patients enrolled in these studies were generally older, overweight men 

with OSA, we believe the findings of our systematic review should be applicable to the 

population of Veterans served by VA facilities. 

Many of the study providers who were not SSPs had prior sleep training and therefore the results 

may not be fully generalizable to all primary care providers.While data are not conclusive,

because our findings indicated similar Epworth Sleepiness Scores, quality of life, and treatment 

compliance scores among patients evaluated and treated by non-SSPs compared to SSPs, it may 

be reasonable to consider expanded use of non-SSP providers who have received training in 

sleep medicine, especially where SSPs are in limited supply and demand for OSA services is 

high. Similarly, greater use of at-home APAP may lessen dependence on backlogged PSG 

laboratories, as most health outcomes were similar between groups.

Our report focused on methods that might improve the ‘supply’ side of OSA evaluation and 

treatment, through use of non-SSPs, electronic consultation, and at-home APAP titration and 

treatment. However, healthcare systems struggling to match supply to demand might also 

consider whether the ‘demand’ is truly appropriate. We found little to no data in screen-detected 

patients (ie, those found to have abnormal AHI either through direct referral to sleep laboratories 

or based on results of screening questionnaires such as the Berlin questionnaire but without 

excessive daytime sleepiness). The evidence to date indicates that the main benefit of OSA 

detection and treatment is improvement in patient-reported sleepiness symptoms among those 

with unexplained daytime somnolence. Therefore, VA healthcare providers and decision-makers 

could potentially achieve the highest value care, including resource use, by targeting case finding 

approaches and subsequent evaluation and treatment to individuals with unexplained daytime 

somnolence and who express interest in further evaluation and treatment. Theorectically, this 

referral approach could be readily be implemented by developing and using electronic medical 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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record templates that describe the evidence-based rationale for the referral recommendations 

while requesting that referring providers include information specifically about daytime 

somnolence and the patient’s willingness for further evaluation and treatment in the consult.

RESEARCH GAPS/FUTURE RESEARCH

Comparative effectiveness trials were lacking for all key questions. Key questions 1 and 2 would 

particularly benefit from trials to address the outcomes resulting from non-SSP case finding and 

care of sleep apnea patients (Key Question 1) and outcomes resulting from electronic 

consultation (Key Question 2). Limited available data suggest that care led by non-SSPs may 

potentially provide equivalent outcomes to care led by SSPs. Comparative effectiveness trials are 

needed in order to determine whether such results can be achieved in routine practice, outside of 

controlled research settings. The available data suggest that with appropriate training, non-SSPs 

can potentially provide equivalent outcomes, but the operationalization of such training is 

unclear. Therefore, future comparative effectiveness trials should describe their training 

programs in detail. Such trials should also collect clinical outcomes where possible. 

In regards to case finding, future studies should compare outcomes among differing strategies 

such as offering sleep studies and treatment to a broad set of patients (eg, with OSA risk factors, 

regardless of number of risk factors or symptoms) versus a narrow set of criteria (eg, high OSA 

risk or very symptomatic). Outcomes of interest in such studies would include consultation rates, 

sleep study rates, percent of sleep studies confirming OSA, severity of OSA, changes in 

sleepiness, and adherence to CPAP. Such studies might also compare case finding led by sleep 

specialists, primary care providers, nurses, or even automated through electronic medical record 

(EMR) systems.

As more healthcare systems implement comprehensive EMRs, we anticipate Key Question 2 will 

become more feasible to study. In the current climate of increasing numbers of sleep referrals, 

yet a declining number of SSPs, EMR-based electronic consultation holds significant promise to 

provide equivalent outcomes in a more cost-effective, time-efficient manner. Although many 

systems have already implemented electronic consultation systems,

66 evidence supporting this 

practice is largely lacking and further studies should be conducted. We think comparative 

effectiveness study designs such as stepped-wedge randomization (where sites are randomly 

assigned to the time point at which they implement electronic consultation) would allow the 

creation of good-quality evidence to quantify the risks, benefits, and economic impacts of 

electronic consultation for patients with known or suspected OSA.

Many studies have addressed Key Question 3 and while we found similar sleepiness, quality of 

life, and adherence between APAP and CPAP, future studies should include longer-term followup to allow better determination of long-term clinical ouctomes. Future studies should also 

include more rigorous collection and reporting of adverse event data.

A large gap in evidence is related to the effectiveness of treatment for individuals without 

excessive daytime sleepiness (screen detected or case-finding in at-risk asymptomatic 

individuals) and on outcomes other than daytime sleepiness. For example, a recently published 

multi-site randomized trial showed that CPAP was not effective for secondary prevention of 

cardiovascular events in those with established cardiovascular disease and moderate to severe 

OSA.

16 Additional information gaps include the effectiveness of treatment in those with mild 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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AHI regardless of symptoms. These gaps are supported by recent evidence reports and 

accompanying clinical practice recommendations by the ACP and USPSTF and described in 

greater detail in the introduction and above. There are also critically important gaps to fill due to 

the dramatic increase in patients with, or suspected to have, OSA and thus being referred for 

evaluation and treatment. 

CONCLUSIONS

Among patients suspected of having OSA, evidence suggests that primary care providers and 

sleep-specialist nurses might provide similar outcomes to SSPs, although the strength of this 

evidence was only moderate and many outcomes were inconsistently reported. Likewise, among 

patients diagnosed with OSA, evidence suggests that at-home APAP titration and treatment 

provides similar outcomes to fixed pressure CPAP titrated in the PSG laboratory, although the 

strength of evidence was generally low to moderate. 

We found no evidence addressing the topic of electronic consultation for the management of 

known or suspected OSA.

Future studies are needed to determine which patients derive the most benefit from treatment and 

should be prioritized for testing and treatment, whether newer models of care with less reliance 

on SSP time (either through utilization of other types of providers or electronic consultation) 

result in similar outcomes to traditional models, and if effective, how such models should be 

implemented.
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APPENDIX A. SEARCH STRATEGIES 

Ovid (Medline) KQ1 and KQ2: 

1. Sleep Apnea Syndromes/di,th [Diagnosis, Therapy] 

2. Sleep Apnea, Obstructive/di,th [Diagnosis, Therapy] 

3. (protocol: or algorithm:).mp. 

4. Patient care team/ or nurse’s practice patterns/ or health personnel/ or allied health 

personnel/ 

5. Sleep apnea syndromes/nu or sleep apnea, obstructive/nu 

6. (nurse led or nurse-led).ti,ab. 

7. (nurse: or nursing or technician:).mp. 

8. Primary health care/ or physicians/ or (nurse* or technician or special* or primary care or 

physician).ti,ab. 

9. “referral and consultation”/ or (electronic adj consult).mp. or consult*.mp. or telemedicine/ 

or remote consultation/ 

10. Mass screening/

11. Continuous positive airway pressure/mt, nu [methods, nursing] 

12. Polysomnography/nu [nursing] 

13. Chart review.mp. or risk assessment/ 

14. 1 or 2 

15. 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 

16. 14 and 15 

17. Limit 16 to (English language and yr = ”2000-Current”)

18. Limit 17 to “all child (0 to 18 years)”

19. Limit 17 to “all adult (19 plus years)”

20. 18 not 19 

21. 17 not 20 

Ovid (Medline) KQ3: 

1. Sleep Apnea Syndromes/th [therapy] or Sleep Apnea, Obstructive/th [therapy] 

2. (titrat* and (manual or conventional or standard or fixed or (auto* or APAP))).mp. 

3. Home care services/

4. (positive-pressure respiration/ or continuous positive airway pressure/ or intermittent 

positive-pressure ventilation/ or CPAP.mp.) and (calibration/ or (telemetric or titrat*).mp.)

5. 2 or 3 or 4 

6. 1 and 5 

7. Limit 6 to (English language and yr = ”2000-Current”)

8. Limit 7 to “all child (0 to 18 years)” 

9. Limit 7 to “all adult (19 plus years)”

10. 8 not 9 

11. 7 not 10 
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CINAHL KQ1 and KQ2: 

1. (MH “Sleep Apnea Syndromes/DI/TH”)

2. (MH “Sleep Apnea, Obstructive/DI/TH”)

3. AB (protocol* or algorithm*) 

4. (MH “Multidisciplinary Care Team”) OR “MH “Team Nursing”) OR (MH “Total Patient 

Care Nursing”)

5. (MH “Nursing Practice”) OR (MH “Scope of Nursing Practice”)

6. (MH “Health Personnel”) OR (MH “Allied Health Personnel”)

7. (MH “Sleep Apnea Syndromes/NU”) OR (MH “Sleep Apnea, Obstructive/NU”)

8. “nurse led”

9. “nurse-led”

10. AB (nurse* or nursing or technician*) 

11. (MH “Primary Health Care”)

12. (MH “Physicians”)

13. (MH “Referral and Consultation”) OR (MH “Remote Consultation”) 

14. (MH “Telemedicine”)

15. AB (electronic adj consult) OR AB consult* 

16. (MH “Health Screening”)

17. (MH “Continuous Positive Airway Pressure/MT/NU”) 

18. (MH “Polysomnography/NU”) 

19. 1 or 2 

20. S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 

OR S15 OR S16 OR S17 OR S18 

21. 19 AND 20 (Limits: Published dates 2000 to present, English Language) 

CINAHL KQ3:

1. (MH “Sleep Apnea Syndromes/TH”) OR (MH “Sleep Apnea, Obstructive/TH”)

2. (MH “Positive Pressure Ventilation”) OR (MH “Continuous Positive Airway Pressure”) 

OR (MH “Intermittent Positive Pressure Ventilation”) 

3. (MH “Calibration”)

4. AB “telemetric or titra*

5. 3 OR 4

6. 2 AND 5

7. AB titra* AND AB ((manual or conventional or standard or fixed or (auto* or APAP))) 

8. (MH “Home Health Care”)

9. 6 OR 7 OR 8

10. 1 AND 9 (Limits: Published dates 2000 to present, English Language) 
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APPENDIX B. PEER REVIEW COMMENTS/AUTHOR RESPONSES

REVIEWER COMMENT RESPONSE

1. Are the objectives, scope, and methods for this review clearly described? 

Yes Thank you

Yes

Yes

Yes

Yes

Yes

No - See comments. Methods incomplete. Concepts appeared in Results and 

Conclusions that were omitted in the Introduction and Methods.

Thank you for the suggestions. We address the 

specific issues in the comments below.

2. Is there any indication of bias in our synthesis of the evidence?

No Thank you

No

No

No

No

No

No

3. Are there any published or unpublished studies that we may have overlooked?

No Thank you

Yes - Epidemiology should be updated. Consider ref Peppard Am J Epid 2013. Consider 

reference to cost associated with sleep apnea (Frost and Sullivan report just released, 

available on AASM website). The operational partner also has data on staffing, 

workload, and prosthetic costs related to sleep apnea, which may support the review 

(looking at alternative provider types to deliver sleep care, burden of disease within VA, 

etc.)

Thank you for the suggested references. We added 

the Peppard 2013 data to the Introduction. Although 

we typically only include data from peer review 

journals, we have included the Frost & Sullivan report 

for the AASM. 

No Thank you

No

No

No

No

4. Additional suggestions or comments can be provided below. If applicable, 

please indicate the page and line numbers from the draft report.
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I congratulate the sponsor and the ESP team on the conduct of a methodologically 

rigorous evidence synthesis report on a topic of great clinical importance. 

(1) The introduction (page 1) suggests that screening is most appropriate for 

symptomatic patients. I agree with this suggestion. This text, and the related text on 

page 10, however did not mention the American Heart Association/American Stroke 

Association (AHA/ASA) Stroke Prevention Guidelines which recommends screening all 

patients with stroke for OSA (regardless of symptoms) given the robust evidence that 

OSA is present in the overwhelming majority of stroke patients and the evidence that 

treatment with PAP improves outcomes. I believe that none of the articles that were the 

basis of those AHA/ASA guideline recommendations would be included in this ESP 

review because they did not meet inclusion criteria (e.g., to my knowledge, none 

compared CPAP to APAP). 

(2) I do not understand why dashed lines were used in the conceptual model figures 

from the Intermediate to the Clinical Outcomes boxes. Perhaps a legend might be 

added.

(3) I like the use of italics to distinguish "titration" versus "treatment" in the last question.

(4) In non-VA settings, many facilities use standard screening tools (e.g., Berlin) to 

identify patients for PSG-referral (without the intervening oversight of either a primary 

care provider or sleep specialist). This alternative model could be mentioned in the 

Background or Discussion related to question 1.

(5) Given that the gaps in literature section may be useful to investigators writing IIR 

applications, I encourage the authors to be comprehensive in describing studies that 

would advance the field. For example, there are many alternative approaches to case 

finding (e.g., screening tools, direct use of APAP as a diagnostic test) and treatment 

(e.g., remote PAP monitoring, mandibular advancement devices and other approaches 

for PAP-intolerant patients) that merit investigation.

Thank you

1) Thank you. It is outside the scope of this review to 

evaluate guidelines and recommendations for 

screening (for example, after stroke). Our purpose in 

the introduction was to “set the stage” for our 

evaluation of alternative care models. 

2) A legend (footnote) has been added.

3) Thank you.

4) We have now included this as part of our expanded 

explanation of ‘screen-detected’ patients and noted 

the limited data on screen-detected patients in the 

Applicability and Implementation section.

5) We have expanded the gaps/future research 

section.

Overall excellent job with the review!! Very comprehensive and highlights important 

evidence gaps. 

Under Research Gaps/Future Research: consider suggesting further evaluation on the 

implementation of the recommendations, not just CER of Key question 1. Key Question 

2 has no published data/trials. A large pragmatic approach to studying this within the VA 

system is not only feasible but should be done since several programs have been using 

e-consults and never published outcomes. Any way to bridge this for focused HSRD 

would be helpful. Lastly, consider summarizing the burden of OSA, lack of providers, and 

clinical need for sleep medicine before wading into outcomes. This would be helpful for 

folks who skip to the summary directly.

Thank you.

We have modified the Executive Summary to include 

the burden of OSA and to include the discussion of 

Key Question 2, as we agree with the reviewer 

statement.

The report is excellent! I thought the Executive Summary was too long. Thank you. We shortened the Executive Summary.

(1) It is unfortunate that the studies by Berry, Kuna and Rosen were excluded from 

analysis and discussion (see page 51, line 3). These are three of the most important 

studies in the area of alternative care models for treatment of OSA, as the models of 

1) Thank you for the suggestion. As the reviewer 

notes, these studies also ‘bundled’ HST vs. PSG with 

APAP vs. CPAP titration, and comparing HST vs. 
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care in practice are not restricted to home auto-CPAP versus laboratory-based CPAP 

titration. Efficiency of care is more strongly impacted by the use of home (HST) versus 

lab-based (PSG) testing. While this ESP report does not address the evidence 

supporting HST use as an alternative to PSG, HST use for diagnosis of OSA has 

become common clinical practice, especially within the VA, and these studies provide 

strong evidence that the HST-APAP approach achieves equivalent outcomes to the 

PSG-CPAP approach. This strengthens the current findings of key Question 3 regarding 

similarity of outcomes with APAP and CPAP. I strongly urge the authors to include a 

detailed analysis of these papers under Key Question 3.

(2) Although it would significantly alter the scope of the report, an additional Key 

Question asking whether HST is a valid alternative to PSG for diagnosis of OSA would 

be welcome. Unfortunately, the USPSTF draft report was seriously flawed in this area, in 

particular failing to take into account the impact of night-to-night variation in OSA severity 

on PSG-HST comparisons.

(3) Finally, the authors correctly observe that in the studies comparing sleep specialist to 

non-sleep specialist care, the non-specialists generally have had additional training or 

experience in management of sleep apnea patients. While this important point is clearly 

stated under Limitations in the Evidence Report (page 50, penultimate paragraph), it is 

absent from the Executive Summary. As most readers will probably not get beyond the 

Executive Summary, it is important to include there as well, and also in the Summary of 

Findings for Key Question #1 on page 22.

PSG was clearly not a goal of our study. However, the 

APAP vs. CPAP titration data generally suggested the 

same findings as we found in other studies, so we 

have expanded our discussion about these articles. 

Even though they did not strictly meet our inclusion 

criteria, .

2) We are not able to alter the scope at this time. HST 

vs PSG could be nominated for a future ESP report.

3) Thank you for the suggestion. We added this (and 

other) limitations to the Executive Summary.

Very clear layout of questions, only a few things that require clarification, major one is 

defining RDI- term has been used variably over time so this term needs to be defined for 

each study that used it, written in a very accessible way for the non-sleep specialist

Page 6, line 36: Does this mean that care between the 2 groups was similar or that only 

the SSP group showed improvement (I think you mean the former but this is a little 

unclear).

Page 7, line 6: RDI not defined prior to this; the definition of RDI has varied over time, for 

example prior to about the early 2000’s RDI was equivalent to AHI, but at time 

subsequently RDI has included RERAs (Respiratory Effort Related Events). 

Recommend that this evolution in definition as it pertains to the studies that used the 

term, be stated somewhere in the document.

Page 9, line 54: term "screen-detected pts" is used frequently, may be helpful at 

beginning of document to define this term- unclear to me if this means screened with 

validated measure such as a questionnaire or something else

Page 28, line 45: The choice of this metric ( ≥ 4 hours of CPAP use on ≥ 70% of nights) 

for compliance is not based on any data. Wondering if this should be explicitly stated 

somewhere as we don't want to give the idea that this is # is sufficient for compliance.

Thank you for the suggestions. We made changes to 

clarify the text.

Page 6. This sentence has been modified.

Page 7, line 6: We added what this study reported for 

their RDI definition. Another study used RDI as part of 

a pre-test probability determination but did not define 

RDI.

Page 9: We have clarified this term—thank you. 

Page 28. We comment in several places that 

measures of compliance varied. We extracted the 

compliance measures as reported in the included 

studies. We agree with the reviewer regarding the 

lack of evdidence for the ‘ > 4hrs for 70% of nights’ 
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Page 37, line 10: “Technologist time was higher on titration morning” Does this mean 

that physician interpretation took less time for APAP than in-lab CPAP titration? This is 

true and is due largely to the larger amount of data available for the in-lab studies.” 

Page 37, line 13: “Physician time for titration study reporting was lower in the home 

APAP group” This statement is also unclear. Does it mean that physician interpretation 

requires less time for APAP than CPAP? This is true largely due to increased information 

available for the in-lab studies.

Table 6: Does # on front of arrow indicate the number of studies showing this result? Is 

this information only listed for cases where the data could not be pooled?

metric, but given that many studies report this (and it 

is used for reimbursement—we did add this statement

on page 27), we felt compelled to include it.

Page 37, line 10. This statement has been clarified.

Page 37, line 13. his statement has been clarified.

Table 6: Yes, the number is the number of studies. All 

reported outcomes are presented on the arrow tables.

• An abstract would be helpful.

• Introduction, p. 12, lines 30-32: Provide references for estimates for OSA prevalence.

• The distinction between intermediate and clinical outcomes is unclear. What is the 

difference between “weight (sic), BMI, libido, blood pressure, or HBA1c (sic)” 

(intermediate) and “libido, weight change, BMI, blood pressure, or HbA1c” (clinical)?

• I find the limitation to English-speaking and European (do you mean Western 

European) countries problematic, regardless of an (unstated) interest in making 

applicable to the VA. Why not high income parts of Asia, Middle East, and Latin 

America? By North America, do you mean just US and Canada? Similarly, what is the 

justification for limiting to English language? Google Translate (and other methods) are 

highly effective.

• Implicitly, you have restricted to published, peer-reviewed articles. Is this the case?

• If ESS and SF-36 are all on the same scale (as they presumably are), why were 

standardized mean differences (and not weighted mean differences) used? SMD is 

clinically difficult to interpret. (The Cohen reference call out is missing the year). What 

were your minimum criteria for conducting a meta-analysis (how few studies would you 

meta-analyze)?

-Thank you for the suggestion. An abstract has been 

added.

 

-We revised and added data from Peppard 2013.

-We consider clinical outcomes to be patient-centered 

outcomes – something the patient can feel. Therefore, 

we attempt to distinguish between a change in a sleep 

scale score or weight (for example) and a clinically 

meaningful change in sleep score or weight.

-As described in the Limitations, our goal was to 

identify studies most applicable to clinical practice in 

the US and the VA. Regarding the non-English 

language studies, Google Translate has been 

evaluated and has not reached acceptable levels of 

accuracy. Standard methods for systematic reviews 

including through AHRQ and the ESP are to limit 

inclusion to articles published in English language.

-Yes. We searched MEDLINE and CINAHL.

