Features of a Mobile Support App for Patients With Chronic Obstructive Pulmonary Disease: Literature Review and Current Applications

From illness management to quality of life: rethinking consumer health informatics opportunities for progressive, potentially fatal illnesses

OBJECTIVES

Investigate how people with chronic obstructive pulmonary disease (COPD)-an example of a progressive, potentially fatal illness-are using digital technologies (DTs) to address illness experiences, outcomes and social connectedness.

MATERIALS AND METHODS

A transformative mixed methods study was conducted in Canada with people with COPD (n = 77) or with a progressive lung condition (n = 6). Stage-1 interviews (n = 7) informed the stage-2 survey. Survey responses (n = 80) facilitated the identification of participants for stage-3 interviews (n = 13). The interviews were thematically analyzed. Descriptive statistics were calculated for the survey. The integrative mixed method analysis involved mixing between and across the stages.

RESULTS

Most COPD participants (87.0%) used DTs. However, few participants frequently used DTs to self-manage COPD. People used DTs to seek online information about COPD symptoms and treatments, but lacked tailored information about illness progression. Few expressed interest in using DTs for self- monitoring and tracking. The regular use of DTs for intergenerational connections may facilitate leaving a legacy and passing on traditions and memories. Use of DTs for leisure activities provided opportunities for connecting socially and for respite, reminiscing, distraction and spontaneity.

DISCUSSION AND CONCLUSION

We advocate reconceptualizing consumer health technologies to prioritize quality of life for people with a progressive, potentially fatal illness. "Quality of life informatics" should focus on reducing stigma regarding illness and disability and taboo towards death, improving access to palliative care resources and encouraging experiences to support social, emotional and mental health. For DTs to support people with fatal, progressive illnesses, we must expand informatics strategies to quality of life.

Clinical Efficacy of Mobile App-Based, Self-Directed Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

Background

Pulmonary rehabilitation is well known to improve clinical symptoms (including dyspnea), quality of life, and exercise capacity in patients with chronic obstructive pulmonary disease (COPD). However, researchers have reported difficulties in practicing center-based pulmonary rehabilitation. Recently, mobile app-based pulmonary rehabilitation has become available in clinical practice. We investigated the clinical outcomes of mobile app-based pulmonary rehabilitation in patients with COPD.

Objective

The objective of our study was to evaluate the clinical efficacy of mobile app-based pulmonary rehabilitation versus conventional center-based pulmonary rehabilitation for patients with COPD, using a systematic review and meta-analysis.

Methods

A systematic search of the literature published between January 2007 and June 2023 was performed, using the PubMed, Embase, Cochrane, and CINAHL databases to identify relevant randomized controlled trials involving patients with COPD. Pulmonary rehabilitation programs needed to provide an exercise program on a smartphone app. Study outcomes, including exercise capacity, symptom scores, quality of life, and hospitalization, were evaluated. The meta-analysis evaluated mean differences in 6-minute walk test distances (6MWDs), COPD Assessment Test (CAT) scores, modified Medical Research Council (mMRC) dyspnea scale scores, St. George Respiratory Questionnaire (SGRQ) scores, and risk ratios for hospitalization resulting from disease exacerbation.

Results

Of the 1173 screened studies, 10 were included in the systematic review and 9 were included in the meta-analysis. Further, 6 studies were multicenter studies. There were a total of 1050 participants, and most were aged ≥65 years. There were discrepancies in the baseline participant characteristics, smartphone apps, interventions, and study outcomes among the included studies. In the meta-analysis, 5 studies assessed 6MWDs (mean difference 9.52, 95% CI -3.05 to 22.08 m), 6 studies assessed CAT scores (mean difference -1.29, 95% CI -2.39 to -0.20), 3 studies assessed mMRC dyspnea scale scores (mean difference -0.08, 95% CI -0.29 to 0.13), 2 studies assessed SGRQ scores (mean difference -3.62, 95% CI -9.62 to 2.38), and 3 studies assessed hospitalization resulting from disease exacerbation (risk ratio 0.65, 95% CI 0.27-1.53). These clinical parameters generally favored mobile app-based pulmonary rehabilitation; however, a statistically significant difference was noted only for the CAT scores (P=.02).

Conclusions

Despite some discrepancies in the baseline participant characteristics and interventions among studies, mobile app-based pulmonary rehabilitation resulted in favorable exercise capacity, symptom score, quality of life, and hospitalization outcomes when compared with conventional pulmonary rehabilitation. In the meta-analysis, the CAT scores of the mobile app-based pulmonary rehabilitation group were significantly lower than those of the control group (P=.02). In real-world practice, mobile app-based pulmonary rehabilitation can be a useful treatment option when conventional center-based pulmonary rehabilitation is not feasible.

Content, Mechanism, and Outcome of Effective Telehealth Solutions for Management of Chronic Obstructive Pulmonary Diseases: A Narrative Review

Telehealth (TH) solutions for Chronic Obstructive Pulmonary Disease (COPD) are promising behavioral therapeutic interventions and can help individuals living with COPD to improve their health status. The linking content, mechanism, and outcome of TH interventions reported in the literature related to COPD care are unknown. This paper aims to summarize the existing literature about structured TH solutions in COPD care. We conducted an electronic search of the literature related to TH solutions for COPD management up to October 2023. Thirty papers presented TH solutions as an innovative treatment to manage COPD. TH and digital health solutions are used interchangeably in the literature, but both have the potential to improve care, accessibility, and quality of life. To date, current TH solutions in COPD care have a variety of content, mechanisms, and outcomes. TH solutions can enhance education as well as provide remote monitoring. The content of TH solutions can be summarized as symptom management, prompt physical activity, and psychological support. The mechanism of TH solutions is manipulated by factors such as content, mode of delivery, strategy, and intensity. The most common outcome measures with TH solutions were adherence to treatment, health status, and quality of life. Implementing effective TH with a COPD care bundle must consider important determinants such as patient's needs, familiarity with the technology, healthcare professional support, and data privacy. The development of effective TH solutions for COPD management also must consider patient engagement as a positive approach to optimizing implementation and effectiveness.

Multidisciplinary Development and Initial Validation of a Clinical Knowledge Base on Chronic Respiratory Diseases for mHealth Decision Support Systems

Most mobile health (mHealth) decision support systems currently available for chronic obstructive respiratory diseases (CORDs) are not supported by clinical evidence or lack clinical validation. The development of the knowledge base that will feed the clinical decision support system is a crucial step that involves the collection and systematization of clinical knowledge from relevant scientific sources and its representation in a human-understandable and computer-interpretable way. This work describes the development and initial validation of a clinical knowledge base that can be integrated into mHealth decision support systems developed for patients with CORDs. A multidisciplinary team of health care professionals with clinical experience in respiratory diseases, together with data science and IT professionals, defined a new framework that can be used in other evidence-based systems. The knowledge base development began with a thorough review of the relevant scientific sources (eg, disease guidelines) to identify the recommendations to be implemented in the decision support system based on a consensus process. Recommendations were selected according to predefined inclusion criteria: (1) applicable to individuals with CORDs or to prevent CORDs, (2) directed toward patient self-management, (3) targeting adults, and (4) within the scope of the knowledge domains and subdomains defined. Then, the selected recommendations were prioritized according to (1) a harmonized level of evidence (reconciled from different sources); (2) the scope of the source document (international was preferred); (3) the entity that issued the source document; (4) the operability of the recommendation; and (5) health care professionals' perceptions of the relevance, potential impact, and reach of the recommendation. A total of 358 recommendations were selected. Next, the variables required to trigger those recommendations were defined (n=116) and operationalized into logical rules using Boolean logical operators (n=405). Finally, the knowledge base was implemented in an intelligent individualized coaching component and pretested with an asthma use case. Initial validation of the knowledge base was conducted internally using data from a population-based observational study of individuals with or without asthma or rhinitis. External validation of the appropriateness of the recommendations with the highest priority level was conducted independently by 4 physicians. In addition, a strategy for knowledge base updates, including an easy-to-use rules editor, was defined. Using this process, based on consensus and iterative improvement, we developed and conducted preliminary validation of a clinical knowledge base for CORDs that translates disease guidelines into personalized patient recommendations. The knowledge base can be used as part of mHealth decision support systems. This process could be replicated in other clinical areas.

