How will telemedicine change clinical practice in chronic obstructive pulmonary disease?

The Potential Use and Value of a Wearable Monitoring Bracelet for Patients With Chronic Obstructive Pulmonary Disease: Qualitative Study Investigating the Patient and Health Care Professional Perspectives

BACKGROUND

The occurrence of exacerbations has major effects on the health of people with chronic obstructive pulmonary disease (COPD). Monitoring devices that measure (vital) parameters hold promise for timely identification and treatment of exacerbations. Stakeholders' perspectives on the use of monitoring devices are of importance for the successful development and implementation of a device.

OBJECTIVE

This study aimed to explore the potential use and value of a wearable monitoring bracelet (MB) for patients with COPD at high risk for exacerbation. The perspectives of health care professionals as well as patients were examined, both immediately after hospitalization and over a longer period. Furthermore, potential facilitators and barriers to the use and implementation of an MB were explored.

METHODS

Data for this qualitative study were collected from January to April 2023. A total of 11 participants (eg, n=6 health care professionals [HCPs], 2 patients, and 3 additional patients) participated. In total, 2 semistructured focus groups were conducted via video calls; 1 with HCPs of various professional backgrounds and 1 with patients. In addition, 3 semistructured individual interviews were held with patients. The interviews and focus groups addressed attitudes, wishes, needs, as well as factors that could either support or impede the potential MB use. Data from interviews and focus groups were coded and analyzed according to the principles of the framework method.

RESULTS

HCPs and patients both predominantly emphasized the importance of an MB in terms of promptly identifying exacerbations by detecting deviations from normal (vital) parameters, and subsequently alerting users. According to HCPs, this is how an MB should support the self-management of patients. Most participants did not anticipate major differences in value and use of an MB between the short-term and the long-term periods after hospitalization. Facilitators of the potential use and implementation of an MB that participants highlighted were ease of use and some form of support for patients in using an MB and interpreting the data. HCPs as well as patients expressed concerns about potential costs as a barrier to use and implementation. Another barrier that HCPs mentioned, was the prerequisite of digital literacy for patients to be able to interpret and react to the data from an MB.

CONCLUSIONS

HCPs and patients both recognize that an MB could be beneficial and valuable to patients with COPD at high risk for exacerbation, in the short as well as the long term. In particular, they perceived value in supporting self-management of patients with COPD. Stakeholders would be able to use the obtained insights in support of the effective implementation of MBs in COPD patient care, which can potentially improve health care and the overall well-being of patients with COPD.

Exploring cardiopulmonary rehabilitation in the middle east and North Africa region: A narrative review of challenges and opportunities

BACKGROUND AND OBJECTIVES

Cardiopulmonary Rehabilitation (CR) is crucial for managing conditions like congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and post-COVID-19 complications. This review examines CR practices in the Middle East and North Africa (MENA) region, exploring challenges, disparities, and emerging trends.

METHODS

A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science to identify studies published between date of inception and April 24th, 2024, focusing on CR programs, outcomes, challenges, and strategies specific to the MENA region. Data extraction included study design, population characteristics, CR interventions, and key findings.

RESULTS

CR programs in the MENA region vary widely in scope and execution. While efforts are underway to integrate CR services into national healthcare policies, significant challenges persist, including limited infrastructure, shortages of trained professionals, and cultural barriers. Emerging trends include the use of telehealth and digital monitoring tools to expand access to CR services and policy reforms aimed at improving service delivery and patient access.

CONCLUSION

CR plays a crucial role in improving the quality of life and health outcomes for cardiopulmonary patients, including those in the MENA region. However, significant challenges hinder the widespread adoption and effectiveness of CR programs. Addressing these challenges requires efforts to increase public education, reduce costs, expand funding, and enhance interprofessional collaboration. Future research should assess virtual rehabilitation, cultural adjustments, and long-term outcomes to tailor interventions to MENA's needs, ultimately enhancing CR accessibility and patient outcomes.

Effect of telemonitoring and telerehabilitation on physical activity, exercise capacity, health-related quality of life and healthcare use in patients with chronic lung diseases or COVID-19: A scoping review

BACKGROUND

Telemonitoring and telerehabilitation can support home-based pulmonary rehabilitation (PR) and benefit patients with lung diseases or COVID-19. This study aimed to (1) identify which telemonitoring and telerehabilitation interventions (e.g. videoconferencing) are used to provide telehealth care for people with chronic respiratory conditions or COVID-19, and (2) provide an overview of the effects of telemonitoring and telerehabilitation on exercise capacity, physical activity, health-related QoL (HRQoL), and healthcare use in patients with lung diseases or COVID-19.

METHODS

A search was performed in the electronic databases of Ovid MEDLINE, EMBASE, and Cinahl through 15 June 2021. Subject heading and keywords were used to reflect the concepts of telemonitoring, telerehabilitation, chronic lung diseases, and COVID-19. Studies that explored the effect of a telerehabilitation and/or telemonitoring intervention, in patients with a chronic lung disease such as asthma, chronic obstructive pulmonary diseases (COPD), or COVID-19, and reported the effect of the intervention in one or more of our outcomes of interest were included. Excluding criteria included evaluation of new technological components, teleconsultation or one-time patient assessment.

RESULTS

This scoping review included 44 publications reporting the effect of telemonitoring (25 studies), telerehabilitation (8 studies) or both (11 studies) on patients with COPD (35 studies), asthma (5 studies), COPD and asthma (1 study), and COVID-19 (2 studies). Patients who received telemonitoring and/or telerehabilitation had improvements in exercise capacity in 9 out of 11 (82%) articles, better HRQoL in 21 out of 25 (84%), and fewer health care use in 3 out of 3 (100%) articles compared to pre-intervention. Compared to controls, no statistically significant differences were found in the intervention groups' exercise capacity in 5 out 6 (83%) articles, physical activity in 3 out of 3 (100%) articles, HRQoL in 21 out of 25 (84%) articles, and healthcare use in 15 out of 20 (75%) articles. The main limitation of the study was the high variability between the characteristics of the studies, such as the number and age of the patients, the outcome measures, the duration of the intervention, the technological components involved, and the additional elements included in the interventions that may influence the generalization of the results.

CONCLUSION

Telemonitoring and telerehabilitation interventions had a positive effect on patient outcomes and appeared to be as effective as standard care. Therefore, they are promising alternatives to support remote home-based rehabilitation in patients with chronic lung diseases or COVID-19.

Telemedicine and Resource Utilization in Pulmonary Clinic

BACKGROUND

Telemedicine use increased with the Covid-19 pandemic. The impact of telemedicine on resource use in pulmonary clinics is unknown.

METHODS

This retrospective cohort study identified adults with pulmonary clinic visits at the University of Miami Hospital and Clinics (January 2018-December 2021). The primary exposure was telemedicine versus in-person visits. Standard statistics were used to describe the cohort and compare patients stratified by visit type. Multivariable logistic regression models evaluated the association of telemedicine with resource use (primarily, computed tomography [CT] orders placed within 7 days of visit).

RESULTS

21,744 clinic visits were included: 5,480 (25.2%) telemedicine and 16,264 (74.8%) in-person. In both, the majority were < 65-years-old, female, and identified as Hispanic white. Patients seen with telemedicine had increased odds of having CT scans ordered within 7 days (adjusted odds ratio [aOR] 1.34, [95% confidence interval 1.04-1.74]); and decreased odds of chest x-rays (aOR 0.37 [0.23-0.57]). Telemedicine increased odds of contact of any kind with our healthcare system within 30-days (aOR 1.56 [1.29-1.88]) and 90-days (aOR 1.39 [1.17-1.64]). Specifically, telemedicine visits had decreased odds of emergency department visits and hospitalizations (30 days: aOR 0.54 [0.38-0.76]; 90 days: aOR 0.68 [0.52-0.89]), but increased odds of phone calls and electronic health record inbox messages (30 days: aOR 3.44 [2.73-4.35]; 90 days: aOR 3.58 [2.95-4.35]).

CONCLUSIONS

Telemedicine was associated with an increased odds of chest CT order with a concomitant decreased odds of chest x-ray order. Increased contact with the healthcare system with telemedicine may represent a larger time burden for outpatient clinicians.

Effect of internet-based pulmonary rehabilitation on physical capacity and health-related life quality in patients with chronic obstructive pulmonary disease-a systematic review and meta-analysis

PURPOSE

Pulmonary rehabilitation (PR) is now recognized as the most effective treatments for individuals with chronic obstructive pulmonary disease (COPD), internet-based PR arises a promising method. The aim of this study was to conduct a systematic review and meta-analysis for assessing the effect of internet-based PR programs on physical capacity and health-related quality of life in patients with COPD.

MATERIALS AND METHODS

Randomized controlled trials were identified through systematically searches in PubMed, EMBASE, web of science, CENTRAL, Cochrane Library, and Google Scholar databases.

