Abstract
Background
Patients with chronic obstructive pulmonary disease (COPD) often do not seek care until they experience an exacerbation. Improving self-management for these patients may increase health-related quality of life and reduce hospitalizations. Patients are willing to use wearable technology for real-time data reporting and perceive mobile technology as potentially helpful in COPD management, but there are many barriers to the uptake of these technologies.
Objective
We aimed to understand patients’ experiences using a wearable and mobile app and identify areas for improvement.
Methods
We conducted semi-structured interviews as part of a larger prospective cohort study wherein patients used a wearable and app for 6 months. We asked which features patients found accessible, acceptable and useful.
Results
We completed 26 interviews. We summarized our research findings into four main themes: (1) information, support and reassurance, (2) barriers to adoption, (3) impact on communication with health care providers, and (4) opportunities for improvement. Most patients found the feedback received through the app to be reassuring and useful. Some patients experienced technical difficulties with the app and found the wearable to be uncomfortable.
Conclusions
Patients found a wearable device and mobile application to be acceptable and useful for the management of COPD. We identified barriers to adoption and opportunities for improvement to the design of our app. Further research is needed to understand what people with COPD and their healthcare providers want and will use in a mobile app and wearable for COPD management.
1. Introduction
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation and respiratory symptoms such as dyspnea, cough and sputum production, and is currently the third leading cause of death worldwide. Patients with COPD often seek care only when experiencing an exacerbation [Citation1]. Severe exacerbations can result in hospitalization leading to considerable healthcare costs [Citation2].
Self-management interventions have the potential to increase health-related quality of life and reduce hospital admissions, although studies have not consistently demonstrated this to date [Citation3–5]. One method of delivering self-management interventions is through mobile applications such as smartphones and wearable technology. Wearable technology such as smartwatches can passively monitor heart rate, respiratory rate, physical activity and coughing, and this may help: increase physical activity by giving patients feedback on their step counts and providing reminders to move; predict early exacerbations identifying biomarkers with an association to symptom scores; and improve care by enabling easier communication with providers [Citation6–9]. Our research questions were designed to understand the degree to which our interventions were acceptable to patients. We interviewed patients after they had used the intervention for an extended a period of time, in order to more accurately assess potential adherence [Citation10].
Patients expressed that they are able and willing to integrate monitoring technology into their daily lives [Citation11], but different factors go into whether or not people are willing to adopt mobile health strategies. Patients do not wish to use technology when it is difficult to use or unreliable; it is not recommended for use by a health care provider; it interferes with their daily lives; it is not comfortable to wear; or they do not find it useful [Citation12]. In our previous work, we developed a COPD monitoring system (WearCOPD) consisting of a mobile app and a paired smartwatch. We found that patients will use wearables for real-time data collection to help them manage the challenges they face due to their health status, both during daily life and exacerbations. We concluded that technology may address feelings of fear and panic associated with exacerbations while providing reassurance and connectedness [Citation13]. In the qualitative portion of our previous study, participants requested changes from the previous version of our system including the addition of self-management tools and the ability to monitor their condition through the mobile app, and we have since implemented these changes. This study is a qualitative evaluation of our updated system (WearCOPD V2) designed to help people with COPD monitor their condition and improve self-management.
2. Methods and materials
2.1. Study design
As part of a larger prospective cohort study evaluating the system, we conducted a qualitative study to determine what patients with COPD found useful after using our wearable device and mobile app (WearCOPD V2) for disease management. Our research questions were:
What impact did the mobile app and smartwatch have on participants’ COPD management?
What issues and barriers to adoption did patients face while using the app?
What more would be useful in a smartphone and smartwatch app for management of COPD?
The University Health Network Research Ethics Board approved this study (Study ID: 18-5462).
3. Methods
3.1. Recruitment
Between February 2019 and May 2021, we enrolled 34 patients with COPD from hospitals and respirology clinics in Toronto and Thunder Bay, Ontario, Canada. Patients were eligible to participate if they had a diagnosis of COPD, spoke English and did not have a cognitive barrier impairing participation. Of note, 18 of our patients were enrolled after the start of the COVID-19 pandemic. We asked all patients enrolled in our cohort study to complete a semi-structured interview at the end of their time on study; 26 patients agreed, including 3 that dropped out of the cohort study.
