Journal of Telemedicine and Telecare http://jtt.sagepub.com/
Long-term telerehabilitation of COPD patients in their homes: interim results from a pilot study in Northern Norway Paolo Zanaboni, Linda Aarøen Lien, Audhild Hjalmarsen and Richard Wootton J Telemed Telecare 2013 19: 425 DOI: 10.1177/1357633X13506514 The online version of this article can be found at: http://jtt.sagepub.com/content/19/7/425
Published by: http://www.sagepublications.com
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RESEARCH/Original article
Long-term telerehabilitation of COPD patients in their homes: interim results from a pilot study in Northern Norway
Journal of Telemedicine and Telecare 19(7) 425–429 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506514 jtt.sagepub.com
Paolo Zanaboni1, Linda Aarøen Lien2, Audhild Hjalmarsen3 and Richard Wootton1,4
Summary We investigated the feasibility of a long-term telerehabilitation service for COPD patients comprising exercise training at home, telemonitoring and education/self-management. The service was offered as a 2-year follow-up programme by a physiotherapist. Equipment included a treadmill, a pulse oximeter and a tablet computer. Participants had weekly videoconference sessions with the physiotherapist. A website was used to access a training programme and to fill in a daily diary and a training diary. Ten patients with moderate or severe COPD participated in a pilot study in Northern Norway. After more than one year, all participants were still participating actively and no drop-outs had occurred. On average, there were 2.0 training sessions/week, 3.3 measurements/week registered via the website and 0.5 videoconference contacts/week. There was a reduction of 27% in the COPD-related hospital costs. Feedback from the participants was very positive. Long-term telerehabilitation of COPD patients at home is feasible and interim results suggest that it reduces healthcare utilization. Accepted: 1 September 2013
Introduction Chronic obstructive pulmonary disease (COPD) is a lung ailment characterized by a persistent blockage of airflow from the lungs.1 It is an underdiagnosed, life-threatening lung disease that interferes with normal breathing and is not fully reversible.1 Acute events are associated with exacerbations in which ventilatory lung function is reduced.2 These episodes can lead to a dramatic worsening of the patient’s condition and to hospital admission.3 The largest part of the health service expenditure on COPD is for hospitalization and emergency department (ED) visits (73%). These commonly occur in the latter stages of the disease.4 Pulmonary rehabilitation is an integral part of the longterm management of COPD.5 It typically includes exercise training as an essential, mandatory component, together with patient assessment, education and psychosocial support.6,7 Guidelines for the management of COPD recommend that programmes of pulmonary rehabilitation and maintenance should be tailored to the individual’s needs to improve quality of life, help people to self manage their disease as effectively as possible,8 reduce symptoms, optimize functional status, increase participation, and reduce healthcare costs by stabilizing or reversing systemic manifestations of the disease.7,9 Despite this, many people with COPD do not attend or complete their rehabilitation programme, and long-term maintenance has been difficult to achieve after short-term treatment.6
A possible solution is to move pulmonary rehabilitation to the patient’s home, promote self-management and empower patients with telemedicine tools. However, there have been very few studies which have specifically focused on telerehabilitation.10,11 Furthermore, most telemedicine interventions in COPD have been of relatively short duration. For example, the median length of follow-up in the studies reviewed by Bolton et al.12 was 6 months. There have been few published studies of longer-term effects, e.g. follow-up lasting more than 6 months.6,7
Aim We have investigated the feasibility of a long-term telerehabilitation service for COPD patients consisting of three components: (1) exercise training at home, (2) telemonitoring, and (3) education/self-management. This 1
Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway 2 Skibotn Rehabilitering, LHL Helse AS, Norway 3 Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway 4 Faculty of Health Sciences, University of Tromsø, Norway Corresponding author: Dr P Zanaboni, Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway. Email: [email protected]
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service gives patients with COPD the opportunity to be instructed, guided and monitored by a physiotherapist in their training at home.
