Telehealthcare management for patients with chronic obstructive pulmonary disease

Keywords::

• COPD
• healthcare cost
• quality of life
• telehealthcare
• telemonitoring
• telephone support

Chronic obstructive pulmonary disease (COPD) is a chronic disease with high morbidity and mortality in the elderly. The WHO estimates that approximately 200 million people are living with COPD worldwide. Of these, 65 million have moderate-to-severe COPD [101]. COPD is projected to be the third leading cause of mortality and the seventh leading cause of burden of disability worldwide by 2030 [1,101]. In the past two decades, despite medical advances and gradual decline in mortality with other chronic diseases (e.g., cardiovascular diseases and stroke), mortality from COPD has been rising exponentially [2]. This is partly due to limited availability of resources and lack of dedicated staff for the respiratory diseases in developing countries, and inadequate healthcare and research funding provision for patients with COPD compared with other chronic diseases [3].

In the past decade, there have been many initiatives to manage the burden of COPD and reduce healthcare cost. One aspect of the initiatives was to examine the efficacy of telehealthcare for patients with COPD. Telehealthcare is the provision of personalized healthcare over a distance [4]. There are several essential steps of activities for the telehealthcare to function effectively: information is transferred electronically from patients’ homes to healthcare professionals at a specified location, data acquisition (gathering) from the patients (e.g., using a video or telephone contacts), monitoring, and interpreting of the data gathered by the healthcare professionals using clinical judgment in order to provide individually tailored treatment plans [5]. The recent press release by the Department of Health [102] in the UK indicates that telehealthcare is at the forefront of the government’s agenda to expend more effort and resources to examine its efficacy in patients with chronic long-term conditions. This is a very encouraging initiative, which is based on a relatively medium-to-large sample size of randomized controlled trials of patients with chronic conditions [6,7] that showed that telemonitoring and telephone support services were beneficial in reducing healthcare costs and improving quality of life.

A recent systematic review by Bolton and colleagues [8] suggests that there is currently limited evidence available for the efficacy of telehealthcare to reduce healthcare costs in patients with COPD. Furthermore, in a Cochrane review, McLean and colleagues [9] indicated that telehealthcare in COPD “appears to have possible impact on quality of life and the number of times patients attend the emergency department and the hospital”. Therefore, it is uncertain whether current evidence mitigates the wider provision of telehealthcare for patients with COPD. If this is the case, what is the current evidence? What are the clinical implications and challenges of telehealthcare provision? What should be the future direction?

What is the current evidence?

In 2010, a systematic review and meta-regression analysis of nine original studies (n = 528) by Polisena and coworkers examined the efficacy of telehealthcare (which comprised of home monitoring and telephone support) compared with usual care in patients with COPD [10]. Their analysis showed that telehealthcare was effective by 21% in reducing length of stay in hospital and emergency department visits, but found an increased death rate in the telephone support group compared with the usual care group. In addition, there was no significant difference in quality of life and patients’ satisfaction with the service between the telehealthcare group and the usual care group. By contrast, a recent quasi-experimental controlled clinical trial from Canada showed that telemonitoring was more effective in increasing patients’ satisfaction with the service and empowerment (ability to manage their own care) than that of the usual home care group [11]. However, there was no cost reduction in both groups. In addition, the telemonitoring group did not show an improvement in their quality of life but the control group showed a decline in their quality of life. In the same study, both patients and care providers have reported positive attitudes towards home telemonitoring. A small pilot study from the UK showed that telemonitoring was perceived by patients as improving access to professional care but raised concerns for clinicians’ possible overtreatment (large increase in prescription of antibiotics and steroids) of patients with COPD [12]. These findings suggest that there are organizational, clinical and service-related issues that need to be addressed before this supportive technology can be made widely available.

Jarad and Sund examined early detection of acute exacerbations and adherence to telemonitoring in patients with adult cystic fibrosis (CF) and COPD [13]. In a 6-month follow-up, patients with CF (n = 51) and COPD (n = 19) were asked to perform spirometry, and the presence of exacerbations was monitored using a predefined criteria. When exacerbations were detected, patients were offered treatment according to a predesigned protocol. Their findings indicate that over three-fifths of adult patients with CF withdrew from the study due to a lack of adherence to daily monitoring compared with 5% of patients with COPD. A higher percentage of exacerbations were detected and treated in patients with COPD compared with adult patients with CF using this technology. It seems that patients with COPD tend to comply better with the telehealthcare monitoring program compared with patients with CF. Patients with COPD were older and more likely to be retired due to ill health or natural wastage compared with adult patients with CF. Further work in this area is needed.

In a quasi-experimental multicentered study, Trappenburg and colleagues examined the benefits of telemonitoring plus usual care (using a case manager and education to enhance disease knowledge and self-management; n = 56) versus usual care (n = 59) with a follow-up of 6 months [14]. They demonstrated a statistically significant decrease both in hospital admission rates and in the total number of exacerbations in the telemonitoring group compared with the usual care group (p < 0.05). However, there was no statistically significant difference between the two groups in quality of life during the follow-up period. Pare et al. from Canada examined the cost–effectiveness of telemonitoring (n = 19) compared with the usual home care group (n = 10) in patients with COPD [15]. The findings demonstrated a 15% net cost saving per patient in the telemonitoring care group during the 6-month follow-up. However, they have highlighted that the telehealthcare equipments were expensive and wiped out some of the accrued savings.