3.2. Study intervention
We provided patients with a smartwatch and a smartphone with our app pre-installed and asked them to use both for 6 months. We developed the system in partnership with Samsung Research America, our industry partner, based on feedback from our previous work [Citation13] and beta testing with a small group of people with COPD.
We designed the software on the wearable to continuously measure heart rate and activity level. The mobile app included daily reminders to take controller medication, fill out a symptom questionnaire, do a guided pursed-breathing session and check blood oxygen on their smartwatch or oximeter. It gave participants feedback on their heart rate and daily activity levels (including passive step counts). Patients also had the option to record when they started and finished exercises. We gamified the experience by awarding patients stars if they met their daily exercise goals (active minutes and total steps) to increase engagement. The application also allowed participants to enter their COPD action plan. Participants were trained on how to use the intervention in person by research personnel. They were also provided with links to educational resources and a video showing how to complete pursed-breathing exercises.
3.3. Data collection
We developed an interview guide to explore the above research questions. We interviewed participants at the end of the study intervention to gain insights into what mobile app and wearable features they found accessible, acceptable and useful, and collect their suggestions to improve the system. A trained interviewer conducted semi-structured interviews. Interviews were audio-recorded and transcribed verbatim. Interview duration was 30 min to 1 h. Interviews were conducted in person at Toronto General Hospital and Sunnybrook Health Sciences Center (n = 14) or over the phone (n = 12).
3.4. Data analysis and reflexivity
We used codebook thematic analysis in relation to our research question across the interviews. Anonymized transcripts were independently coded by four researchers (HR, TS, RW and MC) to establish themes early in the coding process. The development of themes was guided by a review of relevant literature, our research question, and the quantitative outcomes of the study [Citation14]. The researchers began by familiarizing themselves with the transcripts and discussing general ideas and patterns apparent in the data. Each coder then individually went through a subset of the interviews and coding segments of the interviews to systematically assign text to those themes. Additionally, 27% of the interviews were coded by two or more of the researchers to ensure consistency across coding. The final step was a research team meeting to review the themes and subthemes and to discuss final interpretations and modifications. We aimed to be reflexive in our own backgrounds and experiences for the duration of the coding and analysis, including a discussion on how they may have impacted our analysis.
In addition to identifying emergent themes, we chose to quantify our qualitative outcomes using a codebook through a concurrent triangulation approach [Citation15]. We chose this approach in order to address our second and third research questions; we wanted to identify barriers to use as well as the most useful features of our application in order to better develop further models.
4. Results
A total of 34 patients were enrolled in our prospective cohort study, and 6 of these patients dropped out of the study, all within the first 30 days. Of the 34 originally enrolled, 26 patients were interviewed, including three who dropped out of the study. The remaining eight patients did not respond to requests from the research team. Patient characteristics are summarized in . Patient technology utilization and technical efficacy were fairly high; the majority of patients indicated that they had previously used a smartphone and a computer and had Wi-Fi at home. Almost half of our patients (42%) had used a wearable before. During the study, most participants did not experience exacerbations (81%), while 4 experienced 1–3 exacerbations (15%) and 1 participant had more than 5 exacerbations (5%).
Table 1. Patient demographics.
We summarized our research findings into the following themes: (1) information, support and reassurance, (2) barriers to adoption, (3) impact on communication with health care providers, and (4) opportunities for improvement.
4.1. Information, support and reassurance
Patients described that the information provided by the app and smartwatch was helpful in providing reassurance and feedback that their vitals were stable while they were exercising. This reassurance helped some patients reinforce the habit of exercising regularly. Patient 21, a 56 year old woman, described their improvement by the end of the study:
Oh, I'm way better than when I started. When I started, I couldn’t walk from my kitchen to my living room without grasping for breath. I was coughing at the beginning, like all the time. I'm not coughing anymore. My condition has improved from when I started.
Patients reported becoming more cognizant of the need to monitor their symptoms, and two patients mentioned buying additional monitoring devices after completing the study, including a blood pressure monitor and an oxygen saturation monitor. Notably, five participants (20%) interpreted their data, including heart rate values, as a sign that they needed to slow down. Patient 11, a 79 year old man, described how this feedback influenced how they approached exercise:
I know one time it said my heart rate was too high and I was doing an exercise at the time but I had had a cup of coffee. Right before and I think even during, when I first started to do the exercise, and it didn’t take long, it told me that my heart rate was too high and to slow down, and so I did.