RESULTS

Twelve studies (1433 patients) were included. For physical capacity, there was no significant difference between groups was found according to the 6-min walk test (6MWT) (MD10.42, 95% CI -2.92 to 23.77, p = 0.13, I2 = 0%). For the health-related quality of life, no significant difference between groups was found regarding the St George's Respiratory Questionnaire (SGRQ) (MD -0.64, 95% CI -3.52 to 2.23, p = 0.66), COPD assessment test (CAT)(MD -0.34, 95% CI -1.62 to 0.94, p = 0.60), modified Medical Research Council scale (mMRC)(MD 0.17, 95% CI -0.06 to 0.39, p = 0.15) and Chronic Respiratory Questionnaire (CRQ)(MD 1.32 95% CI -5.88 to 8.53, p = 0.72).

CONCLUSIONS

This study has established the potential for delivery of PR via the internet in demonstrating non-inferiority of physical capacity and health-related quality of life (HRQoL) compared with conventional PR.IMPLICATIONS FOR REHABILITATIONLong-term rehabilitation training for patients with chronic obstructive pulmonary disease needs a more convenient and feasible way.In this study, internet-based rehabilitation showed similar effects as conventional rehabilitation on physical activity and health-related quality of life.Internet-based rehabilitation strategies would be helpful for this population.All internet-based rehabilitation strategies should be simple and sustainable.

Telehealth nursing interventions for phenotypes of older adults with COPD: an exploratory study

Introduction

Inconclusive results exist around the effectiveness of telemonitoring for patients with COPD, and studies recommended conducting subgroup analyses to identify patient phenotypes that could benefit from these services. This exploratory study investigated what type of COPD patients were receiving which type of telenursing interventions more frequently using the telemonitoring platform.

Methods

A sample of 36 older adults with COPD were receiving telenursing services for 12 months and were asked to answer five COPD-symptom related questions and submit their vital signs daily.

Results

Findings revealed two phenotypes of older adults for whom the frequency of telenursing calls and related interventions differed. Although no statistically significant differences were observed in participants' GOLD grades and hospitalizations, cluster one participants used their COPD action plan significantly more frequently, and were in frequent contact with the telenurse.

Discussion

It is paramount that further research is needed on the development of patient phenotypes who may benefit from telemonitoring.

Effectiveness of patient decision aid supported shared decision-making intervention in in-person and virtual hybrid pulmonary rehabilitation in older adults with chronic obstructive pulmonary disease: A pilot randomized controlled trial

INTRODUCTION

Tele-pulmonary rehabilitation is increasingly advocated but cannot completely substitute for in-person services for chronic conditions. Adherence to Pulmonary rehabilitation (PR) remains low in chronic obstructive pulmonary disease (COPD) patients. Shared decision-making (SDM) promotes patients' participation in PR decisions and helps patients and healthcare providers to jointly make decisions that patients are informed and aligned with patient preferences and values, which are critical for patient adherence to PR.

OBJECTIVE

This study aimed to develop a hybrid in-person and virtual model of home-based PR services for older COPD patients and study the effectiveness of the patient decision aid (PDA)-supported recurring SDM intervention on patient adherence to PR, rehabilitation outcomes, and decision-related outcomes, as well as to explore the mechanisms of the intervention on PR adherence.

METHODS

A total of 78 older COPD patients were randomly assigned to the PR group (n = 39) or PDA-PR group (n = 39). Both groups were conducted hybrid in-person and virtual PR intervention for 3 months. The primary outcomes were patients' quality of life and PR adherence. The secondary outcomes were dyspnea symptoms, exercise self-efficacy, knowledge, and decision-related outcomes.

RESULTS

A total of 72 participants completed the 3-month PR program. There were statistically significant differences in PR adherence (p = 0.033), COPD assessment test (CAT) scores (p = 0.016), PR knowledge (p < 0.001), decision self-efficacy (p < 0.001), decision conflict (p < 0.001), and decision regret scores (p = 0.027) between the two groups. The modified Medical Research Council Dyspnoea scale (mMRC) score was significantly decreased only in PDA-PR group (p = 0.011). No statistically significant differences were observed in St George's Respiratory Questionnaire (SGRQ) score (p = 0.078), Exercise Self-Regulatory Efficacy Scale (Ex-SRES) score (p = 0.29) and COPD knowledge (p = 0.086) between the two groups. PR value score had a significant effect on adherence to PR (p = 0.007) and CAT score (p = 0.028).

CONCLUSIONS

PDA supported recurring SDM intervention was helpful in maintaining older COPD patients' PR adherence and had advantages in improving quality of life, enhancing PR knowledge, decision self-efficacy, and reducing decision conflict and decision regret, but did not improve SGRQ and Ex-SRES. PR value score influenced patients' rehabilitation adherence and quality of life.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR): ChiCTR1900028563; http://apps.who.int/trialsearch/default.aspx.

Telehealth and telemedicine in the management of adult patients after hospitalization for COPD exacerbation: a scoping review

Objective: A substantial number of people with COPD suffer from exacerbations, which are defined as an acute worsening of respiratory symptoms. To minimize exacerbations, telehealth has emerged as an alternative to improve clinical management, access to health care, and support for self-management. Our objective was to map the evidence of telehealth/telemedicine for the monitoring of adult COPD patients after hospitalization due to an exacerbation. Methods: Bibliographic search was carried in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus, Biblioteca Virtual de Saúde/LILACS and Cochrane Library databases to identify articles describing telehealth and telemonitoring strategies in Portuguese, English, or Spanish published by December of 2021. Results: Thirty-nine articles, using the following concepts (number of articles), were included in this review: telehealth (21); telemonitoring (20); telemedicine (17); teleconsultation (5); teleassistance (4); telehomecare and telerehabilitation (3 each); telecommunication and mobile health (2 each); and e-health management, e-coach, telehome, telehealth care and televideo consultation (1 each). All these concepts describe strategies which use telephone and/or video calls for coaching, data monitoring, and health education leading to self-management or self-care, focusing on providing remote integrated home care with or without telemetry devices. Conclusions: This review demonstrated that telehealth/telemedicine in combination with telemonitoring can be an interesting strategy to benefit COPD patients after discharge from hospitalization for an exacerbation, by improving their quality of life and reducing re-hospitalizations, admissions to emergency services, hospital length of stay, and health care costs.

Barriers and facilitators to the adoption of digital health interventions for COPD management: A scoping review

BACKGROUND

Knowledge of the barriers and facilitators in the adoption of digital health interventions (DHI) is sparse yet crucial to facilitate chronic obstructive pulmonary disease (COPD) management.

OBJECTIVES

This scoping review aimed to summarize patient- and healthcare provider-level barriers and facilitators in the adoption of DHIs for COPD management.

METHODS

Nine electronic databases were searched from inception up till October 2022 for English language evidence. Inductive content analysis was used.

RESULTS

This review included 27 papers. Frequent patient-level barriers were poor digital literacy (n = 6), impersonal care delivery (n = 4), and fear of being controlled by telemonitoring data (n = 4). Frequent patient-level facilitators were improved disease understanding and management (n = 17), bi-directional communication and contact with healthcare providers (n = 15), and remote monitoring and feedback (n = 14). Frequent healthcare provider-level barriers were increased workload (n = 5), lack of technology interoperability with existing health systems (n = 4), lack of funding (n = 4), and lack of dedicated and trained manpower (n = 4). Frequent healthcare provider-level facilitators were improved efficiency of care delivery (n = 6) and DHI training programmes (n = 5).

CONCLUSION

DHIs have the potential to facilitate COPD self-management and improve efficiency of care delivery. However, several barriers challenge its successful adoption. Attaining organizational support in developing user centric DHIs that can be integrated and are interoperable with existing health systems is crucial if we are to witness tangible return on investments at the patient-, healthcare provider- and healthcare system-level.

Trends in Telecare Use among Community-Dwelling Older Adults: A Scoping Review

A scoping review was conducted to map and analyze the concept of telecare services and the trends in telecare use. This scoping review was conducted according to Arksey and O'Malley's framework. A search was conducted in CINAHL (via EBSCO), ERIC, Academic Search Ultimate, and MEDLINE/PubMed databases. This scoping review considered quantitative (e.g., analytical observational studies, including prospective and retrospective cohort studies, case-control, analytical cross-sectional, and descriptive-observational studies), qualitative (e.g., phenomenology, grounded theory, ethnography, and action research), and mixed-method primary studies. Forty research articles published from 1 January 2012, to 1 January 2022 were included in this review, these studies met the eligibility criteria as all were focused on telecare and targeting older adults over 65 living at home. The reviewers coded the data in an Excel spreadsheet, including the articles' title, year, author, journal information and subject, research methods, sample size, location, and summary. Then, the researchers analyzed the conceptual definitions, measurement techniques, and findings in detail and the findings were grouped into categories. The trends around the concept of telecare are independent living, remote care, aging in place, and safety. Telecare research focuses mainly on service use, chronic illness, ethics, and cost-effectiveness. Technology acceptance among older individuals is a critical factor for telecare use. The results found in the literature about the cost-effectiveness of telecare are inconsistent.

