CHEST
Commentary
Telemedicine in COPD Time to Pause Roger S. Goldstein, MBChB, FCCP; and Sachi O’Hoski, MScPT
There is increasing interest in the use of telemedicine to assist in the management of chronic diseases. Telemedicine possibilities for patients with COPD include medical consultations, in-home patient monitoring, and remote rehabilitation. Teleconsultations have been used successfully, saving time and travel costs for patients with only a few subsequently requiring face-to-face visits. Despite many reports, the impact of telemonitoring on the detection of exacerbations, reductions in health-care utilization, and cost savings is equivocal. Given the health-care costs and commitment involved in telemonitoring, well-designed longer-term multicenter studies with appropriate follow-up are required prior to its more widespread application. Emerging evidence from preliminary trials of telerehabilitation for the pulmonary patient is encouraging. It may represent a useful tool for increasing access and building capacity, especially in remote areas. CHEST 2014; 145(5):945–949 Abbreviations: AECOPD 5 acute exacerbation of COPD; CHF 5 congestive heart failure; HCP 5 health-care professional; PR 5 pulmonary rehabilitation; TM 5 telemonitoring
the last decade there has been increasing interOver est in the use of telemedicine to assist in the man-
agement of chronic diseases.1,2 Telemedicine technology and devices have been used for care of patients with COPD to provide medical consultations, in-home patient monitoring, and remote pulmonary rehabilitation. Telemedicine consultations, in which the physician and patient are connected via a video conference device rather than meeting in person, have been shown, in preliminary communications, to be feasible and acceptable for the management of patients with a variety of pulmonary conditions, including COPD.3 If a healthcare professional, such as a nurse or respiratory therapist, is present at the satellite site, then he or she can provide clinical information such as vital signs, chest
Manuscript received July 17, 2013; revision accepted December 6, 2013. Affiliations: From the West Park Healthcare Centre and University of Toronto, Toronto, ON, Canada. Funding/Support: Dr Goldstein is supported by the West Park Healthcare Centre Foundation. Correspondence to: Roger S. Goldstein, MBChB, FCCP, West Park Healthcare Centre, 82 Buttonwood Ave, Toronto, ON, M6M 2J5, Canada; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1656 journal.publications.chestnet.org
auscultation, or pulse oximetry. Raza and colleagues3 found that the technology was reliable, wait times for appointments were similar to in-person wait times, and, over a 7-year period in which 314 patients had 684 videoconference clinical encounters, only 8% of patients required a subsequent in-person visit. Most referrals were for abnormal radiology (38%) or for COPD (26%). The most frequent postconsultation diagnosis was COPD (29%) followed by benign pulmonary nodule (11%). Over the study period, patients were saved 473,340 km (294,120 miles) of travel and 748 work days, with 94% of patients receiving medical subspecialty care close to home.3 This has exciting implications for patients in terms of time and cost savings as well as for the environment and the healthcare system, as a result of which some clinicians now include telemedicine consultation within their scope of practice. Telemonitoring (TM) involves the use of equipment, sensors, and questionnaires by patients in their homes, followed by transmission of the data to a health-care professional (HCP) or team at a central location,4-6 either in real time or in a record-and-store fashion.2 There may be a range of predetermined baseline acceptable values set for each piece of information collected, causing an alert to be sent to an HCP when the data CHEST / 145 / 5 / MAY 2014
945
submitted by the patient falls outside of these values.6 The patient is then contacted by the central site and provided with health-care assistance. TM has recently been introduced to assist with the management of patients with COPD. Given the progressive nature of the condition, the dominant symptoms of dyspnea, and the clinical course punctuated by acute exacerbations of COPD (AECOPDs), it has been suggested that daily TM of patients’ signs and symptoms will detect changes in their clinical status sufficiently early to improve care and decrease health-care resource utilization by decreasing unscheduled visits to the family physician or specialist, home visits, ED visits, and hospitalizations.7,8 Despite plentiful communications on this topic, the benefits of TM in regard to its impact on clinical outcomes and cost-effectiveness remain to be clearly demonstrated. COPD is one of the most expensive chronic diseases in the developed world, mainly due to its increasing prevalence, with attendant exacerbation rates and hospitalizations as the condition progresses. In the United States in 2006, there were . 