Effects of use of an eHealth platform e-Vita for COPD patients on disease specific quality of life domains

User Engagement With mHealth Interventions to Promote Treatment Adherence and Self-Management in People With Chronic Health Conditions: Systematic Review

BACKGROUND

There are numerous mobile health (mHealth) interventions for treatment adherence and self-management; yet, little is known about user engagement or interaction with these technologies.

OBJECTIVE

This systematic review aimed to answer the following questions: (1) How is user engagement defined and measured in studies of mHealth interventions to promote adherence to prescribed medical or health regimens or self-management among people living with a health condition? (2) To what degree are patients engaging with these mHealth interventions? (3) What is the association between user engagement with mHealth interventions and adherence or self-management outcomes? (4) How often is user engagement a research end point?

METHODS

Scientific database (Ovid MEDLINE, Embase, Web of Science, PsycINFO, and CINAHL) search results (2016-2021) were screened for inclusion and exclusion criteria. Data were extracted in a standardized electronic form. No risk-of-bias assessment was conducted because this review aimed to characterize user engagement measurement rather than certainty in primary study results. The results were synthesized descriptively and thematically.

RESULTS

A total of 292 studies were included for data extraction. The median number of participants per study was 77 (IQR 34-164). Most of the mHealth interventions were evaluated in nonrandomized studies (157/292, 53.8%), involved people with diabetes (51/292, 17.5%), targeted medication adherence (98/292, 33.6%), and comprised apps (220/292, 75.3%). The principal findings were as follows: (1) >60 unique terms were used to define user engagement; "use" (102/292, 34.9%) and "engagement" (94/292, 32.2%) were the most common; (2) a total of 11 distinct user engagement measurement approaches were identified; the use of objective user log-in data from an app or web portal (160/292, 54.8%) was the most common; (3) although engagement was inconsistently evaluated, most of the studies (99/195, 50.8%) reported >1 level of engagement due to the use of multiple measurement methods or analyses, decreased engagement across time (76/99, 77%), and results and conclusions suggesting that higher engagement was associated with positive adherence or self-management (60/103, 58.3%); and (4) user engagement was a research end point in only 19.2% (56/292) of the studies.

CONCLUSIONS

The results revealed major limitations in the literature reviewed, including significant variability in how user engagement is defined, a tendency to rely on user log-in data over other measurements, and critical gaps in how user engagement is evaluated (infrequently evaluated over time or in relation to adherence or self-management outcomes and rarely considered a research end point). Recommendations are outlined in response to our findings with the goal of improving research rigor in this area.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022289693; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022289693.

Mapping Digital Public Health Interventions Among Existing Digital Technologies and Internet-Based Interventions to Maintain and Improve Population Health in Practice: Scoping Review

BACKGROUND

The rapid progression and integration of digital technologies into public health have reshaped the global landscape of health care delivery and disease prevention. In pursuit of better population health and health care accessibility, many countries have integrated digital interventions into their health care systems, such as web-based consultations, electronic health records, and telemedicine. Despite the increasing prevalence and relevance of digital technologies in public health and their varying definitions, there has been a shortage of studies examining whether these technologies align with the established definition and core characteristics of digital public health (DiPH) interventions. Hence, the imperative need for a scoping review emerges to explore the breadth of literature dedicated to this subject.

OBJECTIVE

This scoping review aims to outline DiPH interventions from different implementation stages for health promotion, primary to tertiary prevention, including health care and disease surveillance and monitoring. In addition, we aim to map the reported intervention characteristics, including their technical features and nontechnical elements.

METHODS

Original studies or reports of DiPH intervention focused on population health were eligible for this review. PubMed, Web of Science, CENTRAL, IEEE Xplore, and the ACM Full-Text Collection were searched for relevant literature (last updated on October 5, 2022). Intervention characteristics of each identified DiPH intervention, such as target groups, level of prevention or health care, digital health functions, intervention types, and public health functions, were extracted and used to map DiPH interventions. MAXQDA 2022.7 (VERBI GmbH) was used for qualitative data analysis of such interventions' technical functions and nontechnical characteristics.

RESULTS

In total, we identified and screened 15,701 records, of which 1562 (9.94%) full texts were considered relevant and were assessed for eligibility. Finally, we included 185 (11.84%) publications, which reported 179 different DiPH interventions. Our analysis revealed a diverse landscape of interventions, with telemedical services, health apps, and electronic health records as dominant types. These interventions targeted a wide range of populations and settings, demonstrating their adaptability. The analysis highlighted the multifaceted nature of digital interventions, necessitating precise definitions and standardized terminologies for effective collaboration and evaluation.