Telehealth and COVID-19 Pandemic: An Overview of the Telehealth Use, Advantages, Challenges, and Opportunities during COVID-19 Pandemic

The use of telehealth and digital health platforms has increased during the COVID-19 pandemic due to the implementation of physical distancing measures and restrictions. To address the pandemic threat, telehealth was promptly and extensively developed, implemented, and used to maintain continuity of care offered through multi-purpose technology platforms considered as virtual healthcare facilities. The aim of this paper is to define telehealth and discuss some aspects of its utilization, role, and impact, but also opportunities and future implications particularly during the COVID-19 pandemic. In order to support our reflection and consolidate our viewpoints, numerous bibliographical sources and relevant literature were identified through an electronic keyword search of four databases (PubMed, Web of Science, Google Scholar, and ResearchGate). In this paper, we consider that telehealth to be a very interesting approach which can be effective and affordable for health systems aiming to facilitate access to care, maintain quality and safety of care, and engage patients and health professionals and users of health services. However, we also believe that telehealth faces many challenges, such as the issue of lack of human contact in care, confidentiality, and data security, also accessibility and training in the use of platforms for telehealth. Despite the many challenges it faces, we believe telehealth has enormous potential for strengthening and improving healthcare services. In this paper, we also call for and encourage further studies to build a solid and broad understanding of telehealth challenges with its short-term and long-term clinical, organizational, socio-economic, and ethical impacts.

Exploring patients' and health professionals' perspectives on health literacy needs in the context of chronic obstructive pulmonary disease

OBJECTIVE

Persons with chronic obstructive pulmonary disease (COPD) require complex follow-up by healthcare professionals (HCPs) and may experience several health literacy (HL) needs. This study aimed to explore such needs in people with COPD and the HCPs who care for them.

METHODS

From October 2016 to August 2017 a qualitative study with four focus groups (FG) were performed in people with COPD (n = 14) and three in multidisciplinary HCPs (n = 21). An inductive thematic analysis was used to investigate HL needs.

RESULTS

Four HL needs emerged: 1) strengthening the feeling of security; 2) combating the burden of insufficient knowledge on COPD and lack of informational flow; 3) supporting motivation for endurance and self-management; and 4) strengthening dignity.

DISCUSSION

This study highlights a gap between people with COPD who express important HL needs and HCPs' capabilities to care for these needs. For HCPs to increase HL in such cases, HCPs need to improve their own HL. It is essential to find solutions on how to improve HL in HCPs who care for people with COPD and to increase the availability of interventions that increase HL in COPD. Education programs, health organizations, and governments should be aware of HL needs in such situations.

Experiences of patients with chronic obstructive pulmonary disease receiving integrated telehealth nursing services during COVID-19 lockdown

Objective

Even though telemonitoring existed prior to COVID-19, the need was accelerated for patients with COPD due to the limited medical consultations and the anxiety for being infected. To our knowledge, no qualitative study has explored the experiences of COPD patients and the potential benefits of receiving integrated telehealth nursing services during the lockdown.

Methods

Ten participants were interviewed after receiving telehealth nursing services for 3 months; data was analyzed thematically.

Results

Irrespective of COPD severity, all participants expressed that the existing fragmented follow-up care was intensified during COVID. The telenursing services provided them with the comfort and reassurance that a clinician is available for support, advice, and care during the times of isolation. Despite diverse opinions regarding the respiratory-related questions for follow-up, all were enthusiastic about the use of the oximeter in their daily lives. None perceived sharing data as an issue, instead they encouraged the exchange across levels of care.

Conclusion

Despite an appreciation for the service, it is imperative for sustainability reasons that standardized protocols are developed to balance patient preferences in terms of response frequency and the clinical data needed for a telenurse to provide appropriate interventions.

Prediction model study focusing on eHealth in the management of urinary incontinence: the Personalised Advantage Index as a decision-making aid

OBJECTIVE

To develop a prediction model and illustrate the practical potential of personalisation of treatment decisions between app-based treatment and care as usual for urinary incontinence (UI).

DESIGN

A prediction model study using data from a pragmatic, randomised controlled, non-inferiority trial.

SETTING

Dutch primary care from 2015, with social media included from 2017. Enrolment ended on July 2018.

PARTICIPANTS

Adult women were eligible if they had ≥2 episodes of UI per week, access to mobile apps and wanted treatment. Of the 350 screened women, 262 were eligible and randomised to app-based treatment or care as usual; 195 (74%) attended follow-up.

PREDICTORS

Literature review and expert opinion identified 13 candidate predictors, categorised into two groups: Prognostic factors (independent of treatment type), such as UI severity, postmenopausal state, vaginal births, general physical health status, pelvic floor muscle function and body mass index; and modifiers (dependent on treatment type), such as age, UI type and duration, impact on quality of life, previous physical therapy, recruitment method and educational level.

MAIN OUTCOME MEASURE

Primary outcome was symptom severity after a 4-month follow-up period, measured by the International Consultation on Incontinence Questionnaire the Urinary Incontinence Short Form. Prognostic factors and modifiers were combined into a final prediction model. For each participant, we then predicted treatment outcomes and calculated a Personalised Advantage Index (PAI).

RESULTS

Baseline UI severity (prognostic) and age, educational level and impact on quality of life (modifiers) independently affected treatment effect of eHealth. The mean PAI was 0.99±0.79 points, being of clinical relevance in 21% of individuals. Applying the PAI also significantly improved treatment outcomes at the group level.

CONCLUSIONS

Personalising treatment choice can support treatment decision making between eHealth and care as usual through the practical application of prediction modelling. Concerning eHealth for UI, this could facilitate the choice between app-based treatment and care as usual.

TRIAL REGISTRATION NUMBER

NL4948t.

A machine-learning-based prediction method for easy COPD classification based on pulse oximetry clinical use

Chronic Obstructive Pulmonary Disease (COPD) is a progressive, obstructive lung disease that restricts airflow from the lungs. COPD patients are at risk of sudden and acute worsening of symptoms called exacerbations. Early identification and classification of COPD exacerbation can reduce COPD risks and improve patient’s healthcare and management. Pulse oximetry is a non-invasive technique used to assess patients with acutely worsening symptoms. As part of manual diagnosis based on pulse oximetry, clinicians examine three warning signs to classify COPD patients. This may lack high sensitivity and specificity which requires a blood test. However, laboratory tests require time, further delayed treatment and additional costs. This research proposes a prediction method for COPD patients’ classification based on pulse oximetry three manual warning signs and the resulting derived few key features that can be obtained in a short time. The model was developed on a robust physician labeled dataset with clinically diverse patient cases. Five classification algorithms were applied on the mentioned dataset and the results showed that the best algorithm is XGBoost with the accuracy of 91.04%, precision of 99.86%, recall of 82.19%, F1 measure value of 90.05% with an AUC value of 95.8%. Age, current and baseline heart rate, current and baseline pulse ox. (SPO2) were found the top most important predictors. These findings suggest the strength of XGBoost model together with the availability and the simplicity of input variables in classifying COPD daily living using a (wearable) pulse oximeter.

Effectiveness of a home telemonitoring program for patients with chronic obstructive pulmonary disease in Germany: Evidence from the first three years

Introduction

Chronic obstructive pulmonary disease (COPD) affects more than 6 million people in Germany. Monitoring the vital parameters of COPD patients remotely through telemonitoring may help doctors and patients prevent and treat acute exacerbations of COPD, improving patients’ quality of life and saving costs for the statutory health insurance system.

Objective

To evaluate the effects from October 2012 until December 2015 of a structured home telemonitoring program implemented by a statutory health insurer in Germany.

Methods

We conducted a retrospective cohort study using administrative data. After building a balanced control group using Entropy Balancing, we calculated difference-in-difference estimators to account for time-invariant heterogeneity. We estimated differences in mortality rates using Cox regression and conducted subgroup and sensitivity analyses to check the robustness of the base case results. We observed each patient in the program for up to 3 years depending on his or her time of enrolment.

Results

Among patients in the telemonitoring cohort, we observed significantly higher inpatient costs due to COPD (€524.2, p<0,05; €434.6, p<0.05) and outpatient costs (102.5, p<0.01; 78.8 p<0.05) during the first two years of the program. Additional cost categories were significantly increased during the first year of telemonitoring. We also observed a significantly higher number of drug prescriptions during all three years of the observation period (2.0500, p < 0.05; 0.7260, p < 0.05; 3.3170, p < 0.01) and a higher number of outpatient contacts during the first two years (0.945, p<0.01, 0.683, p<0.05). Furthermore, we found significantly improved survival rates for participants in the telemonitoring program (HR 0.68, p<0.001).

Conclusion

On one hand, telemonitoring was associated with higher health care expenditures, especially in the first year of the program. For example, we were able to identify a statistically significant increase in inpatient costs due to COPD, outpatient contacts and drug prescriptions among individuals participating in the telemonitoring program. On the other hand, the telemonitoring program was accompanied by a survival benefit, which might be related to higher adherence rates, more intense treatment, or an improved understanding of COPD among these patients.

Diabetes care in the time of COVID ‐19: video consultation as a means of diabetes management

Background: This review specifically focuses on the use of video consultation in diabetes management, in comparison to standard care. The population of chronic condition sufferers in the UK is considerable and teleconsultation use has, in recent years, been explored. COVID‐19 has created an additional pressure on health services to use teleconsultation. Diabetes mellitus affects approximately four million people in the UK. If clinical outcomes are uncompromised, the benefits of using a remote service could encourage the use of video consultation for diabetes management in normal practice.