Table 2. Application features by usefulness.
Although most patients reported some positive impact on behavior and exacerbation management, 7 (27%) said there was no change to their behavior. Of these patients, 4 (15.4%) reported that technical issues prevented the platform from having an impact, 2 (7.7%) said that after living with a chronic illness, their COPD was already well-managed and 1 (3.8%) stated that it had no impact because COPD was not their most debilitating diagnosis. Notably, two of the three patients that dropped out of the study who were interviewed indicated that they felt that the intervention had no impact on their self-management.
4.2. Communication with health care provider
While the platform did not include any additional means for patients to reach their health care providers, we were interested to see whether it had any impact on interactions with providers. Six patients said they had shown the app and some of their results to their health care provider. Two of these patients said their health care provider was minimally interested. Importantly, 18 (69%) of our patients were recruited and interviewed during the COVID-19 pandemic, and, as such, did not see their respirologist for the length of their participation in the study. Impact on patient’s communication with health care providers was therefore limited, but this outcome may have been influenced by the pandemic.
Patient 16, a 74 year old man, noted that they had a “valuable outcome from the program” after they showed the app to their health care provider. They filled in their action plan with their respirologist, which led the respirologist to reevaluate their medications. This led to the prescription of a new medication that the patient found worked well.
4.3. Barriers to use
Patients said their biggest challenges were technical problems with the app and wearable. Of patients interviewed, 12 (46%) cited battery issues, 7 (27%) felt that the sensor data was not always accurate, 4 (15.4%) had issues connecting the watch to the study phone and 3 (11.5%) found the touch screen was difficult to use. Additionally, eight patients (30.8%) had concerns with the size of the watch and the comfort of the strap, including two of the three patients interviewed who dropped out of the study. Patients also found it was cumbersome to have to carry the study phone in addition to their own phone, which was a requirement of the research study.
4.4. Opportunities for improvement
Participants noted many opportunities for improvement. Initially, the phone provided to patients had a sensor where they could measure their oxygen saturation. This feature was disabled due to a concern that it was not accurate. In their interviews, six patients (23.1%) specifically noted that they wanted an oxygen saturation sensor. In addition to the oxygen monitor, participants said they wanted more tracking of non-COPD health information, with Patient 4, a 70 year old man who dropped out of the study, noting:
I think this needs a lot of work before it can be useful. It needs to recognize the daily life of a COPD person, which needs to take into account the fact that the person may have other conditions that also impact on their life and their health and how they’re feeling, having nothing to do with COPD.
5. Discussion
We conducted a qualitative evaluation of the experiences of patients with COPD using a smartphone and smartwatch self-management application for 6 months. Patients saw the potential for a wearable and an app to improve care by facilitating self-management. They appreciated having their heart rate monitored, tracking their symptoms, and receiving reminders to be active. Patients said that seeing feedback on their physiological symptoms and connecting it to how they were feeling was useful. Some participants did not find their health care providers were interested in reviewing this data. They also described some barriers to adoption, which included technical malfunctions and a bulky wearable. Patients wanted to be able to see more feedback on their condition, and they wanted the app to also monitor their other medical conditions.
While there is potential for smartphone and wearable tools to improve care in chronic disease management, there remain barriers to uptake [Citation12]. This study adds further information about which features people with COPD want in a mobile self-management system, as well as current barriers to use. Patients in previous studies have expressed a desire for individualization in apps and other digital health technologies [Citation16–18], and that accessibility and inclusivity are key areas that need to be addressed [Citation19]. Previous studies have also shown that health care providers have mixed perspectives on the usefulness and practicality of wearable devices and mobile apps in COPD patient care [Citation5,Citation16,Citation17,Citation20]. This study adds valuable detail by asking people with COPD to evaluate a smartphone app and wearable that they used regularly.