Methods
. aged 18–75 years; . resident in Northern Norway (Finnmark, Troms or Nordland Counties); . Norwegian-speaking. The exclusion criteria were:
The study was conducted by the Norwegian Centre for Integrated Care and Telemedicine (NST) in collaboration with the University Hospital of North Norway and the rehabilitation centre Skibotn Rehabilitering, LHL Helse AS. The service was offered as a long-term intervention, with a 2-year follow-up. The service was designed as a comprehensive intervention which combines exercise training at home, telemonitoring and education/self-management. After the patients had attended pulmonary rehabilitation, we supplied them with equipment for home exercise and videoconferencing so that they could exercise under the supervision of a physiotherapist, and participate in group training with their peers. We chose to monitor pulse oximetry as a useful measure to routinely assess patients with COPD and to predict exacerbations. We developed a web-based education/self-management platform, which could be accessed by the participants through the home telemedicine unit. The study was approved by the appropriate ethics committee.
Patients The inclusion criteria were: . moderate/severe diagnosis of COPD in accordance with the GOLD guidelines;7 . completion of a rehabilitation programme during the previous 6 months;
. unwillingness or inability to give informed consent; . presence of comorbidities or physical conditions which might interfere with home rehabilitation and selfmanagement; . home environment not suitable for installation and use of training and monitoring equipment (e.g. space, Internet connection, family needs).
Equipment Participants were provided with equipment for home training support consisting of a treadmill, a pulse oximeter (Nonin GO2 LED), a tablet computer (Apple iPad 2) and a tablet holder (Figure 1). The tablet computer was used to perform videoconferencing and to access the project’s website. A mobile application was chosen for videoconferencing (LifeSize, ClearSea). This could connect the participants’ tablet to H.323 and SIP standards-based systems, as well as to desktop computers or other mobile clients. Communication was performed with AES encryption. In addition, a virtual room supporting up to 20 participants in continuous-presence, multisite videoconferencing was available from the Norwegian Health Network. Videoconference sessions were initiated from the rehabilitation centre and performed through the application running on the participant’s tablet. Participants used the
Figure 1. Equipment for exercise training at home, telemonitoring and self-management.
Downloaded from jtt.sagepub.com at MEMORIAL UNIV OF NEWFOUNDLAND on June 19, 2014
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website to access an individual training programme, to fill in a daily diary and a training diary, and to access historical data. The information sent by the participants through the website was interpreted by a physiotherapist.
videoconferences or peer-group exercise with other participants.
Study procedures
Approximately 6 months after recruitment, four participants were interviewed by telephone and asked the following open question: ‘‘What did this study mean to you?’’. Responses were recorded, transcribed and translated into English.
Participants were enrolled by a lung specialist and a trained physiotherapist during a baseline clinic visit. A clinical assessment was performed and the following information was collected: clinical history; spirometry; 6-minute walking distance; bodyweight and height; Modified Medical Research Council Dyspnoea Scale13; socio-economic status; COPD Assessment Test (CAT)14; St George’s Respiratory Questionnaire15; and EQ-5D Health Questionnaire.16 The equipment was installed and tested at the participant’s home by the research team. The physiotherapist performed a remote training session on the use of the equipment and the home telemedicine unit for education/self-management. Participants were asked to fill in a daily electronic form including the following items: oxygen saturation (at rest); and the Breathlessness, Cough and Sputum Scale (BCSS).17 Each participant received an individual training programme consisting of regular exercise (e.g. recommended three times a week) on the treadmill and strength training. The training programme could be modified by the physiotherapist according to the participant’s conditions. After each training session, participants were asked to fill in an electronic form including the following items: programme completion; Borg CR10 scale18; oxygen saturation (lowest value during exercise); and heart rate (highest value during exercise). Participants had weekly videoconference sessions with the physiotherapist. The sessions consisted of individual
Feedback from the participants
Healthcare utilization Data on COPD-related hospital accesses were obtained for each participant for the 6 months before enrolment, and compared to those related to the first 6 months of the pilot. The data were collected from the electronic records system of the main regional hospital in Tromsø.