Aims: A systematic review of the use of video consultation in place of standard consultation in the management of diabetes mellitus. Both clinical and non‐clinical outcomes are reviewed, in addition to patient satisfaction levels after using video consultation.

Methods: A systematic literature search was conducted to select published articles from web‐based health databases. Data extraction and analysis of results followed.

Results: Twelve studies were selected. Overall, the clinical outcomes (HbA_1c, low‐density lipoprotein levels and blood pressure) appeared to be uncompromised with the use of video consultation. Patient satisfaction was high, with few limitations found. The economic and time saving benefits of this approach proved to be additional advantages.

Conclusions: Despite there being a lack of literature identified in this field, the results support the use of video consultation in diabetes management. The evidence suggests that this approach should be utilised in the time of COVID‐19 and beyond. Future research should assess the use of video consultation over a reasonable duration through randomised controlled trials. Copyright © 2022 John Wiley & Sons.

How is the organisational settings, content and availability of comprehensive multidisciplinary pulmonary rehabilitation for people with COPD in primary healthcare in Norway: a cross-sectional study

OBJECTIVE

To examine the organisational settings, content and availability of comprehensive multidisciplinary pulmonary rehabilitation (PR) programmes for people with chronic obstructive pulmonary disease (COPD) in primary healthcare in Norway.

DESIGN

This was a cross-sectional survey study examining the content, organisational settings and availability of comprehensive multidisciplinary PR for people with COPD.

SETTING AND PARTICIPANTS

When the survey was conducted, Norway had 436 municipalities/primary healthcare services who were invited to participate.

OUTCOME MEASURES

The main outcome was the question related to accessibility to a PR programme in primary healthcare. We also examined in what degree the single interventions which are a part of a PR programme were one of the municipalities services and if there were regional differences regarding PR.

RESULTS

Of the 436 municipalities, 158 answered the survey (36% response rate), and the survey covered for 45% of the total population in Norway. Five per cent of the responders reported having multidisciplinary PR for patients with COPD. The most frequently reported single interventions that can be a part of a multidisciplinary PR programme were reported as follows: group exercise training for all diagnoses (27%), reablement (25%) and home-care treatment by a physiotherapist and/or occupational therapist (24%). Southern-Eastern Norway had a significantly lower number of these interventions than Western Norway, Central Norway, and Northern Norway (p<0.001).

CONCLUSION

Only 5% of the Norwegian primary healthcare services (municipalities) had a multidisciplinary PR programme for patients with COPD. PR is the most important and cost-effective treatment within integrated care of patients with COPD. National strategies are therefore needed to increase the availability of PR for patients with COPD in Norwegian municipalities.

Potential downside issues with telemedicine for individuals with chronic respiratory diseases

Telemedicine refers to the use of communications technologies to provide or enhance medical care through mitigating the negative effects of patient-caregiver distance on medical evaluation and treatment. The general concept, telemedicine, can refer to a number of interventions, such as telemonitoring, tele-consultations, tele-education, tele-communication, and tele-rehabilitation. While telemedicine has seen steady growth its trajectory has increased during the COVID-19 pandemic. As a tool in health care delivery, telemedicine is often met with patient satisfaction often resulting from ease of use and accessibility.  Additionally, outcomes may improve, although the medical literature is not consistent in this regard.  However, enthusiasm over its beneficial effects should be tempered by negative aspects, including the decrease in direct patient-clinician interaction (such as loss of information from the physical examination) and potentially serious privacy risks. Finding a happy median between positive and negative features of telemedicine remains a work in progress.

Do Not Give Up Your Stethoscopes Yet—Telemedicine for Chronic Respiratory Diseases in the Era of COVID-19

Telemedicine in its many forms has been utilized across numerous medical specialties to facilitate and expand access to medical care, optimize existing healthcare infrastructure to encourage patient–provider communication, reduce provider burnout, and improve patient surveillance. Since the emergence of the novel coronavirus (COVID-19) pandemic there has been widening of existing socioeconomic disparities in healthcare access for those with chronic respiratory diseases, sparking interest in expanding the use of telemedicine modalities to enhance access to pulmonology specialist care, pulmonary rehabilitation, symptom monitoring, and early identification of clinical exacerbations. Furthermore, the use of telemedicine has been expanded into the intensive care setting to improve patient outcomes and offset provider demands following the increase in critically ill patients due to COVID-19. While an invaluable modality by which to broaden healthcare access and increase the efficacy of care delivery, telemedicine must be used in conjunction with face-to-face physical evaluation and appropriate clinical testing to optimize its benefit. We present here our view of the benefits and disadvantages of the use of telemedicine in the management of chronic respiratory disorders from the perspective of practicing clinicians.

The Role of Digital Tools in the Timely Diagnosis and Prevention of Acute Exacerbations of COPD: A Comprehensive Review of the Literature

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease of the airways and lung parenchyma with multiple systemic manifestations. Exacerbations of COPD are important events during the course of the disease, as they are associated with increased mortality, severe impairment of health-related quality of life, accelerated decline in lung function, significant reduction in physical activity, and substantial economic burden. Telemedicine is the use of communication technologies to transmit medical data over short or long distances and to deliver healthcare services. The need to limit in-person appointments during the COVID-19 pandemic has caused a rapid increase in telemedicine services. In the present review of the literature covering published randomized controlled trials reporting results regarding the use of digital tools in acute exacerbations of COPD, we attempt to clarify the effectiveness of telemedicine for identifying, preventing, and reducing COPD exacerbations and improving other clinically relevant outcomes, while describing in detail the specific telemedicine interventions used.

Use of a Digital Chronic Obstructive Pulmonary Disease Respiratory Tracker in a Primary Care Setting: A Feasibility Study

Introduction

Telemonitoring is a promising self-management strategy to improve health care outcomes. This study evaluated real-world adoption of the chronic obstructive pulmonary disease (COPD) Co-Pilot daily symptom monitoring tool by patients and primary care providers (PCPs).

Methods

An open-label, 6-month, single-arm, multicenter, noninterventional feasibility study enrolled 97 patients aged ≥ 40 years with symptomatic or poorly controlled COPD and ≥ 10 pack-year smoking history. Patients received smartphones and training to use the COPD Co-Pilot application. During the study, patients tracked symptoms daily; an increase in symptom score of ≥ 1.0 point from baseline (symptom alert) prompted patients to contact their PCP via toll-free number. The primary endpoint was time to clinical recommendation (TTCR) from a symptom alert; adherence to completing daily symptom reports through the COPD Co-Pilot application and patient satisfaction were also measured.

Results

Overall, 87 of 96 patients (90.6%) received 2142 symptom alerts; 42 alerts (equivalent to 2% of all symptom alerts) resulted in 23 patients contacting their PCP. Median TTCR was 7.1 h (interquartile range [IQR]: 4.0–29.9). Among 15 patients using the toll-free number, median TTCR was 2.1 h (IQR 0.0–7.2) versus 19.6 h (IQR 4.5–45.2) for eight patients using other contact methods. Average COPD Co-Pilot adherence overall was 75.2% (95% CI 74.6–75.9). Patients responded favorably regarding the application’s ease of use, functionality, and information provided.

Conclusions

The COPD Co-Pilot tool was associated with relatively high levels of adherence, suggesting patients’ willingness to monitor symptoms daily. Although a limited number of patients initiated PCP contact, patients who used the study-provided toll-free number had substantially shorter median TTCR, suggesting that this tool could help empower patients to better manage their COPD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41030-021-00168-3.

Sensor-based platforms for remote management of chronic diseases in developing regions: A qualitative approach examining the perspectives of healthcare professionals

The continuous monitoring of chronic diseases serves as one of the cornerstones in the efforts to improve the quality of life of patients and maintain the healthcare services provided to them. This study aims to provide an in-depth understanding of the perspectives of healthcare professionals on using sensor-based networks (SBN) used for remote and continuous monitoring of patients with chronic illness in Kosovo, a developing country. A qualitative research method was used to interview 26 healthcare professionals. The study results demonstrate the positive attitudes of participants to using SBN, and considers their concerns on the impact of these platforms on the patient's life, the number of visits in the medical centre, data privacy concerning interactions between patients and their medical personnel and the costs of the platform. Further to that, the study makes an important contribution to knowledge by identifying the challenges and drawbacks of these platforms and provides recommendations for system designers.

Improving primary care access to respirologists using eConsult

BACKGROUND

Patients and primary care providers (PCPs) can experience frustration about poor access to specialist care. The Champlain Building Access to Specialists through eConsultation (BASETM) is a secure online platform that allows PCPs to ask a clinical question to 142 different specialty groups. The specialist is expected to respond within 7 days.

METHODS

This is a retrospective review of the Champlain BASETM respirology eConsults from January 2017 to December 2018. The eConsults were categorized by types of questions asked by the referring provider and by the clinical content of the referral. Specialists' response time and time spent answering the clinical question were analyzed. Referring providers' close-out surveys were reviewed to assess the impact of the respirology eConsult service on traditional referral rates and clinical course of action.