Effectiveness of smartphone application in increasing knowledge on COPD and its non-pharmacological management in COPD patients

Chronic obstructive pulmonary disease (COPD) is among top ten of the world's causes of death. The development of the "Paru Sehat" smartphone application is a positive initiative and might have the potential to improve the disease management of COPD, improve patient's quality of life, and reduce complications associated with COPD. However, its effectiveness in improving the knowledge of the COPD patients is unknown. The aim of this study was to determine the effectiveness of "Paru Sehat" in increasing knowledge on COPD and its non-pharmacological management in COPD patients. A quasi-experimental study with a one-group pretest-posttest was conducted among stable COPD patients at Prof. Chairuddin Panusunan Lubis Hospital, Medan, Indonesia. Bristol COPD knowledge questionnaire (BCKQ) was used to assess the knowledge scores of the patients before and after exposure to the "Paru Sehat" twice a week for four weeks. A dependent Student t-test was used to compare the knowledge scores between pre- and post-intervention for both knowledge domains (i.e., knowledge on the disease and non-pharmacological management). Student t-test or one-way ANOVA were used to determine the association between patients' characteristics and the knowledge scores within pre- and posttreatment. Our data indicated a significant improvement of the knowledge scores on disease between pre- and post-treatment (15.92±3.79 vs 19.56±3.68, p<0.001). The knowledge score on non-pharmacological management also increased significantly post-treatment (7.52±2.02) compared to pre-treatment (10.08±2.379), p<0.001. In addition, this study found that educational attainment was associated with the scores of both knowledge domains of which individuals with senior high school or higher education level had significantly improvement of knowledge scores. This study highlights that although "Paru Sehat" application could improve the knowledge on COPD and its non-pharmacological management, its effects are less effective among individuals with low educational attainment.

Digital technology for delivering and monitoring exercise programs for people with cystic fibrosis

BACKGROUND

Although exercise is recommended as part of the cystic fibrosis (CF) therapeutic routine, adherence to exercise is still limited. Digital health technologies can provide easy-to-access health information and may help improve healthcare and outcomes in individuals with long-term conditions. However, its effects for delivering and monitoring exercise programs in CF have not yet been synthesized.

OBJECTIVES

To evaluate the benefits and harms of digital health technologies for delivering and monitoring exercise programs, increasing adherence to exercise regimens, and improving key clinical outcomes in people with CF.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 21 November 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or quasi-RCTs of digital health technologies for delivering or monitoring exercise programs in CF.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. physical activity, 2. self-management behavior, and 3. pulmonary exacerbations. Our secondary outcomes were 4. usability of technologies, 5. quality of life, 6. lung function, 7. muscle strength, 8. exercise capacity, 9. physiologic parameters, and 10.

ADVERSE EVENTS

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We identified four parallel RCTs (three single-center and one multicenter with 231 participants aged six years or older). The RCTs evaluated different modes of digital health technologies with distinct purposes, combined with diverse interventions. We identified important methodologic concerns in the RCTs, including insufficient information on the randomization process, blinding of outcome assessors, balance of non-protocol interventions across groups, and whether the analyses performed corrected for bias due to missing outcome data. Non-reporting of results may also be a concern, especially because some planned outcome results were reported incompletely. Furthermore, each trial had a small number of participants, resulting in imprecise effects. These limitations on the risk of bias, and on the precision of effect estimates resulted in overall low- to very low-certainty evidence. We undertook four comparisons and present the findings for our primary outcomes below. There is no information on the effectiveness of other modes of digital health technologies for monitoring physical activity or delivering exercise programs in people with CF, on adverse events related to the use of digital health technologies either for delivering or monitoring exercise programs in CF, and on their long-term effects (more than one year). Digital health technologies for monitoring physical activity Wearable fitness tracker plus personalized exercise prescription compared to personalized exercise prescription alone One trial (40 adults with CF) evaluated this outcome, but did not report data for any of our primary outcomes. Wearable fitness tracker plus text message for personalized feedback and goal setting compared to wearable fitness tracker alone The evidence is very uncertain about the effects of a wearable fitness tracker plus text message for personalized feedback and goal setting, compared to wearable technology alone on physical activity measured by step count at six-month follow-up (mean difference [MD] 675.00 steps, 95% confidence interval [CI] -2406.37 to 3756.37; 1 trial, 32 participants). The same study measured pulmonary exacerbation rates and reported finding no difference between groups. Web-based application to record, monitor, and set goals on physical activity plus usual care compared to usual care alone Using a web-based application to record, monitor, and set goals on physical activity plus usual care may result in little to no difference on time spent in moderate-to-vigorous physical activity measured via accelerometry compared to usual care alone at six-month follow-up (MD -4 minutes/day, 95% CI -37 to 29; 1 trial, 63 participants). Low certainty-evidence from the same trial suggests that the intervention may result in little to no difference on pulmonary exacerbations during 12 months of follow-up (median 1 respiratory hospitalization, interquartile range [IQR] 0 to 3) versus control (median 1 respiratory hospitalization, IQR 0 to 2; P = 0.6). Digital health technologies for delivering exercise programs Web-based versus face-to-face exercise delivery The evidence is very uncertain about the effects of web-based compared to face-to-face exercise delivery on adherence to physical activity as assessed by the number of participants who completed all exercise sessions after three months of intervention (risk ratio 0.92, 95% CI 0.69 to 1.23; 1 trial, 51 participants).

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of an exercise program plus the use of a wearable fitness tracker integrated with a social media platform compared with exercise prescription alone and on the effects of receiving a wearable fitness tracker plus text message for personalized feedback and goal setting, compared to a wearable fitness tracker alone. Low-certainty evidence suggests that using a web-based application to record, monitor, and set goals on physical activity plus usual care may result in little to no difference in time spent in moderate-to-vigorous physical activity, total time spent in activity, pulmonary exacerbations, quality of life, lung function, and exercise capacity compared to usual care alone. Regarding the use of digital health technologies for delivering exercise programs in CF, the evidence is very uncertain about the effects of using a wearable fitness tracker plus personalized exercise prescription compared to personalized exercise prescription alone. Further high-quality RCTs, with blinded outcome assessors, reporting the effects of digital health technologies on clinically important outcome measures, such as physical activity participation and intensity, self-management behavior, and the occurrence of pulmonary exacerbations in the long term are needed. The results of six ongoing RCTs identified through our searches may help clarify the effects of different modes of digital health technologies for delivering and monitoring exercise programs in people with CF.

Effectiveness of internet-based self-management interventions on pulmonary function in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

AIM

To investigate the effectiveness of internet-based self-management interventions on pulmonary function in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight electronic databases including PubMed, Web of Science, Cochrane library, Embase, CINAHL, China National Knowledge Infrastructure, Wangfang and Weipu databases were systematically searched from inception of the database to January 10, 2022.

METHODS

Statistical analysis was performed using Review Manager 5.4 and results were reported as mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CI). Outcomes were the forced expiratory volume in 1 second (FEV1), forced volume capacity (FVC) and percent of FEV1/FVC. The Cochrane Risk of Bias Tool was used to assess the risk of bias of included studies. The study protocol was not registered.