Outcome measures The primary outcome measure was the number of hospital admissions. Secondary measures were: long-term exercise maintenance; adherence to the exercise programme; hospital length-of-stay, healthcare costs; quality of life.
Results Ten participants were enrolled in the study from January 2012 to May 2012. The participants were all residents in Northern Norway (6 were from the Troms County and 4 from the Finnmark County), see Figure 2. The most remote patient lived almost 800 km (driving distance) from Tromsø. The baseline characteristics of the participants are shown in Table 1. The results of the questionnaires (COPD Assessment Test, St George’s Respiratory
Figure 2. Location of the participants.
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Table 1. Baseline characteristics of the participants. Continuous variables are reported as median [interquartile range].
Table 3. Healthcare utilization in the 6 months before and after enrolment for the 10 participants.
Measure Patients, n Age, years Sex Males, n (%) Females, n (%) Patients on LTOT, n (%) FEV1 (% predicted) GOLD Class II, n (%) Class III, n (%) BMI, kg/m2 Distance walked in 6 min, m Distance from main hospital, km Travel time, min Patients living alone, n (%) Patients working, n (%)
10 54.0 [51.0–56.8] 5 5 3 38.5
(50%) (50%) (30%) [34.0–61.3]
2 8 25.8 520 117 134 5 2
(20%) (80%) [22.8–30.4] [464–554] [30–414] [37–372] (50%) (20%)
Hospital Hospital Hospital Hospital
admissions (n) length-of-stay (days) visits (n) costs (NOK)
6 months before enrolment
6 months after enrolment
2 10 23 202,871
2 4 15 148,748
participants occurred four times. On average, 3.3 (SD 2.1) measurements/week were recorded via the website.
Healthcare utilization There was a 27% difference in the COPD-related hospital costs as consequence of fewer accesses and shorter lengthof-stay, see Table 3. However, this difference was not significant (P¼0.50).
Feedback from the participants The responses of the four participants were: Table 2. Baseline questionnaire results. Values shown are median [interquartile range]. Measure COPD Assessment Test (CAT) St George’s Respiratory Questionnaire Symptom score Activity score Impact score EQ-5D (utility scores)
23 51.7 60.5 73.0 37.3 0.61
[19–25] [45.6–56.4] [44.9–66.0] [66.1–82.3] [31.1–43.4]] [0.50–0.76]
Questionnaire, EQ-5D Health Questionnaire) submitted at baseline are summarised in Table 2.
Use of the telerehabilitation service The average duration of follow-up was 445 days (SD 26). All participants trained regularly on a treadmill installed at their home. On average, there were 2.0 (SD 1.1) training sessions/week registered via the website. No drop-outs occurred during the study. All participants had individual videoconferences with the physiotherapist and recorded daily measurements via the website. The average number of videoconference contacts was 0.5 /week (SD 0.1). When videoconferencing with a patient was not possible for technical reasons (e.g. a slow Internet connection), telephone contact was established instead. Other reasons for not performing a videoconference included health-related problems, absence from home (e.g. holidays), unavailability and personal reasons. Multisite videoconferencing was tested on two occasions, and unsupervised contacts among
‘‘It meant a lot. I got in good physical shape, and improved psychologically as well. It also helped me in coping. It was great to be able to go to the store 3 km away. It also became easier to clean the house. I look better, and I have received good comments. I have only positive things to say about the training’’. ‘‘It’s still a bit early in the study, but so far my shape has improved in a relatively short time. I notice that I can be more active in daily life. I also believe that I can get in even better shape. It takes both time and effort in training, but you get so much back in terms of a better life’’. ‘‘Training meant a lot for my health, no doubt. My doctor asked me why I haven’t been there for a long time. I clarified it with training. There has been a tremendous improvement in breathing and intensity, and what I can manage in everyday life. I am also very surprised that this could be possible’’. ‘‘It is positive. I got in better shape. I can bear more and keep doing everyday activities longer. It takes just one hour, but instead of sitting on the couch and crying over your own condition, you can go on the treadmill and cry over how heavy it is – ha, ha. I’m excited every time I go training on the treadmill. Training inside is not weather-dependent so you don’t have to worry about bad weather, slippery roads and darkness’’.