RESULTS

Of the 26 679 cases submitted to the Champlain BASE TM eConsult service, 268 were respirology cases (1%). 91% were sent by family physicians and 9% by nurse practitioners. The median time to respond by specialists was 0.8 days, and the median time billed by specialists was 20 min. The most common topics were pulmonary nodules and masses (16.4%), cough (10.4%), infective problems (8.6%), chronic obstructive pulmonary disease (8.6%) and dyspnea Not Yet Diagnosed (NYD) (7.8%). The most common types of questions asked by PCP were related to investigations warranted (43.1% of cases), general management (17.5%), monitoring (12.6%), need for a respirology referral (12.3%) and drug of choice (6.3%). In 23% of cases, the PCP indicated they were planning to refer the patient for an in-person consultation but no longer needed to after receiving the eConsult advice (avoided referrals). On the other hand, in 13% of cases, the PCP was not going to refer but did after the eConsult (prompted referrals). The eConsult led to a new or additional clinical course of action by the PCP in 49% of cases. In 51% of cases, the PCP suggested the clinical topic would be well suited to a CME event.

CONCLUSIONS

Participation in eConsult services can improve timely access to respirologists while potentially avoiding clinic visits and significantly impacting referring PCPs clinical course of action. Using the most common clinical topics and types of questions for CME planning should be considered. Future research may include a cost analysis and provider perspectives on the role of eConsult in respirology care.

Mobile applications in peripheral arterial disease (PAD): a review and introduction of a new innovative telemonitoring application: JBZetje

Introduction:Peripheral arterial disease (PAD) is an occlusive vascular disease of the lower extremities with increasing incidence and prevalence numbers and therefore rising health care costs. Mobile applications have great potential to improve health system efficiency and can assist in overcoming the increasing health care costs. In this review all available mobile applications developed for PAD are summarized and a new innovative application is introduced.Areas covered:Available applications for PAD are scarce and currently aim at prevention, teleconsultation and telemonitoring via questionnaires and activity tracking. Integration in the daily workflow of the physician is an overlooked aspect of these applications. JBZetje is an innovative mobile application that provides remote care, information services and self-service tools, and enables connection with the electronic health record (EHR).Expert opinion:Connection of the application with the EHR generates a complete overview of a patient's current health status. This will reinforce the tendency toward personalized medicine and will probably lead to reduced health care costs and increase the quality of care. Future feasibility studies should answer the question whether the use of mobile applications is feasible in the PAD population.

Telemedicine for Follow-up Management of Patients After Liver Transplantation: Cohort Study

Background

Technical capabilities for performing liver transplantation have developed rapidly; however, the lack of available livers has prompted the utilization of edge donor grafts, including those donated after circulatory death, older donors, and hepatic steatosis, thereby rendering it difficult to define optimal clinical outcomes.

Objective

We aimed to investigate the efficacy of telemedicine for follow-up management after liver transplantation.

Methods

To determine the efficacy of telemedicine for follow-up after liver transplantation, we performed a clinical observation cohort study to evaluate the rate of recovery, readmission rate within 30 days after discharge, mortality, and morbidity. Patients (n=110) who underwent liver transplantation (with livers from organ donation after citizen's death) were randomly assigned to receive either telemedicine-based follow-up management for 2 weeks in addition to the usual care or usual care follow-up only. Patients in the telemedicine group were given a robot free-of-charge for 2 weeks of follow-up. Using the robot, patients interacted daily, for approximately 20 minutes, with transplant specialists who assessed respiratory rate, electrocardiogram, blood pressure, oxygen saturation, and blood glucose level; asked patients about immunosuppressant medication use, diet, sleep, gastrointestinal function, exercise, and T-tube drainage; and recommended rehabilitation exercises.

Results

No differences were detected between patients in the telemedicine group (n=52) and those in the usual care group (n=50) regarding age (P=.17), the model for end-stage liver disease score (MELD, P=.14), operation time (P=.51), blood loss (P=.07), and transfusion volume (P=.13). The length and expenses of the initial hospitalization (P=.03 and P=.049) were lower in the telemedicine group than they were in the usual care follow-up group. The number of patients with MELD score ≥30 before liver transplantation was greater in the usual care follow-up group than that in the telemedicine group. Furthermore, the readmission rate within 30 days after discharge was markedly lower in the telemedicine group than in the usual care follow-up group (P=.02). The postoperative survival rates at 12 months in the telemedicine group and the usual care follow-up group were 94.2% and 90.0% (P=.65), respectively. Warning signs of complications were detected early and treated in time in the telemedicine group. Furthermore, no significant difference was detected in the long-term visit cumulative survival rate between the two groups (P=.50).

Conclusions

Rapid recovery and markedly lower readmission rates within 30 days after discharge were evident for telemedicine follow-up management of patients post–liver transplantation, which might be due to high-efficiency in perioperative and follow-up management. Moreover, telemedicine follow-up management promotes the self-management and medication adherence, which improves patients’ health-related quality of life and facilitates achieving optimal clinical outcomes in post–liver transplantation.

Telemedicine Services in Chronic Obstructive Pulmonary Disease: A Systematic Review of Patients' Adherence

BACKGROUND

The current systematic review aimed to determine the effect of telemedicine services on adherence in patients with chronic obstructive pulmonary disease (COPD) and to describe the type of adherence and applied devices and modules.

MATERIALS AND METHODS

We reviewed PubMed, Scopus, Web of Science, and Embase databases to identify relevant studies from the time of inception of these databases to March 10, 2019, using three groups of keywords. The first group comprised words describing COPD, the second group included words describing types of telemedicine interventions, and the third group contained words describing adherence. The reference list of identified articles was also hand-searched to retrieve possibly relevant articles.

RESULTS

In total 21 articles were included, in which 13 reported a positive effect for telemedicine on patients' adherence. Adherence to treatment was classified under six categories. The highest frequency belongs to the adherence to performing exercises and participation in training sessions, using the system, using devices, measuring (like blood pressure, oxygen saturation, heart rate, weight, temperature, sputum volume) and reporting symptoms and the results of measurements, completing tasks, and medication.

CONCLUSION

This study demonstrated the effectiveness of telemedicine services on adherence to treatment plans in patients with COPD. The following factors contribute to the effectiveness of telemedicine services: patient support by healthcare professionals and easy access to them, uninterrupted execution of telemedicine programs, follow-up and supervision of providers, creating and maintaining motivation in patients, and provision of different self-management modules.

Exploring health literacy needs in Chronic obstructive pulmonary disease (COPD): Associations between demographic, clinical variables, psychological well-being and health literacy

BACKGROUND

The World Health Organization (WHO) points to health literacy as an important factor in prevention and control of non-communicable diseases (NCDs), including COPD.

OBJECTIVE

To investigate associations between selected demographic and clinical variables, psychological well-being and health literacy.

METHODS

Health literacy was measured using the nine domain Health Literacy Questionnaire (HLQ) and one domain from the eHealth Literacy Questionnaire (eHLQ). Using data from a cross-sectional sample of 158 people with COPD, recruited from a hospital-based patient list period (2014-2016), multiple regression analyses were performed.

RESULTS

The strongest associated variables with health literacy were psychological well-being, measured by the WHO-5 well-being index and education, indicating that higher psychological well-being and educational level are associated with higher levels of health literacy.

CONCLUSION

The present study highlights the importance of specifically looking to psychological factors in determining potentially health literacy needs among people with COPD.

Effectiveness of a Mobile Health and Self-Management App for High-Risk Patients With Chronic Obstructive Pulmonary Disease in Daily Clinical Practice: Mixed Methods Evaluation Study

BACKGROUND

Mobile health and self-management interventions may positively affect behavioral change and reduce hospital admissions for patients with chronic obstructive pulmonary disease (COPD). However, not all patients qualify for these interventions, and systematic, comprehensive information on implementation- and compliance-related aspects of mobile self-management apps is lacking. Due to the tendency to target digital services to patients in stable phases of disease, it is especially relevant to focus on the use of these services in broad clinical practice for patients recently discharged from hospital.

OBJECTIVE

This study aims to evaluate the effects of a mobile health and self-management app in clinical practice for recently discharged patients with COPD on use of the app, self-management, expectations, and experiences (technology acceptance); patients' and nurses' satisfaction; and hospital readmissions.

METHODS

A prototype of the app was pilot tested with 6 patients with COPD. The COPD app consisted of an 8-week program including the Lung Attack Action Plan, education, medication overview, video consultation, and questionnaires (monitored by nurses). In the feasibility study, adult patients with physician-diagnosed COPD, access to a mobile device, and proficiency of the Dutch language were included from a large teaching hospital during hospital admission. Self-management (Partners in Health Scale), technology acceptance (Unified Theory Acceptance and Use of Technology model), and satisfaction were assessed using questionnaires at baseline, after 8 weeks, and 20 weeks. Use was assessed with log data, and readmission rates were extracted from the electronic medical record.