RESULTS

Eight randomized controlled trials (RCTs) including 476 participants met the inclusion criteria and were included in meta-analysis. It was found that internet-based self-management interventions showed a significant improvement in FVC(L), while FEV1 (%), FEV1 (L), FEV1/FVC (%) and FVC (%) did not significantly improve.

CONCLUSIONS

Internet-based self-management interventions were effective in improving pulmonary function in patients with COPD, caution should be exercised in interpreting the results. RCTs of higher quality are needed in the future to further demonstrate the effectiveness of the intervention.

RELEVANCE TO CLINICAL PRACTICE

It provides evidence for internet-based self-management interventions in improving pulmonary function in patients with COPD.

IMPACT

The results suggested that internet-based self-management interventions could improve the pulmonary function in people with COPD. This study provides a promising alternative method for patients with COPD who have difficulty seeking face-to-face self-management interventions, and the intervention can be applied in clinical settings.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Telemedical Interventions for Chronic Obstructive Pulmonary Disease Management: Umbrella Review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a growing epidemic, with a heavy associated economic burden. Education, physical activity, and pulmonary rehabilitation programs are important aspects of the management of COPD. These interventions are commonly delivered remotely as part of telemedicine interventions. Several systematic reviews and meta-analyses have been conducted to assess the effectiveness of these interventions. However, these reviews often have conflicting conclusions.

OBJECTIVE

We aim to conduct an umbrella review to critically appraise and summarize the available evidence on telemedicine interventions for the management of COPD.

METHODS

In this umbrella review, the MEDLINE, Embase, PsycINFO, and Cochrane databases were searched from inception to May 2022 for systematic reviews and meta-analyses relating to telemedicine interventions for the management of COPD. We compared odds ratios, measures of quality, and heterogeneity across different outcomes.

RESULTS

We identified 7 systematic reviews that met the inclusion criteria. Telemedicine interventions used in these reviews were teletreatment, telemonitoring, and telesupport. Telesupport interventions significantly reduced the number of inpatient days and quality of life. Telemonitoring interventions were associated with significant reductions in respiratory exacerbations and hospitalization rates. Teletreatment showed significant effectiveness in reducing respiratory exacerbations, hospitalization rate, compliance (acceptance and dropout rate), and physical activity. Among studies that used integrated telemedicine interventions, there was a significant improvement in physical activity.

CONCLUSIONS

Telemedicine interventions showed noninferiority or superiority over the standard of care for the management of COPD. Telemedicine interventions should be considered as a supplement to usual methods of care for the outpatient management of COPD, with the aim of reducing the burden on health care systems.

Features and characteristics of publicly available mHealth apps for self-management in chronic obstructive pulmonary disease

Mobile health applications (mHealth apps) may be able to support people living with chronic obstructive pulmonary disease (COPD) to develop the appropriate skills and routines for adequate self-management. Given the wide variety of publicly available mHealth apps, it is important to be aware of their characteristics to optimize their use and mitigate potential harms.

Objective

To report the characteristics and features of publicly available apps for COPD self-management.

Methods

MHealth apps designed for patients' COPD self-management were searched in the Google Play and Apple app stores. Two reviewers trialed and assessed the eligible apps using the MHealth Index and Navigation Database framework to describe the characteristics, qualities, and features of mHealth apps across five domains.

Results

From the Google Play and Apple stores, thirteen apps were identified and eligible for further evaluation. All thirteen apps were available for Android devices, but only seven were available for Apple devices. Most apps were developed by for-profit organizations (8/13), non-profit organizations (2/13), and unknown developers (3/13). Many apps had privacy policies (9/13), but only three apps described their security systems and two mentioned compliance with local health information and data usage laws. Education was the common app feature; additional features were medication reminders, symptom tracking, journaling, and action planning. None provided clinical evidence to support their use.

Conclusions

Publicly available COPD apps vary in their designs, features, and overall quality. These apps lack evidence to support their clinical use and cannot be recommended at this time.

Feasibility of Enhanced Recovery After Surgery Protocols Implemented Perioperatively in Endoscopic Submucosal Dissection for Early Gastric Cancer: A Single-Center Retrospective Study

Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has advantages over traditional radical gastrectomy. We investigated whether enhanced recovery after surgery (ERAS) protocols are appropriate in the ESD perioperative period. Materials and Methods: We screened 129 consecutive patients, and 12 were excluded. All study patients underwent ESD for EGC. Of the 117 included patients, 57 received traditional perioperative care between January 2017 and December 2018, and 60 patients received perioperative care according to ERAS protocols between January 2019 and September 2020. The primary study endpoint was ESD-related complications. Secondary endpoints included the following postoperative parameters: anal exhaust time, incidence of nausea or vomiting, length of hospitalization, fever rate, abdominal pain on the visual analog scale (VAS), and reported perioperative satisfaction. Results: Complications were comparable between the 2 groups. In the ERAS group, no patients experienced delayed bleeding or perforation. One traditional group patient bled, and one perforated. Postoperative anal exhaust time, nausea or vomiting incidence, hospitalization, fever rate, and VAS pain scores were significantly lower, and perioperative satisfaction rate was significantly higher in the ERAS group. Conclusions: ERAS protocols are both feasible and safe for patients undergoing ESD. ERAS protocols enhance the advantages of ESD for EGC without increasing complications.

Prediction of Chronic Obstructive Pulmonary Disease Exacerbation Events by Using Patient Self-reported Data in a Digital Health App: Statistical Evaluation and Machine Learning Approach

Background

Self-reporting digital apps provide a way of remotely monitoring and managing patients with chronic conditions in the community. Leveraging the data collected by these apps in prognostic models could provide increased personalization of care and reduce the burden of care for people who live with chronic conditions. This study evaluated the predictive ability of prognostic models for the prediction of acute exacerbation events in people with chronic obstructive pulmonary disease by using data self-reported to a digital health app.

Objective

The aim of this study was to evaluate if data self-reported to a digital health app can be used to predict acute exacerbation events in the near future.

Methods

This is a retrospective study evaluating the use of symptom and chronic obstructive pulmonary disease assessment test data self-reported to a digital health app (myCOPD) in predicting acute exacerbation events. We include data from 2374 patients who made 68,139 self-reports. We evaluated the degree to which the different variables self-reported to the app are predictive of exacerbation events and developed both heuristic and machine learning models to predict whether the patient will report an exacerbation event within 3 days of self-reporting to the app. The model’s predictive ability was evaluated based on self-reports from an independent set of patients.

Results

Users self-reported symptoms, and standard chronic obstructive pulmonary disease assessment tests displayed correlation with future exacerbation events. Both a baseline model (area under the receiver operating characteristic curve [AUROC] 0.655, 95% CI 0.689-0.676) and a machine learning model (AUROC 0.727, 95% CI 0.720-0.735) showed moderate ability in predicting exacerbation events, occurring within 3 days of a given self-report. Although the baseline model obtained a fixed sensitivity and specificity of 0.551 (95% CI 0.508-0.596) and 0.759 (95% CI 0.752-0.767) respectively, the sensitivity and specificity of the machine learning model can be tuned by dichotomizing the continuous predictions it provides with different thresholds.

Conclusions

Data self-reported to health care apps designed to remotely monitor patients with chronic obstructive pulmonary disease can be used to predict acute exacerbation events with moderate performance. This could increase personalization of care by allowing preemptive action to be taken to mitigate the risk of future exacerbation events.