-There is no established minimal important difference 

for the ESS, so we used SMDs to facilitate 

interpretation of effect (how large was the effect 

based on the suggested cut points of 0.2 (small), 0.5 

(moderate), and 0.8 (large)) and how precise was the 
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• I would suggest a much more detailed, explicit explanation for assessing the strength 

of evidence. Owens 2010 gives general guidance. What specifically was done here? 

Particularly, when and how did you determine the evidence was insufficient? Table 4 (for 

example) is opaque. It is unclear why strength of evidence is ranked as it is and what 

were the strengths and weakness of the evidence. Were directness, precision,

sparseness, dose-effect, etc. assessed? Also, it would be more helpful to the reader to 

divide Table 4 into separate tables for each KQ.

• Results summaries. It would be helpful to incorporate strength of evidence into the 

summaries. The summaries are written in a highly subjective manner, suggesting 

interpretation by the researchers not objective summary. Examples from KQ 1 include 

“good” [agreement], “similar”, and “may be”.

• The abbreviation SSP is not used consistently.

• Statements such as “At baseline the patients’ average age was 55.2 years...” are 

unclear. This sounds like the description of a single study by appear to be a summary 

across the 8 studies. Where did 55.2 come from? Were the mean ages meta-analyzed? 

Is this the median? 

• In what ways were high risk of bias (and medium risk of bias) studies likely to be 

biased?

• While the tables succinctly summarize the results of the studies, they provide highly 

limited data. While the Appendix tables provide the details, they are too difficult to read. I 

would recommend a separate set of tables in the main text that provide the summary 

numerical results. Also the call out to “Appendix Tables 2-3” left out which appendix (C). 

And the formatting of the vertical portions of the tables needs fixing.

• Figure 3 has “Mental Health” in the wrong place. It should be below the headers. 

Overall, the figure is unclear. It is not at all clear that the sub-analyses are in fact subanalyses. Without close inspection, there appear to be 5 studies each for mental health 

and vitality (3 nurse and 2 PCP). A sub-analysis of a single study (PCP) is uninformative 

and misleading. The text part of the figure gives no clear distinction between the studies, 

estimate (if the upper or lower confidence limit 

crosses an effect size of 0.5 in either direction this 

would be considered imprecise). We will present the 

data as a WMD and an SMD.

References have been converted to superscript 

format. For this review we focused our meta-analysis 

on ESS and SF-36 scores. 

-We added more detail in the Methods section. The 

strength of evidence was insufficient if no studies 

reported the outcome (eg, access to care) or if there 

was one small study with few events. Directness etc. 

were assessed and a table has been added

(Appendix D). We divided Table 4 into separate tables 

for each KQ.

-Strength of evidence has been added to the 

summary statements at the start of each KQ. Similar 

is a standard term as is “may be” when evidence is 

very low or even low.

-The abbreviation is now used throughout.

-The statements are intended to provide an overview 

of the population in the included studies. Table 1 

indicates that the values are means (unless otherwise 

noted) and reports the number of studies included in 

determining the mean. The means are weighted 

means. This has been added to the tables.

-Details on risk of bias are presented in Appendix C, 

Tables 1 and 7 (Study Characteristics)

-Thank you for the suggestion. There were a variety of 

measures used for the different outcomes (eg,

different components of the SF-36) and then different 

reporting of the results (ie, mean differences, effect 

sizes). We thought the “arrow” tables and the Strength 

of Evidence tables were the best way to convery 

results in the text. The reference to Appendix C and 

the vertical alignment have been corrected.

-The Figures have been revised for clarity deleting 

‘sub-analysis” lines and additional information in the 

legend. WMDs are presented. 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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sub-analyses, and overall analyses. What are the sample sizes, baseline values, followup times of the individual studies? Again, why is this done as a SMD and not a WMD? 

The figure needs a proper legend. Std diff and CI are not defined.

• Page 27, lines 19 and following. It is not clear why adverse events are summarized if 

the RCT did not provide separate data for the two treatment groups. There is no 

evidence to address the KQ. Also, the term treatment group is unclear for KQ 1 which 

compares providers not treatments.

• Tables 2 and 3, with thought, partly distinguish the difference between clinical and 

intermediate outcomes better than the methods but the distinction seems to be more 

categorical vs. continuous rather than clinical vs. intermediate. Table 3 should probably 

better clarify that weight and BP etc. are continuous outcomes.

• Limitations: Consider whether you are able to make any determination about possibility 

of bias due to the agendas of the authors. It seems plausible that studies of nonspecialists vs. specialists (or home vs. lab titration which could greatly affect lab income) 

are being conducted by researchers with an agenda (eg, to promote non-specialists).

• Research Gaps/Future Research: Consider also talking about within-study gaps, 

particularly related to possible reporting bias. KQ 1 and 2 are explicitly discussed in this 

section; why isn't KQ 3?

• Conclusions: I believe the conclusions section is the first mention of a decreasing 

supply of sleep physicians.

-We agree and have modified the statements about 

adverse events for KQ1 throughout the report. We 

also changed the “treatment group” wording.

-As noted above, we considered weight and symptom 

scores as intermediate outcomes but attainment of a 

minimally important difference in one of those 

outcomes as a clinical or patient-centered outcome. 

We attempted to clarify in the summary statements.

-We could not determine bias, but these are by nature 

unblinded studies. However, the reviewer raises an 

important issue and we now suggest (in the Executive 

Summary and full report) that future studies have 

outcomes collected in a blinded fashion where 

feasible.

- We have added some gaps/future research 

regarding KQ3 in this section (but only in the full 

report, rather than the Executive Summary—we felt 

that the gaps in KQ1 and KQ2 were more important 

for the Executive Summary). Thank you.

Thank you for noting this—we now discuss the 

decreasing supply in the introduction.
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APPENDIX C. EVIDENCE TABLES 

Table 1. Study Characteristics for KQ1

Author, year

Study Design

Location

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments 

Received

Inclusion/Exclusion Criteria

Patient Characteristics 

(expressed in mean (sd) 

unless otherwise noted)

Risk of Bias

Chai-Coetzer 

201331

RCT

Australia

Participants 

screened in 

primary care 

Primary care 

management (n = 

81)

Usual care, sleep 

specialist (n = 74)

6 months

Case finding 

(diagnosis) and 

Management

Primary care 

management 

included physicians 

and communitybased nurses who 

participated in an 

education program 

on obstructive sleep 

apnea and its 

management. 

Patient treated with 

CPAP, conservative 

therapy, mandibular 

advancement splint. 

One of the 4 nurses 

had 15 years of 

experience in a 

tertiary sleep 

center.

Inclusion: aged 25-70, high 

diagnostic likelihood of moderate 

to severe OSA, defined as a 

score of ≥ 5 out of 10 points on a 

4-item questionnaire and an 

overnight 3% oxygen 

desaturation index ( ≥ 3%ODI) of

≥ 16 events per hour and an ESS 

score of ≥ 8 or persistent 

hypertension despite taking ≥ 2 

antihypertensive agents

Exclusion: severe morbid obesity 

(BMI > 50), neuromuscular 

disease, unstable psychiatric 

disease or cognitive impairment 

considered likely to interfere, 

hospitalization in the previous 3 

months for MI, unstable angina, 

cardiac failure, or CVA or New 

York Heart Association class III 

or IV symptoms, or lung disease 

with awake resting oxygen 

saturation of 

<92%

N = 155

Primary Care:

n = 81

Mean age: 57.2 (10.9)

Male gender, %: 85

BMI: 33.1 (5.5)

Oximetry ≥ 3% ODI, events/h: 

32.7 (18.2)

BP, systolic mmHg: 134 

BP, diastolic mmHg: 84.5

ESS: 12.8 (3.9)

OSA 50 questionnaire score: 8.2 

(1.5)

Specialist: 

n = 74

Mean age: 54.5 (11.8)

Male gender, %: 77

BMI: 33.7 (5.6)

Oximetry: 35.7 events/h (17.4)

BP, systolic mmHg: 135.9

BP, diastolic mmHg: 85.23

ESS: 12.5 (3.9)

OSA 50 questionnaire score: 8.1 

(1.7)

Sequence generation:

adequate

Allocation concealment:

adequate

Blinding: NR

Incomplete outcome 

data: reasons for dropout 

reported, ITT analyses (all 

randomized) but uneven 

dropouts by arm (21% and 

8%) and > 10% dropped 

out

Selective outcome 

reporting: no

Risk of Bias: Medium
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Author, year

Study Design

Location

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments 

Received

Inclusion/Exclusion Criteria

Patient Characteristics 

(expressed in mean (sd) 

unless otherwise noted)

Risk of Bias

Chamorro 201332

Retrospective 

record review 

Spain

Sleep unit

Primary care 

pulmonologist vs 

sleep specialist (n = 

96)

unclear

Diagnosis

Examine 

concordance 

between test 

prescribed by 

primary care 

pulmonologist and 

ideal test 

recommended by 

sleep specialist

Inclusion: patients with suspicion 

of OSAH referred to sleep unit by 

primary care pulmonologist in 

2010

n = 96

Mean age: 58.7 (12.6)

Male gender, %: 71

BMI: 30.26 (5.39)

ESS: 11.57 (4.7)

HTN: 38%

Diabetes: 14%

Selection bias: 

inadequate

Blinding of outcome 

assessment: inadequate

Intention-to-treat 

analysis: adequate

Attrition bias: adequate

Selective outcome 

reporting: adequate

Risk of Bias: High

Andreu 201229

RCT

Spain

Pulmonology 

section of the 

University 

Hospital

Group A: Home 

respiratory 

polygraphy and 

home follow-up by 

sleep unit nurse (n

= 22)

Group B:

Supervised 

polysomnography 

and hospital followup with sleep unit 

pulmonologist (n = 

22)

Group C: Home 

respiratory 

polygraphy and 

hospital follow-up 

with sleep unit 

pulmonologist (n = 

21)

6 months 

Treatment

All received CPAP

Inclusion: high level of clinical 

suspicion of OSAS based on an

Epworth Sleepiness Scale (ESS) 

score ≥ 12 and a Sleep Apnoea 

clinical score (SACS) ≥ 15

Exclusion: impaired lung function 

(COPD, obesity-hypoventilation, 

and restrictive disorders), 

associated pathologies 

(psychiatric disorders, 

neoplasms, restless leg 

syndrome, and other dyssomnias 

or parasomnias), or previously 

treated with CPAP

n = 65

Mean age: 52

Male gender, %: 83

BMI: 34

Hypertension: 49%

Habitual snoring: 100%

SACS: 40 (26)

AHI(/hr): 43 (20)

ODI(/hr): 44 (26)

Neck circumference (cm): 45.5 

(3.5)

Sequence generation: 

adequate

Allocation concealment:

adequate

Blinding: no

Incomplete outcome 

data: 58/65 (89%) 

completed program; intentto-treat analysis included 

all but 1 patient (refused 

PSG)

Selective outcome 

reporting: some outcomes 

not reported by group but 

overall adequate

Risk of Bias: Medium 
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Author, year

Study Design

Location

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments 

Received

Inclusion/Exclusion Criteria

Patient Characteristics 

(expressed in mean (sd) 

unless otherwise noted)

Risk of Bias

Pamidi 201235

Retrospective 

chart review

Chicago

University sleep 

disorders center

Sleep Specialists, 

initial PSG ordered 

by a sleep specialist 

(n = 105)

Non-sleep 

Specialist,

Initial PSG ordered 

by a non-sleep 

specialist (60% 

primary care 

physicians, 8% 

otolaryngologists, 

7% pulmonologists, 

6% neurologists, 

6% 

endocrinologists, 

5% cardiologists, 

3% surgeons, and 

4% other) (n = 298)

30 days

Case finding

Referred patients 

received in-lab PSG 

and CPAP titration 

done by sleep 

laboratory 

personnel, had 

CPAP set up in 

homes by a durable

medical equipment 

provider

Inclusion: evaluated medical 

records of adults who were CPAP 

naïve and were referred for their 

first in-laboratory PSG for 

suspicions of OSA

Exclusion: previous CPAP use, 

requirement for bi-level PAP or 

adaptive servoventilation, central 

sleep apnea, and lack of 

adherence data due to a lack of 

or faulty wireless modem 

transmission device

n = 403

Mean age:52.5 (14)

Male gender, %: 47

Race, African American: 54%

Non-African American: 46% 

(significantly fewer African 

Americans in sleep specialist 

group)

BMI: 36.3 (9.1)

Hypertension: 58.5%

(significantly more hypertensives 

in sleep specialist group)

T2DM: 26%

ESS: 9.2 (5.2)

CES-D scale: 16 (11)

Total sleep time, min: 324, P = 

.98

Arousal index, events/h: 29, P = 

.54

AHI(/hr): 36 

ODI(/hr): 23 (significantly higher 

in non-sleep specialist group)

SpO2: 80.6 (9.8)

Selection bias: adequate

Blinding of outcome 

assessment: N/A 

(objective – wireless 

transmission of data)

Intention-to-treat 

analysis: adequate

Attrition bias: inadequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

73

Author, year

Study Design

Location

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments 

Received

Inclusion/Exclusion Criteria

Patient Characteristics 

(expressed in mean (sd) 

unless otherwise noted)

Risk of Bias

Lettieri 201133

Observational 

cohort study

United States

Communitybased Hospital 

and Academic 

Sleep Center

Group1 (n = 70):

primarily managed 

by primary care 

physician

Group2 (n = 70):

managed by sleep 

specialist

Group3 (n = 70):

managed by sleep 

specialist

4-6 week follow-up

Titration

All treated with 

CPAP, titration via 

home APAP, or inlab CPAP 

Inclusion: diagnosed with OSA by 

HST or PSG (met criteria for 

OSAS according to AASM 

guidelines), eligible for home 

sleep study program (2 or more 

high-risk features such as 

habitual snoring, daytime fatigue, 

nonrestorative sleep, weight gain, 

and witnessed apneas; no 

suspicion of concomitant sleep 

disorders and no significant 

underlying comorbidities), 

diagnosed OSAS defined as AHI

> 5 with compatible symptoms

Exclusion: not eligible for HST 

(cardiopulmonary disease, heart 

failure, CAD, previous 

cerebrovascular accident, poorly 

controlled asthma, moderate to 

severe COPD [FeV1 < 50%], 

supplemental oxygen 

requirement)

n = 210

Group 1:

Mean age: 50.4 (9.2)

Male gender, %: 64.3%

BMI: 32.2 (4.8)

Baseline ESS: 14.8 (54.8)

Baseline fatigue: 6.3 (1.5)

AHI(/hr): 20.7 (12.2)

Group 2: 

Mean age: 47.1 (8)

Male gender, %: 71.4

BMI: 30 (3.5)

Baseline ESS: 14.1 (4.2)

Baseline fatigue: 6.7 (1.7)

AHI(/hr): 23.1 (13)

Group 3:

Mean age: 45.5 (5.4)

Male gender, %: 68.6%

BMI: 28.5 (3)

Baseline ESS: 13.9 (4.4)

Baseline fatigue: 6.5 (1.4)

AHI(/hr): 19.3 (9.4)

Selection bias: 

inadequate; unclear how 

patients in Groups 2 and 3 

were selected to achieve 

same number as in Group 

1; participants in all groups 

had to meet the same 

criteria for HST and APAP 

Blinding of outcome 

assessment: NR 

(adherence was objective 

measure)

Intention-to-treat 

analysis: adequate after 

exclusions for Group 1 and 

selection of equal number 

for Groups 2 and 3

Attrition bias: adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

74

Author, year

Study Design

Location

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments 

Received

Inclusion/Exclusion Criteria

Patient Characteristics 

(expressed in mean (sd) 

unless otherwise noted)

Risk of Bias

Antic 200930

RCT

Australia

Academic sleep 

medicine

services, after 

referral for clinical 

suspicion of OSA

Specialist nurse (n

= 100 randomized, 

90 analyzed) 

Sleep physician (n

= 95 randomized, 

84 analyzed)

3 months

Management

Specialist nurse 

was experienced in 

sleep disorders, 

supervising home 

auto-adjusting 

positive airway 

pressure to set 

therapeutic 

continuous positive 

airway pressure 

(CPAP). Sleep 

physician group had 

clinical care 

supervised by a 

sleep physician for 

in-lab CPAP 

titration and 

treatment

Inclusion: referred with a clinical 

suspicion of OSA, ESS score of ≥ 

8, history of snoring ‘‘most 

nights’’ or ‘‘every night,’’ age 18-

75 years, and patient willing to try 

CPAP 

Exclusion: unstable 

cardiovascular diseases (eg,

recent unstable angina, 

myocardial infarction, stroke or 

TIA within the previous 6 months, 

or severe left ventricular failure), 

neuromuscular disease affecting 

or potentially affecting respiratory 

muscles, moderate to severe 

respiratory disease or hypoxemia 

or awake SaO2<92%, or 

psychiatric disease that limited 

the ability to give informed 

consent or complete the study

n = 195

Nurse-led: 

n = 100

Mean age: 49.9 (SEM 1.2)

Male gender, %: 72

BMI: 35.1 (SEM.7)

≥ 2% oxygen saturation dips, 

events/h: 49.2 (SEM 2.1)

ESS: 13.7 (SEM 0.4)

Specialist-led: 

n = 95

Mean age: 50.3 (SEM 1.3)

Male gender, %: 76

BMI: 34 (SEM.6)

AHI: 67.9 events/h (SEM 2.82)

> / = 2% oxygen saturation 

dips, events/h: 52.5 (SEM 2.7)

ESS: 13.4 (SEM 0.4)

Sequence generation:

adequate

Allocation concealment: 

adequate (explained in 

online supplement)

Blinding: open-label but 

questionnaires and 

measurements 

administered by research 

assistants with no 

involvement in clinical care 

of patients and were 

blinded to patient allocation

Incomplete outcome 

data: reasons for dropout 

reported, # randomized 

were not included in the 

analyses

Selective outcome 

reporting: No

Risk of bias: Low

Palmer 200434

RCT

Scotland

Hospital/peripher

al clinics

Specialist nurse (n

= 87 randomized, 

79 at baseline, 68 

at follow-up)

Hospital-based 

consultant (n = 87 

randomized, 77 at 

baseline, 71 at 

follow-up)

3 months

OSA management/ 

treatment

Home visit by 

specialist nurse or 

hospital-based 

consultant review at 

general respiratory 

clinic for routine 

annual review for 

CPAP users

Inclusion: All patients in Highland 

who had a diagnosis of SAHS 

and a CPAP machine on 

10/01/2000

Exclusion: Not described(none)

n = 174 randomized, 156 at 

baseline, 139 at follow-up

Nurse:

n = 79 at baseline

Age: 54 (10)

Male gender, %: 84

ESS: 8 (5)

Consultant Clinic: 

n = 77 at baseline

Age: 55 (11)

Male gender, %: 87

ESS: 9 (6)

Sequence Generation: 

NR

Allocation concealment:

NR

Blinding: NR

Incomplete outcome 

data: unclear, 80% of 

target population finished 

both baseline and follow-up 

questionnaire, some 

reasons given, not uneven 

Selective Reporting:

adequate

Risk of Bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

75

Author, year

Study Design

Location

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments 

Received

Inclusion/Exclusion Criteria

Patient Characteristics 

(expressed in mean (sd) 

unless otherwise noted)

Risk of Bias

Scharf 200436

Retrospective 

telephone survey

and laboratory 

chart review

USA

University 

Specialty Hospital 

and a laboratory 

serving the

medical 

community at 

large

Primary care 

practitioners (n = 

44)

Usual care, sleep 

specialists (n = 59)

The mean time from 

diagnostic PSG

to interview for 

primary care group 

was 7.0 months and

7.2 months for 

usual care

Management

In primary care 

group all patients 

referred by primary 

care practitioners 

for usual care 

patients were seen 

by sleep specialists. 