In summary, the feedback was very positive, and all participants acknowledged that they succeeded in maintaining their training programme after enrolment.
Discussion The present study describes preliminary results from a comprehensive intervention, which combines exercise training
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at home, telemonitoring, and education/self-management. Since the intervention is of relatively long-term duration – up to 2 years – it represents a novel example of integrated disease management of COPD patients. After more than one year since enrolment, all participants continue to participate actively, and no drop-outs have occurred. This duration is longer than other telemedicine studies for COPD patients.12 Telerehabilitation therefore appears to be a feasible intervention for long-term exercise maintenance. Longterm exercise maintenance via telerehabilitation also appears promising in reducing healthcare utilization. We believe that three factors in the telerehabilitation programme positively affected exercise maintenance. First, participants were provided with appropriate equipment to train at home. Training would not have been otherwise possible, due to long distances, limited availability of rehabilitation services in small municipalities, and the weather conditions in Northern Norway. Second, the dialogue with a physiotherapist responsible for supporting participants via videoconferencing played a key role in exercise maintenance and tailoring. Third, participants took part in the study not only as individuals, but as a group of people with similar problems and challenges. Few participants knew each other before recruitment, others met during the study, thus creating an informal social network. Videoconferencing has the potential to enhance motivation through both supervised and unsupervised peer-group rehabilitation sessions, in which multiple patients can train and communicate simultaneously. This is a novel aspect of telerehabilitation. Group videoconferencing was tested with positive feedback, and its benefits will be investigated further as the study progresses. In summary, the evidence base for the use of telemedicine in COPD, and especially telerehabilitation, is still limited. Our pilot study demonstrates that long-term telerehabilitation of COPD patients is feasible, and appears promising in reducing the burden for the healthcare system and patients. It also provides valuable experience and data to justify and design a large-scale implementation. Based on the results of the pilot trial, together with the evidence reported by other trials, a multicentre randomized controlled trial is now being planned in order to provide scientific evidence of the clinical benefits and costeffectiveness of long-term telerehabilitation for COPD patients. Acknowledgements The study was funded by the Northern Norway Regional Health Authority (ref. HST1014-11).
References 1. WHO. Chronic obstructive pulmonary disease (COPD). Fact sheet No 315. See http://www.who.int/mediacentre/ factsheets/fs315/en/ (last checked 31 August 2013).
2. Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet 2007;370:786–96. 3. Garcia-Aymerich J, Serra Pons I, Mannino DM, Maas AK, Miller DP, Davis KJ. Lung function impairment, COPD hospitalisations and subsequent mortality. Thorax 2011;66:585–90. 4. Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest 2000;117(Suppl. 2): 5–9. 5. Lacasse Y, Maltais F, Goldstein RS. Pulmonary rehabilitation: an integral part of the long-term management of COPD. Swiss Med Wkly 2004;134:601–5. 6. Ries AL, Kaplan RM, Myers R, Prewitt LM. Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial. Am J Respir Crit Care Med 2003;167:880–8. 7. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD. See http://www.goldcopd.org/ uploads/users/files/GOLD_Report_2013_Feb20.pdf (last checked 1 September 2013). 8. National Institute for Health and Care Excellence. CG101 Chronic obstructive pulmonary disease (update): full guideline. See http://guidance.nice.org.uk/CG101/Guidance/pdf/ English (last checked 31 August 2013). 9. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006;173:1390–1413. 10. Dinesen B, Seeman J, Gustafsson J. Development of a program for tele-rehabilitation of COPD patients across sectors: co-innovation in a network. Int J Integr Care 2011;11:e012. 11. Holland AE, Hill CJ, Rochford P, Fiore J, Berlowitz DJ, McDonald CF. Telerehabilitation for people with chronic obstructive pulmonary disease: feasibility of a simple, real time model of supervised exercise training. J Telemed Telecare 2013 [Epub ahead of print]. 12. Bolton CE, Waters CS, Peirce S, et al. Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD. J Eval Clin Pract 2011;17:1216–22. 13. Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999;54:581–586. 14. Jones PW, Harding G, Berry P, et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009;34:648–654. 15. Jones PW, Quirk FH, Baveystock CM. The St George’s Respiratory Questionnaire. Respir Med 1991;85(Suppl B): 25–31. 16. EuroQol Group. EuroQol – a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199–208. 17. Leidy NK, Rennard SI, Schmier J, Jones MK, Goldman M. The breathlessness, cough, and sputum scale: the development of empirically based guidelines for interpretation. Chest 2003;124:2182–91. 18. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign, IL: Human Kinetics, 1998.