Apps on Google Play Store to assist in self-management of hypertension in Indian context: features analysis study

BACKGROUND

A large number of individuals with hypertension are turning to the Internet and m-health technologies for assistance. There is a need to study the content of smartphone applications on hypertension. The study aimed to review and investigate the functional and analytical characteristics of apps related to the self-management of hypertension available on Google Play Store.

METHODS

Search was conducted in February 2021 in India using the Google Play Store database to identify currently available Android-based apps related to self-management of hypertension/high blood pressure (BP). Keywords used were: 'Hypertension', 'High blood pressure', 'DASH diet', 'Hypertension diet', and 'Blood pressure diet'. A total of 822 apps were screened based on the duplicates, inclusion, and exclusion criteria. A total of 210 were included for further analysis.

RESULTS

Eighteen percent (n=37) of the apps had an overall rating of 4.5 or above. About 41% of the apps belonged to the medical category and 41% of the apps were characterized in the health and fitness category. Feature of logging/recording the BP measurement was seen in 73% of the apps. In-app graphing to analyze BP trends was reported in 64 % of the included apps. A few apps focused on tracking medication (n=19), sodium intake (n=2), and calorie intake (n=4).

CONCLUSIONS

The features were common across all the included apps and were focusing only on recording the BP, providing statistics and trends of BP, and providing educational information. App developers should now aim to provide other components of self-management techniques to help individuals tackle hypertension.

Efficacy of Web-Based Supportive Interventions in Quality of Life in COPD Patients, a Systematic Review and Meta-Analysis

Background: Adults living with Chronic Obstructive Pulmonary Disease (COPD) often have difficulties when trying to access health care services. Interactive communication technologies are a valuable tool to enable patients to access supportive interventions to cope with their disease. The aim of this revision and meta-analysis is to analyze the content and efficacy of web-based supportive interventions in quality of life in COPD. Methods: Medline (via PubMed), Web of Science, and Scopus were the databases used to select the studies for this systematic review. A screening, analysis, and assessment of the methodological quality was carried out by two independent researchers. A meta-analysis of the extracted data was performed. Results: A total of 9 of the 3089 studies reviewed met the inclusion criteria. Most repeated web content elements were educational and involved communication with healthcare professional content. Finally, seven of the nine studies were included in a quantitative analysis. Web-based supportive interventions significantly improved quality of life when added to usual care (SMD = −1.26, 95% CI = −1.65, −0.86; p < 0.001) but no significant differences were found when compared with an autonomous pedometer walking intervention (p = 0.64) or a face-to-face treatment (p = 0.82). Conclusion: This systematic review and meta-analysis suggests that web-based supportive interventions may complement or accompany treatments in COPD patients due to the advantages of online interventions. The results obtained should be treated with caution due to the limited number of studies in this area and methodological weaknesses.

Development of a smartphone application for Korean patients with chronic obstructive pulmonary disease: Self-monitoring based action plans

AIM

The purpose of this study was to develop and evaluate a smartphone application (app) of a COPD action plan (AP) based on symptom self-monitoring (SM) [AP-SM Sapp] to support the early detection of, and response to, symptoms.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent respiratory diseases worldwide. Disease control is important to prevent progression of COPD caused by exacerbations; action plans are a successful strategy to prevent and manage COPD exacerbations. However, the digital literacy that COPD patients need to support technology-based COPD action plans is poorly understood.

METHODS

A systematic literature review identified components for the app's development. Content validity testing with 12 clinical experts identified 35 critical components for inclusion in the app's development. The app was then submitted to user experience evaluation by thirteen technology experts and nine COPD patients.

RESULTS

In user evaluation of the app, experts evaluated the AP-SM Sapp as a good quality app (57.37 ± 9.13) and COPD patients as an average quality app (44.44 ± 3.94) (range 0-69; higher scores indicating greater endorsement of app quality). Revisions based on these critiques produced a final version.

CONCLUSION

The app was developed to support COPD patients in the early detection of symptoms so that exacerbations could be prevented or managed appropriately. Although the app used simple messages and pictographs to enhance digital literacy (thus narrowing the digital literacy gap), efficient onboarding will be important if barriers to app use are to be further reduced.

Developing a Multidisciplinary Approach to the COPD Care Pathway

Chronic obstructive pulmonary disease (COPD) is characterized as a predominately preventable and treatable inflammatory lung disease caused by progressive obstructed airflow from the lungs. In the United States and worldwide, it is becoming a major cause in hospital admissions as well as an increase in morbidity and mortality. The rising total cost of care for COPD is concerning for all health care industries. The disease has significant impact on the patient's quality of life and psychological well-being. A worldwide initiative is underway in developing a care model that is multifactorial through continuous monitoring of patients to manage and control symptoms, achieve medication adherence, and provide socioeconomic resources. The primary aim of this study was to prevent exacerbations, hospital admissions, and readmissions. Various models have shown positive results; however, the significant financial investment is the major barrier to success. Recently, one health system in the United States was able to improve care, decrease readmissions, and reduce total cost of care by investing in a multidisciplinary team of specialists. In the utilization of the care model, the primary endpoint will conclude that COPD is financially and socioeconomically manageable.

Digital interventions for the management of chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with dyspnoea, cough or sputum production (or both) and affects quality of life and functional status. More efficient approaches to alternative management that may include patients themselves managing their condition need further exploration in order to reduce the impact on both patients and healthcare services. Digital interventions may potentially impact on health behaviours and encourage patient engagement.

OBJECTIVES

To assess benefits and harms of digital interventions for managing COPD and apply Behaviour Change Technique (BCT) taxonomy to describe and explore intervention content.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 28 April 2020). We found other trials at web-based clinical trials registers.

SELECTION CRITERIA

We included RCTs comparing digital technology interventions with or without routine supported self-management to usual care, or control treatment for self-management. Multi-component interventions (of which one component was digital self-management) compared with usual care, standard care or control treatment were included.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. Discrepancies were resolved with a third review author. We assessed certainty of the evidence using the GRADE approach. Primary outcomes were impact on health behaviours, self-efficacy, exacerbations and quality of life, including the St George's Respiratory Questionnaire (SGRQ). The minimally important difference (MID) for the SGRQ is 4 points. Two review authors independently applied BCT taxonomy to identify mechanisms in the digital interventions that influence behaviours.

MAIN RESULTS

Fourteen studies were included in the meta-analyses (1518 participants) ranging from 13 to 52 weeks duration. Participants had mild to very severe COPD. Risk of bias was high due to lack of blinding. GRADE ratings were low to very low certainty due to lack of blinding and imprecision. Common BCT clusters identified as behaviour change mechanisms in interventions were goals and planning, feedback and monitoring, social support, shaping knowledge and antecedents. Digital technology intervention with or without routine supported self-management Interventions included mobile phone (three studies), smartphone applications (one study), and web or Internet-based (five studies). Evidence is very uncertain about effects on impact on health behaviours as measured by six-minute walk distance (6MWD) at 13 weeks (mean difference (MD) 26.20, 95% confidence interval (CI) -21.70 to 74.10; participants = 122; studies = 2) or 23 to 26 weeks (MD 14.31, 95% CI -19.41 to 48.03; participants = 164; studies = 3). There may be improvement in 6MWD at 52 weeks (MD 54.33 95% CI -35.47 to 144.12; participants = 204; studies = 2) but studies were varied (very low certainty). There may be no difference in self-efficacy on managing Chronic Disease Scale (SEMCD) or pulmonary rehabilitation adapted index of self-efficacy tool (PRAISE). Evidence is very uncertain. Quality of life may be slightly improved on the chronic respiratory disease questionnaire (CRQ) at 13 weeks (MD 0.45, 95% CI 0.01 to 0.90; participants = 123; studies = 2; low certainty), but is not clinically important (MID 0.5). There may be little or no difference at 23 or 52 weeks (low to very low certainty). There may be a clinical improvement on SGRQ total at 52 weeks (MD -26.57, 95% CI -34.09 to -19.05; participants = 120; studies = 1; low certainty). Evidence for COPD assessment test (CAT) and Clinical COPD Questionnaire (CCQ) is very uncertain. There may be little or no difference in dyspnoea symptoms (CRQ dyspnoea) at 13, 23 weeks or 52 weeks (low to very low certainty evidence) or mean number of exacerbations at 26 weeks (low-certainty evidence). There was no evidence for the number of people experiencing adverse events. Multi-component interventions Digital components included mobile phone (one study), and web or internet-based (four studies). Evidence is very uncertain about effects on impact on health behaviour (6MWD) at 13 weeks (MD 99.60, 95% CI -15.23 to 214.43; participants = 20; studies = 1). No evidence was found for self-efficacy. Four studies reported effects on quality of life (SGRQ and CCQ scales). The evidence is very uncertain. There may be no difference in the number of people experiencing exacerbations or mean days to first exacerbation at 52 weeks with a multi-component intervention compared to standard care. Evidence is very uncertain about effects on the number of people experiencing adverse events at 52 weeks.