All treated with 

CPAP

Inclusion: over 18 years

old diagnosed with OSA 

Exclusion: NR

n = 103

Mean age: 49.4 (12.7)

Male gender, %: 58.2

BMI: 36.1 (13.4)

Diabetes: 19%

HTN: 53%

Unexplained daytime 

sleepiness/fatigue: 68%

Snoring: 83%

Selection bias: adequate 

groups; unclear regarding 

possible confounders

Blinding of outcome 

assessment: NR

Intention-to-treat 

analysis: adequate

Attrition bias: 37% survey 

response rate but 

comparable for 2 sites and 

non-responders were 

similar age, gender, RDI

Selective outcome 

reporting: adequate

Risk of Bias: Medium

AHI = apnea/hypopnea index; CES-D = Center of Epidemiology study depression scale; COPD = chronic obstructive pulmonary disorder; ESS = Epworth 

Sleepiness Scale; ODI = oxygen desaturation index; OSAS = obstructive sleep apnea syndrome; SpO2 = oxygen saturation measured by pulse oximetry; T2DM

= type 2 diabetes mellitus
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

76

Table 2. Clinical Outcomes for KQ1

Study

Intervention (n)

Control (n)

All-cause Mortality 

% (n/N)

Resource Utilization 

(hospitalization, etc) Access to Carea MID, Sleep Symptom Scores

MID,

Urinary Symptom 

Scores

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Chai-Coetzer 201331

Primary care (n = 

81)

Usual care (n = 74)

NR NR

Baseline 

initiated 

CPAP: 90% 

(n = 73) 

conservative 

measures: 

2% (n = 2) 

6 months

using 

CPAP: 63% 

( n = 51) 

conservative 

measures: 

9% (n = 7) 

Baseline: 

initiated on 

CPAP: 70% 

(n = 52) 

conservative 

measures: 

24% (n = 

18) 

6 months 

using 

CPAP: 61% 

(n = 45) 

conservative 

measures: 

16% (n = 

12) 

RR of using 

CPAP at 6 

m: 1.11 

(0.95, 1.31)

NR NR NR NR NR NR

Andreu 201229

Nurse (n = 22)

Sleep pulmonologist 

(n = 43)

NR NR

Extra visits 

9 

Extra calls 

24

Extra visits 

Group B: 0

Group C: 5 

Extra calls

Group B:

17

Group C: 

13

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

77

Study

Intervention (n)

Control (n)

All-cause Mortality 

% (n/N)

Resource Utilization 

(hospitalization, etc) Access to Carea MID, Sleep Symptom Scores

MID,

Urinary Symptom 

Scores

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Antic 200930

Nurse (n = 100)

Usual care (n = 95)

NR NR

Number of 

physician 

visits per 

patient

0.2 (SEM 

0.1)

Effect size: 

2.24 (1.88, 

2.6)

Scheduled 

nursing time 

per patient 

153 min

(SEM 3.9)

P<.001

Unscheduled 

nursing time 

per patient 

8.4 min 

(SEM 1.5) 

Effect size: 

-0.15 (-0.43, 

0.13)

Number of 

physician 

visits per 

patient

2.4 (SEM 

0.1)

P<.001a

Scheduled 

nursing time 

per patient 

103 min

(SEM 4.2)

Effect size: 

1.25 (0.94, 

1.56)

Unscheduled 

nursing time 

per patient 

11.4 min

(SEM 2.5)

P = .31a

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

78

Study

Intervention (n)

Control (n)

All-cause Mortality 

% (n/N)

Resource Utilization 

(hospitalization, etc) Access to Carea MID, Sleep Symptom Scores

MID,

Urinary Symptom 

Scores

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Palmer 200434

Nurse (n = 68)

Consultant Clinic (n

= 71)

NR NR

61% of patients seen by 

the consultant required 

onward referral to 

specialist nurse for 

practical help 

Average time spent with 

nurse: 26 (6) minutes

Average time spent with 

consultant: 10 (6) minutes

Effect size: 0.32 (-0.01, 

0.66)

NR NR NR NR NR NR

Scharf 200436

Primary care (n = 

44)

Usual care (n = 59)

NR NR

Patients 

offered 

CPAP

79% (35/44)

RR: 0.92 

(0.77, 1.1)

P = .367

Accepted 

treatment 

with CPAP

83% (29/35) 

P = NSa

Patients 

offered 

CPAP

86% (51/59)

P = NSa

Accepted 

treatment 

with CPAP

86% (44/51)

RR: 0.96 

(0.8, 1.16)

NR NR NR NR NR NR

a

between groups

SEM = standard error of the mean; RR = risk ratio; NS = not statistically significant; NR = not reported
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

79

Table 3. Clinical Outcomes for KQ1, Continued 

Study

Intervention (n)

Control (n)

Quality of Life Patient Satisfaction Remission Cognitive Symptoms Other (describe)

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Chai-Coetzer 

201331

Primary care (n = 

81)

Usual care (n = 

74)

SF-36 Vitality

Baseline 43.6

Change at 6 

m 

16.1 (11.0, 

21.2)

Adjusted 

difference: 

2.51 (-3.88, 

8.9)

P<.001 from 

baseline

SF-36 Mental

Baseline 66.5

Change at 6 

m 

7.9 (4.0, 11.8) 

P<.001 from 

baseline

P = .54a

SF-36 Vitality

Baseline 34.6

Change at 6 m

19.9 (14.4, 

25.4) P<.001 

from baseline

P = .44a

SF-36 Mental

Baseline 61.6

Change at 6 m

8.4 (4.5, 12.3) 

P<.001 from 

baseline

Adjusted 

difference: 1.57 

(-3.41, 6.55)

VSQ-9

Small but statistically 

significant differences in 

5/9 items in favor of the 

primary care group

No difference in overall 

satisfaction

Effect sizes for the 9 

items were small 

(range, 0.14-0.41) and 

may not be clinically 

significant

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

80

Study

Intervention (n)

Control (n)

Quality of Life Patient Satisfaction Remission Cognitive Symptoms Other (describe)

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Antic 200930

Nurse (n = 100) 

Usual care (n = 

95)

SF-36 Vitality

change at 3 

m 

-16.12 (SEM 

2.17); n = 89

Effect size: 

-0.04 (-0.34, 

0.26)

SF-36 Mental 

change at 3 

m 

-4.81 (SEM 

1.46); n = 89

Effect size: 

0.017 (-0.28, 

0.32)

No significant 

differences 

between 

groups in any 

of the quality 

of life indices

SF-36 Vitality

change at 3 m

-15.31 (SEM 

2.06); n = 81

Mean 

difference: 

-0.81 (-6.75, 

5.12)

SF-36 Mental 

change at 3 m

-5.09 (SEM 

2.11); n = 81

Mean 

difference: 0.27 

(-4.71, 5.27)

VSQ-9

Total patient 

satisfaction with 

treatment was not 

statistically significantly 

different between the 2 

groups

Mean scores, Nurse 

3.73 (SD 0.47); n = 89 

vs UC 3.76 (SD 0.43); 

n = 79, P = .68a

Effect size: -0.06 (-0.37, 

0.24)

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

81

Study

Intervention (n)

Control (n)

Quality of Life Patient Satisfaction Remission Cognitive Symptoms Other (describe)

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Palmer 200434

Nurse (n = 68)

Consultant Clinic 

(n = 71)

SF-36 PCS

Baseline

39 (16) P = 

.10

3 months

39 (17)

Change

-1 (8)

Effect size: 

0.24 (-0.1, 

0.57)

MCS

Baseline:

51 (11) P = 

.51

3 months

52 (13)

Change

1 (7)

No significant 

difference in 

any 

parameter 

between 

groups or 

from baseline 

for nurse

Also reported 

SF-36 vitality 

and mental 

health scores

SF-36 PCS

Baseline

34 (17)

3 months

35 (17)

Change

2 (9)

P = .16

MCS

Baseline

49 (14)

3 months

51 (11)

Change

2 (10)

P = .64

Effect size: 

0.08 (-0.25, 

0.42)

General health 

and social 

functioning 

both 

significantly 

improved from 

baseline 

P<.025 for 

consultant 

group

There were some 

“preference” data 

reported that were 

different (P = .00) by 

study arm

NR NR NR NR

HADS 

Anxiety

Baseline

6.1 (4.8)

P = .5a

3 m

5.4 (5)

Effect size: 

0 (-0.33, 

0.33)

Change

-0.6 (3.1)

Depression

Baseline

4.4 (4.3)

3 m

4.3 (4.4)

Change

0.2 (2.9)

HADS 

Anxiety

Baseline

6.7 (5.2)

3 m 

5.4 (4.2)

Change

-1.1 (4.2) P

= .54a

Depression

Baseline

5.5 (4.8) P

= .18a

3 m

4.7 (4.4)

Effect size: 

-0.09 (-0.42, 

0.24)

Change

-0.6 (3.1) P

= .27a
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

82

Study

Intervention (n)

Control (n)

Quality of Life Patient Satisfaction Remission Cognitive Symptoms Other (describe)

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Scharf 200436

Primary care (n = 

44)

Usual care (n = 

59)

NR NR NR NR NR NR NR NR

Subjective 

symptoms 

improvement

(from 

diagnostic 

PSG to 

interview 

mean 7 m)

80% (28/35)

RR: 1.09 

(0.86, 1.4)

Subjective 

symptoms 

improvement

(from 

diagnostic 

PSG to 

interview 

mean 7.2 

m)

74% (36/49)

P = NSa

a

between groups 

HADS = Hospital Anxiety and Depression Scale; NS = not statistically significant; NR = not reported; MCS = mental component summary (SF-36); PCS = physical component 

summary (SF-36); PSG = polysomnography; SEM = standard error of the mean; UC = usual care; VSQ-9 = Visit- Specific Satisfaction Questionnaire
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

83

Table 4. Intermediate Outcomes for KQ1

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Chai-Coetzer 201331

Primary care (n = 

81)

Usual care (n = 74)

NR NR NR NR

ESS

Baseline 

12.8

6 months: 

7.0

Change:

5.8

(4.4, 7.2) 

P<.001 

from 

baseline

Adjusted 

difference in 

mean 

change: 

-0.13 (lower 

bound -1.5) 

(for noninferiority 

test)

ESS

Baseline 

12.5

6 months: 

7.0

Change:

5.4

(4.2, 6.6) 

P<.001 

from 

baseline

P = .43a

FOSQ

Baseline 

14.7

Change at 6 

m 

2.8

(2.0, 3.6) 

P<.001 

from 

baseline

Adjusted 

difference: 

0.18 (-0.58, 

0.94)

SASQ

Baseline 

71.2

Change at 6 

m 

-29.7 (-23.0, 

-36.4) 

P<.001

FOSQ

Baseline 

14.2

Change at 6 

m 

2.8

(2.2, 3.4) 

P<.001 

from 

baseline

P = .64a

SASQ

Baseline 

72.1

Change at 6 

m 

-31.2 (-23.8, 

-38.6) 

P<.001

P = .85a

Adjusted 

difference: 

0.18 (-0.58, 

0.94)

Baseline:

101.9kg

Change at 6 

m 

-0.1 (-2.5, 

2.3)

Adjusted 

difference: -

0.43 (-3.43, 

2.57)

Baseline: 

103.2

Change at 6 

m

0.3 (-1.5, 

2.1)

P = .78a
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

84

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Andreu 201229

Nurse (n = 22)

Sleep pulmonologist 

(n = 43)

NR NR NR NR

ESS

Baseline

15 (3)

6 months

6 (5)

P<.001 

from 

baseline

P = NSa

 

Effect size 

vs B: 0

(-0.59, 0.59)

Effect size 

vs C: 0.22 

(-0.38, 0.82)

ESS 

Baseline

B: 16 (4)

C: 16 (3)

6 months

B: 6 (4)

C: 5 (4)

P<.001 

from 

baseline for 

both groups

FOSQ

Baseline

16 (3)

6 months

18 (2)

P<.001 

from 

baseline

P = NS

Effect size 

vs B: 0 

(-0.6, 0.6)

Effect size 

vs C: -0.63 

(-1.24, -

0.02)

FOSQ

Baseline

B: 16 (3)

C: 16 (3)

6 months

B: 18 (2)

C: 19 (1)

P<.001 

from 

baseline

NR NR

Pamidi 201235

Sleep specialist (n = 

105)

Non-sleep specialist 

(n = 298)

Events/hr

Baseline

38

Residual

3.7 

(median)

P<.001a

Events/hr

Baseline

31

P = .06a

Residual 

4.9

NR NR NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

85

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Lettieri 201133

Group 1: Primary 

care (n = 70)

Group 2: Sleep 

specialist (n = 70)

Group 3: Sleep 

specialist (n = 70)

NR NR NR NR

ESS 

Group 1

Baseline 

14.8 (4.8)

P = .48a

Follow-up 

9.1 (3.6)

P = .39a

Effect size 

vs 2: 0.23 

(-0.1, 0.56)

Effect size 

vs 3: 0.07 

(-0.26, 0.4)

Change

38.5%

P = .28a

ESS

G2:

Baseline 

14.1 (4.2)

Follow-up

8.4 (2.3)

Change

39.8%

G3:

Baseline 

13.9 (4.4)

Follow-up 

8.9 (2.1)

Change

36% 

NR NR NR NR

Antic 200930

Nurse (n = 100)

Usual care (n = 95)

NR NR NR NR

ESS

Baseline 

13.7

Change at 3 

m 

4.02

(SEM 0.52);

n = 90

MD = -0.13

(-1.52, 1.25)

P = NSa

ESS

Baseline 

13.4

Change at 3 

m 

4.15

(SEM 0.47); 

n = 84

FOSQ

Change at 3 

m 

-13.6 

(SEM 2.02);

n = 89

MD = -0.38

(-5.97, 5.20)

P = NSa

Maintenance of 

wakefulnes

s test, min

Change at 3 

m 

30.18 (SEM 

1.24)

FOSQ

Change at 3 

m 

-13.22

(SEM 1.96);

n = 81

Maintenance of 

wakefulnes

s test, min

Change at 3 

m 

31.68 (SEM 

1.08)

MD -1.49 

(-4.76, 1.78) 

P = NSa

NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

86

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Palmer 200434

Nurse (n = 68)

Consultant Clinic (n

= 71)

NR NR NR NR

ESS:

Baseline

8 (5) P = 

.24a

3 months

8 (6)

Effect size: 

0 (-0.33, 

0.33)

Change

0.2 (4)

Symptom 

Score

Baseline

P = .14a

3 months

11 (9)

Effect size: 

-0.3 (-0.63, 

0.04)

Change

-2 (7)

P<.025 

from 

baseline

ESS:

Baseline

9 (6)

3 months

8 (6)

Change

-0.9 (4)

P = .30

Symptom 

Score

Baseline

17 (12)

3 months

14 (11)

Change

-3 (9)

P<.025 

from 

baseline

P = .94a

NR NR NR NR

a

between groups

ESS = Epworth Sleepiness Scale (non-inferiority margin was -2.0); FOSQ = Functional Outcomes of Sleep Questionnaire; MD = mean difference; NS = not 

statistically significant; NR = not reported; RR = risk ratio; SASQ = Sleep Apnea Symptoms Questionnaire; SEM = standard error of the mean
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

87

Table 5. Intermediate Outcomes for KQ1, Continued

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy Compliance/Adherence

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Chai-Coetzer 201331

Primary care (n = 

81)

Usual care (n = 74)

NR NR

Systolic

Baseline:

134 mmHg

Change at 6 

m 

-2.2 (-6.3, 

1.9)

Adjusted 

difference: 

1.52 (-4.14, 

7.18)

Diastolic

Baseline:

84.5 mmHg

Change at 6 

m 

-1.4 (-4.3, 

1.5)

P = .48a

Systolic

Baseline:

136 mmHg

Change at 6 

m 

-4.4 (-9.1, 

0.3)

P = .60a

Diastolic

Baseline:

85 mmHg

Change at 6 

m 

-0.5 (-3.6, 

2.6)

Adjusted 

difference: -

1.32 (-4.97, 

2.33)

NR NR NR NR

Hours/night

4.8 (2.1) (n

= 51)

Effect size: 

-0.39 (-0.79, 

0.02)

Hours/night

5.4 (0.30)

(n = 44)

P = .11a
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

88

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy Compliance/Adherence

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Andreu 201229

Nurse (n = 22)

Sleep pulmonologist 

(n = 43)

NR NR NR NR NR NR NR NR

6 months

Compliant 

(≥ 4 hours/

night on 

70% of 

nights): 

16/22 (73%)

P = NS

RR vs C: 

1.27 (0.81, 

2.0)

Minutes 

used: 

271 (130)

Effect size 

vs B: -0.16 

(-0.43, 0.76)

6 months

Compliant

B: 15/21 

(68%)

C: 12/21 

(57%)

RR vs B: 

1.02 (0.7, 

1.48)

Minutes 

used:

B: 252 

(100)

C: 263 

(112)

P = NSa

Effect size 

vs C: 0.07 

(-0.53, 0.66)
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

89

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy Compliance/Adherence

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Pamidi 201235

Sleep specialist (n = 

105)

Non-sleep specialist 

(n = 298)

NR NR NR NR NR NR NR A 

Mean 

CPAP 

usage, min:

219 (152)

Effect size: 

-0.35 (-0.57, 

-0.12)

% days ≥ 

4h CPAP 

usage: 46% 

CPAP use ≥ 

4hours/

night on ≥ 

70% of 

nights:

98/298 

(32.9%)

RR: 0.72 

(0.55, 0.94)

CPAP 

usage:

279 (179)

P = .005a

% days ≥ 

4h CPAP: 

63%

P = .004a

CPAP use ≥ 

4hours/

night on ≥ 

70% of 

nights:

48/105 

(45.7%)

P = .01a

Consultation with 

sleep 

specialist 

significant 

predictor of 

CPAP 

adherence 

(1st 30 days 

of therapyb)
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

90

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy Compliance/Adherence

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Lettieri 201133

Group 1: Primary 

care (n = 70)

Group 2: Sleep 

specialist (n = 70)

Group 3: Sleep 

specialist (n = 70)

NR NR NR NR NR NR NR NR

Hours/night 

4.7 (2) 

P = .98a

%nights 

used 70.7% 

(26) P = 

.94a

Effect size 

vs 2: -0.11 

(-0.44, 0.22)

Effect size 

vs 3: -0.07 

(-0.4, 0.26)

Use > 4 

hours/

night for > 

70% of 

nights

54.3%

P = .84a

Hours/night 

G2:

4.7 (1.1) 

Effect size: 

0 (-0.33, 

0.33)

G3: 4.8 

Effect size: 

-0.05 (-0.4, 

0.22)

G2: 73.2% 

(18)

G3:

72.4% (22)

G2: 51.4%

G3: 50%

Antic 200930

Nurse (n = 100)

Usual care (n = 95)

NR NR NR NR NR NR

No significant difference 

between groups in 

satisfaction with time 

waiting (P = .71a

) 

Effect size: 0.06 (-0.24, 

0.36)

Patients receiving nurseled care were more 

satisfied with their 

impression of wait time (P

= .004a

) 

Effect size: 0.46 (0.15, 

0.76)

Hours/night

4.11 (SE 

0.28) (n = 

94)

Hours/night

4.56 (SE 

0.30) (n = 

81)

MD:-0.45

(-1.26, 0.36)
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

91

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy Compliance/Adherence

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Palmer34

2004

Nurse (n = 68)

Consultant Clinic (n

= 71)

NR NR NR NR NR NR NR NR

Daily hours 

of CPAP 

use

Baseline

(n = 71) 

4.91 (2.85)

P = .46a

Follow-up

(n = 63) 

5.93 (2.67)

Effect size: 

0.11 (-0.24, 

0.46)

Change

(n = 58) 

0.66 (1.71)

P = .5a

P = .004 

from 

baseline

Daily hours 

of CPAP 

use

Baseline

(n = 71) 

5.24 (2.5)

Follow-up

(n = 63) 

5.64 (2.54)

P = .54a

Change

(n = 61) 

0.45 (1.69)

P = .041 

from 

baseline

Scharf 200436

Primary care (n = 

44)

Usual care (n = 59)

NR NR NR NR NR NR

Interval 

between 

PSG and 

CPAP study 

≤1 m: 

8.6% (3/35)

35.3% 

(18/51) P = 

.012a

Compliantc

3 m after 

onset of 

treatment 

all patients:

41% (18/44)

RR: 0.8 

(0.52, 1.24)

Of patients 

accepting 

CPAP

62% (18/29) 

P = NSa

Compliantc

3 m after 

onset of 

treatment, 

all patients

51% (30/59)

P = NSa

Of patients 

accepting 

CPAP

68% (30/44)

RR: 0.91 

(0.64, 1.29) a

between groups; b

Mean adherence 58 min higher per day with sleep specialist consultation prior to initial PSG; after adjustment for age, race, BMI, medical insurance, AHI, ESS, 

CES-D, and education level c

compliant defined as use for at least 4h/night 5 nights per week, estimated by the patient over the prior month 

MD = mean difference; NS = not statistically significant; NR = not reported; PSG = polysomnography; RR = risk ratio; SE = standard error
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

92

Table 6. Intermediate outcomes for KQ1, Continued

Study

Intervention (n)

Control (n)

Case Finding (describe) Harms, Adverse Events 

(describe)

Harms, Adverse Events 

(describe)

Harms (Overdiagnosis, 

False 

Positives/Negatives)