CONCLUSIONS

Although this scoping review was able to map characteristics and technical functions among 13 intervention types in DiPH, emerging technologies such as artificial intelligence might have been underrepresented in our study. This review underscores the diversity of DiPH interventions among and within intervention groups. Moreover, it highlights the importance of precise terminology for effective planning and evaluation. This review promotes cross-disciplinary collaboration by emphasizing the need for clear definitions, distinct technological functions, and well-defined use cases. It lays the foundation for international benchmarks and comparability within DiPH systems. Further research is needed to map intervention characteristics in this still-evolving field continuously.

TRIAL REGISTRATION

PROSPERO CRD42021265562; https://tinyurl.com/43jksb3k.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33404.

Home-Based Spirometry in Patients with Interstitial Lung Diseases: A Real-Life Pilot "FACT" Study from Serbia

(1) Background: home-based spirometry, as a form of telemedicine in pulmonology, was previously successfully implemented in clinical practice in developed countries. However, experiences from developing countries are lacking. The aim of this study was to assess the reliability and feasibility of home-based spirometry in patients with interstitial lung diseases from Serbia. (2) Methods: 10 patients were given a personal hand-held spirometer with operating instructions and asked to perform daily domiciliary spirometry for the next 24 weeks. The K-BILD questionnaire was used to assess patients' quality of life, while the questionnaire designed specifically for this study was used to assess their attitudes toward and satisfaction with domiciliary spirometry. (3) Results: there was a significant positive correlation between office- and home-based spirometry at the beginning (r = 0.946; p < 0.001) and end of the study (r = 0.719; p = 0.019). The compliance rate was nearly 70%. The domiciliary spirometry did not affect patients' overall quality of life or anxiety levels, as measured via different domains of the K-BILD. Patients expressed positive experiences and high satisfaction with the home spirometry program. (4) Conclusions: home-based spirometry may represent a reliable form of spirometry, exploited in routine clinical practice; however, additional research in developing countries with a larger sample size is required.

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.

Kronik Obstrüktif Akciğer Hastalığı Olan Hastaların Aktiflik Düzeyi ve Yaşam Kalitesi

Giriş: Kronik obstrüktif akciğer hastalarının etkili semptom yönetiminin, kendi bakımına katılan, aktif bir hasta ile sağlanabileceği bilinmektedir. Amaç: Kronik obstrüktif akciğer hastalığı (KOAH) olan hastalarda aktiflik düzeyini, aktifliği etkileyen faktörleri ve aktiflik düzeyi ile yaşam kalitesi arasındaki ilişkiyi belirlemektir. Yöntem: Tanımlayıcı, kesitsel ve ilişkisel tipte olan bu araştırma Kasım 2019- Mart 2020 tarihleri arasında bir üniversite hastanesinin göğüs hastalıkları polikliniğinde 120 KOAH’lı hasta gerçekleştirilmiştir. Veriler Hasta Tanıtım Formu, KOAH Değerlendirme Testi (CAT), Hasta Aktiflik Düzeyi Ölçeği (HADÖ) ve yaşam kalitesi için St. George Solunum Anketi (SGRQ) kullanılarak toplanmıştır. Verilerin değerlendirilmesinde tanımlayıcı istatistikler, Pearson korelasyon ve regresyon analizi kullanılmıştır. Bulgular: Bireylerin, HADÖ puan ortalaması 67.05 ± 14.69, CAT puan ortalaması 22.33 ± 7.48, SGRQ semptom puan ortalaması 55.80 ± 20.23, SGRQ aktivite puan ortalaması 74.78 ± 21.59, SGRQ etki puan ortalaması 49.78 ± 21.30, SGRQ toplam puan ortalaması 58.35 ± 20.0 olarak bulunmuştur. HADÖ ile CAT arasında istatistiksel olarak anlamlı ve negatif yönlü (r = -.415; p = .01), HADÖ ile SGRQ toplam puan arasında istatistiksel olarak anlamlı ve negatif yönlü (r = -.529; p = .01), CAT ile SGRQ toplam puan arasında istatistiksel olarak anlamlı ve pozitif yönlü (r = .846; p = .01) ilişki vardır. CAT ve yaş arttıkça HADÖ düzeyi düşmektedir (R2 = .247). SGRQ toplam puan ve yaş arttıkça HADÖ düzeyi düşmektedir (R2 = .329). Sonuç: KOAH’lı hastalarda aktiflik düzeyi yüksek bulunmuştur. Hasta aktifliğini etkileyen faktörler yaş, eğitim düzeyi, gelir durumu, çalışma durumu, hastalık süresi, KOAH evresi, yıllık hastane yatış sayısı, yıllık atak, KOAH durumu ve yaşam kalitesidir. Hasta aktiflik düzeyi arttıkça yaşam kalitesi artmaktadır.