1.25 million hospitalizations due to AECOPD, with an average length of hospital stay of 5.9 (⫾6.1) days resulting in a total inpatient cost of $11.98 billion US dollars.9 Regardless of the reason for hospitalization, the prevalence of COPD even as a comorbidity increases the incidence of in-hospital mortality.10 Patient and HCP satisfaction with TM is generally positive.1,11-14 Patients report that the equipment is easy to use,1,12,15-18 despite the fact that the majority of the patients are . 65 years of age and may have limited exposure to technology. This is likely due to the training they receive when the equipment is installed. They also report that they feel safe knowing they are being monitored regularly13,15,17,18 and that home monitoring is convenient13 and makes medical care more accessible.19 They report satisfaction and empowerment from being involved in self-managing their condition.20 However, some patients are equally satisfied when their care includes regular home visits and telephone calls. Only a few studies have suggested added benefit to quality of life when home monitoring is compared with home care21 or usual care.22,23 Not only have studies shown no between-group differences resulting from the addition of TM,18,24,25 some HCPs have expressed concern that, in addition to increasing their workload,13,17,19 it creates the potential for overtreatment13 and increased dependency on technology,21 which varies in accuracy and reliability. To interpret the symptoms and signs in context, it is preferable for the same HCP to be monitoring the same patients on an ongoing basis. Patients have indicated that this consistency adds to their comfort level with TM.13,15,19 Given the cost of TM in human resources, equipment, and patients’ time, firm evidence of cost-effectiveness 946
is required, especially regarding the impact of earlier detection of AECOPD. Both randomized and nonrandomized trials have reported fewer exacerbations in the TM intervention group compared with control participants,25,26 with one study noting that regular monitoring of oxygen saturation, heart rate, and symptoms resulted in exacerbation prediction by an HCP 73% of the time.27 Although one randomized trial concluded that TM decreased ED visits compared with a control group receiving home care22 and two other studies reported a decrease in visits within the intervention group,17,28 one study observed a small increase in ED visits in the intervention group25 and another reported no betweengroup differences.21 Hospital admissions have been reported to decrease when a period of TM was compared with the time prior to the intervention,17,27-30 or when patients receiving TM were compared with those receiving usual care18,20,25,26 or home care.21,31 However, other randomized controlled trials have concluded that there were no between-group differences in hospital admissions,16,24 and, in one pre-to-post study, admissions increased in the 6 months following the intervention.32 The impact of TM on the length of hospital stay is also inconclusive with reports of a decrease,18,29,32 no within-group change or betweengroup difference,16,21,24 and an increase in the TM group.31 The impact of TM on home-care visits and visits to primary care is also inconsistent with reports of decreased contact,17,28,31 no between-group differences,22,24 and increased visits in the TM group.18,21 This outcome is of concern if, instead of fostering self-management and independence,33 intensive monitoring of symptoms and vital signs encourages requests for clarification of symptoms or increased care for comorbidities as well as dependence on repeated coaching from a case manager. Of the few studies evaluating the cost-effectiveness of adding TM to care of patients with COPD, both no cost benefit20 and reduced costs among the intervention group have been reported.18,23,26,31 Crist and colleagues,7 in a retrospective chart review following a home health-care strategy for patients with a variety of chronic conditions, estimated a projected savings of $216 to $681 per patient per week in home-care costs. These savings were among patients with wounds, IV therapies, diabetes, and stroke, rather than for those with a respiratory diagnosis. Details of adherence to TM in COPD are lacking. However, as in most chronic disease management programs, patient adherence to TM has been shown to be .77% in the mediumterm,16,17,27 but markedly decreases over time.14 The absence of conclusive evidence of benefit from TM in COPD should not be taken as evidence of absence of benefit as many studies have suffered from Commentary