Costs per Patient

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Chai-Coetzer 201331

Primary care (n = 

81)

Usual care (n = 74)

NR NR NR NR NR NR NR NR $1819.44 $3067.86

Chamorro 201332

Primary care 

pulmonologist and 

sleep specialist (n = 

96)

Concordance between 

primary care 

pulmonologist and sleep 

specialist kappa = .74, 

P<.001

NR NR NR NR NR NR NR NR

Andreu 201229

Nurse (n = 22)

Sleep pulmonologist 

(n = 43)

NR NR

Dryness (54%)

Nasal congestion (40%)

Abrasions (25%)

NR NR NR NR

Cost per 

patient 

€590 (43)

Effect size 

vs B: 8.1 

(6.4, 10.1)

Effect size 

vs C 0.75 

(0.13, 1.37)

Cost per 

patient

B: €849

(11)

P<.001 vs A 

and C

C: €644 

(93) P<.05 

vs A

Lettieri 201133

Group 1: Primary 

care (n = 70)

Group 2: Sleep 

specialist (n = 70)

Group 3: Sleep 

specialist (n = 70)

NR NR

12.9% discontinued 

therapy

Group 2:

8.6% discontinued

Group 3: 

10% discontinued

P = .78a

NR NR NR NR NR NR

Antic 200930

Nurse (n = 100)

Usual care (n = 95) NR NR NR NR NR NR NR NR

Within-trial costs were 

significantly less with 

nurse-led care (A$1,111 

per patient less)
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

93

Study

Intervention (n)

Control (n)

Case Finding (describe) Harms, Adverse Events 

(describe)

Harms, Adverse Events 

(describe)

Harms (Overdiagnosis, 

False 

Positives/Negatives)

Costs per Patient

Non-sleep 

specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control Non-sleep specialist Control

Palmer 200434

Nurse (n = 68)

Consultant Clinic (n

= 71)

NR NR NR NR NR NR NR NR

Total cost 

(to NHS) of 

nurse home 

visit: $83.62 

(79.76)

Cost to 

patient was 

set at $0, 

no 

accounting 

for time off 

work, etc

Total cost to 

NHS of 

clinic visit: 

$9.94 (6.38)

Total cost to 

patient 

$37.81 

(37.13)

a

between groups

NHS = National Health Service (UK)
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

94

Table 7. Study Characteristics for KQ3

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Bakker 201140

Crossover RCT

Wellington, New 

Zealand

Sleep clinic

APAP vs CPAP for 

treatment (n = 12)

Outcomes assessed 

after 6 nights with 4-

night washout 

period

Treatment

APAP (5-20 cm H2O) 

and CPAP with 

pressure set during 

manual titration

Inclusion: English-speaking, 

PAP naïve, morbidly obese 

(BMI ≥ 40kg/m2

), ≥ 18 years 

old, AHI ≥ 15/hour, manually 

titrated pressure ≥ 14 cmH2O 

Exclusion: cardiac, 

respiratory, psychiatric, sleep 

co-morbidities (including 

central sleep apnea and those 

with irregular sleep patterns)

n = 12

Mean age: 45.9 (range 23-59)

Male gender, %: 75

BMI: 49.9 (5.2)

Obesity, %: 100

ESS: 17.4 (4.7) 

AHI (/hr): 75.8 (32.7)

Mean O2 desaturation: 8% (4.2)

Sequence generation:

adequate

Allocation concealment:

not reported

Blinding: unclear, blinded 

during data collection but 

not data entry, patient was 

blinded

Incomplete outcome data:

adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium

Lettieri 201133

Observational 

cohort study

United States

Community 

Based Hospital 

and Academic 

Sleep Center

Group 1 (n = 70): 

unattended Type III 

home sleep study 

and home APAP 

titration (not 

included for KQ3 

comparison)

Group 2 (n = 70): 

in-lab Type I 

attended sleep 

study and in-lab 

CPAP titration

Group 3 (n = 70): 

in-lab Type I sleep 

study, unattended 

home APAP titration

4-6 week follow-up

Titration

All treated with CPAP, 

titration via home 

APAP or in-lab CPAP

Inclusion: diagnosed with 

OSA by HST or PSG 

(according to AASM 

guidelines), eligible for home 

sleep study program ( ≥ 2 

high-risk features such as 

habitual snoring, daytime 

fatigue, nonrestorative sleep, 

weight gain, and witnessed 

apneas; no suspicion of 

concomitant sleep disorders 

and no significant underlying 

comorbidities), diagnosed 

OSAS defined as AHI > 5 with 

compatible symptoms

Exclusion: not eligible for HST 

(cardiopulmonary disease, 

heart failure, CAD, previous 

cerebrovascular accident, 

poorly controlled asthma, 

moderate to severe COPD 

(FeV1 < 50%), supplemental 

oxygen requirement)

n = 140 (groups 2 and 3 only)

Group 2: 

n = 70

Mean age: 47.1 (8)

Male gender, %: 71.4

BMI: 30 (3.5)

ESS: 14.1 (4.2)

Fatigue: 6.7 (1.7)

AHI (/hr): 23.1 (13)

Group 3: 

n = 70

Mean age: 45.5 (5.4)

Male gender, %: 68.6

BMI: 28.5 (3)

ESS: 13.9 (4.4)

Fatigue: 6.5 (1.4)

AHI (/hr): 19.3 (9.4)

Selection bias: 

inadequate; unclear how 

patients in Groups 2 and 3 

were selected to achieve 

same number as in Group 

1; participants in all groups 

had to meet the same 

criteria for HST and APAP 

Blinding of outcome 

assessment: NR 

(adherence was objective 

measure)

Intention-to-treat 

analysis: adequate after 

exclusions for Group 1 and 

selection of equal number 

for Groups 2 and 3

Attrition bias: adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

95

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Drummond 

201043

RCT 

US

VA Medical 

Center

Empiric APAP (n =

54 randomized, 42 

completed)

Usual care (n = 55 

randomized, 44 

completed)

1 month

Treatment

APAP: cost-free autoCPAP unit on day of 

randomization; 

returned to clinic at 1 

month for assessment; 

remained on APAP 

and awaited in-lab 

PSG and CPAP 

titration; final 

assessment 1 month 

after PSG

Usual care: 2nd

assessment at 1 

month after 

randomization; waited 

for in-lab PSG with 

CPAP titration; 

returned after 1 month 

of CPAP for 

assessment

Inclusion: consecutive 

patients referred for PSG; ≥ 2 

categories of Berlin 

questionnaire positive

Exclusion: age > 80; history of 

CHF; MI in past 6 months; 

COPD with FEV1<60% 

predicted; stroke; alternative 

sleep diagnosis; prior 

diagnosis of OSA

N = 109 randomized, 86 

completed protocol

Mean age: 55

Male gender, %: 93

Race: African American: 32%, 

Caucasian: 68%

BMI: 35.1

ESS: 14.4

Sequence generation: NR

Allocation concealment:

adequate

Blinding: No

Incomplete outcome data:

86 (79%) completed 

protocol; reported using 

intention-to-treat analysis 

with last observation carried 

forward

Selective outcome 

reporting: No

Risk of bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

96

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

McArdle 201038

RCT

Australia

Tertiary hospital 

sleep service

Manual titration (n =

83); in-lab CPAP 

titration with full 

PSG monitoring

Home APAP (n = 

86); used APAP 

overnight at home

Lab APAP (n = 80); 

APAP titration in-lab 

without full PSG 

(outcomes not 

extracted; in-lab 

APAP was not 

comparison of 

interest)

4 weeks

Titration

All received fixed 

CPAP at pressure 

determined by sleep 

specialist

Inclusion: symptoms of OSA 

(ESS ≥ 8, AHI ≥ 15 events/hr), 

age 17-85, living near sleep 

service and no previous 

treatment for OSA

Exclusion: BMI > 45, 

significant lung or cardiac 

disease, neuromuscular 

disease, previous stroke, 

predominant central sleep 

apnea, periodic leg 

movements > 15/hr, severe 

medical illness or planned 

surgery, language 

impairment, or psychiatric 

illness

Manual: 

n = 83

Mean age: 50 (12)

Male gender,%:75

BMI: 32.4 (5.7)

Hypertension: 34%

Diabetes: 11%

ESS: 14.1 (4)

AHI (/hr): 38

Time oxygen saturation < 90%, 

min: 5

Home APAP:

n = 86

Mean age: 50 (12)

Male gender, %: 59 (69)

BMI: 32.2 (5.2)

Hypertension: 29%

Diabetes: 15%

ESS: 13.8 (4.1)

AHI (/hr): 38

Time oxygen saturation < 90%, 

min: 2

Sequence generation:

adequate

Allocation concealment:

opaque envelopes

Blinding: adequate

Incomplete outcomes 

reporting: per protocol and 

ITT analysis, some 

outcomes not reported as 

ITT

Selective outcome 

reporting: data not given 

for all outcomes

Risk of bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

97

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Vennelle 201061

RCT (crossover)

UK, Sleep 

center

APAP vs CPAP (n =

192 randomized, 

181 completed)

Outcomes assessed 

after each 6-week 

treatment period

No washout period 

so no data from first 

2 weeks of each 

study arm were 

included in analysis

Treatment

Same CPAP device 

with 2 modes: fixedpressure mode 

(determined during 

overnight in-lab CPAP 

titration) and variable 

pressure mode

Inclusion: diagnosis of 

OSAHS; ESS ≥ 10 or history 

of troublesome sleepiness 

when driving, AHI ≥ 15 on 

PSG or ≥ 25 apneas and 

hypopneas per hour in limited 

sleep study, age 18-70, no 

previous CPAP use

Exclusion: severe 

neurological deficit sufficient 

to compromise CPAP usability 

or understanding; significant 

comorbidity such as severe 

COPD, stroke, unstable 

diabetes, or active angina; 

coexisting narcolepsy or 

periodic limb movement 

syndrome; contraindications 

to CPAP use including recent 

pneumothorax

N = 200 randomized, 181 

analyzed

Mean age: 50 (10)

Male gender, %: 77

BMI: 34.5 (7.8)

ESS: 14 (3)

Mean AHI (/hr): 33 (18) among n

= 123 who had PSG

Sequence generation: 

adequate

Allocation concealment: 

adequate

Blinding: adequate 

(patients, staff involved in 

data acquisition or analysis)

Incomplete outcomes 

reporting: 9.5% did not 

complete study (19/200)

Selective outcome 

reporting: adequate

Risk of Bias: Low

Damjanovic 

200941

RCT (controlled 

parallel group 

study)

Germany

Standard support 

and APAP (n = 25)

Standard support 

CPAP (n = 25)

Intensive support 

APAP (n = 25)

Intensive support

CPAP (n = 25)

3- and 9-month 

follow up

Treatment

CPAP pressure was 

the pressure level with 

the lowest RDI during 

polysomnography

Intensive support 

groups visited by 

specially trained 

members of authors’ 

sleep lab at 1, 2, 4, 5, 

and 6 months to 

optimize treatment 

and provide support

Inclusion: newly diagnosed 

OSAS patients, AHI ≥ 15, with 

or without corresponding 

daytime symptoms

Exclusion: any global 

respiratory failure, central 

sleep apnea, severe mental or 

psychological impairment

n = 100 randomized, 78 at 9 

months

Mean age: 57 (12)

Male gender, %: 78

BMI: 31 (5)

APAP:

n = 50

ESS: 8.5 (0.8)

AHI (/hr): 41.8 (3.5)

CPAP:

n = 50

ESS: 9.3 (0.7)

AHI (/hr): 45.5 (3.6)

Sequence generation: NR

Allocation concealment: 

NR

Blinding: NR

Incomplete outcomes 

reporting: 22% (22/100)

with no follow-up at 9 

months; difference between 

intensive and standard 

support groups

Selective outcomes 

reporting: adequate

Risk of bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

98

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Galetke 200845

RCT (crossover)

Germany, 

universityassociated 

sleep laboratory

APAP vs CPAP (n =

20)

Outcomes assessed 

after 8 weeks of a 

treatment with full 

in-lab sleep study 

after 16 weeks

Treatment

Conventional CPAP at 

fixed pressure 

obtained during 

manual titration and 

APAP therapy 

(responds to snoring 

apneas/hypopneas 

and inspiratory flow 

limitation), range 4-15 

cmH2O 

One machine with 2 

modes

Inclusion: OSAS newly 

diagnosed with AHI > 10/h, 

based on full in-laboratory 

PSG data and clinical 

symptoms

Exclusion: COPD, CHF, acute 

neurological or psychiatric 

disorders, other major intrinsic 

sleep disorders, or malignant 

diseases

n = 20

Mean age: 55.5

Male gender, %: 80

BMI: 29.3

ESS: 10.3 (5.7)

AHI (/hr): 32.9 (19.1)

Arousals/hr: 17.6 (9.2)

Snoring, n of epochs: 436.3 

(209.6)

SaO2 min, %: 77.8 (8.4)

Sequence generation: NR

Allocation concealment: 

NR

Blinding: single blind 

(patients); data analysis 

either automated or done by 

technologists not involved in 

study

Incomplete Outcome: 

adequate

Selective reporting: 

adequate

Risk of bias: Medium
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

99

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Fietze 200744

RCT (titration 

done as 

crossover, but 

treatment 

randomized)

Germany

APAP (n = 10)

CPAP (n = 11)

Outcomes assessed 

after 6 weeks of 

treatment

Treatment

Titration done as a 

crossover over 2 

nights, both APAP and 

CPAP titration done 

in-lab

Treatment with second 

titration device was 

continued for 6 weeks; 

APAP set between 4 

and 16 cmH2O 

Inclusion: suspected sleep 

apnea; if AHI > 10/hr in home 

cardiorespiratory polygraph 

and symptoms of excessive 

sleepiness or AHI > 20/hr 

patients had PSG in lab; 

patients included if AHI ≥ 

10/hr; if AHI > 10/hr at home 

and AHI <10/hr in lab included 

if also had excessive 

sleepiness; BMI <40; age 35-

70

Exclusion: other sleep 

disorders (including leg 

movements), acute cardiac, 

pulmonary or other internal 

medicine-related disorders, 

acute psychiatric or 

neurological disorders, or 

abuse of sleep-inducing 

agents or other drugs; 

suspected or confirmed 

central sleep apnea; previous 

treatment (eg, CPAP, oral 

devices, or 

uvulopalatopharyngoplasty)

n = 21

Mean age: 54.2 (11.7)

Male gender, %: 95

BMI: 30.9 (5.7)

APAP:

n = 10

AHI: 43.3 (30.2)

Sleep latency, min: 17.7 (13.6)

Total sleep time, min: 355.7 

(27.9)

CPAP:

n = 11

AHI: 40.4 (26.1)

Sleep latency, min: 11.2 (6.4)

Total sleep time, min: 379.5 

(63.8)

Sequence Generation: NR

Allocation Concealment: 

NR

Blinding: NR

Incomplete Outcomes: 

adequate

Selective Reporting: 

adequate

Risk of Bias: Medium 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

100

Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Meurice 200750

RCT

France 

Sleep 

laboratories 

Group 1 (n = 17 

randomized, 14 at 6 

months): fixed 

CPAP 

Group 2 (n = 17

randomized, 13 at 6 

months): GK 418P 

APAP device

Group 3 (n = 17, 15 

at 6 months): 

AutoSet device

Group 4 (n = 17, 12 

at 6 months): PV10i 

device

Group 5 (n = 15, 11 

at 6 months): 

Somnosmart 1 

device

6 months

Treatment

Fixed CPAP pressure 

manually determined 

during laboratory 

titration, APAPs all set 

in auto-adjust mode 

during the titration 

night

All patients treated at 

home for 6 months 

with machine they 

used during titration 

night 

Inclusion: naïve to nasal 

CPAP, no nasopharyngeal 

surgery, AHI > 30/hr or > 10 

micro-arousals/hr 

Exclusion: > 20% of 

respiratory disturbances 

characterized as central 

events or taking sedative 

treatments

n = 83 at randomization, n = 65 

at 6 months

Mean Age: 56 (10)

BMI: 30.8 (5.3)

AHI (/hr): 52.3 (17.8)

Sequence Generation:

adequate

Allocation Concealment:

adequate

Blinding: unclear

Incomplete outcome 

reporting: adequate, > 

10% dropped out but 

balanced and reasons given

Selective outcome 

reporting: adequate

Risk of Bias: Medium 
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Mulgrew 200739

RCT

Canada

Tertiary referral 

sleep disorders 

program

In-lab CPAP titration 

(n = 35 assigned, 30 

completed)

Auto-CPAP titration 

(n = 33 assigned, 31 

completed)

3-month follow-up

Titration

For ambulatory APAP 

group CPAP set at 

95%

Inclusion: adults referred from 

catchment area of sleep 

disorders program at 

University of British Colombia 

Hospital for assessment of 

suspected OSA who have 

clinical suspicion of moderate 

to severe OSA; high pretest 

probability of moderate to 

severe OSA, medically stable, 

not taking sedative 

medications

Exclusion: pregnant, FEV1 or 

FVC <70%, known cause for 

daytime sleepiness, lifethreatening comorbid illness, 

major psychiatric disorder, 

MVA attributable to 

hypersomnolence in 

preceding 5 years, previous 

treatment for OSA, 

contraindication for nasal 

CPAP, inability to provide 

informed consent

n = 68

CPAP: 

n = 35

Mean age: 52 (11)

Male gender, %: 75

BMI: 38 (8)

Median ESS: 14 (11-19IQR)

Median RDI: 31 (21-47IQR)

Median SACS: 30 (18-42IQR)

Auto-CPAP: 

n = 33

Mean age: 55 (10)

Male gender, %: 79

BMI: 39 (9)

Median ESS: 14 (12-16IQR)

Median RDI: 27 (17-57IQR)

Median SACS: 32 (22-48)

Sequence Generation: 

inadequate, block 

randomized using large 

envelopes with folded cards 

inside

Allocation concealment:

inadequate

Blinding: NR

Incomplete outcome 

reporting: adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Nolan 200751

RCT (crossover)

Ireland 

Respiratory 

sleep disorders 

unit

APAP (n = 29)

CPAP (n = 29)

(n = 34 enrolled, 29 

completed)

Outcomes assessed 

after each 8-week 

treatment period

Treatment

CPAP therapy 

pressure calculated 

from overnight labbased autotitration 

study (95% percentile)

Variable pressure set 

between 4-20 cmH2O 

Inclusion: consecutive 

patients from sleep disorders 

unit with newly diagnosed 

mild to moderate OSAS (AHI

≥ 5 and <30) and compatible 

clinical features; awaiting a 

trial of CPAP therapy, ESS 

score ≥ 7 

Exclusion: known 

cardiovascular disease other 

than hypertension, previous 

CPAP therapy, preexisting 

chronic airways disease, or 

previous upper airway surgery

n = 29

Mean age: 52.8 (8.3)

Male gender, %: 90

BMI: 29.9 (4.7)

Blood pressure, mmHg: 132/84 

(23/13)

Neck circumference (cm): 42 (2)

Sequence generation: not 

reported

Allocation concealment: 

adequate

Blinding: adequate 

(investigator blinded; patient 

partially blinded)

Incomplete outcomes: 

5/34 (15%) dropped out, 1 

due to side effects, 4 lost to 

follow-up

Selective reporting: 

adequate

Risk of Bias: Medium

Patruno 200755

RCT

Italy

Fixed level CPAP (n

= 16)

APAP (n = 15)

Treated for 3 

months

Treatment

CPAP: pressure 

determined during 

titration

APAP: pressure set to 

deliver levels from 4 to 

15 cmH2O 

Repeat sleep study at 

end of 3-month 

treatment

Inclusion: newly diagnosed 

OSA (AHI > 20/h and diurnal 

hypersomnolence [ESS score

> 12]); free of diseases other 

than arterial hypertension; 

never treated for OSA

Exclusion: taking treatments 

other than ACE inhibitors, 

calcium channel clockers, and 

diuretics

n = 31 (n = 40 were enrolled, 9 

were excluded and not analyzed)

Mean age: 48

Male gender, %: 81

BMI: 36.5

ESS: 15 (2.7)

AHI (/hr): 46.5 (13.5)

SaO2, mean, %: 90

SaO2, nadir, %: 72

Hypertensive: n = 17

BP, systolic mmHg: 143 (10)

BP, diastolic mmHg: 87 (5)

Glucose, mg/dL: 103.9 (6.8)

Sequence generation: NR

Allocation Concealment: 

NR

Blinding: compliance 

recorded by the computer; 

other outcomes NR

Incomplete Outcome: not 

ITT, > 10% attrition with 

reasons, balance NR

Selective Reporting: 

adequate

Risk of Bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Richard 200758

Retrospective 

cohort

Netherlands

CPAP (n = 78)