Digital healthcare in COPD management: a narrative review on the advantages, pitfalls, and need for further research

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality despite current treatment strategies which focus on smoking cessation, pulmonary rehabilitation, and symptomatic relief. A focus of COPD care is to encourage self-management, particularly during COVID-19, where much face-to-face care has been reduced or ceased. Digital health solutions may offer affordable and scalable solutions to support COPD patient education and self-management, such solutions could improve clinical outcomes and expand service reach for limited additional cost. However, optimal ways to deliver digital medicine are still in development, and there are a number of important considerations for clinicians, commissioners, and patients to ensure successful implementation of digitally augmented care. In this narrative review, we discuss advantages, pitfalls, and future prospects of digital healthcare, which offer a variety of tools including self-management plans, education videos, inhaler training videos, feedback to patients and healthcare professionals (HCPs), exacerbation monitoring, and pulmonary rehabilitation. We discuss the key issues with sustaining patient and HCP engagement and limiting attrition of use, interoperability with devices, integration into healthcare systems, and ensuring inclusivity and accessibility. We explore the essential areas of research beyond determining safety and efficacy to understand the acceptability of digital healthcare solutions to patients, clinicians, and healthcare systems, and hence ways to improve this and sustain engagement. Finally, we explore the regulatory challenges to ensure quality and engagement and effective integration into current healthcare systems and care pathways, while maintaining patients' autonomy and privacy. Understanding and addressing these issues and successful incorporation of an acceptable, simple, scalable, affordable, and future-proof digital solution into healthcare systems could help remodel global chronic disease management and fractured healthcare systems to provide best patient care and optimisation of healthcare resources to meet the global burden and unmet clinical need of COPD.

Blended Self-Management Interventions to Reduce Disease Burden in Patients With Chronic Obstructive Pulmonary Disease and Asthma: Systematic Review and Meta-analysis

Background

Chronic obstructive pulmonary disease (COPD) and asthma have a high prevalence and disease burden. Blended self-management interventions, which combine eHealth with face-to-face interventions, can help reduce the disease burden.

Objective

This systematic review and meta-analysis aims to examine the effectiveness of blended self-management interventions on health-related effectiveness and process outcomes for people with COPD or asthma.

Methods

PubMed, Web of Science, COCHRANE Library, Emcare, and Embase were searched in December 2018 and updated in November 2020. Study quality was assessed using the Cochrane risk of bias (ROB) 2 tool and the Grading of Recommendations, Assessment, Development, and Evaluation.

Results

A total of 15 COPD and 7 asthma randomized controlled trials were included in this study. The meta-analysis of COPD studies found that the blended intervention showed a small improvement in exercise capacity (standardized mean difference [SMD] 0.48; 95% CI 0.10-0.85) and a significant improvement in the quality of life (QoL; SMD 0.81; 95% CI 0.11-1.51). Blended intervention also reduced the admission rate (relative ratio [RR] 0.61; 95% CI 0.38-0.97). In the COPD systematic review, regarding the exacerbation frequency, both studies found that the intervention reduced exacerbation frequency (RR 0.38; 95% CI 0.26-0.56). A large effect was found on BMI (d=0.81; 95% CI 0.25-1.34); however, the effect was inconclusive because only 1 study was included. Regarding medication adherence, 2 of 3 studies found a moderate effect (d=0.73; 95% CI 0.50-0.96), and 1 study reported a mixed effect. Regarding self-management ability, 1 study reported a large effect (d=1.15; 95% CI 0.66-1.62), and no effect was reported in that study. No effect was found on other process outcomes. The meta-analysis of asthma studies found that blended intervention had a small improvement in lung function (SMD 0.40; 95% CI 0.18-0.62) and QoL (SMD 0.36; 95% CI 0.21-0.50) and a moderate improvement in asthma control (SMD 0.67; 95% CI 0.40-0.93). A large effect was found on BMI (d=1.42; 95% CI 0.28-2.42) and exercise capacity (d=1.50; 95% CI 0.35-2.50); however, 1 study was included per outcome. There was no effect on other outcomes. Furthermore, the majority of the 22 studies showed some concerns about the ROB, and the quality of evidence varied.

Conclusions

In patients with COPD, the blended self-management interventions had mixed effects on health-related outcomes, with the strongest evidence found for exercise capacity, QoL, and admission rate. Furthermore, the review suggested that the interventions resulted in small effects on lung function and QoL and a moderate effect on asthma control in patients with asthma. There is some evidence for the effectiveness of blended self-management interventions for patients with COPD and asthma; however, more research is needed.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019119894; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=119894

The impact of the involvement of a healthcare professional on the usage of an eHealth platform: a retrospective observational COPD study

Background

Ehealth platforms, since the outbreak of COVID-19 more important than ever, can support self-management in patients with Chronic Obstructive Pulmonary Disease (COPD). The aim of this observational study is to explore the impact of healthcare professional involvement on the adherence of patients to an eHealth platform. We evaluated the usage of an eHealth platform by patients who used the platform individually compared with patients in a blended setting, where healthcare professionals were involved.