design flaws and only one systematic review has focused solely on studies in patients with COPD.34 Bolton and colleagues,34 in a review that included six studies, reported reduced exacerbations and hospital admissions in the TM group. However, the small sample sizes, lack of consistency in study design, lack of detailed intervention descriptions, lack of economic evaluations, and diverse outcome measures used, led them to conclude that large, well-designed trials are required before broader application of TM can be recommended. Although systematic reviews that have included participants with a mixed variety of chronic conditions (such as COPD, heart failure, diabetes, and stroke) have reported benefits of TM (such as decreased ED visits and hospitalizations),4-6,14 poor research quality with inconsistencies in design and outcomes meant that their findings were very qualified and difficult to generalize.1,2,4-6,14 TM is a complex intervention that includes both the electronic transmission of patient information as well as a follow-up response by a healthcare professional. Other components such as telephone support,2,4-6,11,14 increased contact and attention,2,24,27 better care coordination,6,14,32 and increased education25,27 are sometimes included. As some of these other components are also provided to the control group, it can be difficult to isolate and evaluate a single variable. The conclusions regarding the use of TM in COPD are consistent with studies of its application in other chronic diseases. For example, in studies in diabetic patients investigating the impact of TM on glycemic control and hospitalizations, authors have noted the lack of subject homogeneity, small sample sizes, short follow-up periods, variation in treatments, and differing outcome measures.35,36 In contrast, in patients with congestive heart failure (CHF) with whom TM and telephone support were used, all-cause mortality, heart failure-related hospitalizations, length of stay, and resource utilization were reduced as well as quality of life improved, such that a review concluded that further randomized trials of TM in the CHF population were not warranted for proof of concept but more research was required to establish the most effective models of care, optimal duration, and cost benefit.37 One of the challenges to TM in people with COPD is that there is no concrete symptom or sign that separates a period free of exacerbation from a period of exacerbation.38 This might well be one of the contributors to the reported success in CHF where weight gain from fluid retention is a reliable sign. Given the equivocal evidence of effectiveness of TM in COPD11 as well as most other chronic diseases, more robust clinical trials to provide methodologically sound clinical evidence are required before recommending more widespread application of this technology.4-6,14,20 Unfortunately, in some jurisdictions, payers are rushjournal.publications.chestnet.org
ing to introduce TM in response to the pressures for reducing hospitalization among patients with COPD. This is occurring despite the paucity of good evaluative research. It may be that treating COPD as a single disease misses the important effects of attendant conditions.39 Many of the reported studies have considered the impact of comorbidities other than cognitive or physical impairments that would alter the clinical course, the likelihood of hospitalization, and the patient’s ability to use the technology.12,13,18,20,21,31 It is inconclusive whether TM in COPD is effective. If it is the play of chance with some poorly designed trials being positive and others negative, then better designed trials with more power and longer follow, or meta-analysis, may provide the necessary evidence. Although many studies have included patients with severe disease (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stage III or IV)12,20,21,25,31 they have varied in terms of their inclusion and exclusion criteria regarding the exacerbation history25,27,30 and the previous use of healthcare services such as home visits, hospitalizations, or rehabilitation,21,24,31,32 as well as requirements for supplemental oxygen.12,18 Whereas a small group of severely affected patients with severe symptoms, frequent exacerbations, multiple comorbidities, and limited community support might well benefit from TM, the absence of standardized interventions, such as controlled trials with a minimum of one year of follow-up, that include a costbenefit analysis makes it impossible to be confident of the role of TM in overall care of the patient with COPD. In the United Kingdom, the Department of Health released the results of a large 2-year trial of TM in which family physician practices were randomized to intervention or control groups.40 Participants included those with COPD, CHF, or diabetes who had at least one unplanned medical event in the preceding 12 months. The end point was the number of patients hospitalized during the 12-month trial. The authors reported a significantly lower proportion of admissions (OR, 0.82; 95% CI, 0.7-0.97; P 5 .017) and a lower mortality (4.6% vs 8.36%, OR 0.54 [95% CI, 0.39-0.75; P , .001]) among the intervention group over the 12-month period. Of note, the largest difference was in the first three months following the start of the trial and was due to an increase in hospitalizations in the control group. This group was composed of older patients who had a higher incidence of COPD and CHF and a lower incidence of diabetes and who had an increased length of stay as well as health-care costs prior to the trial period. Subsequently, in a multicenter primary care randomized controlled trial, Pinnock and colleagues41 reported on 256 patients with COPD who completed selfmonitoring or TM over a 1-year period. They reported CHEST / 145 / 5 / MAY 2014