APAP (n = 96)

Follow-up: 2 months 

to 8 years, unclear 

when data collected

Treatment Inclusion: all patients with 

OSAS (defined as AHI > 5 in 

overnight PSG accompanied 

by daytime symptoms) offered 

nCPAP between Jan 1997 

and July 2005; if AHI > 30 – 

offered nCPAP as 1st

treatment; if AHI<30 – offered 

alternative treatments (oral 

device, surgery)

Exclusion: none reported

n = 174

Mean age: 56.7

Male gender, %: 80.5

BMI: 33

CPAP:

n = 78

AHI (/hr): 47.2 (22.3) 

ESS: 5.6 (4.5)

APAP:

n = 96

AHI (/hr): 52.0 (23.1)

ESS: 7.1 (5.1) 

Selection bias: unclear

Blinding of outcome 

assessment: NR

Intention-to-treat 

analysis: inadequate

Attrition bias: adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium

Nolan 200652

quasi RCT 

crossover (all 

patients on 

CPAP then 

random 

crossover 

assignment of 3 

APAP devices)

Ireland 

University sleep 

disorders center

CPAP vs 3 APAP 

devices (n = 27)

Baseline values 

based on median of 

53 months of CPAP; 

Outcomes assessed 

after 4-week home 

trial with each of 3 

APAP devices

Treatment

APAP

a) Autoset Spirit 

(reviews shape of 

inspiratory flow curve 

on breath-by-breath 

basis)

b) Breas PV 10i 

(creates model of 

patient’s breathing 

signal and compares 

to template to set 

device)

c) RemStar Auto 

(compares inspiratory 

flow shape to rolling 

patient database)

CPAP

Different devices, 

used for 37-85 months 

prior to start of study

Inclusion: attending 

Respiratory Sleep Disorders 

Unit, confirmed diagnosis of 

OSAS, already established on 

fixed-pressure CPAP with 

nasal mask and device that 

downloaded time-coded 

compliance data

Exclusion: malignant or 

psychiatric disease; on 

regular narcotics, sedatives, 

or psychoactive medications

n = 27

Mean age: 53

Male gender, %: 93

BMI: 36.2

Diagnostic AHI(/h): 48 (29-76)

Diagnostic ESS: 15 (9-19)

Sequence generation: NR 

(Note: sequence generation 

only for 3 APAP devices)

Allocation concealment: 

adequate

Blinding: investigator 

performing analysis and 

person assigning APAP 

devices; patients were not 

informed about APAP 

technologies but were told 

they were newer treatment 

machines

Incomplete outcome data: 

No patients lost to follow-up 

Selective outcome 

reporting: No 

Risk of bias: Low
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Nussbaumer 

200654

RCT (crossover)

Switzerland

Outpatient clinic

APAP vs CPAP (n =

34 randomized, 30 

completers)

1 month

Treatment

APAP pressure 

ranged from 5 to 15 

cmH20, CPAP 

pressure set at 90th

percentile

Inclusion: consecutive 

patients with excess 

sleepiness and AHI > 10 /hr

Exclusion: CHF, chronic 

rhinitis, other sleep disorders

n = 34, data for 30 completers

Mean age: 49 (SE2)

Male gender, %: 90

BMI: 31.3 (SE.6)

ESS: 12.7 (0.6)

AHI (/hr): 41.1 (3.6)

Sequence generation: 

adequate

Allocation concealment: 

adequate

Blinding: double-blind 

(patients and attending 

physicians)

Incomplete outcome data: 

4 (12%) did not complete 

protocol

Selective outcome 

reporting: No

Risk of bias: Low

West 200662

RCT

UK

Outpatient sleep 

clinic

Group 1 (n = 31): 

Auto-titration 

pressure

Group 2 (n = 33): 

Fixed pressure 

Group 3 (n = 34): 

Fixed pressure

6 months

Treatment

Autotitration pressure 

(Group 1), fixed 

pressure determined 

by the 95% from 1 

week of autotitration 

(Group 2), and fixed 

pressure determined 

by algorithm based on 

neck size and dip rate 

(Group 3)

Inclusion: aged 18-75 years 

with excessive daytime 

sleepiness (ESS > 9) and 

proven OSA on 1 night 

respiratory PSG; > 10 dips /hr 

in SaO2 of > 4% confirmed as 

being caused by upper airway 

obstruction eligible for 

inclusion; no exclusion on 

basis of other co-morbidities

Exclusion: respiratory failure 

requiring urgent treatment

n = 98, 86 at 6 months

Mean age: 46

Male gender, %: 85

Maintenance of Wakefulness 

test, mins: 18

4% oxygen saturation dips, 

events/h: 34

Mean BP mm Hg: 96

Sequence generation:

adequate

Allocation concealment: 

unclear

Blinding: patients and the 

outcomes assessors

Incomplete outcome data: 

Unclear if the analyses 

include all randomized. 

Reasons for dropout were 

reported. 

Selective outcome 

reporting: no

Risk of bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Hukins 200446

RCT (crossover)

Australia

Hospital’s sleep 

disorders center

APAP (n = 32)

CPAP (n = 23)

2-month treatment 

period with 

outcomes assessed 

last 30 days

Treatment

Fixed-pressure 

(CPAP) or autotitrating 

(APAP) mode of the 

AutoSet T (default 

pressure 4-20 cmH2O)

Received each 

treatment for 2 

months, outcomes 

reported for last 30 

days of those 2 

months to allow for 

washout period

Inclusion: AHI ≥ 5 in 

association with 

hypersomnolence, optimal 

CPAP pressure determined 

by overnight pressure 

determination PSG, no 

previous home use of CPAP, 

and informed consent

Exclusion: significant 

comorbidity (unstable 

ischemic heart disease, 

neuromuscular disease, 

kyphoscoliosis, or severe 

COPD), significant 

complication (hypercapnic 

respiratory failure or right 

heart failure), presence of 

non-obstructive sleep apnea, 

or inability to use masks 

compatible with Autoset T

n = 55

APAP:

n = 32

Mean age: 51 (11.9)

Male gender, %: 84

BMI: 35.8 (6.7)

ESS: 13 (5)

Diagnostic AHI: 59.7 (30.1)

CPAP:

n = 23

Mean age: 49.3 (12.5)

Male gender, %: 91%

BMI: 34.3 (6.3)

ESS: 11.8 (5.3)

Diagnostic AHI: 50.2 (24.9)

Sequence generation: 

adequate (shuffled sealed 

envelopes)

Allocation concealment: 

adequate

Blinding: attempted to 

blind patients (used same 

machine for APAP and 

CPAP)

Incomplete Outcome: no, 

more than 10% attrition, no 

reasons given

Selective reporting: 

unclear 

Risk of bias: Medium 

Hussain 200447

RCT (crossover)

Canada

Unclear

Fixed CPAP vs 

Autotitrating CPAP 

(n = 10)

4 weeks separated 

by a 2-week 

washout period

Treatment

APAP set between 3-

20 cm H2O, fixed 

CPAP pressure 

determined by 

overnight titration

Inclusion: CPAP-naïve 

patients with symptomatic 

OSAH (AHI > 15/h)

Exclusion: none reported

n = 10

Mean age: 44.9 (9.7)

Male gender, %: 90

BMI: 35.9 (12.9)

ESS: 11.1 (6.4)

AHI (/hr): 47.2 (35.6)

Snoring: 100%

Unrefreshing sleep: 80%

Witnessed apnea: 80%

Excessive daytime sleepiness: 

70%

Arousal index: 17.3 (17.7)

Desaturation index: 53 (36)

Sequence Generation: not 

reported

Allocation concealment: 

not reported

Blinding: only patients 

blinded, compliance 

collected by machine

Incomplete outcome 

reporting: adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Marrone 200448

RCT (crossover)

Italy

University sleep 

center

Fixed CPAP vs 

APAP (n = 22)

1 month

Treatment

APAP pressure set to 

range between 4-18 

cmH20, CPAP level 

determined during 

PSG with APAP 

titration in lab

Inclusion: patients referred for 

suspected OSAS and 

consecutive subjects with AHI

≥ 30 and no overt 

cardiopulmonary disease 

were requested to participated 

in study (all accepted)

Exclusion: none reported

n = 22

Mean age: 53.4

Male gender, %: 95

BMI: 32.6

ESS: 16.3 (5)

Sequence generation: NR

Allocation concealment: 

NR

Blinding: patients

Incomplete outcome data: 

NR

Selective outcome 

reporting: No

Risk of bias: Medium

Masa 200437

RCT 

Spain

Sleep centers

Standard Titration

(n = 126 

randomized, 107 

analyzed): in-lab 

CPAP titration

AutoAdjusted 

Titration (n = 119 

randomized, 106 

analyzed): at home 

APAP titration

Predicted Formula 

Titration (n = 115 

randomized, 102 

analyzed): used a 

formula to calculate 

optimal pressure 

(did not extract 

outcomes for this 

group) 

12 weeks

Titration

Standard vs home 

titration

Inclusion: requiring CPAP 

treatment (AHI ≥ 30, ESS ≥ 

12), age 18-70

Exclusion: psychophysical 

incapacity to perform 

questionnaires; chronic 

disease; drug or alcohol 

addiction; Cheyne-Stokes 

syndrome; life-threatening 

SAHS; previous 

uvulopalatopharyngoplasty; 

absence of a partner at home; 

important chronic nasal 

obstruction; lack of skill in 

adjusting nasal mask in 

daytime CPAP trial; refusal to 

participate

Standard: 

n = 107

Mean age: 51 (9.1)

Male gender, %: 86.9

BMI: 33.6 (8.4)

HTN: 55.4%

Sleep, hr/nt: 6.9 (1.1) 

Habitual snoring: 90.7%

Apneas observed: 62.6%

Nocturia: 23.4%

Restlessness: 47.7%

Morning headache: 14% 

AutoAdjusted: 

n = 106

Mean age: 52.2 (10.4) 

Male gender, %: 89.6

BMI: 33.1 (6.3)

HTN: 57.4%

Sleep, hr/nt:7.0 (1.5)

Habitual snoring: 85.8%

Apneas observed: 58.5%

Nocturia: 31.1% 

Restlessness: 43.4%

Morning headache: 12.3% 

Sequence Generation: not 

reported

Allocation concealment: 

not reported

Blinding: not reported

Incomplete outcome 

reporting: adequate, > 

10% dropout but reasons 

given and not significantly 

uneven by groups

Selective Outcome 

reporting: adequate

Risk of bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Noseda 200453

RCT (crossover)

Brussels, 

Belgium

Hospital

Auto CPAP vs 

CPAP for treatment 

(n = 27 randomized 

24 evaluable)

8 weeks

Treatment

Fixed CPAP set at the 

pressure judged to be 

effective during the 

titration night at the 

sleep laboratory, in the 

auto CPAP mode the 

pressure was set 

between 4-14 cm H2O 

Inclusion: high pressure 

variability during 14 day run-in 

period on APAP (VI > 2.75cm 

H2O), AHI > 20/hr and a 

microarousal index (MAI) > 30

Exclusion: previous treatment 

with CPAP, central sleep 

apnea or Cheyne-Stokes 

respiration, major facial or 

pharyngeal anatomic 

abnormalities likely to require 

surgery, night or rotating shift 

work, severe chronic heart 

failure or COPD, seizure 

disorder, mental retardation, 

sedative, hypnotic or 

antidepressant therapy, 

previous

uvulopalatopharyngoplasy, 

prolonged hypoventilation 

during REM sleep

n = 27

Mean Age: 49 (10)

BMI: 32.3 (4.9)

ESS: 10.7 (2.4)

AHI (/hr): 50.9 (25.2)

AI: 24.6 (22.6)

MAI: 43 (12.9)

Sequence Generation:

unclear, a randomization 

table was used

Allocation concealment:

unclear

Blinding: single blind

Incomplete outcome 

reporting: > 10% dropped 

out but balanced

Selective outcome 

reporting: adequate

Risk of Bias: Medium

Massie 200349

RCT (crossover)

Multi-site

Unclear 

CPAP vs APAP as 

treatment (n = 46 

randomized, 44 

completed)

6 weeks 

Treatment

CPAP: fixed pressure 

as determined by 

board-certified sleep 

specialist or equivalent 

(by AASM standards)

APAP: pressure 

ranged between 4-20 

cm H2O 

Inclusion: need for CPAP 

pressure > 10cm, 

symptomatic OSAHS with AHI

≥ 15, age 18-65

Exclusion: preexisting lung 

disease, awake resting SaO2

<90%, or ≥ 10 central apnea 

hypopnea events per hour, 

taking meds known to 

significantly interfere with 

sleep or respiration

n = 46 randomized, 44 completed

Mean age: 49 (10)

Male gender, %: 82

BMI: 32 (4)

Sequence generation: not 

reported

Allocation concealment: 

not reported

Blinding: not reported

Incomplete outcome 

reporting: adequate

Selective outcome 

reporting: adequate

Risk of bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Planès 200356

RCT

France

Four sleep 

laboratories

Auto-nCPAP, 

initiated at home (n

= 16)

Conventional 

nCPAP, initiated in 

sleep lab with 

titrating PSG (n = 

14)

2 months

Treatment 

nCPAP, conventional 

and auto 

APAP home pressure 

set to 2 cmH2O above 

to 4 cmH2O below 

max pressure 

delivered by device 

during 1st week (at 

least 15 hours) of use 

Inclusion: severe obstructive 

OSAS with AHI ≥ 30 

events/hour and obstructive 

events > 80% of total events, 

clinical indications for nCPAP 

according to American 

Thoracic Society 

recommendations

Exclusion: none reported

N = 35 recruited

Mean age: 54.3

Male gender, %: 77

BMI: 32.4

ESS: 14.8

Hypertension: n = 7 

No history of nCPAP or surgery 

for snoring

No comorbidities noted

n = 30 with outcomes

Conventional: 

AHI (/hr):61.0

SaO2: 12.7

Auto: 

AHI (/hr):57.5

SaO2: 24.9

Sequence generation: NR

Allocation concealment: 

NR

Blinding: No

Incomplete Outcome 

Reporting: 5/35 didn’t 

complete treatment (unable 

to tolerate nCPAP)

Selective outcome 

reporting: No

*patients who didn’t tolerate 

their assigned treatment 

were allowed to switch 

interventions... only one did 

auto to conventional

Risk of bias: Medium

Senn 200359

RCT (crossover)

Switzerland

AutoAdjust LT vs 

AutoSet T vs

Fixed-Pressure 

CPAP mode (n = 

29)

 

2-week adaptation 

period with either 

APAP device then 1 

month with each in 

random order, 

outcomes assessed 

at end of each 

month

Treatment

AutoAdjust LT 

responds to apneahypopnea and 

snoring,

AutoSet T responds to 

apnea-hypopnea, 

snoring and changes 

in inspiration flow 

contour, fixedpressure CPAP mode 

is either APAP set in 

fixed mode

Inclusion: OSAS based on 

complaints of excessive 

sleepiness, snoring, and 

apnea-hypopnea index > 

10/hr

Exclusion: not naïve to CPAP 

therapy

n = 31 recruited, 29 completed

Mean age: 53

Male gender, %: 79

BMI: 33.3

ESS: 14.2 (0.7)

AHI (/hr): 45.8 (4.2)

Time with SaO2 <90%, % time in 

bed: 12.6 (3.4)

Sequence generation: NR

Allocation concealment: 

NR

Blinding:single-blind 

(patients blinded to study 

purpose and treatment 

modes)

Incomplete outcome 

reporting: adequate

Selective outcome 

reporting: adequate

Risk of bias: Medium
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Author, year

Study design

Location / 

Setting

Intervention 

Groups

Follow-up

Aim of Study

Treatments Received

Inclusion/ Exclusion Criteria

Patient Characteristics 

(expressed in means unless 

otherwise noted)

Risk of Bias

Randerath 

200157

RCT (crossover)

Germany

University sleep 

laboratory

APAP vs CPAP (n =

52 randomized, 47 

completed study)

Outcomes assessed 

after each 6-week 

treatment period

Treatment

APAP using forced 

oscillation set to 

between 4 and 18 

cmH2O 

CPAP using the 

pressure titrated 

during diagnostic 

polysomnography

Inclusion: referred to a 

university sleep laboratory by 

“pneumologists” and general 

practitioners, OSA diagnosed 

(AHI ≥ 10) from PSG, 

underwent basic lung function 

examination

Exclusion: 1 patient excluded 

after bronchial carcinoma 

diagnosed

n = 52 enrolled, 47 completed

Mean age: 54.7 (10.1)

Male gender, %: 87

BMI: 32.4 (5.8)

AHI (/hr): 35.1 (26)

Snoring(/hr): 49 (36)

Total number of arousals (/hr): 

34.0 (21.7)

Sequence generation: not 

reported

Allocation Concealment: 

not reported

Blinding: adequate 

(patients, physicians, and 

technicians)

Incomplete outcome 

reporting: adequate (5/52 

[10%] quit study

Selective outcome 

reporting: adequate

Risk of Bias: Medium

D’Ortho 200042

RCT (crossover)

France 

APAP vs CPAP (n =

25)

Outcomes assessed 

after each 2-month 

treatment period

Treatment

Constant CPAP or 

auto-CPAP mode of 

“REM + Auto” 

apparatus

CPAP titration done in 

lab to identify effective 

pressure for constant 

CPAP

APAP range set at 6-

16 cmH2O

Inclusion: clinical suspicion of 

OSAS confirmed by PSG, AHI

> 10/h of sleep with 

obstructive events > 80% of 

total events and clinical 

indication for CPAP treatment 

according to American 

Thoracic Society 

recommendations

Exclusion: restless legs, 

cardiac failure, 

cerebrovascular disease, or 

lung disease

n = 25

Mean age: 57 (11)

Male gender, %: 88

BMI: 32 (5) 

ESS: 12.7 (5.3)

Sleep onset latency, min:37

Total sleep time, min: 375 (65)

Arousal/awakening index, 

events(/h): 45.6 (25.8)

AHI (/hr): 57.8 (5.8)

Mean SaO2, %: 93 (3.0)

Sequence generation: NR

Allocation concealment: 

NR

Blinding: single blinded 

(patients)

Incomplete outcome 

reporting: adequate

Selective outcome 

reporting: adequate

Risk of Bias: Medium

Teschler 200060

RCT (crossover)

Australia

APAP vs CPAP as 

treatment (n = 10)

Outcomes assessed 

and PSG every 2

months 

Treatment

APAP was CPAP 

device operated in 

auto mode

CPAP pressure 

determined during 

manual titration night 

following diagnostic 

night

Inclusion: newly diagnosed 

moderate to severe OSAS 

(AHI > 20/hour); residence 

within 50 km of clinic 

Exclusion: primary diagnosis 

of asthma, emphysema, 

allergic rhinitis, or cardiac 

failure

n = 10

Mean age: 52.2 (2)

Male gender, %: 100

BMI: 33.8 (1.3)

AHI (/hr): 52.9

Sequence generation: 

unclear

Allocation concealment: 

unclear

Blinding: double-blind 

(patients, staff)

Incomplete outcome data: 

No reported missing data

Selective outcome 

reporting: No

Risk of bias: Medium
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CPAP = continuous positive airway pressure; CVA = cerebrovascular accident; ESS = Epworth Sleepiness Scale (cut-off score of 8 or more suggests the 

presence of at least mild daytime sleepiness); MI = myocardial infarction; ODI = oxygen desaturation index; OSA = obstructive sleep apnea; OSAH = 

obstructive sleep apnea-hypopnea; OSAHS = obstructive sleep apnea-hypopnea syndrome; OSAS = obstructive sleep apnea syndrome; PSG = polysomnogram; 

RDI = respiratory disturbance index; AASM = American Academy of Sleep Medicine; VI = variability index; MAI = micro arousal index 
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Table 8. Clinical Outcomes for KQ3

Study

Intervention (n)

Control (n)

All-cause Mortality 

% (n/N)

Resource Utilization 

(hospitalization, etc) Access to Care MID, 

Sleep Symptom Scores

MID,

Urinary Symptom 

Scores

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Drummond 201043

APAP (n = 54)

Usual care (n = 55)

No deaths Hospitalized 

for chest pain

5/43 (12%)

4/44 (9%)

NR NR NR NR NR NR

McArdle

201038

Manual CPAP 

titration (n = 83)

Home APAP 

titration (n = 86)

-all outcomes per 

protocol NOT ITT 

unless specified

NR NR

Humidifiers/

pt, 4 weeks

0.65 (0.61)

Chin straps, 4 

weeks

0.26 (0.47) 

Staff time/pt 

(min)

Technologist:, 

titration 

morning

14 (9.1)

Physician, 

titration study 

reporting

12.7 (4.9)

0.49 (0.53)

ES: -0.3

(-0.02, -0.58)

P = NS

0.63 (0.66)

ES: -0.65

(-0.96, -0.34)

P = .001

10.1 (6.8) 

ES: 0.48 

(0.18, 0.79)

P = .01

1.3 (4.5) 

ES: 2.42 

(2.02, 2.80)

P<.001

All other 

measures of 

staff time/pt: P

= NS

NR NR NR NR NR NR

Vennelle 201061

APAP and CPAP (n

= 192 randomized, 

181 analyzed)

One person died for 

reasons unrelated to the 

trial

Patients 

sought help 

from sleep 

center 13 

times

25 times (P =

.70)

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Study

Intervention (n)

Control (n)

All-cause Mortality 

% (n/N)

Resource Utilization 

(hospitalization, etc) Access to Care MID, 

Sleep Symptom Scores

MID,

Urinary Symptom 

Scores

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Richard 2007

APAP (n = 96)

CPAP (n = 78)

5/232 patients who 

returned questionnaires 

died before posttreatment evaluation 

(group not reported)

NR NR NR NR NR NR NR NR

West 200662

Group 1, APAP (n = 

31)

Group 2, 1 wk 

titration CPAP (n = 

33) 

Group 3, algorithm 

CPAP (n-34)

NR NR

There was no difference 

between the groups in terms 

of the number of extra calls or 

extra visits made to the sleep 

nurses because of CPAP 

problems

NR NR NR NR NR NR

Hukins 200446

APAP and CPAP (n

= 55) NR NR

Unplanned 

contacts: 21 

(15 clinic, 6 

phone)

Total duration 

of unplanned 

contacts: 440 

minutes

18 (11 clinic, 7 

phone)

P = .73

455 minutes

P = .56

NR NR NR NR NR NR

Senn 200359

Auto Adjust and

AutoSet and

Fixed (n = 29) NR NR NR NR NR NR

ESS: clinically relevant 

change defined as 

change by 2 points

All treatment modalities 

improved scores by > 5 

points.