AUTHORS' CONCLUSIONS

There is insufficient evidence to demonstrate a clear benefit or harm of digital technology interventions with or without supported self-management, or multi-component interventions compared to usual care in improving the 6MWD or self-efficacy. We found there may be some short-term improvement in quality of life with digital interventions, but there is no evidence about whether the effect is sustained long term. Dyspnoea symptoms may improve over a longer duration of digital intervention use. The evidence for multi-component interventions is very uncertain and as there is little or no evidence for adverse events, we cannot determine the benefit or harm of these interventions. The evidence base is predominantly of very low certainty with concerns around high risk of bias due to lack of blinding. Given that variation of interventions and blinding is likely to be a concern, future, larger studies are needed taking these limitations in consideration. Future studies are needed to determine whether the small improvements observed in this review can be applied to the general COPD population. A clear understanding of behaviour change through the BCT classification is important to gauge uptake of digital interventions and health outcomes in people with varying severity of COPD. Currently there is no guidance for interpreting BCT components of a digital intervention for changes to health outcomes. We could not interpret the BCT findings to the health outcomes we were investigating due to limited evidence that was of very low certainty. In future research, standardised approaches need to be considered when designing protocols to investigate effectiveness of digital interventions by including a standardised approach to BCT classification in addition to validated behavioural outcome measures that may reflect changes in behaviour.

eHealth Program to Reduce Hospitalizations Due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Retrospective Study

BACKGROUND

Hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD) is associated with poor prognosis. eHealth interventions might improve outcomes and decrease costs.

OBJECTIVE

This study aimed to evaluate the effect of an eHealth program on COPD hospitalizations and exacerbations.

METHODS

This was a real-world study conducted from April 2018 to December 2019 in the Bravis Hospital, the Netherlands. An eHealth program (EmmaCOPD) was offered to COPD patients at risk of exacerbations. EmmaCOPD consisted of an app that used questionnaires (to monitor symptoms) and a step counter (to monitor the number of steps) to detect exacerbations. Patients and their buddies received feedback when their symptoms worsened or the number of steps declined. Generalized estimating equations were used to compare the number of days admitted to the hospital and the total number of exacerbations 12 months before and (max) 18 months after the start of EmmaCOPD. We additionally adjusted for the potential confounders of age, sex, COPD severity, and inhaled corticosteroid use.

RESULTS

The 29 included patients had a mean forced expiratory volume in 1 second of 45.5 (SD 17.7) %predicted. In the year before the intervention, the median total number of exacerbations was 2.0 (IQR 2.0-3.0). The median number of hospitalized days was 8.0 days (IQR 6.0-16.5 days). Afterwards, there was a median 1.0 (IQR 0.0-2.0) exacerbation and 2.0 days (IQR 0.0-4.0 days) of hospitalization. After initiation of EmmaCOPD, both the number of hospitalized days and total number of exacerbations decreased significantly (incidence rate ratio 0.209, 95% CI 0.116-0.382; incidence rate ratio 0.310, 95% CI 0.219-0.438). Adjustment for confounders did not affect the results.

CONCLUSIONS

The eHealth program seems to reduce the number of total exacerbations and number of days of hospitalization due to exacerbations of COPD.

Assessing the quality of mobile applications in chronic disease management: a scoping review

While there has been a rapid growth of digital health apps to support chronic diseases, clear standards on how to best evaluate the quality of these evolving tools are absent. This scoping review aims to synthesize the emerging field of mobile health app quality assessment by reviewing criteria used by previous studies to assess the quality of mobile apps for chronic disease management. A literature review was conducted in September 2017 for published studies that use a set of quality criteria to directly evaluate two or more patient-facing apps supporting promote chronic disease management. This resulted in 8182 citations which were reviewed by research team members, resulting in 65 articles for inclusion. An inductive coding schema to synthesize the quality criteria utilized by included articles was developed, with 40 unique quality criteria identified. Of the 43 (66%) articles that reported resources used to support criteria selection, 19 (29%) used clinical guidelines, and 10 (15%) used behavior change theory. The most commonly used criteria included the presence of user engagement or behavior change functions (97%, n = 63) and technical features of the app such as customizability (20%, n = 13, while Usability was assessed by 24 studies (36.9%). This study highlights the significant variation in quality criteria employed for the assessment of mobile health apps. Future methods for app evaluation will benefit from approaches that leverage the best evidence regarding the clinical impact and behavior change mechanisms while more directly reflecting patient needs when evaluating the quality of apps.

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.

A Hybrid Model to Classify Patients with Chronic Obstructive Respiratory Diseases

Over the last decades, an increase in the ageing population and age-related diseases has been observed, with the increase in healthcare costs. As so, new solutions to provide more efficient and affordable support to this group of patients are needed. Such solutions should never discard the user and instead should focus on promoting more healthy lifestyles and provide tools for patients’ active participation in the treatment and management of their diseases. In this concern, the Personal Health Empowerment (PHE) project presented in this paper aims to empower patients to monitor and improve their health, using personal data and technology assisted coaching. The work described in this paper focuses on defining an approach for user modelling on patients with chronic obstructive respiratory diseases using a hybrid modelling approach to identify different groups of users. A classification model with 90.4% prediction accuracy was generated combining agglomerative hierarchical clustering and decision tree classification techniques. Furthermore, this model identified 5 clusters which describe characteristics of 5 different types of users according to 7 generated rules. With the modelling approach defined in this study, a personalized coaching solution will be built considering patients with different necessities and capabilities and adapting the support provided, enabling the recognition of early signs of exacerbations and objective self-monitoring and treatment of the disease. The novel factor of this approach resides in the possibility to integrate personalized coaching technologies adapted to each kind of user within a smartphone-based application resulting in a reliable and affordable alternative for patients to manage their disease.

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.