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Long-term telerehabilitation of COPD patients in their homes: interim results from a pilot study in Northern Norway Paolo Zanaboni, Linda Aarøen Lien, Audhild Hjalmarsen and Richard Wootton J Telemed Telecare 2013 19: 425 DOI: 10.1177/1357633X13506514 The online version of this article can be found at: http://jtt.sagepub.com/content/19/7/425
Published by: http://www.sagepublications.com
Additional services and information for Journal of Telemedicine and Telecare can be found at: Email Alerts: http://jtt.sagepub.com/cgi/alerts Subscriptions: http://jtt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 10, 2013 What is This?
Downloaded from jtt.sagepub.com at MEMORIAL UNIV OF NEWFOUNDLAND on June 19, 2014
RESEARCH/Original article
Long-term telerehabilitation of COPD patients in their homes: interim results from a pilot study in Northern Norway
Journal of Telemedicine and Telecare 19(7) 425–429 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506514 jtt.sagepub.com
Paolo Zanaboni1, Linda Aarøen Lien2, Audhild Hjalmarsen3 and Richard Wootton1,4
Summary We investigated the feasibility of a long-term telerehabilitation service for COPD patients comprising exercise training at home, telemonitoring and education/self-management. The service was offered as a 2-year follow-up programme by a physiotherapist. Equipment included a treadmill, a pulse oximeter and a tablet computer. Participants had weekly videoconference sessions with the physiotherapist. A website was used to access a training programme and to fill in a daily diary and a training diary. Ten patients with moderate or severe COPD participated in a pilot study in Northern Norway. After more than one year, all participants were still participating actively and no drop-outs had occurred. On average, there were 2.0 training sessions/week, 3.3 measurements/week registered via the website and 0.5 videoconference contacts/week. There was a reduction of 27% in the COPD-related hospital costs. Feedback from the participants was very positive. Long-term telerehabilitation of COPD patients at home is feasible and interim results suggest that it reduces healthcare utilization. Accepted: 1 September 2013
Introduction Chronic obstructive pulmonary disease (COPD) is a lung ailment characterized by a persistent blockage of airflow from the lungs.1 It is an underdiagnosed, life-threatening lung disease that interferes with normal breathing and is not fully reversible.1 Acute events are associated with exacerbations in which ventilatory lung function is reduced.2 These episodes can lead to a dramatic worsening of the patient’s condition and to hospital admission.3 The largest part of the health service expenditure on COPD is for hospitalization and emergency department (ED) visits (73%). These commonly occur in the latter stages of the disease.4 Pulmonary rehabilitation is an integral part of the longterm management of COPD.5 It typically includes exercise training as an essential, mandatory component, together with patient assessment, education and psychosocial support.6,7 Guidelines for the management of COPD recommend that programmes of pulmonary rehabilitation and maintenance should be tailored to the individual’s needs to improve quality of life, help people to self manage their disease as effectively as possible,8 reduce symptoms, optimize functional status, increase participation, and reduce healthcare costs by stabilizing or reversing systemic manifestations of the disease.7,9 Despite this, many people with COPD do not attend or complete their rehabilitation programme, and long-term maintenance has been difficult to achieve after short-term treatment.6
A possible solution is to move pulmonary rehabilitation to the patient’s home, promote self-management and empower patients with telemedicine tools. However, there have been very few studies which have specifically focused on telerehabilitation.10,11 Furthermore, most telemedicine interventions in COPD have been of relatively short duration. For example, the median length of follow-up in the studies reviewed by Bolton et al.12 was 6 months. There have been few published studies of longer-term effects, e.g. follow-up lasting more than 6 months.6,7