NR NR

a

APAP: a) RemStar Auto, b) Autoset Spirit, c) Breas Pv 10i

ES = effect size; ESS = Epworth Sleepiness Scale; NR = not reported
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Table 9. Clinical Outcomes for KQ3, Continued 

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Bakker 201140

CPAP and APAP 

(n = 12)

NR NR

6 preferred APAP, 3 

preferred CPAP, 3 had 

no preference

NR NR NR NR NR NR

McArdle

201038

Manual CPAP 

titration (n = 83)

Home APAP 

titration (n = 86)

- all outcomes per 

protocol NOT ITT 

unless specified

SF-36 Physical 

Baseline: 58 

(median) (n = 

62) 

Week 4: 73 (n

= 59)

Change: 7.8 

(18.6) (n = 58)

SF-36 Mental 

Baseline: 53 

(median) (n = 

62)

Week 4: 70 (n

= 59)

Change: 11.4 

(15.0) (n = 58)

SF-36 Physical 

Baseline: 57 

(median) (n = 

62)

Week 4: 66 (n = 

60)

P = NS between 

groups

Change: 7.5 

(13.5) (n = 60)

ES: 0.02 

(-0.34, 0.38)

SF-36 Mental 

Baseline: 54 

(median) (n = 

62)

Week 4: 68 (n = 

60)

P = NS between 

groups

Change: 8.4 

(14.2) (n = 60)

ES: 0.21

(-0.15, 0.57) 

NR NR NR NR

Trails A, 

sec

Baseline: 

28 (median) 

(n = 60)

Week 4: 26 

(n = 60)

Trails B, 

sec

Baseline: 

74 (median) 

(n = 59)

Week 4:

73 (n = 58)

Trails A, 

sec

Baseline: 

28 (median) 

(n = 62)

Week 4: 26 

(n = 61)

P = NS 

between 

groups

Trails B, 

sec

Baseline: 

71 (median) 

(N = 62)

Week 4:

73 (n = 61)

P = NS 

between 

groups

NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

114

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Vennelle 201061

APAP and CPAP 

(n = 192, n = 181 

analyzed)

SF-36

58 (SEM 0.1)

P = NS 

difference 

between 

groups for any 

SF-36 

components

SF-36

58 (SEM 0.1)

P = .9

Preferred 

by 69/181 

(38%)

Preferred 

by 72/181 

(40%)

P = NS

40/181 

(22%) had 

no 

preference

Significant 

order effect 

(P = .009)

NR NR NR NR NR NR

Galetke 200845 

APAP and CPAP 

(n = 20)

NR NR

Preferred 

by 13/20 

(65%)

Preferred 

by 7/20 

(35%) 

P<.01

NR NR NR NR NR NR

Fietze 200744

APAP n = 10

CPAP n = 11

SF-36

Psychic (Mental Health):

Baseline: 50.7 (6.5) 

6-week: 52.3 (9.1)

Bodily (Physical Health):

Baseline: 46.4 (11.8) 

6-week: 49 (10.2)

Did not differ between CPAP and 

APAP groups

NR NR NR NR NR NR NR NR

Meurice

200750

At 6 months

Group 1, n = 14

Group 2, n = 13

Group 3, n = 15

Group 4, n = 12

Group 5, n = 11

SF36 

(emotional) 

Group 2

initial: 49.5 

(8.3)

6-month: 46 

(12.9)

Group 3

initial: 45.7 

(7.9) 

6-month: 46.2 

(13.3)

Group 4

SF36 

(emotional)

Group 1

initial: 43.1 (9.4)

6 month: 47.3 

(8.7)

P = NS from 

baseline

NR NR NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

initial: 43.3 

(12.3)

6-month: 50.8 

(7.1)

Group 5

initial: 47.5 (7)

6-month: 42.5 

(10.5)

All P = NS from 

baseline

SF36 

(physical) 

Group 2

initial: 42.7 

(13.8)

6-month: 50.5 

(7.7)

Group 3 

initial: 48.6 

(5.3)

6-month: 47.8 

(8.7)

Group 4

initial: 46.2 

(7.8)

6-month: 48.9 

(6.3)

Group 5

initial: 46.7 

(8.7)

6-month: 48.8 

(7.7)

All P = NS from 

baseline

SF36 (physical)

Group 1

initial: 45.6 (8.6)

6 month: 47.5 

(9)

P = NS from 

baseline
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

116

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Mulgrew 200739

CPAP titration (n

= 35)

APAP titration (n = 

33)

SAQLI

Median (IQR)

Baseline:

3.5 (2.8, 4.1)

3 months:

5.8 (4.9, 6.3)

Baseline:

2.8 (2.1, 4.2)

3 months:

5.5 (4.8, 6.2)

Difference at 3 

months: -0.19 

(95% CI -0.7, 

0.3), P = .41

6% would 

have 

preferred 

lab CPAP

All patients 

expressed 

overall 

satisfaction

62% would 

have 

preferred 

home 

management

NR NR NR NR NR NR

Nolan 200751

APAP and CPAP 

(n = 29)

NR NR

Preferred 

by 13/29 

(45%)

Preferred 

by 13/29 

(45%)

3/29 (10%) 

did not 

express a 

preference

Observed 

order effect 

– preferred 

machine 

received for 

first leg of 

trial

NR NR NR NR NR NR

Richard 2007

APAP (n = 96)

CPAP (n = 78)

NR NR

VAS

10 point 

scale

7.5 (2.3) (n

= 95)

VAS

10 point 

scale

7.5 (1.9) (n

= 76)

P = .88

NR NR NR NR NR NR

Nolan 2006

CPAP and 

3APAPs (n = 27)a

SF-36

No significant differences between 

3 APAP devices or between 

APAP devices and CPAP

14/27 (52%) preferred 

APAP 13/27 (48%) 

preferred CPAP 

Preferred RemStar Auto: 

6/14 (43%)

Preferred Autoset Spirit: 

5/14 (36%)

Preferred Breas PV 10i: 

3/14 (21%)

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

117

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Nussbaumer 

200654

APAP and CPAP

(n = 30)

SF-36

Physical

Baselined 

82 (SE 4)

At 1 month 84 

(SE 4)

Mental

Baselined

65 (SE 4)

At 1 month

76 (SE 3)

SF-36 Physical

At 1 month 85 

(SE 4)

Mental

At 1 month 73 

(SE 3)

All P = NS vs 

baseline and 

between groups

Preferred 

APAP: 

26/30 

(87%)

Preferred 

CPAP: 4/30 

(13%)

P<.001

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

118

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

West 200662

Group 1, APAP (n

= 31)

Group 2, 1 wk 

titration CPAP (n

= 33) 

Group 3, 

algorithm CPAP 

(n-34)

Data reported 

as median 

(5th/95th%)

SAQLI

Baseline

3.9 (1.7/6.0)

P = .4

Change, 6 m

1.6 (-4.8/4.3)

P = .7

P<.05 baseline

SF-36 MC

Pre CPAP 57.2 

(19.8/87.5)

P = .9

6 m: 79.3 

(30.5/94.1)

P = .9

P<.05 baseline

SF-36 PC

Pre CPAP 62.5 

(17.2/93.2)

P = .6

6 m: 78.8 

(20/96.2)

P = .5

Data reported as 

median 

(5th/95th%)

SAQLI

Group 2:

Baseline

3.1 (1.5/5.8)

Change, 6 m

1.5 (-5.6/4.7)

Group 3: 

Baseline

3.5 (1.9/6.1)

Change, 6 m

1.4 (-5.2/3.4)

SF-36 MC

Group 2:

Pre CPAP 56.8 

(26/89.4)

6 m: 81.5 

(27.8/95)

Group 3:

Pre CPAP 56.6 

(16.6/88.7)

6 m: 82.7 

(35.4/95.4)

SF-36 PC

Group 2:

Pre CPAP 65.7 

(25.2/90)

6 m: 85.2 

(26.6/95.3)

Group 3:

Pre CPAP 62.6 

(25.9/92.5)

6 m: 83.3 

(40.9/98.3)

NR NR NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

119

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Hukins 200446

APAP and CPAP 

(n = 55)

SF-36, significant improvements 

in both treatment modes in the 

Role Physical and Vitality 

domains all P<.05), but no 

difference between groups; other 

domains P = NS

Subjective 

ease of 

CPAP use

7.15 (2.41)

Attitude to 

CPAP

7.33 (2.05)

Ease of use

6.84 (2.54) 

P = .47

Attitude

9.91 (2.02)

P = .20

Both used 

VAS 0-10

NR NR NR NR NR NR

Hussain 200447

CPAP and APAP 

(n = 10) NR NR

Preferred 

by 10% of 

patients

Patients 

reported 

similar 

satisfaction 

with 

therapy

Preferred 

by 60% of 

patients

P = .06

NR NR NR NR NR NR

Marrone 200448

APAP and CPAP 

(n = 22) NR NR

Preferred 

APAP: 

14/22 

(64%)

Preferred 

CPAP: 4/22 

(18%)

No 

preference: 

4/22 (18%)

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Masa 200437

Standard titration 

(n = 107)

Autoadjusted 

titration (n = 106)

SF 36 Physical

Pre: 45.9 (8.6)

Post: 47.3 (7.8)

Change at 3 

months: -1.4 

(7.7) 

SF 36 Mental

Pre: 47.5 

(10.4)

Post: 51.8 (9.2)

Change at 3 

months:-4.0 

(10.8)

SF 36 Physica

Pre: 44.3 (8.7)

Post: 48.6 (7.3)

Change at 3 

months: -4.3 

(6.9)

P<.01 between 

groups

SF 36 Mental

Pre: 45.6 (12.2)

Post: 49.4 (10.4)

Change at 3 

months: -3.9 

(10.0)

P = NS between 

groups

NR NR NR NR NR NR NR NR

Noseda 200453

CPAP and APAP 

(n = 24)

NR NR

Preferred 

by 16 

patients

Preferred 

by 8 

patients

NR NR NR NR NR NR

Massie 200349

CPAP and APAP 

(n = 44)

SF-36 Vitality: 

65 (20)

SF Mental 

health: 80 (14)

P<.05

SF-36 Vitality: 

58 (23)

P<.05

SF Mental 

Health: 75 (18)

P > .07 for all 

other domains

NR NR NR NR NR NR NR NR

Planès 200356

Auto (n = 16)

Conventional (n = 

14)

NR NR NR NR NR NR NR NR

Tolerance 

score: 22.9 

(5.8)

Tolerance 

score: 18.8 

(10.5)

P = NS
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

121

Study

Intervention (n)

Control (n)

Quality of Lfe Patient Satisfaction Remission Cognitive Symptoms Other (describe)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Senn 200359

Auto Adjust and 

AutoSet and Fixed 

(n = 29)

SF-36 health transition, vitality, 

social functioning, and mental 

component summary scores were 

significantly improved by all 

treatments, no significant between 

group differences

SF-36 vitality reached clinically 

relevant treatment effect (change 

of at least 10 points) for all 

treatments

Effect sizes

AutoSet: 0.63

AutoAdjust: 0.65

Fixed: 0.78

Treatment preference

21/29 (72%) no 

preference

4/29 (14%) preferred an 

auto mode

4/29 (14%) preferred a 

fixed mode

17/29 (59%) preferred 

one auto device brand

11/29 (38%) preferred 

the other brand

1/29 (3%) had no 

preference

NR NR NR NR NR NR

Randerath 200157

APAP and

CPAP (n = 47 

completed)

NR NR

Preferred 

by 35/47 

(74%)

Preferred 

by 12/47 

(26%) 

P<.01

NR NR NR NR NR NR

D’Ortho 200042

APAP and CPAP 

(n = 25)

NR NR

Preferred 

mode:

15/25 

(60%)

Preferred 

mode: 8/25 

(32%)

(2/25 [8%] 

unable to 

tolerate 

either)

NR NR NR NR NR NR

a

APAP: a) RemStar Auto, b) Autoset Spirit, c) Breas Pv 10i

NR = not reported; NS = not statistically significant; PCS = physical component summary; MCS = mental component summary; SAQLI = Sleep Apnea Quality

of Life Index; SEM = standard error of the mean; VAS = visual analog scale
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

122

Table 10. Intermediate Outcomes for KQ3

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Bakker 201140

CPAP and APAP (n

= 12)

Ontreatment 

(by machine 

at home): 

13.2 (10.2)

Ontreatment 

(during 

PSG): 

9.8/hr (9.5)

Ontreatment 

(by machine 

at home): 

8.0 (6.4) P

= .06

Ontreatment 

(during 

PSG): 

7.3/hr (6.6) 

P = .35

Mean SpO2 

94.8 (2.1)

ODI 4% 

6.8/hr(7.9)

ODI3% 16.1/hr 

(16.6)

Time <90% 

SpO2

1.5% (2.6)

Mean SpO2 

95.5% (1.4) P

= .03

ODI 4% 5.1/hr

(5.1) P = .21

ODI 3% 

11.4/hr (10.8) 

P = .15

Time <90% 

SpO2

1.2% (2.2) P = 

.50

ESS 

Baseline: 

17.4 (4.7)

post-APAP: 

10.8 (5.7) 

ESS 

Baseline: 

17.4 (4.7)

post-CPAP:

10.1 (6.1) 

P = .12

Total sleep 

time, min 

382 (53.4)

Total sleep 

time, min 

393.1 (44.9)

P = .74

NR NR

Lettieri 201133

Group 2: PSG+lab 

CPAP titration (n = 

70)

Group 3: 

PSG+APAP titration 

(n = 70)

NR NR NR NR

ESS

Baseline: 

13.9 (4.4)

Follow-up: 

8.9 (2.1)

Change:

36%

ESS 

Baseline: 

14.1 (4.2) 

Follow-up:

8.4 (2.3)

Change:

39.8%

NR NR NR NR

Drummond 201043

APAP (n = 54)

Usual care (n = 55)

NR NR NR NR

ESS

Baseline

14.8 (4.9)

1 month 

11.6 (5.4)

P = NS from 

baseline

ESS

Baseline

14.1 (5.0) 

1 month 

12.7 (5.0)

P = .25

FOSQ

Baseline

14.0 (3.6)

1 month

15.5 (3.0)

FOSQ

Baseline

14.2 (3.3)

1 month

14.6 (3.8)

P = .17

NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

123

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

McArdle 201038

Manual CPAP 

titration (n = 83)

Home APAP titration 

(n = 86)

-all outcomes per 

protocol NOT ITT 

unless specified

Baseline:

38.0

4 weeks:

8.0

Baseline:

38.0

P = NS

4 weeks: 

7.1

P = NS

SaO2 <90%, 

time, min

Baseline: 2

4 weeks: 0

Avg SaO2

4 weeks: 96% 

(2.0) 

Baseline: 5

4 weeks: 0

P = NS

95.8% (2.0)

P = NS

ESS

Baseline: 

13.8 (4.4)

(n = 61)

4 weeks: 

8.3 (4.5)

(n = 62)

Change: 

-5.5 (5.2) (n

= 62)

ITT ESS

Baseline:

14.0 (4.2)

(n = 70)

4 weeks: 

8.5 (4.4)

(n = 69)

Change:

-5.6 (5.0)

(n = 69)

ESS 

Baseline

14.4 (4.0)

(n = 62)

4 weeks: 

8.7 (5.1) n = 

61

P = NS

Change:

-5.7 (5.3)

n = 61

P = NS

ITT ESS 

Baseline:

14.3 (4.0)

(n = 71)

4 weeks:

8.6 (5.1)

(n = 70)

P = NS

Change:

-5.7 (5.6) (n

= 70)

P = NS

Arousal 

Index, 

events/h

4 weeks:

22 (9)

TST, min

4 weeks:

364 (71) 

Arousal 

Index, 

events/h

4 weeks:

23 (12) 

P = NS

TST, min

4 weeks:

351 (79)

P = NS

NR NR

Vennelle 201061

APAP and CPAP (n

= 192, 181 analyzed)

Residual 

A+H/h

6.7 

(SEM 0.4)

(NOTE: only 

70/181 had 

baseline 

A+H/h 

measure 

with mean 

of 49 [20])

Residual 

A+H/h

6.3 

(SEM 0.4) P

= .17

NR NR

ESS

Baseline: 

14 (3) 

(overall)

At 6 weeks:

9.5

(SEM 0.4)

ESS

At 6 weeks:

10.0 

(SEM 0.3)

P = .031

NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

124

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Damjanovic, 200941

Standard APAP (n = 

25)

Standard CPAP (n = 

25)

Intensive APAP (n = 

25)

Intensive CPAP (n = 

25)

3 months:

4.8 (0.7)

9 months:

3.6 (0.8)

3 months:

6.7 (0.9)

9 months:

5.4 (1.4)

P = NS

ODI

Baseline:

35.6 (3.9)

3 months:

2.1 (0.3)

9 months:

2.9 (0.7)

ODI

Baseline:

41.1 (3.8)

3 months:

4.1 (0.7)

9 months:

4.8 (1.3)

P = NS

ESS

3 months:

6.4 (0.7)

9 months:

5.9 (0.7)

ESS

3 months:

7 (0.7)

9 months:

6.6 (0.7)

P = NS

ARI

Baseline:

30.6 (3.3)

3 months:

12.3 (1.3)

9 months:

12.9 (1.5)

ARI

Baseline: 

34.5 (3.1)

3 months:

16.4 (1.4)

9 months:

13.2 (1.5)

P = NS

NR NR

Galetke 200845

APAP and CPAP (n

= 20)

Baseline 

32.9 (19.1) 

(combined 

group)

After 8 

weeks: 5.6 

(3.6)

After 8 

weeks:

4.6 (2.9)

P = NS 

SaO2 min, %

Baseline 77.8 

(8.4) 

(combined 

group)

After 8 weeks: 

86.5 (5.2)

SaO2 min, %

After 8 weeks:

88.3 (3.6)

P = NS 

ESS 

Baseline 

10.3 (5.7) 

(combined 

group)

After 8 

weeks:

4.9 (4.6)

ESS 

After 8 

weeks:

6.6 (4.8)

P = NS 

Arousals/h

Baseline: 

17.6 (9.2 

(combined)

After 8 

weeks:

13.6 (8.6)

Snoring, n 

of epochs

Baseline: 

436.3 

(209.6)

After 8 

weeks: 

54.9 (108.5)

Arousals/h

After 8 

weeks:

12.6 (7.3)

Snoring, n 

of epochs

After 8 

weeks:

78.8 (88.3)