Methods

In this observational cohort study, log data from September 2011 until January 2018 were extracted from the eHealth platform Curavista. Patients with COPD who completed at least one Clinical COPD Questionnaire (CCQ) were included for analyses (n = 299). In 57% (n = 171) of the patients, the eHealth platform was used in a blended setting, either in hospital (n = 128) or primary care (n = 29). To compare usage of the platform between patients who used the platform independently or with a healthcare professional, we applied propensity score matching and performed adjusted Poisson regression analysis on CCQ-submission rate.

Results

Using the eHealth platform in a blended setting was associated with a 3.25 higher CCQ-submission rate compared to patients using the eHealth platform independently. Within the blended setting, the CCQ-submission rate was 1.83 higher in the hospital care group than in the primary care group.

Conclusion

It is shown that COPD patients used the platform more frequently in a blended care setting compared to patients who used the eHealth platform independently, adjusted for age, sex and disease burden. Blended care seems essential for adherence to eHealth programs in COPD, which in turn may improve self-management.

Digital Health Technology and Telemedicine-Based Hospital and Home Programs in Pulmonary Medicine During the COVID-19 Pandemic

BACKGROUND

The current coronavirus disease 2019 (COVID-19) pandemic has caused a significant strain on medical resources throughout the world. A major shift to telemedicine and mobile health technologies has now taken on an immediate urgency. Newly developed devices designed for home use have facilitated remote monitoring of various physiologic parameters relevant to pulmonary diseases. These devices have also enabled home-based pulmonary rehabilitation programs. In addition, telemedicine and home care services have been leveraged to rapidly develop acute care hospital-at-home programs for the treatment of mild-to-moderate COVID-19 illness.

AREAS OF UNCERTAINTY

The benefit of remote monitoring technologies on patient outcomes has not been established in robust trials. Furthermore, the use of these devices, which can increase the burden of care, has not been integrated into current clinical workflows and electronic medical records. Finally, reimbursement for these telemedicine and remote monitoring services is variable.

DATA SOURCES

Literature review.

THERAPEUTIC ADVANCES

Advances in digital technology have improved remote monitoring of physiologic parameters relevant to pulmonary medicine. In addition, telemedicine services for the provision of pulmonary rehabilitation and novel hospital-at-home programs have been developed. These new home-based programs have been adapted for COVID-19 and may also be relevant for the management of acute and chronic pulmonary diseases after the pandemic.

CONCLUSION

Digital remote monitoring of physiologic parameters relevant to pulmonary medicine and novel hospital-at-home programs are feasible and may improve care for patients with acute and chronic respiratory-related disorders.

Telerehabilitation for chronic respiratory disease

BACKGROUND

Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

OBJECTIVES

To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

MAIN RESULTS

We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

AUTHORS' CONCLUSIONS

This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.

The Health Diary Telemonitoring and Hospital-Based Home Care Improve Quality of Life Among Elderly Multimorbid COPD and Chronic Heart Failure Subjects

Background

Elderly, multimorbid patients with advanced chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF) exhibit poor health-related quality of life (HRQoL). Telemonitoring, based on digital pen technology, supported by hospital-based home care (HBHC) significantly reduces the number of hospitalizations. We hypothesized that the same intervention would prevent the deterioration of HRQoL that follows upon disease progression.

Methods

Elderly computer-illiterate subjects with ≥2 hospitalizations the previous year were included. HRQoL was assessed at inclusion (baseline) and at 1, 6 and 12 months employing EuroQol-5 Dimensions (EQ-5D) and RAND-36 for general HRQoL, and Minnesota Living with Heart Failure Questionnaire (MLHFQ) and St. Georges Respiratory Questionnaire (SGRQ) for disease-specific HRQoL. Healthcare contacts, hospitalizations, as-needed medications, prescription changes and healthcare costs were registered.

Results

Ninety-four patients were enrolled of which 53 subjects completed the 12-month study period. Compared to baseline, most domains of RAND-36 were improved significantly at 1 time-point or more. Only among COPD subjects, the disease-specific HRQoL was worsened at the 12 month evaluation. Measures of healthcare dependency were associated with poor HRQoL.

Conclusion

The Health Diary system and HBHC together improve general HRQoL, and measures of healthcare dependency are associated with HRQoL variables.