A randomised controlled feasibility trial of E-health application supported care vs usual care after exacerbation of COPD: the RESCUE trial

Exacerbations of COPD are one of the commonest causes of admission and readmission to hospital. The role of digital interventions to support self-management in improving outcomes is uncertain. We conducted an open, randomised controlled trial of a digital health platform application (app) in 41 COPD patients recruited following hospital admission with an acute exacerbation. Subjects were randomised to either receive usual care, including a written self-management plan (n = 21), or the myCOPD app (n = 20) for 90 days. The primary efficacy outcome was recovery rate of symptoms measured by COPD assessment test (CAT) score. Exacerbations, readmission, inhaler technique quality of life and patient activation (PAM) scores were also captured by a blinded team. The app was acceptable in this care setting and was used by 17 of the 20 patients with sustained use over the study period. The treatment effect on the CAT score was 4.49 (95% CI: -8.41, -0.58) points lower in the myCOPD arm. Patients' inhaler technique improved in the digital intervention arm (101 improving to 20 critical errors) compared to usual care (100 to 72 critical errors). Exacerbations tended to be less frequent in the digital arm compared to usual care; 34 vs 18 events. Hospital readmissions risk was numerically lower in the digital intervention arm: OR for readmission 0.383 (95% CI: 0.074, 1.987; n = 35). In this feasibility study of the digital self-management platform myCOPD, the app has proven acceptable to patients to use and use has improved exacerbation recovery rates, with strong signals of lower re-exacerbation and readmission rates over 90 days. myCOPD reduced the number of critical errors in inhaler technique compared to usual care with written self-management. This provides a strong basis for further exploration of the use of app interventions in the context of recently hospitalised patients with COPD and informs the potential design of a large multi-centre trial.

Issues in reporting of systematic review methods in health app-focused reviews: A scoping review

No guidelines exist for the conduct and reporting of manuscripts with systematic searches of app stores for, and then appraisal of, mobile health apps ('health app-focused reviews'). We undertook a scoping review including a systematic literature search for health app-focused reviews describing systematic app store searches and app appraisal, for apps designed for patients or clinicians. We created a data extraction template which adapted data elements from the PRISMA guidelines for systematic literature reviews to data elements operationalised for health app-focused reviews. We extracted the data from included health app-focused reviews to describe: (1) which elements of the adapted 'usual' methods of systematic review are used; (2) methods of app appraisal; and (3) reporting of clinical efficacy and recommendations for app use. From 2798 records, the 26 included health app-focused reviews showed incomplete or unclear reporting of review protocol registration; use of reporting guidelines; processes of screening apps; data extraction; and appraisal tools. Reporting of clinical efficacy of apps or recommendations for app use were infrequent. The reporting of methods in health app-focused reviews is variable and could be improved by developing a consensus reporting standard for health app-focused reviews.

Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study

Background:

The use of mobile health (mHealth) interventions has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes. Further research is needed to determine which mHealth features are required to potentially enhance COPD self-management.

Aim:

The aim of this study was to explore the potential features of an mHealth intervention for COPD management with healthcare providers (HCPs) and patients with COPD. It could inform the development and successful implementation of mHealth interventions for COPD management.

Methods:

This was a qualitative study. We conducted semi-structured individual interviews with HCPs, including nurses, pharmacists and physicians who work directly with patients with COPD. Interviews were also conducted with a diverse sample of patients with COPD. Interview topics included demographics, mHealth usage, the potential use of medical devices and recommendations for features that would enhance an mHealth intervention for COPD management.

Results:

A total of 40 people, including nurses, physicians and pharmacists, participated. The main recommendations for the proposed mHealth intervention were categorised into two categories: patient interface and HCP interface. The prevalent features suggested for the patient interface include educating patients, collecting baseline data, collecting subjective data, collecting objective data via compatible medical devices, providing a digital action plan, allowing patients to track their progress, enabling family members to access the mHealth intervention, tailoring the features based on the patient’s unique needs, reminding patients about critical management tasks and rewarding patients for their positive behaviours. The most common features of the HCP interface include allowing HCPs to track their patients’ progress, allowing HCPs to communicate with their patients, educating HCPs and rewarding HCPs.

Conclusion:

This study identifies important potential features so that the most effective, efficient and feasible mHealth intervention can be developed to improve the management of COPD.

The reviews of this paper are available via the supplemental material section.

Development and Preliminary Evaluation of the Effects of an mHealth Web-Based Platform (HappyAir) on Adherence to a Maintenance Program After Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

Background

Pulmonary rehabilitation is one of the main interventions to reduce the use of health resources, and it promotes a reduction in chronic obstructive pulmonary disease (COPD) costs. mHealth systems in COPD aim to improve adherence to maintenance programs after pulmonary rehabilitation by promoting the change in attitude and behavior necessary for patient involvement in the management of the disease.

Objective

This study aimed to assess the effects of an integrated care plan based on an mHealth web-based platform (HappyAir) on adherence to a 1-year maintenance program applied after pulmonary rehabilitation in COPD patients.

Methods

COPD patients from three hospitals were randomized to a control group or an intervention group (HappyAir group). Patients from both groups received an 8-week program of pulmonary rehabilitation and educational sessions about their illness. After completion of the process, only the HappyAir group completed an integrated care plan for 10 months, supervised by an mHealth system and therapeutic educator. The control group only underwent the scheduled check-ups. Adherence to the program was rated using a respiratory physiotherapy adherence self-report (CAP FISIO) questionnaire. Other variables analyzed were adherence to physical activity (Morisky-Green Test), quality of life (Chronic Obstructive Pulmonary Disease Assessment Test, St. George’s Respiratory Questionnaire, and EuroQOL-5D), exercise capacity (6-Minute Walk Test), and lung function.

Results

In total, 44 patients were recruited and randomized in the control group (n=24) and HappyAir group (n=20). Eight patients dropped out for various reasons. The CAP FISIO questionnaire results showed an improvement in adherence during follow-up period for the HappyAir group, which was statistically different compared with the control group at 12 months (56.1 [SD 4.0] vs 44.0 [SD 13.6]; P=.004) after pulmonary rehabilitation.

Conclusions

mHealth systems designed for COPD patients improve adherence to maintenance programs as long as they are accompanied by disease awareness and patient involvement in management.

Trial Registration

ClinicalTrials.gov NCT04479930; https://clinicaltrials.gov/ct2/show/NCT04479930

The Use of a Smartphone App and an Activity Tracker to Promote Physical Activity in the Management of Chronic Obstructive Pulmonary Disease: Randomized Controlled Feasibility Study

Background

Chronic obstructive pulmonary disease (COPD) is highly prevalent and significantly affects the daily functioning of patients. Self-management strategies, including increasing physical activity, can help people with COPD have better health and a better quality of life. Digital mobile health (mHealth) techniques have the potential to aid the delivery of self-management interventions for COPD. We developed an mHealth intervention (Self-Management supported by Assistive, Rehabilitative, and Telehealth technologies-COPD [SMART-COPD]), delivered via a smartphone app and an activity tracker, to help people with COPD maintain (or increase) physical activity after undertaking pulmonary rehabilitation (PR).

Objective

This study aimed to determine the feasibility and acceptability of using the SMART-COPD intervention for the self-management of physical activity and to explore the feasibility of conducting a future randomized controlled trial (RCT) to investigate its effectiveness.

Methods

We conducted a randomized feasibility study. A total of 30 participants with COPD were randomly allocated to receive the SMART-COPD intervention (n=19) or control (n=11). Participants used SMART-COPD throughout PR and for 8 weeks afterward (ie, maintenance) to set physical activity goals and monitor their progress. Questionnaire-based and physical activity–based outcome measures were taken at baseline, the end of PR, and the end of maintenance. Participants, and health care professionals involved in PR delivery, were interviewed about their experiences with the technology.

Results

Overall, 47% (14/30) of participants withdrew from the study. Difficulty in using the technology was a common reason for withdrawal. Participants who completed the study had better baseline health and more prior experience with digital technology, compared with participants who withdrew. Participants who completed the study were generally positive about the technology and found it easy to use. Some participants felt their health had benefitted from using the technology and that it assisted them in achieving physical activity goals. Activity tracking and self-reporting were both found to be problematic as outcome measures of physical activity for this study. There was dissatisfaction among some control group members regarding their allocation.