Most participants described that the platform had a positive impact on their health-related quality of life by providing them information, support and reassurance. Other studies have reported similarly positive outcomes of digital healthcare interventions for COPD patients [Citation4,Citation17,Citation21,Citation22]. However, patients have also expressed concerns over the use of remote monitoring, especially when able to view their own data. Huniche et al. reported that many patients found reading their data could be encouraging and reassuring, while others found it to be “depressing, worrisome, and at times disturbing” [Citation23]. Notably, the Huniche et al. study utilized self-monitoring wherein patients were tasked with monitoring their own data directly, and did not have a clinician or algorithm monitoring their condition, which may have increased patient burden. In their systematic review of qualitative studies on digital monitoring for COPD patients, Walker et al. concluded that while patients generally reported improvement in disease-related knowledge, confidence, and sense of safety, certain patients were concerned about potentially jeopardizing personal relationships with their healthcare providers, and increased burden on themselves [Citation24]. In some of these studies, the use of the self-management intervention was a replacement for regularly communication with providers, whereas in our study it was supplemental. While many patients view self-monitoring at home as reassuring and supportive, efforts should be made in the design of interventions to reduce the likelihood that viewing data will cause patients to experience agitation and fear.
The researchers who completed coding and analysis reflected on reflexivity and the impact of our backgrounds and experiences on our results after analysis was complete. RW is a clinician, and noted that he came in with a healthcare provider’s experiences with treating COPD, and a bias toward remote monitoring and use of technology as a promising form of treatment. TS, a Clinical Research Analyst, had spent a great deal of time with our patients, sometimes on multiple studies, and felt that she already had a strong sense of what patients wanted in a wearable and app. HR, as a Clinical Research Analyst, had a background working with older adults but limited background in COPD and wearable technology. MC, a Clinical Research Coordinator, was new to the research team and had an extensive background in research ethics and methods but limited experience working with older adults with COPD. We all felt that we came into the study with limited knowledge about what patients wanted or would use for remote clinical monitoring. We all were hopeful about the potential of our intervention to help patients, which may have caused us to pay particular attention to our subjects describing the intervention as acceptable and reassuring. We all had limited to no experience living with the barriers to performing daily activities and exercising that many of our patients experience, which made us appreciate their experiences more and built empathy.
A limitation to our study was that our participants could be considered early adopters as they consented for a study of wearable technology. They may not be representative of most patients with COPD. However, this study still provides valuable insights as to what some people with COPD would use. Another limitation was that the majority of our patients were recruited after the outset of the COVID-19 pandemic. For these patients, access to in-person appointments with their respirologists was limited, which may have influenced their experience of the intervention and limited our ability to assess the impact our technology had on communication with healthcare providers. Furthermore, our study did not explicitly attempt to address financial or social barriers to study adoption. A final limitation was that we only enrolled English-speaking patients. Ontario has a diverse population, and the perspectives of English-speaking patients may not be representative of the population as a whole. Conversely, an advantage of mobile apps is that they can be easily translated for use into different languages.
6. Conclusions
Patients perceived significant potential for wearables to help manage COPD at home. They wanted to make connections with and enjoyed viewing their data. Patients expressed that they wanted collection of specific symptom data and access to it, a user-friendly interface and an attractive wearable. These changes have the potential to create a wearable and app that promote patient empowerment through educational strategies to promote and support lifestyle changes, which accommodate patients with minimal experience using technology.
Further engaging people with COPD in the development of a self-management app and wearable will be crucial to ensure that it is useful, effective and accessible for this population and to ensure barriers are addressed. For example, co-design of apps and wearables with patient stakeholders should be considered. Future projects designing wearable technology for COPD patients should integrate these results into the development of an e-health, self-management tool. Further research with health care providers is also necessary to understand if and how they would want to use their patients’ wearable data and how they perceive it could improve the care of their patients. In order to develop technology that is usable by most or all patients with COPD, it will also be important to address social and financial barriers to digital health adoption.
Author contributions
Conception and design – TS, RW
Procurement of data – TS, HR, RW
Analysis of data – TS, HR, RW, MC
Drafting of the original manuscript – TS, RW, HR, AG
Revision of the original manuscript – RW, AG, TS, HR, ED, AM, MC
| Abbreviations: | ||
| COPD | = | Chronic Obstructive Pulmonary Disease |
Acknowledgements
The authors would like to thank the patients who participated in our study.
Disclosure statement
Robert Wu: The funding of this study was in part by Samsung Research America (SRA). This was an Investigator-initiated study with input from SRA. Samsung had control over the application but no control or input in the methods or results of this study. They had no control over the content of the manuscript. No other authors had conflicts of interest relevant to this manuscript.
Declaration of interest
No potential conflict of interest was reported by the author(s).
Data availability statement
The data used in this study is available from the corresponding author upon reasonable request.
Additional information
Funding
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