Aim We have investigated the feasibility of a long-term telerehabilitation service for COPD patients consisting of three components: (1) exercise training at home, (2) telemonitoring, and (3) education/self-management. This 1
Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway 2 Skibotn Rehabilitering, LHL Helse AS, Norway 3 Heart and Lung Clinic, University Hospital of North Norway, Tromsø, Norway 4 Faculty of Health Sciences, University of Tromsø, Norway Corresponding author: Dr P Zanaboni, Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway. Email: [email protected]
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service gives patients with COPD the opportunity to be instructed, guided and monitored by a physiotherapist in their training at home.
Methods
. aged 18–75 years; . resident in Northern Norway (Finnmark, Troms or Nordland Counties); . Norwegian-speaking. The exclusion criteria were:
The study was conducted by the Norwegian Centre for Integrated Care and Telemedicine (NST) in collaboration with the University Hospital of North Norway and the rehabilitation centre Skibotn Rehabilitering, LHL Helse AS. The service was offered as a long-term intervention, with a 2-year follow-up. The service was designed as a comprehensive intervention which combines exercise training at home, telemonitoring and education/self-management. After the patients had attended pulmonary rehabilitation, we supplied them with equipment for home exercise and videoconferencing so that they could exercise under the supervision of a physiotherapist, and participate in group training with their peers. We chose to monitor pulse oximetry as a useful measure to routinely assess patients with COPD and to predict exacerbations. We developed a web-based education/self-management platform, which could be accessed by the participants through the home telemedicine unit. The study was approved by the appropriate ethics committee.
Patients The inclusion criteria were: . moderate/severe diagnosis of COPD in accordance with the GOLD guidelines;7 . completion of a rehabilitation programme during the previous 6 months;
. unwillingness or inability to give informed consent; . presence of comorbidities or physical conditions which might interfere with home rehabilitation and selfmanagement; . home environment not suitable for installation and use of training and monitoring equipment (e.g. space, Internet connection, family needs).
Equipment Participants were provided with equipment for home training support consisting of a treadmill, a pulse oximeter (Nonin GO2 LED), a tablet computer (Apple iPad 2) and a tablet holder (Figure 1). The tablet computer was used to perform videoconferencing and to access the project’s website. A mobile application was chosen for videoconferencing (LifeSize, ClearSea). This could connect the participants’ tablet to H.323 and SIP standards-based systems, as well as to desktop computers or other mobile clients. Communication was performed with AES encryption. In addition, a virtual room supporting up to 20 participants in continuous-presence, multisite videoconferencing was available from the Norwegian Health Network. Videoconference sessions were initiated from the rehabilitation centre and performed through the application running on the participant’s tablet. Participants used the
Figure 1. Equipment for exercise training at home, telemonitoring and self-management.
Downloaded from jtt.sagepub.com at MEMORIAL UNIV OF NEWFOUNDLAND on June 19, 2014
Zanaboni et al.
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website to access an individual training programme, to fill in a daily diary and a training diary, and to access historical data. The information sent by the participants through the website was interpreted by a physiotherapist.
videoconferences or peer-group exercise with other participants.
Study procedures
Approximately 6 months after recruitment, four participants were interviewed by telephone and asked the following open question: ‘‘What did this study mean to you?’’. Responses were recorded, transcribed and translated into English.