Lewis and coworkers examined the efficacy of telemonitoring following a pulmonary rehabilitation program [16]. Patients were randomized to either a telemonitoring group (n = 20) or a usual care group (n = 20). The telemonitoring group monitored their respiratory symptoms and change in health status twice daily in the 6-month follow-up period. There was no difference between the two groups in quality of life or psychological wellbeing. Sorknaes and colleagues showed that nurse-led telehealthcare video consultations following discharge of patients from acute exacerbations of COPD reduced the number of patients requiring early readmissions by 10% compared with the control group within 28 days of follow-up [17]. The finding is relatively small in terms of reducing admissions (as a cost analysis has not been performed), but it has strong implications in terms of targeting patients with COPD who are trapped in the ‘revolving door’ cycle and are most likely to be admitted with frequent acute exacerbations. Patient satisfaction with the service was high.

Positive clinical implications & challenges of telehealthcare provision

There is some evidence to suggest that patients with COPD find telehealthcare acceptable and are satisfied with the service [7,12]. The potential explanation for the satisfaction with the telehealthcare service may include the perceived notion of COPD patients that the healthcare professionals are actively monitoring their condition. It acts as a ‘safety net’ for the COPD patients to interact with, and provides a vehicle for prompt action from, the healthcare professionals. This may have promoted reassurance and increased confidence among patients, reducing some of the anxieties that patients with COPD may have during acute exacerbations. There is consistent evidence from the various studies (taking into account heterogeneity and small sample size) that teleheathcare reduced hospital admissions [10], improved quality of life and reduced healthcare cost [7,9]. Box 1 provides some of the clinical benefits and potential challenges in the use of telehealthcare in the management of patients with COPD. McLean and colleagues provide a detailed clinical review of the advantages and disadvantages of the telehealthcare provision for the long-term conditions including COPD [5]. To date, there are no studies that have investigated the efficacy of complex interventions with and without telehealthcare in patients with COPD.

Future directions

Large randomized controlled clinical trials are needed to demonstrate the efficacy of telehealthcare for patients with COPD in reducing healthcare utilization in the long-term treatment follow-up.

The use of telehealthcare technology is the way forward in the management of patients with COPD, especially for those patients who reside in rural areas. However, this technology should be rigorously evaluated in terms of the cost–benefit analysis, improving the quality of life of patients with COPD and reducing the care burden to their families and caregivers.

In the current economic climate, demand may outstrip supply because of scarcity of the telemedicine equipment. Therefore, it is advisable to use this innovative telehealth technology in selected patients with COPD using standard clinical criteria to complement the existing clinical service (usual care), such as in COPD patients with a history of frequent exacerbations.

Conclusion

Telemonitoring has a potential to improve clinical practice in patients with COPD. Current evidence suggests that telehealthcare is acceptable and feasible to patients with COPD. Further painstaking robust work is required to show the efficacy of telehealthcare in reducing healthcare utilization and costs, and improving quality of life in patients with COPD.

Box 1. Positive implications and challenges of telehealthcare provision.

Positive implications for telehealthcare

• • Innovative educational approach may help patients to engage in web-based technologies in the future

• • Promotes self-management

• • Encourages patients to monitor their own condition

• • Enhances adherence to drug treatments

• • Patient’s satisfaction with the service

• • Creates a platform for early detection and intervention, e.g., to treat acute exacerbations

• • Some encouraging benefits in reducing hospital (re)admission and a trend to improved quality of life

• • Allows patients to be cared for from their own home

• • No treatment-related costs to the patient

Current challenges of the service

• • The cost of setting up the service and gamut of administrative procedures for dispatching and collecting equipment

• • The efficacy of the service to demonstrate ‘minimal clinical importance difference’ to improve quality of life over and above the usual care

• • The long-term efficacy of telehealthcare in reducing mortality in patients with COPD

• • Inability to demonstrate the cost–efficacy of the telehealthcare service as being ‘good value for money’

• • Potential for overprescription of drugs, unless the patient’s condition is carefully monitored

• • The sustainability of the service and adequate cover of healthcare professionals to provide a prompt response if a patient’s health status changes

• • Telehealthcare might be a problem for some older people who are not technologically savvy

• • The potential impact of comorbidities, such as depression, anxiety and cognitive impairment, on the ability of patients with COPD to give informed consent and use the technology successfully is unknown.

• • Ongoing clinical staff training about the purposes of the telehealthcare initiatives and coaching are worthy of consideration

• • Potential safety concerns in terms of data storage and loss of confidentiality

• • The willingness of the healthcare providers to allocate an appropriate budget in order to run and implement the telehealthcare service

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Notes

COPD: Chronic obstructive pulmonary disease.

Data taken from [4,5,8–10].