Get paid in your sleep?
4 reasons people don’t use their CPAP machines, and how to change that behavior
July 13, 2021

Obstructive sleep apnea (OSA) impacts an estimated 1 in 15 adults in the US, causing them to intermittently stop and start breathing in their sleep due to the soft muscles in their throat temporarily relaxing and closing. Continuous Positive Airway Pressure therapy is prescribed to treat sleep apnea by providing a continuous air flow through the nose.


Four Effects of Obstructive Sleep Apnea:

  • Intense snoring
  • Waking up abruptly by the feeling of choking or gasping
  • Extreme Daytime Sleepiness
  • High Blood Pressure


CPAP machines ensure that the individual’s airway stays open, alleviating the effects of OSA and ensuring a vital function in our bodies. Understanding this, adhering to a CPAP care plan seems like an easy decision, but that’s not the case. 


Non-adherence to CPAP regimens


One third to one half of people prescribed CPAP therapy stop using their device in the first two weeks or never fill the prescription at all. 


Without consistent treatment, people with obstructive sleep apnea suffer from mood swings, anxiety, inability to focus, and excessive tiredness during the day—causing people to fall asleep at work, in class or even driving. In fact, one study conducted by the AAA foundation found that almost 10% of vehicle accidents can be attributed to some level of drowsy driving. 


ResMed, a medical device company that specializes in equipment supporting individuals with OSA and other sleep disorders, wanted to improve adherence in CPAP usage to create long-term habit formation and better health outcomes. Knowing that establishing that habit right out of the gate is critical for prolonged CPAP adherence, ResMed partnered with Wellth to address adherence in new CPAP users. 


The challenge? Creating a program that motivates someone to do this treatment and sustain it…. in their sleep! 


4 reasons people struggle with their CPAP adherence

Addressing non-adherence started with understanding why individuals were not adhering to CPAP regimens. What they found was four general contributors to non-adherence.

1. The device can be hard to get used to

CPAP adherence during the first two weeks is a really good indication of how well the individuals will adhere to CPAP usage for the long term. During this time period, the patient is getting used to their device and figuring out how to use it. It can take some time to find the right adjustment, and it can be uncomfortable if they’re not taught how to make the mask fit.

Young woman wearing a CPAP device


An ill-fitted mask can cause insomnia, leading the individual to  remove their mask in their sleep, interrupt their treatment, or create leaks that cause further discomfort. 


When an insurance company only covers a certain mask provider, or up to a certain amount, options are limited and individuals are less likely to find a CPAP mask that works well for them. Having an easily accessible support line to help troubleshoot an ill-fitted mask can be the difference between prolonged adherence and someone quitting the treatment altogether. 


People have also reported dry nose, congestion, or dry mouth as a result of CPAP use, leading to non-adherence. Taking the time to get acquainted with the ins and outs of the CPAP is crucial to ensuring long term use.


Claustrophobia

For some people, a CPAP machine can trigger hyperventilation—making it even more difficult to breath in the mask and triggering a state of panic. Claustrophobia is one of the most reported reasons a patient will cease usage of their CPAP device. 


Some treatment plans will incorporate Cognitive Behavioral Therapy within the first two weeks, then space out therapy sessions as the therapy continues. This can become costly and not sustainable for the patient or the provider. Sedatives can be also incorporated during device usage, but this is not recommended as a long term solution.

Instead, encouraging or incentivizing individuals to practice using the device while awake is a great way to get used to the sensation, train the body, and build a habit to continue to breathe normally while using the device.


2. Insomnia

CPAP machines won’t solve insomnia. If the air pressure or light noise is causing trouble sleeping, adjustments in one’s sleeping environment (such as adding white noise makers) or making adjustments to the fit of the device can help. Providing access to discuss these concerns with a support team when it arises can catch concerns early on and improve adherence for years to come. 


3. Having an Unsupportive Bed Partner

People who are prescribed a CPAP machine who share a room or bed with someone else may not have that support system and worry about the device interrupting their  partner’s sleep. They may also feel some shame or embarrassment from needing to use a CPAP machine or fear residual strain in a relationship. 

As such, the difference between long-term patient adherence from people with a support system and those without is significant and important to address. With the Wellth and ResMed program, individuals who had a built-in support system—including family who encouraged and motivated the individual to use their CPAP machine—improved adherence by 12 percent compared to those who received no external support.

Couple sits separately on a bed


4. CPAP therapy can be expensive


Most people know the struggles of trying to figure out what insurance will and will not cover. Trying to figure out which CPAP treatments and devices are covered by insurance discourages many people from even filling their prescription.

Providing support up front, where individuals diagnosed with OSA receive personalized, friendly outreach from their insurer or a third party support team from the very beginning can help address these concerns, ensure that the member knows about the benefits available, and improve likelihood of adherence down the road.


Measure, Monitor, and Motivate!


Knowing why people struggle getting started with their CPAP device, ResMed partnered with Wellth to remove or overcome these obstacles—using hours of usage per night to quantify their success. 



ResMed Case Study Example


ResMed identified people who were recently prescribed CPAP therapy and were considered “high risk” of quitting treatment too early and connected them with Wellth. Unlike other adherence programs, Wellth creates lasting behavior change for individuals with chronic illnesses through the principles of behavioral economics—making it an effective tool for not only changing conscious behaviors (like medication adherence), but unconscious ones as well (like not subconsciously taking off a CPAP mask during sleep). 


Principles of Behavioral Economics and Restful:

  • Intent-to-Behavior Gap: “I know I should use my CPAP device, but I just keep forgetting”
  • Present Bias: “I tried using my device once but I couldn’t get it to fit right so I just went to sleep because I was tired”
  • Endowment Effect: “Wellth has given you $75 to be paid out after 30 days if you complete at least 4 hours of CPAP usage over 21 nights.”
  • Loss Aversion: “I don’t want to lose the $75 I was given so I’m going to make sure I use my CPAP device regularly!”


To better improve adherence—even during sleep—Wellth created a specialized program, “Restful” to address the specific CPAP use case.


This particular intervention lead to members using their CPAP device an average of 36 minutes longer than they had before. Wellth reported a 32 percent improvement in adherence—for an overall 82.4 percent adherence—and zero-usage days dropped to 13 percent. 


Example of Restful App


“I like the reminders a lot and the messages. I gave my CPAP machine a try because of it.”
-Feedback from Restful member


This program utilized behavioral economics as well as specialist check ins if patterns of non adherence were observed. This allowed members to get any troubleshooting support they needed to use their device effectively. 


The app also provided a powerful “support system”—allowing designated friends or family members to provide support by sharing customized “high fives” and encouraging notes and videos that the member could unlock as they made progress in their program. Wellth members who received these supports increased program completion by 12 percent. 


Lasting behavior change can create even unconscious habits!


It’s easy to put things off when there appears to be a barrier in the way—even if the barrier is as minor as adjusting the CPAP mask to fit. Another example: although we know we should workout, once we find out that there’s a car accident on our route to the gym it becomes very easy to justify skipping the gym altogether. 


Wellth understands this common disconnect, and leverages behavioral economics to help motivate members to push back on human nature to create new and healthy habits. As a result, members in the Wellth and ResMed program achieved over 82 percent adherence to care plan guidelines on CPAP usage—and felt well-rested, more alert, and motivated to take on the day just as they better managed their OSA. 


Download the ResMed CPAP case study for more specifics and results.