Conclusions

mHealth shows promise in helping people with COPD self-manage their physical activity levels. mHealth interventions for COPD self-management may be more acceptable to people with prior experience of using digital technology and may be more beneficial if used at an earlier stage of COPD. Simplicity and usability were more important for engagement with the SMART-COPD intervention than personalization; therefore, the intervention should be simplified for future use. Future evaluation will require consideration of individual factors and their effect on mHealth efficacy and use; within-subject comparison of step count values; and an opportunity for control group participants to use the intervention if an RCT were to be carried out. Sample size calculations for a future evaluation would need to consider the high dropout rates.

Recommendations for Developing Support Tools With People Suffering From Chronic Obstructive Pulmonary Disease: Co-Design and Pilot Testing of a Mobile Health Prototype

BACKGROUND

Gaps exist between developers, commissioners, and end users in terms of the perceived desirability of different features and functionalities of mobile apps.

OBJECTIVE

The objective of this study was to co-design a prototype mobile app for people with chronic obstructive pulmonary disease (COPD). We present lessons learned and recommendations from working on a large project with various stakeholders to develop a mobile app for patients with COPD.

METHODS

We adopted a user-centered, participatory approach to app development. Following a series of focus groups and interviews to capture requirements, we developed a prototype app designed to enable daily symptom recording (experience sampling). The prototype was tested in a usability study applying the think aloud protocol with people with COPD. It was then released via the Android app store, and experience sampling data and event data were captured to gather further usability data.

RESULTS

A total of 5 people with COPD participated in the pilot study. Identified themes include familiarity with technology, appropriate levels for feeding back information, and usability issues such as manual dexterity. Moreover, 37 participants used the app over a 4-month period (median age 47 years). The symptoms most correlated to perceived well-being were tiredness (r=0.61; P<.001) and breathlessness (r=0.59; P<.001).

CONCLUSIONS

Design implications for COPD apps include the need for clearly labeled features (rather than relying on colors or symbols that require experience using smartphones), providing weather information, and using the same terminology as health care professionals (rather than simply lay terms). Target users, researchers, and developers should be involved at every stage of app development, using an iterative approach to build a prototype app, which should then be tested in controlled settings as well as in the wild (ie, when deployed and used in real-world settings) over longer periods.

Compliance and Utility of a Smartphone App for the Detection of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease: Cohort Study

Background

In recent years, mobile health (mHealth)–related apps have been developed to help manage chronic diseases. Apps may allow patients with a chronic disease characterized by exacerbations, such as chronic obstructive pulmonary disease (COPD), to track and even suspect disease exacerbations, thereby facilitating self-management and prompt intervention. Nevertheless, there is insufficient evidence regarding patient compliance in the daily use of mHealth apps for chronic disease monitoring.

Objective

This study aimed to provide further evidence in support of prospectively recording daily symptoms as a useful strategy to detect COPD exacerbations through the smartphone app, Prevexair. It also aimed to analyze daily compliance and the frequency and characteristics of acute exacerbations of COPD recorded using Prevexair.

Methods

This is a multicenter cohort study with prospective case recruitment including 116 patients with COPD who had a documented history of frequent exacerbations and were monitored over the course of 6 months. At recruitment, the Prevexair app was installed on their smartphones, and patients were instructed on how to use the app. The information recorded in the app included symptom changes, use of medication, and use of health care resources. The patients received messages on healthy lifestyle behaviors and a record of their cumulative symptoms in the app. There was no regular contact with the research team and no mentoring process. An exacerbation was considered reported if medical attention was sought and considered unreported if it was not reported to a health care professional.

Results

Overall, compliance with daily records in the app was 66.6% (120/180), with a duration compliance of 78.8%, which was similar across disease severity, age, and comorbidity variables. However, patients who were active smokers, with greater dyspnea and a diagnosis of depression and obesity had lower compliance (P<.05). During the study, the patients experienced a total of 262 exacerbations according to daily records in the app, 99 (37.8%) of which were reported exacerbations and 163 (62.2%) were unreported exacerbations. None of the subject-related variables were found to be significantly associated with reporting. The duration of the event and number of symptoms present during the first day were strongly associated with reporting. Despite substantial variations in the COPD Assessment Test (CAT), there was improvement only among patients with no exacerbation and those with reported exacerbations. Nevertheless, CAT scores deteriorated among patients with unreported exacerbations.

Conclusions

The daily use of the Prevexair app is feasible and acceptable for patients with COPD who are motivated in their self-care because of frequent exacerbations of their disease. Monitoring through the Prevexair app showed great potential for the implementation of self-care plans and offered a better diagnosis of their chronic condition.

Facebook Groups on Chronic Obstructive Pulmonary Disease: Social Media Content Analysis

Facebook Groups facilitate information exchange and engagement for patients with chronic conditions, including those living with Chronic Obstructive Pulmonary Disease (COPD); however, little is known about how knowledge is diffused throughout these communities. This study aimed to evaluate the content that is available on COPD-related Facebook Groups, as well as the communication (self-disclosures, social support) and engagement (agreement, emotional reaction) strategies used by members to facilitate these resources. Two researchers independently searched the “Groups” category using the terms “COPD”, “emphysema”, and “chronic bronchitis”. Twenty-six closed (n = 23) and public (n = 3) COPD Facebook Groups were identified with 87,082 total members. The vast majority of Group members belonged to closed (n = 84,684; 97.25%) as compared to open (n = 2398; 2.75%) groups. Medications were the most commonly addressed self-management topic (n = 48; 26.7%). While overall engagement with wall posts was low, the number of “likes” (an indicator of agreement) was significantly greater for wall posts that demonstrated social support as compared to posts that did not (p < 0.001). Findings from this study showed that COPD Facebook group members share specific disease-related experiences and request information about select self-management topics. This information can be used to improve the quality of self-management support provided to members of popular COPD Facebook groups.

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.

Using wearables and self-management apps in patients with COPD: a qualitative study

Background

Technology such as wearable technology and self-management applications could improve the care of patients with chronic obstructive pulmonary disease (COPD) by real-time continuous monitoring, early detection of COPD and improved self-management. However, patients have not been willing to use technology when it is too difficult to use, interferes with their daily lives or threatens their identity, independence and self-care.

Methods

We conducted a qualitative study to determine what patients with COPD would like to see in a wearable device and a mobile application to help manage their condition. Semi-structured interviews were conducted, recorded and transcribed. Thematic analysis was used to identify themes and concepts.

Results

We interviewed 14 people with COPD with an average age of 69 years. Participants perceived that the technology could improve their ability to manage their condition both in daily life and during exacerbations by connecting how they feel and by knowing their oxygen saturation, heart rate and activity. The technology may help them address feelings of fear and panic associated with exacerbations and may provide reassurance and connectedness. Some people with COPD wanted their healthcare providers to have access to their data, while others were concerned about inundating them with too much information. Of note, people wanted to maintain control of the information; to make connections with the data, but also in order to be alerted when a possible exacerbation occurs.

Conclusion

Patients perceived significant potential for wearables and apps to help manage their condition.