RESULTS

A total of 39 patients were included; 76.4% (133/174) of patients had to be excluded from participation, and 48.9% of those patients (65/133) were excluded because of lack of digital skills, access to a mobile device, or access to the internet. The COPD app was opened most often in the first week (median 6.0; IQR 3.5-10.0), but its use decreased over time. The self-management element knowledge and coping increased significantly over time (P=.04). The COPD app was rated on a scale of 1-10, with an average score by patients of 7.7 (SD 1.7) and by nurses of 6.3 (SD 1.2). Preliminary evidence about the readmission rate showed that 13% (5/39) of patients were readmitted within 30 days; 31% (12/39) of patients were readmitted within 20 weeks, compared with 14.1% (48/340) and 21.8% (74/340) in a preresearch cohort, respectively.

CONCLUSIONS

The use of a mobile self-management app after hospital discharge seems to be feasible only for a small number of patients with COPD. Patients were satisfied with the service; however, use decreased over time, and only knowledge and coping changed significantly over time. Therefore, future research on digital self-management interventions in clinical practice should focus on including more difficult subgroups of target populations, a multidisciplinary approach, technology-related aspects (such as acceptability), and fine-tuning its adoption in clinical pathways.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04540562; https://clinicaltrials.gov/ct2/show/NCT04540562.

Follow-up with Telemedicine in Early Discharge for COPD Exacerbations: Randomized Clinical Trial (TELEMEDCOPD-Trial)

The results reported by different studies on telemonitoring in patients with chronic obstructive pulmonary disease (COPD) have been contradictory, without showing clear benefits to date. The objective of this study was to ascertain whether an early discharge and home hospitalization telehealth program for patients with COPD exacerbation is as effective as and more efficient than a traditional early discharge and home hospitalization program. A prospective experimental non-inferiority study, randomized into two groups (telemedicine/control) was conducted. The telemedicine group underwent monitoring and was required to transmit data on vital constants and ECGs twice per day, with a subsequent telephone call and 2 home visits by healthcare staff (intermediate and at discharge). The control group received daily visits. The main variable was time until first exacerbation. The secondary variables were: number of exacerbations; use of healthcare resources; satisfaction; quality of life; anxiety-depression; and therapeutic adherence, measured at one and 6 months of hospital discharge. A total of 116 patients were randomized (58 to each group) without significant differences in baseline characteristics or time until first exacerbation, i.e. median 48 days (pp. 25-75:23-120) in the control group, and 47 days (pp. 25-75:19-102) in the intervention group; p = 0.52). A significant decrease in the number of visits was observed in the intervention versus the control group, 3.8 ± 1 vs 5.1 ± 2(p = 0.001), without significant differences in the number of exacerbations. In conclusion follow-up via a telemedicine program in early discharge after hospitalization is as effective as conventional home follow up, being the cost of either strategy not significantly different.

Perceptions of Practitioners on Telehealth and App Use for Smoking Cessation and COPD Care-An Exploratory Study

Background and objectives: With the digitalization of modern healthcare delivery, digital media adoption in clinical practice is increasing. Also, healthcare professionals are more and more confronted with patients using smartphone-based health applications (apps). This exploratory study aimed at surveying perceptions on such apps in the context of lung health among a cross section of Austrian practitioners involved in pulmonary care. Materials and Methods: The online questionnaire in German assessed socio-demographic characteristics, telehealth readiness as well as opinions on smoke-free and COPD (chronic obstructive pulmonary disease) apps. We used descriptive statistics to report the finding. Results: We received valid responses from 55 participants (mean age 52.3 years, 69.1% males). Telehealth readiness was medium, indicating existence of certain barriers adversely impacting telehealth use. As for apps targeting smoking cessation and COPD, respondents indicated high relevance for visualization aspects for patients and control/overview features for the treating doctors. Only 40% of participants indicated that they would recommend a COPD app to an older patient. Conclusions: In smoking cessation therapy, doctors commonly adhere to the “5 A’s”: Ask, Advise, Assess, Assist, and Arrange. We suggest adding “App” as sixth A, assuming that in patient follow-up most of the other A’s could also be supported or even replaced by app features in the challenging task to tackle smoking-associated non-communicable diseases.

Challenges and opportunities for telehealth in the management of chronic obstructive pulmonary disease: a qualitative case study in Greece

BACKGROUND

Telehealth (TH) was introduced as a promising tool to support integrated care for the management of chronic obstructive pulmonary disease (COPD). It aims at improving self-management and providing remote support for continuous disease management. However, it is often not clear how TH-supported services fit into existing pathways for COPD management. The objective of this study is to uncover where TH can successfully contribute to providing care for COPD patients exemplified in a Greek care pathway. The secondary objective is to identify what conditions need to be considered for successful implementation of TH services.

METHODS

Building on a single case study, we used a two-phase approach to identify areas in a Greek COPD care pathway where care services that are recommended in clinical guidelines are currently not implemented (challenges) and areas that are not explicitly recommended in the guidelines but that would benefit from TH services (opportunities). In phase I, we used the care delivery value chain framework to identify the divergence between the clinical guidelines and the actual practice captured by a survey with COPD healthcare professionals. In phase II, we conducted in-depth interviews with the same healthcare professionals based on the discovered divergences. The responses were analyzed with respect to identified opportunities for TH and care pathway challenges.

RESULTS

Our results reveal insights in two areas. First, several areas with challenges were identified: patient education, self-management, medication adherence, physical activity, and comorbidity management. TH opportunities were perceived as offering better bi-directional communication and a tool for reassuring patients. Second, considering the identified challenges and opportunities together with other case context details a set of conditions was extracted that should be fulfilled to implement TH successfully.

CONCLUSIONS

The results of this case study provide detailed insights into a care pathway for COPD in Greece. Addressing the identified challenges and opportunities in this pathway is crucial for adopting and implementing service innovations. Therefore, this study contributes to a better understanding of requirements for the successful implementation of integrated TH services in the field of COPD management. Consequently, it may encourage healthcare professionals to implement TH-supported services as part of routine COPD management.

Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2)

Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.

Telemedicine in COPD: An Overview by Topics

COPD is a major cause of morbidity and mortality worldwide and carries a huge and growing economic and social burden. Telemedicine might allow the care of patients with limited access to health services and improve their self-management. During the COVID-19 pandemic, patient's safety represents one of the main reasons why we might use these tools to manage our patients. The authors conducted a literature search in MEDLINE database. The retrieval form of the Medical Subject Headings (Mesh) was ((Telemedicine OR Tele-rehabilitation OR Telemonitoring OR mHealth OR Ehealth OR Telehealth) AND COPD). We only included systematic reviews, reviews, meta-analysis, clinical trials and randomized-control trials, in the English language, with the selected search items in title or abstract, and published from January 1st 2015 to 31st May 2020 (n = 56). There was a positive tendency toward benefits in tele-rehabilitation, health-education and self-management, early detection of COPD exacerbations, psychosocial support and smoking cessation, but the heterogeneity of clinical trials and reviews limits the extent to which this value can be understood. Telemonitoring interventions and cost-effectiveness had contradictory results. The literature on teleconsultation was scarce during this period. The non-inferiority tendency of telemedicine programmes comparing to conventional COPD management seems an opportunity to deliver quality healthcare to COPD patients, with a guarantee of patient's safety, especially during the COVID-19 outbreak.

Design of a Training Model for Remote Management of Patients Hospitalized at Home

Purpose

Hospitalization at Home (HaH) has proven to be more efficient and effective than conventional one, but it also requires a higher number of resources and specialised personnel. Information technologies can make this process scalable and allow physicians and nurses to deliver remote healthcare services for patients hospitalized at home. However, a correct and satisfactory usage of technology requires an adequate training of professionals and patients. This paper describes a new model for training healthcare professionals on managing remote ICT-based services for Hospitalization at Home.

Methods

The model was defined based on mix-method that combined the PICO model and a User Centred Design methodology, oriented to identify and discover the healthcare professionals needs and the training instruments in the literature that directly involved these professionals. These aspects were used in the definition and development of the assessment framework of the proposed training model.

Results

A training model for healthcare professionals focused on achieving an effective uptake of complex digital interventions such as Hospitalization at Home was defined. The selected mix-method led to the identification of four different blocks, that were considered as the main areas to include in a training programme. The model identifies measurable elements for assessing acceptability, workability increment and integration into daily clinical practice outcomes, as well as for evaluating the proposed training content and its outcomes.

Conclusions

The proposed training model highlights the key aspects of training health professionals to favour an effective and successful implementation of complex technological healthcare interventions in the context of ICT-based HaH ICT.

Complex System for Monitoring the Patient's Condition and Diagnosis of Bronchial Asthma

In the present work, three versions of implementation of non-invasive bronchial asthma diagnostic system based on the author’s technique of noninvasive diagnosis of bronchopulmonary diseases are considered. The offered variants of diagnostic system can be used both in medical institutions and at patient’s home for the control of the patient’s condition with the purpose of monitoring the dynamics of the disease during treatment, as well as for preventive purposes. Three variants of implementation of the diagnostic system with various complexity are considered. The results of a radiofrequency scanning of a human chest phantom with included heterogeneity simulating the presence of sputum in the human chest is a consequence of bronchial asthma.