Participants were enrolled by a lung specialist and a trained physiotherapist during a baseline clinic visit. A clinical assessment was performed and the following information was collected: clinical history; spirometry; 6-minute walking distance; bodyweight and height; Modified Medical Research Council Dyspnoea Scale13; socio-economic status; COPD Assessment Test (CAT)14; St George’s Respiratory Questionnaire15; and EQ-5D Health Questionnaire.16 The equipment was installed and tested at the participant’s home by the research team. The physiotherapist performed a remote training session on the use of the equipment and the home telemedicine unit for education/self-management. Participants were asked to fill in a daily electronic form including the following items: oxygen saturation (at rest); and the Breathlessness, Cough and Sputum Scale (BCSS).17 Each participant received an individual training programme consisting of regular exercise (e.g. recommended three times a week) on the treadmill and strength training. The training programme could be modified by the physiotherapist according to the participant’s conditions. After each training session, participants were asked to fill in an electronic form including the following items: programme completion; Borg CR10 scale18; oxygen saturation (lowest value during exercise); and heart rate (highest value during exercise). Participants had weekly videoconference sessions with the physiotherapist. The sessions consisted of individual
Feedback from the participants
Healthcare utilization Data on COPD-related hospital accesses were obtained for each participant for the 6 months before enrolment, and compared to those related to the first 6 months of the pilot. The data were collected from the electronic records system of the main regional hospital in Tromsø.
Outcome measures The primary outcome measure was the number of hospital admissions. Secondary measures were: long-term exercise maintenance; adherence to the exercise programme; hospital length-of-stay, healthcare costs; quality of life.
Results Ten participants were enrolled in the study from January 2012 to May 2012. The participants were all residents in Northern Norway (6 were from the Troms County and 4 from the Finnmark County), see Figure 2. The most remote patient lived almost 800 km (driving distance) from Tromsø. The baseline characteristics of the participants are shown in Table 1. The results of the questionnaires (COPD Assessment Test, St George’s Respiratory
Figure 2. Location of the participants.
Downloaded from jtt.sagepub.com at MEMORIAL UNIV OF NEWFOUNDLAND on June 19, 2014
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Journal of Telemedicine and Telecare 19(7)
Table 1. Baseline characteristics of the participants. Continuous variables are reported as median [interquartile range].
Table 3. Healthcare utilization in the 6 months before and after enrolment for the 10 participants.
Measure Patients, n Age, years Sex Males, n (%) Females, n (%) Patients on LTOT, n (%) FEV1 (% predicted) GOLD Class II, n (%) Class III, n (%) BMI, kg/m2 Distance walked in 6 min, m Distance from main hospital, km Travel time, min Patients living alone, n (%) Patients working, n (%)
10 54.0 [51.0–56.8] 5 5 3 38.5
(50%) (50%) (30%) [34.0–61.3]
2 8 25.8 520 117 134 5 2
(20%) (80%) [22.8–30.4] [464–554] [30–414] [37–372] (50%) (20%)
Hospital Hospital Hospital Hospital
admissions (n) length-of-stay (days) visits (n) costs (NOK)
6 months before enrolment
6 months after enrolment
2 10 23 202,871
2 4 15 148,748
participants occurred four times. On average, 3.3 (SD 2.1) measurements/week were recorded via the website.
Healthcare utilization There was a 27% difference in the COPD-related hospital costs as consequence of fewer accesses and shorter lengthof-stay, see Table 3. However, this difference was not significant (P¼0.50).
Feedback from the participants The responses of the four participants were: Table 2. Baseline questionnaire results. Values shown are median [interquartile range]. Measure COPD Assessment Test (CAT) St George’s Respiratory Questionnaire Symptom score Activity score Impact score EQ-5D (utility scores)
23 51.7 60.5 73.0 37.3 0.61
[19–25] [45.6–56.4] [44.9–66.0] [66.1–82.3] [31.1–43.4]] [0.50–0.76]
Questionnaire, EQ-5D Health Questionnaire) submitted at baseline are summarised in Table 2.