In-depth interviews with COPD patients found that they face significant challenges managing their condition. Patients perceive significant potential for wearables to help with self-management and alerting them to a possible exacerbation.http://bit.ly/2xcyBlB

Identifying an effective mobile health application for the self-management of allergic rhinitis and asthma in Australia

Objective: People with allergic rhinitis (AR) often self-manage in the community pharmacy setting without consulting health care professionals and trivialize their comorbidities such as asthma. A mobile health application (mHealth app) with a self-monitoring and medication adherence system can assist with the appropriate self-management of AR and asthma. This study aimed to identify an app effective for the self-management of AR and/or asthma.Methods: MHealth apps retrieved from the Australian Apple App Store and Android Google Play Store were included in this study if they were developed for self-management of AR and/or asthma; in English language; free of charge for the full version; and accessible to users of the mHealth app. The mHealth app quality was evaluated on three domains using a two-stage process. In Stage 1, the apps were ranked along Domain 1 (Accessibility in both app stores). In Stage 2, the apps with Stage 1, maximum score were ranked along Domain 2 (alignment with theoretical principles of the self-management of AR and/or asthma) and Domain 3 (usability of the mHealth app using Mobile App Rating Scale instrument).Results: Of the 418 apps retrieved, 31 were evaluated in Stage 1 and 16 in Stage 2. The MASK-air achieved the highest mean rank and covered all self-management principles except the doctor's appointment reminder and scored a total MARS mean score of 0.91/1.Conclusions: MASK-air is ranked most highly across the assessment domains for the self-management of both AR and coexisting asthma. This mHealth app covers the majority of the self-management principles and is highly engaging.

Evaluation of an innovative mobile health programme for the self-management of chronic obstructive pulmonary disease (MH-COPD): protocol of a randomised controlled trial

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death globally. In outpatient care, the self-management of COPD is essential, but patient adherence to this remains suboptimal. The objective of this study is to examine whether an innovative mobile health (mHealth)-enabled care programme (MH-COPD) will improve the patient self-management and relevant health outcomes.

METHODS AND ANALYSIS

A prospective open randomised controlled trial has been designed. In the trial, patients with COPD will be recruited from The Prince Charles Hospital, Brisbane, Australia. They will then be randomised to participate in either the MH-COPD intervention group (n=50 patients), or usual care control group (UC-COPD) (n=50 patients) for 6 months. The MH-COPD programme has been designed to integrate an mHealth system within a clinical COPD care service. In the programme, participants will use a mHealth application at home to review educational videos, monitor COPD symptoms, use an electronic action plan, modify the risk factors of cigarette smoking and regular physical activity, and learn to use inhalers optimally. All participants will be assessed at baseline, 3 months and 6 months. The primary outcomes will be COPD symptoms and quality of life. The secondary outcomes will be patient adherence, physical activity, smoking cessation, use of COPD medicines, frequency of COPD exacerbations and hospital readmissions, and user experience of the mobile app.

ETHICS AND DISSEMINATION

The clinical trial has been approved by The Prince Charles Hospital Human Research Ethics Committee (HREC/16/QPCH/252). The recruitment and follow-up of the trial will be from January 2019 to December 2020. The study outcomes will be disseminated according to the Consolidated Standards of Reporting Trials statement through a journal publication, approximately 6 months after finishing data collection.

TRIAL REGISTRATION NUMBER

ACTRN12618001091291.

mHealth Tools for the Self-Management of Patients With Multimorbidity in Primary Care Settings: Pilot Study to Explore User Experience

Background

Given the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions.

Objective

The objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts.

Methods

We conducted a 4-week pilot study of the ePRO tool. Patients’ and providers’ experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method.

Results

In this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool’s potential in helping to improve access to different providers in a team-based primary care setting.

Conclusions

This study identifies a more explicit recognition of the contextual factors that influence patients’ ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial.

The Nurse Practitioners' Perspective on Inhaler Education in Asthma and Chronic Obstructive Pulmonary Disease

Asthma and chronic obstructive pulmonary disease (COPD) can be debilitating conditions adversely affecting a person's quality of life. Effective treatments are available, but common errors in the use of inhalers compound the issue of disease control. The beliefs and concerns of a patient can also have an impact on treatment adherence, the consequences of which are diminished disease control and the occurrence of exacerbations. Once a treatment has been prescribed, it is often nurses who manage the patient long-term, and they may even be the main care provider. This puts nurses in a key position to monitor inhaler technique, communicate with the patient to improve adherence, and even suggest alternative treatments if the patient and therapy are incompatible. This review examines the central role that nurses play in disease management and emphasizes how effective inhaler education can make a difference to disease control. Good communication between the nurse and patient is vital if this is to be achieved. Recent updates to asthma and COPD guidelines are reviewed, and key resources available to help manage patients are highlighted. Finally, with regard to inhaler education, we reconsider the nursing keystones of "Know it," "Show it," "Teach it," and "Review it."

Identifying Medication Management Smartphone App Features Suitable for Young Adults With Developmental Disabilities: Delphi Consensus Study

Background

Smartphone apps can be a tool to facilitate independent medication management among persons with developmental disabilities. At present, multiple medication management apps exist in the market, but only 1 has been specifically designed for persons with developmental disabilities. Before initiating further app development targeting this population, input from stakeholders including persons with developmental disabilities, caregivers, and professionals regarding the most preferred features should be obtained.

Objective

The aim of this study was to identify medication management app features that are suitable to promote independence in the medication management process by young adults with developmental disabilities using a Delphi consensus method.

Methods

A compilation of medication management app features was performed by searching the iTunes App Store, United States, in February 2016, using the following terms: adherence, medication, medication management, medication list, and medication reminder. After identifying features within the retrieved apps, a final list of 42 features grouped into 4 modules (medication list, medication reminder, medication administration record, and additional features) was included in a questionnaire for expert consensus rating. A total of 52 experts in developmental disabilities, including persons with developmental disabilities, caregivers, and professionals, were invited to participate in a 3-round Delphi technique. The purpose was to obtain consensus on features that are preferred and suitable to promote independence in the medication management process among persons with developmental disabilities. Consensus for the first, second, and third rounds was defined as ≥90%, ≥80%, and ≥75% agreement, respectively.

Results

A total of 75 responses were received over the 3 Delphi rounds—30 in the first round, 24 in the second round, and 21 in the third round. At the end of the third round, cumulative consensus was achieved for 60% (12/20) items in the medication list module, 100% (3/3) in the medication reminder module, 67% (2/3) in the medication administration record module, and 63% (10/16) in the additional features module. In addition to the medication list, medication reminder, and medication administration record features, experts selected the following top 3 most important additional features: automatic refills through pharmacies; ability to share medication information from the app with providers; and ability to share medication information from the app with family, friends, and caregivers. The top 3 least important features included a link to an official drug information source, privacy settings and password protection, and prescription refill reminders.

Conclusions

Although several mobile apps for medication management exist, few are specifically designed to support persons with developmental disabilities in the complex medication management process. Of the 42 different features assessed, 64% (27/42) achieved consensus for inclusion in a future medication management app. This study provides information on the features of a medication management app that are most important to persons with developmental disabilities, caregivers, and professionals.

What kind of information and communication technologies do patients with COPD prefer to use? A cross-sectional study in Latin America

The aim of the present study was to assess the frequency of uses and preferences of information and communication technologies (ICTs) among Latin American chronic obstructive pulmonary disease (COPD) patients. We conducted an anonymous cross-sectional survey study on Latin American COPD patients. The adapted version of the Michigan questionnaire was employed in eligible outpatients in different cities of Latin America. We categorized age and educational levels into three groups. The time passed since COPD diagnosis was categorized as ≤5 years and >5 years. χ² and crude and adjusted logistic regressions were performed. A total of 256 patients were enrolled with a mean age of 68.7 years old. The most recurrently used ICTs were short message service (SMS; 47.1%) and WhatsApp (30.7%) for receiving COPD information. Moreover, SMS (85.8%) and Facebook (36.1%) were rated as useful for asking physicians information about COPD. Regression analysis showed that the best predictor for patients using ICTs, for any purpose, was higher education (undergraduate or graduate school). Understanding the preferences of ICTs among COPD patients could help improve patient’s outcomes through developing applications in response to specific requirements of each patient.