D4. Telehealth

Telemonitoring interventions ranging from simple telephone follow-up to daily telemonitoring of physiological or symptom scores, to more complex telemonitoring interventions with greatly enhanced clinical support; have been evaluated in patients with COPD. A Cochrane Review found that telehealth may have an impact on quality of life and emergency attendances in COPD, however, further research is needed to clarify its precise roles, as to date trials have included telecare as part of more complex packages (McLean 2011) [evidence level I).  The positive effect of telemonitoring seen in some trials could thus be due to enhancement of the underpinning clinical service rather than to the telemonitoring communication.

Pinnock et al separated the effects of telemonitoring from the effects of existing services by adding telemonitoring alone to background self-management and clinical support in the usual care group. Adults registered with general practices in Scotland who had been admitted to hospital with an exacerbation of COPD in the previous year and who were thus at risk of future admissions were randomised to telemonitoring or usual care. All participants received self-management advice – education on self-management of exacerbations reinforced with a booklet, a written management plan, and an emergency supply of antibiotics and steroids, integrated within the standard clinical care service for the region. The telemonitoring package consisted of touch screen operated daily questionnaires about symptoms and drug use, with an instrument to measure oxygen saturation. Data were transmitted daily by an internet connection to the clinical monitoring team, which contacted patients whose score reached a validated threshold. Algorithms, based on the symptom score, alerted the clinical monitoring team if daily readings had not been submitted or if a high symptom score had been recorded. Clinicians responded by advising rescue drugs, a home visit, admission to hospital, or further review. Intervention fidelity was high. After 12 months, no difference was seen in hospital admissions for COPD between the two groups (hazard ratio 0.98, 95% CI 0.66 to 1.44). Furthermore, no differences were seen in health-related quality of life (HRQoL), anxiety or depression, self-efficacy, knowledge, or adherence to drugs. This trial suggested that the addition of telemonitoring to the management of high-risk patients, over and above the backdrop of self-management education and a good clinical service, is costly and ineffective (Pinnock 2013) [evidence level II). These findings are in agreement with a 2011 systematic review of telemonitoring, which suggested that in the absence of other care packages the benefit of telemonitoring is not yet proven and that further work is required before its wide-scale implementation (Bolton 2011). A systematic review (Gregersen 2016) examined the effects of telehealth on quality of life in COPD. Of 18 suitable studies found, only three demonstrated significant improvements in quality of life as a consequence of a telehealth intervention.  A further study of telehealth with multiple components (COMET) also failed to demonstrate reduction in hospitalisation based on intention to treat analysis (Kessler 2018).  It is noted there was reduced mortality as a safety/secondary outcome in the per-protocol analysis.

A number of RCTs have been published since the McLean et al (2011) systematic review. An RCT of 577 patients with mild COPD, obtained from UK primary care COPD registers of 71 general practices evaluated a telephone health coaching program which included the provision of a pedometer, written educational documents, diary, inhaler use education and encouragement of medication adherence (Jolly 2018). Most potential participants did not respond to the study invitation.  While there was no benefit on the primary outcome of quality of life as measured by the St George’s Respiratory Questionnaire (SGRQ), nor the secondary outcomes of anxiety and depression, other secondary outcomes of self-reported physical activity and inhaler usage did improve [evidence level II].

PROMETE II was a randomised control trial of a telehealth package offered to 229 patients, recruited from across 5 centres, over 12 months, with a comprehensive range of outcomes (Soriano 2018) [evidence level II].  The intervention included an educational home visit, and provision of home oximeter, blood pressure gauge, spirometer, and oxygen therapy compliance monitor.  It was rated as highly satisfactory with most patients as well as clinicians, and followed on from the earlier single site, 7-month, 30 participant ‘PROMETE’ study, which had demonstrated a reduction in acute exacerbations.  Despite the earlier study’s promising positive finding, the larger PROMETE II study failed to demonstrate any such benefit in any of the diverse range of outcomes, including costs.  This calls into question the generalisability of a single site positive finding (Segrelles Calvo 2014), where a very small number of highly motivated staff may be able to achieve extraordinary positive results, but which may prove difficult to replicate elsewhere.