Use of the telerehabilitation service The average duration of follow-up was 445 days (SD 26). All participants trained regularly on a treadmill installed at their home. On average, there were 2.0 (SD 1.1) training sessions/week registered via the website. No drop-outs occurred during the study. All participants had individual videoconferences with the physiotherapist and recorded daily measurements via the website. The average number of videoconference contacts was 0.5 /week (SD 0.1). When videoconferencing with a patient was not possible for technical reasons (e.g. a slow Internet connection), telephone contact was established instead. Other reasons for not performing a videoconference included health-related problems, absence from home (e.g. holidays), unavailability and personal reasons. Multisite videoconferencing was tested on two occasions, and unsupervised contacts among
‘‘It meant a lot. I got in good physical shape, and improved psychologically as well. It also helped me in coping. It was great to be able to go to the store 3 km away. It also became easier to clean the house. I look better, and I have received good comments. I have only positive things to say about the training’’. ‘‘It’s still a bit early in the study, but so far my shape has improved in a relatively short time. I notice that I can be more active in daily life. I also believe that I can get in even better shape. It takes both time and effort in training, but you get so much back in terms of a better life’’. ‘‘Training meant a lot for my health, no doubt. My doctor asked me why I haven’t been there for a long time. I clarified it with training. There has been a tremendous improvement in breathing and intensity, and what I can manage in everyday life. I am also very surprised that this could be possible’’. ‘‘It is positive. I got in better shape. I can bear more and keep doing everyday activities longer. It takes just one hour, but instead of sitting on the couch and crying over your own condition, you can go on the treadmill and cry over how heavy it is – ha, ha. I’m excited every time I go training on the treadmill. Training inside is not weather-dependent so you don’t have to worry about bad weather, slippery roads and darkness’’.
In summary, the feedback was very positive, and all participants acknowledged that they succeeded in maintaining their training programme after enrolment.
Discussion The present study describes preliminary results from a comprehensive intervention, which combines exercise training
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at home, telemonitoring, and education/self-management. Since the intervention is of relatively long-term duration – up to 2 years – it represents a novel example of integrated disease management of COPD patients. After more than one year since enrolment, all participants continue to participate actively, and no drop-outs have occurred. This duration is longer than other telemedicine studies for COPD patients.12 Telerehabilitation therefore appears to be a feasible intervention for long-term exercise maintenance. Longterm exercise maintenance via telerehabilitation also appears promising in reducing healthcare utilization. We believe that three factors in the telerehabilitation programme positively affected exercise maintenance. First, participants were provided with appropriate equipment to train at home. Training would not have been otherwise possible, due to long distances, limited availability of rehabilitation services in small municipalities, and the weather conditions in Northern Norway. Second, the dialogue with a physiotherapist responsible for supporting participants via videoconferencing played a key role in exercise maintenance and tailoring. Third, participants took part in the study not only as individuals, but as a group of people with similar problems and challenges. Few participants knew each other before recruitment, others met during the study, thus creating an informal social network. Videoconferencing has the potential to enhance motivation through both supervised and unsupervised peer-group rehabilitation sessions, in which multiple patients can train and communicate simultaneously. This is a novel aspect of telerehabilitation. Group videoconferencing was tested with positive feedback, and its benefits will be investigated further as the study progresses. In summary, the evidence base for the use of telemedicine in COPD, and especially telerehabilitation, is still limited. Our pilot study demonstrates that long-term telerehabilitation of COPD patients is feasible, and appears promising in reducing the burden for the healthcare system and patients. It also provides valuable experience and data to justify and design a large-scale implementation. Based on the results of the pilot trial, together with the evidence reported by other trials, a multicentre randomized controlled trial is now being planned in order to provide scientific evidence of the clinical benefits and costeffectiveness of long-term telerehabilitation for COPD patients. Acknowledgements The study was funded by the Northern Norway Regional Health Authority (ref. HST1014-11).
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