Evaluating an Intervention Program Using WeChat for Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

Background

The application of telemedicine in home pulmonary rehabilitation interventions for the management of patients with chronic obstructive pulmonary disease (COPD) has achieved promising results.

Objective

This study aimed to develop a WeChat official account (Pulmonary Internet Explorer Rehabilitation [PeR]) based on social media. It further evaluated the effect of PeR on the quality of life, symptoms, and exercise self-efficacy of patients with COPD.

Methods

The functional modules of PeR were developed by a multidisciplinary team according to the electronic health–enhanced chronic care model (eCCM) components. A total of 106 patients were randomly selected (53 in the PeR group and 53 in the outpatient face-to-face group [FtF]). Pulmonary rehabilitation intervention was conducted for 3 months, and the outcome was observed for 3 months. The primary outcome was patient quality of life measured with the COPD assessment test (CAT). The secondary outcomes were evaluated using the modified Medical Research Council scale (mMRC), exercise self-regulatory efficacy scale (Ex-SRES), and St George’s Respiratory Questionnaire (SGRQ).

Results

The intention-to-treat analysis was used in the study. A total of 94 participants completed the 6-month pulmonary rehabilitation program. No statistically significant differences were observed in CAT (F_1,3=7.78, P=.001), Ex-SRES (F_1,3=21.91, P<.001), and mMRC scores (F_1,3=29.64, P<.001) between the two groups with the variation in time tendency. The Ex-SRES score had a significant effect on the CAT score (P=.03). The partial regression coefficient of Ex-SRES to CAT was 0.81, and Exp (B) was 2.24.

Conclusions

The telemedicine technology was effective using the eCCM combined with a behavioral intervention strategy centering on self-efficacy. Pulmonary rehabilitation at home through PeR and FtF could improve the sense of self-efficacy and quality of life and alleviate symptoms in patients with COPD.

Trial Registration

Chinese Clinical Trial Registry ChiCTR1900022770; https://tinyurl.com/tmmvpq3

Lack of Telemedicine Training in Academic Medicine: Are We Preparing the Next Generation?

Background: Telemedicine focuses on providing medical care to patients in remote locations using telecommunication technologies. It has been shown to be cost-effective, improve health outcomes, and enhance patient satisfaction. This study examines the extent to which medical students and resident physicians are exposed to telemedicine during training. Materials and Methods: The authors accessed the American College of Graduate Medical Education (ACGME) Residency Milestones from specialties and subspecialties mentioned in the 2018 Milestones National Report and searched for key terms, including "Technology," "Telemedicine," "Telehealth," "EMR," "Electronic Medical Record," "EHR," "Electronic Health Record," "Electronics," and "Social Media." The authors also accessed the 2018 American Association of Medical Colleges (AAMC) "Curriculum Inventory and Reports" to retrieve data from surveys of medical schools that included telemedicine in required courses and electives for medical students from 2013 to 2018. Results: From the 104 ACGME specialty milestones, only one specialty (Child and Adolescent Psychiatry) mentioned telehealth in its ACGME Milestone document. According to the AAMC data the number of medical schools surveyed increased every academic year from 140 in 2013/2014 to 147 in 2017/2018, telemedicine education in medical school increased significantly from 41% in 2013/2014 to 60% in 2017/2018 (p = 0.0006). However, the growth in telemedicine education plateaued from 56% in 2015/2016 to 60% in 2017/2018 (p = 0.47). Conclusion: Familiarizing medical students with telemedicine is essential; the next generation of health care providers should be equipped with knowledge of telemedicine as a valuable skill to serve populations that do not have direct access to quality medical care. Methods of implementing telemedicine education into more medical schools and residency programs merits further study.

Developing a strategic understanding of telehealth service adoption for COPD care management: A causal loop analysis of healthcare professionals

BACKGROUND

Telehealth services can improve the quality of health services for chronic obstructive pulmonary disease (COPD) management, but the clinical benefits for patients yet not clear. It is crucial to develop a strategy that supports the engagement of healthcare professionals to promote the sustainable adoption of telehealth services further. The aim of the study was to show how variables related to the perception of telehealth services for COPD by different healthcare professionals interact to influence its adoption and to generate advice for future telehealth service implementation.

METHODS

Data was thematically synthesized from published qualitative studies to create causal loop diagrams, further validated by expert interviews. These diagrams visualize dependencies and their polarity between different variables.

RESULTS

Adoption of telehealth services from the nurse's perspective is directly affected by change management and autonomous decision making. From the physician's perspective, perceived value is the most important variable. Physical activity management and positive user experience are considered affecting perceived value for physiotherapists. There is no consensus where self-management services should be positioned in the COPD care pathway.

CONCLUSION

Our results indicate how complex interactions between multiple variables influence the adoption of telehealth services. Consequently, there is a need for multidimensional interventions to achieve adoption. Moreover, key variables were identified that require attention to ensure success of telehealth services. Furthermore, it is necessary to explore where self-management services are best positioned in the care pathway of COPD patients.

Effectiveness of Telemedicine Intervention for Chronic Obstructive Pulmonary Disease in China: A Systematic Review and Meta-Analysis

Background: Telemedicine market in China has been rapidly developing. However, no systematic review has been published in China. Details of the implementation of telemedicine interventions in the chronic obstructive pulmonary disease (COPD) in China have not been described, and the effectiveness of telemedicine interventions is still unclear. Therefore, in this review, we describe the implementation details of telemedicine intervention in China and access the efficacy of telemedicine. Materials and Methods: A literature search was conducted in Embase, Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), Wan Fang Data, and China Science and Technology Journal Database by July 9, 2018. Results: A total number of 24 studies were meta-analyzed. There are many differences during the implementation of telemedicine in China. Quality of life in the group of the telemedicine intervention was better than that in the control group (mean difference = -4.93 [95% confidence interval; CI -6.86 to -3.01], p < 0.00001), but the heterogeneity is high (I² = 86%, p = 0.0001). The rates of hospitalization were lower than those in the control group (odds ratio = 0.24 [95% CI 0.20-0.29], p < 0.00001), and the heterogeneity was low (I² = 25%, p = 0.14). Conclusion: The implementation of telemedicine in China has not yet been standardized. Nonetheless, results of our review indicated that telemedicine in China can improve the quality of life and reduce the rates of hospitalization in COPD patients.

A Low-Cost Breath Analyzer Module in Domiciliary Non-Invasive Mechanical Ventilation for Remote COPD Patient Monitoring

Smart Breath Analyzers were developed as sensing terminals of a telemedicine architecture devoted to remote monitoring of patients suffering from Chronic Obstructive Pulmonary Disease (COPD) and home-assisted by non-invasive mechanical ventilation via respiratory face mask. The devices based on different sensors (CO₂/O₂ and Volatile Organic Compounds (VOCs), relative humidity and temperature (R.H. & T) sensors) monitor the breath air exhaled into the expiratory line of the bi-tube patient breathing circuit during a noninvasive ventilo-therapy session; the sensor raw signals are transmitted pseudonymized to National Health Service units by TCP/IP communication through a cloud remote platform. The work is a proof-of-concept of a sensors-based IoT system with the perspective to check continuously the effectiveness of therapy and/or any state of exacerbation of the disease requiring healthcare. Lab tests in controlled experimental conditions by a gas-mixing bench towards CO₂/O₂ concentrations and exhaled breath collected in a sampling bag were carried out to test the realized prototypes. The Smart Breath Analyzers were also tested in real conditions both on a healthy volunteer subject and a COPD suffering patient.

The virtual physical exam in the 21st century

The modern Western medical encounter follows a strict framework that weaves subjective and objective components into a unifying diagnosis. As health care changes to incorporate new technology, such as virtual health care, the components that lead to diagnosis must likewise evolve. The virtual physical exam has limitations compared with the traditional exam. Despite this limitation, every year more patients are seen virtually with high satisfaction. Data have shown that supplementary real-time patient-provider video telemedicine increases access and extends established patient-physician relationships which will likely fuel increased telemedicine adoption even further. However, to date, there are limited data regarding the validity of the virtual examination compared with the traditional physical exam. In this paper, we review the use of developing technology related to the virtual physical exam.

Digital health for COPD care: the current state of play

Chronic obstructive pulmonary disease (COPD) imposes a huge burden to our healthcare systems and societies. To alleviate the burden, digital health-"the use of digital technologies for health"-has been recognized as a potential solution for improving COPD care at scale. The aim of this review is to provide an overview of digital health interventions in COPD care. We accordingly reviewed recent and emerging evidence on digital transformation approaches for COPD care focusing on (I) self-management, (II) in-hospital care, (III) post-discharge care, (IV) hospital-at-home, (V) ambient environment, and (VI) public health surveillance. The emerging approaches included digital-technology-enabled homecare programs, electronic records, big data analytics, and environment-monitoring applications. The digital health approaches of telemonitoring, telehealth and mHealth support the self-management, post-discharge care, and hospital-at-home strategy, with prospective effects on reducing acute COPD exacerbations and hospitalizations. Electronic records and classification tools have been implemented; and their effectiveness needs to be further evaluated in future studies. Air pollution concentrations in the ambient environment are associated with declined lung functions and increased risks for hospitalization and mortality. In all the digital transformation approaches, clinical evidence on reducing mortality, the ultimate goal of digital health intervention, is often inconsistent or insufficient. Digital health transformation provides great opportunities for clinical innovations and discovery of new intervention strategies. Further research remains needed for achieving reliable improvements in clinical outcomes and cost-benefits in future studies.