A 12 month program of home-based telerehabilitation included both an exercise program at home (three times weekly) following a two month hospital-based pulmonary rehabilitation program as well as self management education, regular review by a team of health professionals via phone or Skype weekly, self monitoring of lung function and access to a helpline. This program was compared with a hospital-based pulmonary rehabilitation program twice weekly and to usual care.  The control group had no initial pulmonary rehabilitation and both groups received sustained intensive pulmonary rehabilitation.  Both home-based telerehabilitation and centre-based pulmonary rehabilitation reduced exacerbations and hospitalisations compared with usual care (mean+SD for exacerbations 1.7+1.7 versus 1.8+1.4 versus 3.5+1.8 respectively, p<0.001; hospitalisations 0.3+0.7 versus 0.3+0.6 versus 1.2+1.7 respectively, p<0.001). The home-based telerehabilitation group also had a lower rate of ED attendances in the 12 months of follow-up than the hospital-based group and usual care group (0.5+0.9 versus 1.8+1.5 versus 3.5+1.8 respectively, p<0.001).  The home-based program was intensive and the results impressive, however a cost analysis was not included in the study (Vasilopoulou 2017).  In an Australian study of telerehabilitation comparing 8 weeks of group exercise training thrice weekly, compared to usual medical management involving pharmacotherapy and an action plan, the endurance shuttle walk test improved significantly in the trained group compared with usual care: 340 seconds (95% CO 153-526, p<0.001) (MCID 180 seconds). However, there were no significant differences in quality of life or physical activity measured as steps walked per day between the two groups (Tsai 2017) [evidence level II], despite the control group not receiving an exercise intervention.

An RCT that evaluated a simple nurse initiated telephone follow-up of COPD patients following admission to hospital with an acute exacerbation of COPD or pneumonia (n=224), did not demonstrate any reduction in readmission or mortality at 30 or 84 days post discharge.  The intervention group received a nurse initiated phone call at two days post discharge and further calls if deemed necessary.  At 30 and 84 days the proportion of those readmitted in the intervention and control groups was 33 and 34% (p=0.84), and 32 and 27% (p=0.66), respectively.  The intervention group did however report more confidence in disease management (Lavesen 2016).

In another RCT, 470 people with COPD with at least 2 comorbidities were recruited from a metropolitan and a rural centre.  The intervention comprised a combination of telephone consults, action plans, and other components and was found to have no effect on the number of emergency department visits and hospital admissions; however, mortality was reduced (Rose 2018) [evidence level II].  A further RCT including telemonitoring to detect deteriorations over 9 months reported no benefit on outcomes including time to first hospitalisation or quality of life (Walker 2018) [evidence level II].

Baroi et al reviewed feasibility and comparative studies, which used a heterogeneous range of measurement devices (including spirometers, respiratory rate sensors, impedance oscillometers, auscultation microphones, pedometers, capnometers, and oximeters), which aimed to identify COPD, and/or to detect early exacerbations of COPD.  Information communication methods between subjects and clinicians included videoconferencing and questionnaires.  The studies that did report positive results were more likely to be those that were more integrated into existing respiratory outpatient services, and in people with high risk of readmission due to a COPD exacerbation.  The combination of online consultations with availability of home-based nebuliser and medical therapies could provide an effective “virtual hospital” (Baroi 2018).

An intensive, comprehensive health coaching intervention that included motivational interviewing-based intervention delivered via telephone, a written action plan for exacerbations including the use of antibiotics and oral steroids, and an exercise prescription decreased COPD-related hospitalisations at 1, 3, and 6 months after hospital discharge, but not at one year after discharge. The absolute risk reductions of COPD-related rehospitalisation in the health coaching group were 7.5% (p=0.01), 11.0% (p=0.02), 11.6% (p=0.03), 11.4% (p=0.05), and 5.4% (p=0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire (CRQ) emotional score (emotion and mastery domains) and physical score (dyspnoea and fatigue domains) (p<0.05). There were no differences between groups in measured physical activity at any time point (Benzo 2016). It should be noted that several of these individual components have been shown to be effective in isolation.

According to a systematic review and meta-analysis by Bonnevie et al of 15 eligible trials, only small improvements of doubtful clinical significance were attained by at home-based exercise therapy delivered using advanced telehealth technology. Exercise capacity measured by the six minute walk test improved with a mean benefit of 15 minutes, (95% CI 5 to 24) (MCID is considered to be 25 minutes). Similar limited level of benefit was seen in functional dyspnoea and quality of life compared with no exercise therapy.  What benefits were demonstrated were generally similar to in/outpatient exercise therapy, and similar to or slightly better than home-based exercise therapy without advanced telehealth technology (Bonnevie 2021).

Similar to the studies of self management support, the COPD telehealth studies are heterogeneous in design and outcome, and the results are also conflicting, again making it difficult to make recommendations regarding the essential elements of telehealth program in COPD. Telehealth has become and increasingly important aspect of COPD care, particularly during periods of pan/epidemics, as such an important area for further research.