P = NS 

NR NR

Fietze 200744

APAP n = 10 

CPAP n = 11

Baseline: 

43.3 (30.2)

At 6 weeks:

4.4 (3.4)/hr

P = NS

Baseline: 

40.4 (26.1)

At 6 weeks:

3.9 (4.3)/hr

P<.05 form 

baseline

NR NR

ESS baseline 12.9 (5.6)

6 weeks: 6.5 (4.3) P<.01

Did not differ at any point 

in time between the CPAP 

and APAP groups

NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Meurice

200750

At 6 months

Group 1, n = 14

Group 2, n = 13

Group 3, n = 15

Group 4, n = 12

Group 5, n = 11

Group 2

Baseline:

49.9 (16.5)

6 m: 3.7 

(3.9)

Group 3

Baseline:

53.4 (15.1)

6 m: 2.3 

(2.9)

Group 4

Baseline:

48.1 (18.7)

6 m: 8.6 

(10)

Group 5

Baseline:

54.5 (17.7)

6 m: 8.5 

(9.7)

Group 1

Baseline:

56.1 (21.4)

6 m: 2.4 

(3.4)

Mean SaO2

Group 2

Baseline:

92.5% (2.3)

6 m: 95% (1.5)

Group 3

Baseline:

91.8% (2)

6 m: 94.2% 

(1.5)

Group 4

Baseline:

92.6% (3.8)

6 m: 94.6% (2)

Group 5

Baseline:

91.9% (2.8)

6 m: 94.3% 

(1.8)

SaO2<90%, 

min

Group 2

Baseline:

16.2% (16.4)

6 m: 0.3% 

(0.6)

Group 3

Baseline:

23.3% (17.6)

6 m: 0.3% 

(0.6) 

Group 4

Baseline:

11.7% (15.1)

6 m: 3% (5.3)

Group 5

Baseline:

16.7% (18.8)

6 m: 1.1% (2)

Mean SaO2

Group 1

Baseline:

90.8% (6.9)

6 m: 94% (1.8)

P = NS

SaO2 <90%, 

min

Group 1

Baseline:

19.8% (28.7)

6 m: 2.2% 

(7.7)

P = NS

ESS

Group 2

Baseline: 

11.2 (5.6)

6 m: 6.5 

(4.1)

Group 3

Baseline:

12.9 (4.3)

6 m: 5.2 

(4.1)

Group 4

Baseline:

11.3 (3.8)

6 m: 7.2 (4)

Group 5

Baseline:

10 ( 6.2)

6 m: 7.5 

(5.7)

ESS

Group 1

Baseline:

10.6 (5.2)

6 m: 5.9 

(5.1)

P = NS

TST, min

Group 2

Baseline:

400.6 (74.4)

6 m: 382.7 

(94.7)

Group 3

Baseline:

390.1 (65.1)

6 m: 370.5 

(65.2)

Group 4

Baseline:

372.5 (87.8)

6 m: 377.4 

(65.9)

Group 5

Baseline:

371.7 (96.1)

6 m: 356.1 

(43.9)

TST, min

Group 1

Baseline:

373.8 (91.8)

6 m: 376.6 

(50.9)

NR NR
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Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Mulgrew 200739

CPAP titration (n = 

35)

APAP titration (n = 

33)

AHI

Median 

(IQR) 3 m:

2.5/hr

(0.9, 10.1)

AHI

3 m:

3.2/hr

(1.7, 8.4)

Difference 

at 3 m: 0.8 

(95% CI -

0.9, 2.3)

P = .31 

NR NR

ESS

Median 

(IQR)

3 m:

5.0 (3.0, 

9.0)

ESS

3 m:

5.0 (2.0, 

8.0)

Difference 

at 3 m: 0.0 

(95% CI -

2.0, 2.0)

P = .86

NR NR NR NR

Nolan 200751

APAP and CPAP (n

= 29)

Baseline: 

14.7 (8) 

(combined)

At 8 weeks:

2.7 (2.1)

P = .15

At 8 weeks:

3.5 (2.5)

Mean SaO2

Baseline: 92% 

(2.1)

At 8 weeks:

93.2% (1.8)

P = .44

Mean SaO2

At 8 weeks:

93.3% (1.7)

ESS Score

Baseline 

12.3 (4) 

(combined)

At 8 weeks:

8.6 (4.0)

Total sleep 

time, min

Baseline: 

343 (48) 

(combined)

At 8 weeks:

335 (43)

ESS Score

At 8 weeks: 

7.7 (4.6) P

= .35 

Total sleep 

time, min

At 8 weeks: 

349 (55)

P = .09

Total snore 

events

Baseline: 

313 (259)/h 

(combined)

At 8 weeks:

16 (11)

P = .72 

Respiratory 

arousals

Baseline: 16 

(14) 

(combined)

At 8 weeks:

2 (3)

P = .03 

Total snore 

events

At 8 weeks:

17 (16)

Respiratory 

arousals

At 8 weeks: 

5 (4)

Body weight (88.1 

(13.3)kg) did not 

change during the 

course of the study

Patruno 2007

APAP (n = 15)

CPAP (n = 16)

AHI/h

6 (2.3)

P<.001 

AHI/h

2 (1.6)

Significantly 

reduced 

from 

baseline in 

both groups

ODI/h

4.8 (2.1)

P<.001 

SaO2, mean 

95.7% (17.4)

SaO2, nadir

88.1% (1.6)

ODI/h

1.1 (1.3) 

Significantly 

reduced in 

both groups

SaO2, mean 

96.3% (0.8) 

SaO2, nadir

90.8% (1.3)

P = NS

NR NR NR NR NR NR
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Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Nolan 2006

CPAP and 3 APAPs 

(n = 27)a

NR NR NR NR

No further 

significant 

change in 

ESS after 

treatment 

with any 

APAP 

device

Fixed 

pressure 

CPAP 

reduced 

ESS from 

baseline of 

15 (3-110) 

to 5 (3-11) 

P = .002 

NR NR NR NR

Nussbaumer 200654

APAP and CPAP

(n = 30)

Baseline

41.1 (SE 

3.6)

At 1 month

4.6 (0.7)

At 1 month 

5.4 (1.2)

P = NS

ODI

Baselineb

29 (SE 4)

At 1 month

4.2 (0.7)

ODI

At 1 month 4.1 

(0.7)

P = NS

ESS

Baseline

12.7 (SE 

0.6)

At 1 month 

6.6 (SE 0.6) 

ESS

At 1 month 

6.6 (SE 0.6) 

P = NS

NR NR NR NR

West 200662

Group 1, APAP (n = 

31)

Group 2, 1 wk 

titration CPAP (n = 

33) 

Group 3, algorithm 

CPAP (n-34)

All data 

reported as 

median 

(5th/95th 

centile)

6 months

5.2 

(1.5/13.2) 

P = .3

All data 

reported as 

median 

(5th/95th 

centile)

6 months

Group 2:

3.6 

(0.5/15.9)

Group 3:

3.8 

(0.7/26.1)

NR NR

All data 

reported as 

median 

(5th/95th 

centile)

ESS

Pre CPAP 

16.0 

(10.6/23.0)

P = .7

6 m: 6.0 

(0.45/13.8)

All data 

reported as 

median 

(5th/95th 

centile) 

ESS

Group 2:

Pre CPAP 

17.0 

(10.4/22.6)

6 m: 5.0 

(0/15.5)

Group 3:

Pre CPAP 

16.5 

(10.5/22.3)

6 m: 5.0 

(0.5/12.5)

P = .8

All data 

reported as 

median 

(5th/95th 

centile)

MWT (mins)

Pre CPAP 

19.4 

(1.4/40)

P = .8

6 m: 40 

(11.6/40)

P = .2

All data 

reported as 

median 

(5th/95th 

centile)

MWT (mins)

Group 2:

Pre CPAP 

19.5 

(2.9/40)

6 m: 40 

(14.5/40)

Group 3:

Pre CPAP 

15.7 

(2.1/40)

6 m: 40 

(2.2/40)

NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

128

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Hukins 200446

APAP and CPAP (n

= 55) NR NR NR NR

ESS

Both groups improved 

from baseline (P<.001)

P = NS

NR NR NR NR

Hussain 200447

CPAP and APAP (n

= 10)

Baseline: 

47.2 ( 35.6)

Follow-up:

13.1 (8.3)

Baseline: 

47.2 (35.6)

Follow-up:

9.6 (5.4)

P = NS

Desaturation 

index

Baseline:

53 (36)

Follow-up:

15 (14)

Basal O2

Saturation

Baseline:

91.3 (4.5)

Follow-up:

94.6 (1)

Desaturation 

index

Baseline: 

53 (36)

Follow-up:

10 (13)

P = NS 

Basal O2

Saturation

Baseline:

91.3 (4.5)

Follow-up:

95.3 (1.6)

P = NS

Minimum 

oxygen 

saturation 

(P<.05)

ESS

Baseline:

11.1 (6.4)

Follow-up:

8 (5.7)

ESS

Baseline:

11.1 (6.4)

Follow-up:

6.6 (5.9)

P = NS

Arousal 

Index

Baseline: 

17.3 (17.7)

Follow-up:

5.9 (6.5) 

Total sleep 

time, min

Baseline:

381 (92)

Follow-up:

346 (87)

Arousal 

Index

Baseline: 

17.3 (17.7)

Follow-up:

4.9 (3.7)

P = NS

Total sleep 

time, min

Baseline:

381 (92)

Follow-up:

360 (108)

P = NS

NR NR

Marrone 200448

APAP and CPAP (n

= 22) NR NR NR NR

ESS

Baseline

16.3 (5)

1 month

3.9 (2.8)

ESS

Baseline

16.3 (5)

1 month

4.9 (3.7)

P = NS

NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

129

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Masa 200437

Standard titration (n

= 107)

Autoadjusted titration 

(n = 106)

Pretreatment:

62.8 (22.8)

Post:

4.9 (7.6)

Change at 3 

months; 

57.9 (22.6)

Pre:

61.8 (22.0)

Post:

5.1 (6.8)

Change at 3 

months: 

56.6 (21.0)

P = NS

SaO2 <90% of 

TST

Pre:

29.9 (27.3)

Post:

1.4 (4.1)

Change at 3 

months: 28.2 

(26.1)

SaO2 <90% of 

TST

Pre:

25.3 (25.0)

Post:

3.0 (13.9)

Change at 3 

months: 22.0 

(28.1)

P = NS

ESS

Pre:

15.2 (3.5)

Post:

7.2 (4.4)

Change at 3 

months: 8.1 

(5.4)

P = NS 

FOSQ

Pre: 94.4 

(1.07)

Post: 108.0 

14.3)

Change -

14.2 (17.2)

ESS

Pre:

15.9 (3.5)

Post:

7.9 (4.6)

Change at 3 

months: 8.0 

(4.8)

P = NS for 

change 

between 

groups 

FOSQ

Pre: 84.4 

(22.8)

Post: 105.1

(16.0)

Change -

20.8 (20.1) 

P = NS

Arousal 

Index

Pre:

55.5 (19.3)

Post:

12.0 (8.5)

Change at 3 

months: 8.1 

(5.4)

Arousal 

Index

Pre:

55.2 (18..0)

Post:

12.3 (10.0)

Change at 3 

months: 8.0 

(4.8)

P = NS NR NR

Noseda 200453

CPAP and APAP (n

= 24)

NR NR NR NR

ESS

Baseline:

10.7 (2.4)

8 w:

5.1 (2.8)

Sleep 

latency

12 min (12)

Selfestimated 

effective 

sleep

6.1 (1.3) 

ESS

Baseline:

10.7 (2.4)

8 w:

6.1 (2.8)

P<.01

Sleep 

latency

14 (12)

P = NS

Selfestimated 

effective 

sleep

6.2h (1.3) P

= NS

AI

Baseline:

Mean 24.6 

(22.6)

On APAP:

Median

0.45/h

AI

Baseline:

Mean

24.6 (22.6)

On APAP:

Median

0.4/h

P = NS

NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

130

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Massie 200349

CPAP and APAP (n

= 44)

Residual 

AHI

9.6 (5.3)

Residual 

AHI 

10.7 (6.6)

P = NS

NR NR ESS

8 (4)

ESS

9 (4)

P = NS

P<.006 

more restful 

sleep, 

overall 

better sleep 

quality, less 

discomfort 

from 

pressure, 

and less 

trouble 

getting to 

sleep

NR NR NR

Planès 200356

Auto (n = 16)

Conventional (n = 

14)

Events/h

Baseline: 

57.5 (16.5)

2 months: 

7.6 (6.9)

Events/h

Baseline: 

61.0 (17.4)

2 months:

10.4 (12.5) 

P = NS

SaO2<90% 

(time spent)

Baseline: 24.9 

(21.6)

2 months: 

0.3 (0.6)

SaO2<90% 

(time spent)

Baseline: 12.7 

(12.8)

2 months: 

1.9 (5.0)

P = NS

ESS score

Baseline: 

15.5 (4.7)

2 months: 

7.5 (3.4)

P<.0001 

from 

baseline

ESS score

Baseline: 

14.7 (3.9)

2 months: 

7.6 (3.4)

P = NS

NR NR NR NR

Senn 200359

Auto Adjust and 

AutoSet and Fixed (n

= 29)

Mean over 

treatment 

period

AutoSet

7.8 (0.9)

AutoAdjust

6.6 (1.3)

7.4 (1.3)

P = NS 

Time with 

SaO2<90%, % 

time in bed

AutoSet 0.9 

(0.7)

AutoAdjust

2.7 (1.9)

Time with 

SaO2<90%, % 

time in bed

1.1 (0.7)

P = NS 

ESS score

AutoSet”

9.0 (0.6)

AutoAdjust

8.0 (0.8)

ESS score 

8.2 (0.7)

P = NS 

“Overall 

benefit from 

CPAP 

therapy” 5

pt Likert 

scale

AutoSet

4.3 (0.1)

AutoAdjust

4.1 (0.2)

“Overall 

benefit from 

CPAP 

therapy” 

4.3 (0.2)

P = NS

NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

131

Study

Intervention (n)

Control (n)

Apnea-Hypopnea Index 

(AHI) Oxygen Saturation Sleep Symptom Scores

Other Sleep or Urinary 

Symptom Scores Weight Loss

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Randerath 200157

APAP and CPAP (n

= 52, 47 completed)

Baseline:

35.1 (26) 

combined

At 6 weeks: 

5.0 (5.2)

At 6 weeks: 

4.3 (6.3) 

P<.001 

NR NR

ESS

Baseline: 

11.1 (5.1)

At 6 weeks:

7.8 (4.7)

Total sleep 

time

Baseline:

319 (55) 

(combined)

At 6 weeks 

324 (52)

ESS

At 6 weeks:

8.8 (4.6) 

Total sleep 

time

At 6 weeks: 

330 (43)

Snoring

Baseline: 49 

(36)/h 

(combined) 

At 6 weeks:

13 (20)/h

Total 

number of 

arousals

Baseline: 

34.0 

(21.7)/h

At 6 weeks:

10.9 (5.7) 

Snoring 

At 6 weeks:

6 (13) 

P<.001 

Total 

number of 

arousals

At 6 weeks:

12.6 (8.3)

P<.001

NR NR

D’Ortho 200042

APAP and CPAP (n

= 25)

Baseline:

57.8 (5.8) 

(combined)

After 2 

months:

10.6 (9.3)

After 2 

months:

9.7 (1.9)

Mean SaO2, %

Baseline: 93.0 

(3.0) 

(combined)

After 2 

months: 95.6 

(1.6)

Mean SaO2, %

After 2 

months: 95.9 

(1.5)

ESS

Baseline: 

12.7 (5.3 

(combined)

After 2 

months: 9.3 

(4.8) 

ESS

After 2 

months: 9.2 

(5.5) 

P = NS

NR NR NR NR

Teschler 200060

CPAP and APAP (n

= 10)

Baseline: 

52.9 (8.1)

At home:

4.0 (0.3)

At home:

3.7 (0.3)

P = NS, no 

order effect, 

no tx by 

order 

interaction

NR NR NR NR NR NR NR NR

a

APAP: a) RemStar Auto, b) Autoset Spirit, c) Breas Pv 10i; bData from Visual Analog Scale (0-100) with lower values “better”

ESS = Epworth Sleepiness Scale (non-inferiority margin was -2.0); FOSQ = Functional Outcomes of Sleep Questionnaire; ODI = oxygen desaturation index; 

MD = mean difference; SASQ = Sleep Apnea Symptoms Questionnaire, TST = Total sleep time, Ar/AwI = arousals and awakening index, ARI = arousal index; 

SaO2 = oxygen saturation; MWT = maintenance of wakefulness test; NS = not statistically significant; NR = not reported
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

132

Table 11. Intermediate Outcomes for KQ3, Continued

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy

Harms (False 

Positives/Negatives)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

McArdle

201038

Manual CPAP 

titration (n = 83)

Home APAP titration 

(n = 86)

-all outcomes per 

protocol NOT ITT 

unless specified NR NR

SBP

Baseline:

128.4 (14.9)

4 weeks:

126.5 (15.4)

DBP

Baseline:

81.5 (10.1)

4 weeks:

77.0 (10.3)

SBP 

Baseline:

125.2 (17.3)

4 weeks:

122.4 (17.1)

ES: 0.25 

(-0.05, 0.56)

P = NS

DBP

Baseline:

79.1 (9.9)

4 weeks:

76.1 (8.6) 

ES: 0.09

(-0.2, 0.4)

P = NS

NR NR NR NR NR NR

Damjanovic, 200941

Standard APAP (n = 

25)

Standard CPAP (n = 

25)

Intensive APAP (n = 

25)

Intensive CPAP (n = 

25)

BMI did not significantly 

change in the course of 

the study

NR NR NR NR NR NR NR NR

Nolan 200751

APAP and CPAP (n

= 29) NR NR

No significant change in 

blood pressure with either 

APAP or CPAP during the 

course of the study

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

133

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy

Harms (False 

Positives/Negatives)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Patruno 2007

APAP (n = 15)

CPAP (n = 16)

“not significantly affected 

by treatments” SBP

Baseline: 

142 (12)

3 m:

136 (6) P = 

NS, change 

from 

baseline

DBP

Baseline:

87.5 (4)

3 m: 

86 (4) 

P = NS, 

change 

from 

baseline

SBP

Baseline: 

144 (10)

3 m:

132 (8) 

P<.001, 

change 

from 

baseline

DBP

Baseline:

88 (4)

3 m: 

79 (6)

P<.001, 

change 

from 

baseline 

NR NR NR NR NR NR

West 200662

Group 1, APAP (n = 

31)

Group 2, 1 wk 

titration CPAP (n = 

33) 

Group 3, algorithm 

CPAP (n-34)

NR NR

All data 

reported as 

median 

(5th/95th 

centile)

Mean BP

Pre CPAP 

95.8 

(77/122)

P = .9

6 m: 99.6 

(77.3/119)

P = .5

All data 

reported as 

median 

(5th/95th 

centile) 

Mean BP

Group 2:

Pre CPAP 

95.2 

(77.3/118.3)

6 m: 96.7 

(82.7/119)

Group 3:

Pre CPAP 

96.2 

(75.0/120.6)

6 m: 96.4 

(73.3/114.3)

NR NR NR NR NR NR
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

134

Study

Intervention (n)

Control (n)

BMI Blood Pressure HbA1c Time to Initiation of 

Therapy

Harms (False 

Positives/Negatives)

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Planès 200356

Auto (n = 16)

Conventional (n = 

14)

“in neither group did BMI 

change significantly 

during the study”

NR NR NR NR

11.8 (15.5) 

days

P<.01

47.2 (46.5) 

days NR NR

NR = not reported; NS = not statistically significant; BP = blood pressure; SBP = systolic blood pressure; DBP = diastolic blood pressure
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

135

Table 12. Intermediate Outcomes for KQ3, Continued

Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Bakker 201140

CPAP and 

APAP (n = 12)

NR NR NR NR NR NR NR NR

6.3 (1.8) hrs/night 5.8 (2.8) hrs/night (P

= .11)

Lettieri 201133

Group 2: 

PSG+lab CPAP 

titration (n = 70)

Group 3: 

PSG+APAP 

titration (n = 70) NR NR

10% discontinued 

therapy

8.6% discontinued 

therapy

P = NS 

between 

groups

NR NR

Diagnostic PSG cost: 

$704.28

CPAP

titration cost: $753.76 

(Medicare reimbursement 

rates)

% nights used

72.4 (22)

hrs/night, nights 

used

4.8 (1.7)

Use of PAP > 4h/

night for > 70% of 

nights: 50%

% nights used

73.2 (18)