A systematic map and in-depth review of European telehealth interventions efficacy for chronic obstructive pulmonary disease

BACKGROUND

Evidence to support the implementation of telehealth (TH) interventions in the management of chronic obstructive pulmonary disease (COPD) varies throughout Europe. Despite more than ten years of TH research in COPD management, it is still not possible to define which TH interventions are beneficial to which patient group. Therefore, informing policymakers on TH implementation is complicated. We aimed to examine the provision and efficacy of TH for COPD management to guide future decision-making.

METHODS

A mapping study of twelve systematic reviews of TH interventions for COPD management was conducted. This was followed by an in-depth review of fourteen clinical trials performed in Europe extracted from the systematic reviews. Efficacy outcomes for COPD management were synthesized.

RESULTS

The mapping study revealed that systematic reviews with a meta-analysis often report positive clinical outcomes. Despite this, we identified a lack of pragmatic trial design affecting the synthesis of reported outcomes. The in-depth review visualized outcomes for three TH categories, which revealed a plethora of heterogeneous outcomes. Suggestions for reporting within these three outcomes are synthesized as targets for future empirical research reporting.

CONCLUSION

The present study indicates the need for more standardized and updated systematic reviews. Policymakers should advocate for improved TH trial designs, focusing on the entire intervention's adoption process evaluation. One of the policymakers' priorities should be the harmonization of the outcome sets, which would be considered suitable for deciding about subsequent reimbursement. We propose possible outcome sets in three TH categories which could be used for discussion with stakeholders.

A sense of belonging: A meta-ethnography of the experience of patients with chronic obstructive pulmonary disease receiving care through telemedicine

AIM

To synthesize the qualitative research in the literature addressing how patients with chronic obstructive pulmonary disease experience care received by telemedicine.

DESIGN

Meta-ethnography.

DATA SOURCES

Twelve studies, published from 2013 - 2018, were identified by a search of relevant systematic databases in June 2017, including updated searches performed in June 2018.

REVIEW METHODS

The studies were reviewed and critically appraised independently by three researchers. The review followed the seven steps of meta-ethnography developed by Noblit and Hare, including a line-of-argument synthesis.

RESULTS

The synthesis revealed three second-order constructs: presence, transparency, and ambivalence. Using a line-of-argument synthesis, a model was developed that showed patients' experience of a sense of belonging when receiving care by telemedicine.

CONCLUSION

This meta-ethnography contributes to the existing and contradictory evidence base of telemedicine to chronic obstructive pulmonary disease patients. It addresses and adds renewed understanding of who would benefit from telemedicine and why, by illustrating the interrelationship between the conditions of telemedicine care, the severity of COPD, and the need for connectedness and emphasizes that the need to belong in telemedicine care increases with the progression of illness burden and severity.

IMPACT

The present study endorses the view that the patients with a severe illness burden are likely to benefit the most when receiving care by telemedicine. However, the benefits rely on the fact that the telemedicine interventions involve emotional, social, and clinical support, including regular contact with healthcare professionals, to meet the requirements to belong.

eHealth for people with COPD in the Netherlands: a scoping review

Background: In the Netherlands, almost 600,000 people had chronic obstructive pulmonary disease (COPD) in 2017. This decreases quality of life for many and each year, COPD leads to approximately 6,800 deaths and about one billion health care expenditures. It is expected that eHealth may improve access to care and reduce costs. However, there is no conclusive scientific evidence available of the added value of eHealth in COPD care. We conducted a scoping review into the use of eHealth in Dutch COPD care. The aim of the research was to provide an overview of all eHealth applications used in Dutch COPD care and to assess these applications on a number of relevant criteria. Methods: In order to make an overview of all eHealth applications aimed at COPD patients in the Netherlands, literature was searched in the electronic databases PubMed and Google Scholar. In addition, Dutch health care websites were searched for applications that have been evaluated for effectiveness and reliability. The identified eHealth applications were assessed according to five relevant quality criteria, eg, whether research has been conducted on the effectiveness. Results: Thirteen health care programs and patient platforms in COPD care have been found that use eHealth. In addition, 13 self-care and informative websites and 15 mobile apps were found that are available to citizens and patients. Five of 13 care programs and patient platforms were found to be effective in improving quality of life or reducing hospital admissions in small pilot studies. The effectiveness of these and the other eHealth applications should be established in larger studies in the future. Discussion: More research into the effectiveness of eHealth applications for COPD patients is needed. We recommend to develop a nationwide open source platform where well-evaluated eHealth applications can be showcased for patients and health care providers to improve COPD care.

Elderly patients with COPD require more health care than elderly heart failure patients do in a hospital-based home care setting

Background

Elderly patients with advanced stages of COPD or chronic heart failure (CHF) often require hospitalization due to exacerbations. We hypothesized that telemonitoring supported by hospital-based home care (HBHC) would detect exacerbations early, thus, reducing the number of hospitalization. We also speculated that patients with advanced COPD or CHF would present differences regarding exacerbation frequency and the need of HBHC.

Methods

The Health Diary system, based on digital pen technology, was employed. Patients aged ≥65 years with ≥2 hospitalizations the previous year were included. Exacerbations were categorized and treated as either COPD or CHF exacerbation by an experienced physician. All HBHC contacts (home visits or telephone consultations) were registered.

Results

Ninety-four patients with advanced diseases were enrolled (36 COPD and 58 CHF subjects) of which 53 subjects (19 COPD and 34 CHF subjects) completed the 1-year study period. Death was the major reason for not finalizing the study. Compared to the 1-year prior inclusion, the intervention significantly reduced hospitalization. Although COPD subjects were younger with less comorbidity, exacerbations and HBHC contacts were significantly greater in this group.

Conclusions

COPD subjects exhibit exacerbations more frequently, mainly due to disease characteristics, thus, demanding much more HBHC.

What do Cochrane systematic reviews say about telemedicine for healthcare?

BACKGROUND

Telemedicine has emerged as a tool for overcoming the challenges of healthcare systems and is likely to become increasingly viable, since information and communication technologies have become more sophisticated and user-friendly.

OBJECTIVE

We aimed to identify all Cochrane systematic reviews (CSRs) on telemedicine within healthcare and to summarize the current evidence regarding its use.

DESIGN AND SETTING

Review of CSRs, developed at the Discipline of Emergency and Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo.

METHODS

We searched for studies that compared use of telemedicine with conventional treatment or management of diseases within healthcare. Diagnostic telemedicine studies or studies using automatic text, voice-text or even self-managed care were excluded. The main characteristics and the certainty of evidence were synthetized and critically discussed by all authors.

RESULTS

We included 10 CSRs that investigated a broad range of diseases. There is still insufficient evidence to determine what types of telemedicine interventions are effective, for which patients and in which settings, and whether such interventions can be used as a replacement for the standard treatment. Harm relating to telemedicine technologies needs to be better investigated and addressed.

CONCLUSION

Telemedicine might be an excellent way to facilitate access to treatment, monitoring and dissemination of important clinical knowledge. However, given the recognition of systematic reviews as the best evidence resource available for decision-making, further randomized controlled trials with stricter methods are necessary to reduce the uncertainties in evidence-based use of telemedicine.

Can a telemonitoring system lead to decreased hospitalization in elderly patients?

INTRODUCTION

Growing populations of elderly patients with chronic obstructive pulmonary disease (COPD) or heart failure (HF) require more healthcare. A four-year telehealth intervention - the Health Diary system based on digital pen technology - was implemented. We hypothesized that study patients with advanced COPD or HF would have lower rates of hospitalization when using the Health Diary. The aim was to investigate the effects of the intervention on healthcare costs and the number of hospitalizations, as well as other care required in COPD and HF patients.

METHODS

Patients were introduced to the telemonitoring system which was supervised by a specialized hospital-based home care (HBHC) unit. Staff associated with this unit were responsible for the healthcare provided. The study included patients with COPD or HF, aged ≥ 65 years who were frequently hospitalized due to exacerbations - at least two inpatient episodes within the last 12 months. Observed number of hospitalizations and total healthcare costs were compared with the expected values, which were calculated using the generalized estimating equations (GEE) method.

RESULTS

A total of 36 COPD and 58 HF patients with advanced stages of disease were included. The number of hospitalizations was significantly reduced for both HF and COPD patients participating in telemonitoring. Accordingly, hospitalization costs were significantly reduced for both groups, but the total healthcare cost was not significantly different from the expected costs.

CONCLUSION

A telemonitoring system, the Health Diary, combined with a specialized HBHC unit significantly decreases the need for hospital care in elderly patients with advanced HF or COPD without increasing total healthcare costs.