ES: -0.04

(-0.4, 0.3)

hrs/night, nights 

used

4.7 (1.1)

ES: 0.07

(-0.2, 0.4) 

Use of PAP > 4h/

night for > 70% of 

nights

51.4%
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Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

McArdle

201038

Manual CPAP 

titration (n = 83)

Home APAP 

titration (n = 86)

- all outcomes 

per protocol 

NOT ITT unless 

specified

NR NR NR NR NR NR

Staff/pt

A$70.74

Equipment 

etc./pt

A$61.35

Direct 

costs/pt

A$132.09

Travel/pt

A$26.91

Staff/pt

A$250.95

Equipment 

etc./pt

A$93.19

Direct 

costs/pt

A$817.84

Travel/pt

A$15.04

% patients 

continuing CPAP 

use at 4 weeks

85% (n = 63)

ITT: % using 

CPAP at 4 weeks

81% (n = 70)

CPAP use (hrs) at 

4 weeks:

4.39 (2.2) (n = 61)

ITT: CPAP use, 

hrs, at 4 weeks

4.24 (2.2) (n = 68)

% patients 

continuing CPAP 

use at 4 weeks 87% 

(n = 62)

P = NS

ITT:

86% (n = 71)

P = NS

CPAP use (hrs) at 4 

weeks:

4.36 (2.2)

(n = 63)

ES: 0.014

(-0.34, 0.37)

P = NS

ITT

4.38 (2.2) (n = 70)

ES:-0.06 

(-0.4, 0.27)

P = NS

Vennelle 201061

APAP and 

CPAP (n = 192, 

181 analyzed)

NR NR NR NR NR NR NR NR

Mean CPAP use

4.2 (SEM 

0.2)h/night

4.0 (SEM 0.2)h/night

P = .047
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Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Damjanovic 

200941

Standard APAP 

(n = 25)

Standard CPAP 

(n = 25)

Intensive APAP 

(n = 25)

Intensive CPAP 

(n = 25)

NR NR NR NR NR NR NR NR

Daily usage (h)

3 m: 

5.4 (0.2)

9 m: 

5.2 (0.4)

Percent of days

3 m: 

76% (3.9)

9 m: 

67.9% (5)

Hours used/sleep 

time

3 m: 

73.4 (3.1)

9 m: 

72.5 (5)

Daily usage (h)

3 m: 

5.4 (0.3)

9 m: 

5.1 (0.3)

Percent of days

3 m: 

75% (4.1)

9 m: 

69.2% (4.9)

Hours used/sleep 

time

3 m: 

81.4 (5.8)

9 m: 

72.1 (5.2)

No difference 

between groups in 

adherence

Galetke 200845

APAP and 

CPAP (n = 20)

NR NR NR NR NR NR NR NR

382 (107)

min/night

383 (116) min/night

P = NS

Fietze 200744

APAP n = 10

CPAP n = 11 NR NR NR NR NR NR NR NR

Overall use: 77% (25%) of nights

Nocturnal usage:

APAP: 5.0 (1.6)h

CPAP: 4.2 (2.2)h

No significant differences in the course of 

compliance between the 2 patient groups
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138

Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Meurice 200750

At 6 months

Group 1, n = 14

Group 2, n = 13

Group 3, n = 15

Group 4, n = 12

Group 5, n = 11

NR NR NR NR NR NR NR NR

CPAP use, h/night

Group 2

6 m: 5.5 (1.4)

Group 3

6 m: 6.1 (1.6)

Group 4

6 m: 5.1 (1.6)

Group 5

6 m: 7.0 (1.9)

CPAP use

Group 1:

6 m: 

6.5 (1.8)

P = NS

Mulgrew 200739

CPAP titration 

(n = 35)

APAP titration 

(n = 33)

NR NR NR NR NR NR NR NR

CPAP adherence 

(h/night)

Median (IQR)

3 months:

6.0 (5.1, 7.1)

CPAP adherence 

3 months:

5.4 (3.7, 6.4)

Difference at 3 

months: 

-1.12 (95% CI -2.0, 

0.2)

P = .02

Nolan 200751

APAP and 

CPAP (n = 29)

NR NR

All patients experienced 

some side effects on each 

treatment, there was no 

significant difference 

between APAP and CPAP 

in terms of side effects 

(dry mouth, blocked/runny 

nose, pressure felt too 

high, claustrophobic)

NR NR NR NR

Nights used

79% (29)

Mean hrs used per 

night used

4.9 (2.1)

Nights used

81% (25) P = .87

4.9 (1.9) P = .94

Patruno 2007

APAP (n = 15)

CPAP (n = 16)

NR NR NR NR NR NR NR NR

6.2 (0.8) h/day

P = NS

6.0 (1.0) h/day
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139

Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Richard 2007

APAP (n = 96)

CPAP (n = 78)

NR NR NR NR NR NR NR NR

Nights/wkb

6.3 (1.4)

(n = 96)

Hrs/nightb 6.3 (1.8)

(n = 95)

Used ≥ 4h/night, ≥ 

5d/wk:

(74/96) 77.1%

Nights/wk

6.4 (1.4)

(n = 76)

P = .57

Hours/night

6.5 (1.5)

(n = 75)

P = .64

Used ≥ 4h/night, ≥ 

5d/wk:

(64/78)

82.1%

Nolan 2006

CPAP and 

3APAPs (n = 

27)a 

NR NR

Nasal symptoms: greater 

problem for c); P<.05 vs 

a)

Throat/mouth symptoms: 

greater problem for c); 

P<.05 vs a)

Pressure discomfort: 

greater problem for c); 

P<.05 vs a) and b)

NR NR NR NR

Nights used (%)

a) 100 (79-100) P

= NS vs CPAP

b) 96 (42-100) P = 

NS vs CPAP

c) 59 (17-83)

P<.01 vs CPAP, a, 

and b

Hrs/night

a) 7.1 (5.3-8.1) P

= NS vs CPAP

b) 6.8 (5.9-8.0) P

= NS vs CPAP

c) 5.0 (3.8-5.6) 

P<.01 vs CPAP, a, 

and b

Nights used (%) 100 

(94-100)

Hrs/night 6.6 (5.9-

7.9)
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140

Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Nussbaumer 

200654

APAP and 

CPAP

(n = 30)

NR NR

No side effects requiring 

interruption of therapy or 

consultations

Nasal 

stuffinessd 

24 (SE 6)

Sore/dry 

mouth/

throat

27 (SE 5)

Discomfort with 

air 

pressure

8 (SE 2)

Nasal 

stuffiness 

24 (SE 

6) P = 

NS

Sore/dry 

mouth/ 

throat

34 (SE 

6)

P = NS

Discomfort with 

air 

pressure

27 (SE 

5) P<.05

NR NR

% of days with > 4 

hours use

72% (SE 4)

Hrs/night 5.1 (SE 

0.3)

% of days with > 4 

hours use

68% (SE 5)

P = NS

Hrs/night

4.8 (SE 0.3)

P = NS

West 200662

Group 1, APAP 

(n = 31)

Group 2, 1 wk 

titration CPAP 

(n = 33) 

Group 3, 

algorithm CPAP 

(n-34) NR NR NR NR NR NR NR NR

All data reported 

as median 

(5th/95th centile)

Hrs used/night

6 m: 5.49 (0/7.5)

P = .23

Nights used (%)

6 months

100 (5/100)

P = .21

All data reported as 

median (5th/95th 

centile)

Hrs used/night

6 months

Group 2:

4.9 (0/7.2)

Group 3:

4.0 (0/8.3)

Nights used (%)

6 months

Group 2:

98.3 (61/100)

Group 3:

92.6 (33/100)
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141

Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Hukins 200446

APAP and 

CPAP (n = 55)

NR NR

Nasal 

irritation or 

obstruction5

Pressure 

intolerance2

Partner 

dislike 0 

Total 

number of 

side 

effects15

Nasal 

irritation or 

obstruction 

10 P = .27

Pressure 

intolerance 

5 P = .44

Partner 

dislike 1 P = 

.99

Total 

number of 

side effects 

28 P = .02

NR NR NR NR

Avg. nightly use

5.05 (2.38) hours 

per night

P = .14

Percentage of

nights treatment 

used

83.3% (23.3%)

Avg. nightly use

4.86 (2.65) hours per 

night

Percentage of nights 

treatment used

78% (32.6%)

P = .29

Hussain 200447

CPAP and 

APAP (n = 10)

NR NR NR NR NR NR NR NR

H/night

4.3 (1.9)

H/night

3.7 (2.6)

P = NS

Marrone, 200448

APAP and 

CPAP (n = 22) NR NR NR NR NR NR NR NR

Hours/day

4.9 (1.7)

Days of machine 

use

88.8% (15.2%)

Hours/day 4.4 (1.9)

P = NS

Days of machine use

83.9% (18.6%) 

P = NS

Masa 200437

Standard 

titration (n = 

107)

Autoadjusted 

titration (n = 

106)

NR NR

“no important differences” 

between standard and 

autoadjusted titration; 

tendency for more side 

effects (eg, rhinitis, mask 

intolerance, aerophagia, 

headache, smothering 

sensation, bed partner 

intolerance) in 

autoadjusted group 

NR NR NR NR

Use hr/day

5.3 (1.9)

Use hr/day

5.2 (2.0)

ES: 0.05 

(-0.2, 0.32)

P = NR
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142

Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Noseda 200453

CPAP and 

APAP (n = 24)

NR NR NR NR NR NR NR NR

Median 

percentage of 

nights

96.5%

Mean use per 

effective night, h

5.3 (1.9)

P = NS

Median percentage 

of nights

95.5%

P = NS

Mean use per 

effective night, h

5.5 (1.5)

Massie 200349

CPAP and 

APAP (n = 44) NR NR NR NR NR NR NR NR

% of nights used 

92% (11)

Minutes 

used/24hrs

306 (114)

P<.005

% of nights used:

88% (15)

P = NS

Minutes used/24hrs

271 (115)

Planès 200356

Auto (n = 16)

Conventional (n

= 14)

NR NR NR NR NR NR

Hospital 

care: €602 

P<.001 

between 

groups

Telecommunication: €155

Total cost:

€1264 P<.01

Hospital 

care: €1220

Telecommunication: 

€9

P<.001 

between 

groups

Total cost: 

€1720

Compliance 

(defined as 

3hrs/night)

13/16 (81%)

Mean duration 

4.5h (1.7)

Compliance (defined 

as 3hrs/night) 14/14 

(100%)

Mean duration 5.3h 

(1.4)

P = NS between 

groups
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

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Study

Intervention (n)

Control (n)

Harms 

(Overdiagnosis)

Harms, Adverse Events 

(describe)

Harms, Adverse 

Events (describe)

Costs per Patient, US 

dollars (unless otherwise 

noted)

Compliance/Adherence

APAP CPAP APAP CPAP APAP CPAP APAP CPAP APAP CPAP

Senn 200359

Auto Adjust and 

AutoSet and 

Fixed (n = 29)

NR NR

Dry mouth

AutoSet 

8/29 (28%)

AutoAdjust 

7/29 (24%)

Skin 

irritation

AutoSet 

9/29 (31%)

AutoAdjust 

8/29 (28%)

Nasal 

irritation

AutoSet 

5/29 (17%)

AutoAdjust 

8/29 (28%)

Dry mouth 

3/29 (10%)

Skin 

irritation

10/29 (34%)

Nasal 

irritation 

8/29 (28%)

All P = NS 

all “mild”

NR NR NR NR

Mean h/night

AutoSet

5.5 (0.2)

Auto Adjust

5.5 (0.2)

Nights with > 2.5h, 

% AutoSet

83% (3)

Auto Adjust

79% (4)

Mean h/night

5.6 (0.2)

Nights with > 2.5h, 

% 

82% (3)

P<.01 for all 

compared to 

baseline, P = NS

Randerath 

200157

APAP and 

CPAP (n = 47 

completed)

NR NR

Side effects were mild 

under both modes, and no 

significant differences 

were observable

NR NR NR NR

Usage: 98.4% of days (APAP and CPAP)

Minutes/ day 

APAP: 315.4 (94.7)

CPAP: 315.4 (97.4)

D’Ortho 200042

APAP and 

CPAP (n = 25) NR NR NR NR NR NR NR NR

Hours of use per 

night

4.1 (1.8)

CPAP use ≥ 

4h/night

18/25 (72%)

Hours of use per 

night

4.7 (1.8)

P = .20

CPAP use ≥ 4h/night

19/25 (76%) a

APAP: a) RemStar Auto, b) Autoset Spirit, c) Breas Pv 10i b

Excludes failures

ES = effect size; ITT = intent to treat (analysis); NS = not statistically significant; NR = not reported; PSG = polysomnography; SE = standard error
Alternative Care Models for Treatment of OSA Evidence-based Synthesis Program

144

APPENDIX D. STRENGTH OF EVIDENCE 

OUTCOME

Strength of Evidence Elementsa Summary of Findings

Risk of 

Bias Consistency Directness Precision Publication 

Bias Description of Effect

Strength of 

Evidence

Directionb 

KQ1: SLEEP PHYSICIAN CARE COMPARED TO MANAGEMENT BY PRIMARY CARE, SLEEP-SPECIALIST NURSES OR OTHER NON-SLEEP 

PHYSICIANS

Access to care We found no evidence for this outcome. Insufficient

Epworth Sleepiness 

Scale (ESS) Moderate Consistent Direct Precise Unclear

Based on 4 RCTs (n = 568), improvement from 

baseline in ESS scores was similar for patients 

being managed by primary care/sleep-specialist 

nurses compared to sleep specialist physicians 

(SMD = 0.06 [95% CI -0.15, 0.26]). One 

observational study also found ESS scores were 

similar between groups.

Moderate

Similar

Quality of life Moderate Consistent Direct Precise Unclear

Based on 3 RCTs (n = 524), quality of life 

measures were similar for patients being 

managed by primary care/ sleep-specialist 

nurses compared to sleep specialist physicians. 

SMDs for SF-36 Vitality and Mental Health 

scores were -0.04 [95% CI -0.22, 0.15]) and -

0.04 [95% CI -0.22, 0.14], respectively

Moderate

Similar

Compliance, hours 

per night Moderate Consistent Direct Precise Unclear

Based on 4 RCTs (n = 568), compliance was 

similar for patients being managed by primary 

care/sleep-specialist nurses compared to sleep 

specialist physicians (WMD = -0.29 [95% CI -

0.71, 0.12]). One observational cohort study also 

found compliance was similar between groups 

but one study based on retrospective chart 

review reported compliance was greater in the 

sleep specialist physician group compared to the 

non-sleep specialist group.

Moderate

Similar

Adverse events Moderate Unknown Direct Imprecise Unclear

Based on one RCT (n = 65) that did not report 

adverse events by treatment arm, the evidence 

is insufficient to draw conclusions.

Insufficient

KQ3: HOME APAP TECHNOLOGY VERSUS STANDARD IN-CENTER MANUAL CPAP TITRATION

Access to care We found no evidence for this outcome. Insufficient
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145

OUTCOME

Strength of Evidence Elementsa Summary of Findings

Risk of 

Bias Consistency Directness Precision Publication 

Bias Description of Effect

Strength of 

Evidence

Directionb 

Epworth Sleepiness 

Scale (ESS) Moderate Consistent Direct Precise Unclear

Based on 2 RCTs (n = 414) with moderate risk 

of bias, we found improvement from baseline in 

ESS scores was similar for patients allocated to 

home APAP titration compared to patients 

allocated to in-center CPAP titration (SMD = 0.0 

[95% CI -0.22, 0.21]). One moderate risk of bias 

RCT (n = 68) found median change in EES 

scores from baseline was also similar between 

groups (MD -1 [95% CI --1, -4]). One 

observational cohort study also found ESS 

scores were similar between groups.

Moderate

Similar

Quality of life Moderate Consistent Direct Precise Unclear

Based on two RCTs (n = 414) with moderate risk 

of bias, we found quality of life measures were 

similar for patients allocated to home APAP 

titration compared to patients allocated to incenter CPAP titration. The SMDs for SF-36 

Mental Health and Physical Health scores were 

0.08 [95% CI -0.14, 0.29] and -0.21 [95% CI -

0.61, 0.20], respectively. Results for the Physical 

Health scores were imprecise. One moderate 

risk of bias RCT (n = 68) found median 

improvement from baseline in the SAQLI was 

similar between groups (median difference = 

0.17 [95% CI -0.6, 0.9])

Moderate

Similar

Compliance, hours 

per night Moderate Inconsistent Direct Precise Unclear

Based on two RCTs (n = 414) with moderate risk 

of bias, we found compliance was similar for 

patients allocated to home APAP titration 

compared to patients allocated to in-center 

CPAP titration (WMD = 0.02 [95% CI -0.41, 

0.45]). One moderate risk of bias RCT (n = 68) 

found median compliance was better in the 

APAP group versus the CPAP group (MD -1.1 

[95% CI -2.0, -0.2]). One observational cohort 

study found compliance was similar between 

groups

Low

Similar
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OUTCOME

Strength of Evidence Elementsa Summary of Findings

Risk of 

Bias Consistency Directness Precision Publication 

Bias Description of Effect

Strength of 

Evidence

Directionb 

Adverse events

 Moderate Unknown Direct Imprecise Unclear

Based on the findings of one RCT (n = 245) that 

reported no “important differences” in adverse 

events between the home APAP and in-lab 

CPAP and groups, the evidence is insufficient to 

draw conclusions.

Insufficient

KQ3: APAP VERSUS CPAP TREATMENT

Access to care We found no evidence for this outcome. Insufficient

Epworth Sleepiness 

Scale (ESS) Moderate Consistent Direct Precise Unclear

Based on four parallel group RCTs (n = 327)

with aggregate moderate risk of bias, we found 

improvement from baseline in ESS scores was 

similar for patients allocated to APAP treatment 

compared to patients allocated to CPAP 

treatment (SMD = 0.18 [95% CI -0.06, 0.43]). 

Two parallel group trials not pooled (reported as 

a median or data not shown) also found 

improvement from baseline in ESS scores 

similar between groups. Ten crossover RCTs (n

= 269) reported similar improvements between 

groups and two (N = 227) reported greater

improvement with APAP.

Moderate

Similar

Quality of life Moderate Consistent Direct Precise Unclear

Based on 3 parallel group RCTs (n = 202) with 

aggregate moderate risk of bias, we found 

quality of life measures (SF-36, SAQLI) were 

similar for patients allocated to APAP treatment 

compared to patients allocated to CPAP 

treatment (data were not pooled due to variation 

in reporting of results, ie, reported as medians). 

Six crossover RCTs (n = 393) also reported no 

differences in most of the quality of life

measures between the treatment groups.

Moderate

Similar

Compliance, hours 

per night Moderate Consistent Direct Precise Unclear

Based on 5 parallel group RCTs (n = 279) with 

aggregate moderate risk of bias, we found 

compliance was similar for patients allocated to 

APAP treatment compared to patients allocated 

to CPAP treatment (WMD = -0.08 [95% CI -0.55, 

Moderate

Similar
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OUTCOME

Strength of Evidence Elementsa Summary of Findings

Risk of 

Bias Consistency Directness Precision Publication 

Bias Description of Effect

Strength of 

Evidence

Directionb 

0.38]). One parallel group RCT reporting median 

compliance, most of the remaining crossover 

RCTs, and one observational study also found 

compliance was similar between groups.

Adverse events Moderate Consistent Direct Imprecise Unclear

Adverse events were infrequently reported. One 

parallel group RCT (n = 109) reported adverse 

events, chest pain in 12% and 9% of APAP and 

CPAP patients, respectively. Five crossover 

trials reported adverse events for both APAP 

and CPAP treatments. One trial (n = 55) 

reported a higher frequency of total number of 

events and another trial (n = 34) reported a 

higher incidence of pressure discomfort with 

CPAP therapy arm compared with the APAP 

treatment. Three trials (n = 112) reported no 

differences in adverse events between the 

treatment groups.

Low

Similar

AHI = apnea–hypopnea index ; APAP = Auto-adjusted (autoregulated) continuous positive airway pressure; CPAP = continuous positive airway pressure; RCT = 

randomized controlled trial; SF-36 = Short Form-36; SMD = standardized mean difference; WMD = weighted mean difference a

Strength of Evidence Elements

28

Precision: Degree of certainty surrounding an effect estimate; in meta-analysis, the confidence interval around the summary effect size

Consistency: Degree to which reported effect sizes appear to have the same direction of effect

Directness: Whether the evidence links the interventions directly to health outcomes

Risk of bias: Degree to which includes studies have a high likelihood of protection against bias; 2 main elements are study design and aggregate quality of the 

studies

b

Direction of difference between groups