947
that the number of days to admission (the primary end point) did not differ between groups (adjusted hazard ratio, 0.98; 95% CI, 0.66-1.44). The mean number of COPD admissions was similar as was the mean length of stay. There was no between-group difference in health-related quality of life.41 Results of studies such as these will help provide clarity as to best indications and applications of TM. An interesting innovation in telemedicine is the provision of pulmonary rehabilitation (PR) to satellite centers. This addresses issues of access and capacity, as PR is currently available to only a small percentage of eligible patients. Nield and Hoo42 completed a randomized controlled trial in which they used teletechnology to deliver education on pursed lips breathing and coordination of breathing with physical activity. After 4 weeks, the intervention group reported increased program adherence, decreased dyspnea intensity, and no between-group differences in 6-min walk distance, dyspnea distress, or dyspnea severity. Stickland and colleagues43 delivered PR to 147 people with COPD in satellite centers across Alberta, Canada, twice a week for 8 weeks and compared results with 262 similar patients who had attended conventional institutionally based PR. The intervention group received education through a telemedicine network and then exercised with local supervision. Both groups showed similar clinically and statistically significant improvements in quality of life and 12-min walk distance. Two small proof-of-concept home telerehabilitation studies44,45 have evaluated the feasibility of home exercise, supervised from a service center over 8 weeks, on participants with COPD and reported improvements in healthrelated quality of life and 6-min walking distance. These preliminary results are sufficiently interesting to encourage funding of randomized controlled trials of satellite telerehabilitation, to include at least 1 year of follow-up to establish feasibility and cost-effectiveness for this model of care. As noted in the position statement on telemedicine by the American Association of Cardiovascular and Pulmonary Rehabilitation,46 as with all new medical innovations, the clinicians’ obligation includes an explanation of the potential benefits and risks of telemedicine services as well as the patients’ rights and responsibilities. Given the integral part played by the transmission of clinical data, there is the added obligation of ensuring the confidentiality of medical records. In conclusion, consultations using teletechnology are feasible as well as cost-effective and telerehabilitation may be as effective as conventional rehabilitation as well as increasing access to PR. The evidence for TM in COPD remains inconclusive because of issues of trial design, sample size, unstandardized intervention, and limited follow-up. Whether it is the irreversible and progressive nature of COPD that leads 948
inevitably to exacerbations and hospitalization, whether it is the lack of reliable indicators of exacerbation, or even the effectiveness of the support services once an exacerbation has been detected, TM has yet to prove its worth in the COPD population. The enthusiasm for new technology and the urgency of reducing healthcare costs notwithstanding, the resources and patient commitment involved as well as the risk of fostering dependence, requires that longer-term, robust, multicenter studies should precede more widespread use of TM. Such studies should also inform as to the most effective intervention or combinations of interventions as well as the patient phenotype most likely to benefit. It is time to pause before incorporating this modality as part of the standard of care for those with COPD. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.
References 1. Botsis T, Hartvigsen G. Current status and future perspectives in telecare for elderly people suffering from chronic diseases. J Telemed Telecare. 2008;14(4):195-203. 2. Wootton R. Twenty years of telemedicine in chronic disease management—an evidence synthesis. J Telemed Telecare. 2012;18(4):211-220. 3. Raza T, Joshi M, Schapira RM, Agha Z. Pulmonary telemedicine— a model to access the subspecialist services in underserved rural areas. Int J Med Inform. 2009;78(1):53-59. 4. Gaikwad R, Warren J. The role of home-based information and communications technology interventions in chronic disease management: a systematic literature review. Health Informatics J. 2009;15(2):122-146. 5. Polisena J, Tran K, Cimon K, et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and metaanalysis. J Telemed Telecare. 2010;16(3):120-127. 6. McLean S, Nurmatov U, Liu JL, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;7(7):CD007718. 7. Crist TM, Kaufman SB, Crampton KR. Home telemedicine: a home health care agency strategy for maximizing resources. Home Health Care Manage Pract. 1996;8(4):1-9. 8. European Commission. Commission Communication COM/ 2008/0689 final. Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions (COM/2008/0689 final) on telemedicine for the benefit of patients, healthcare systems and society. European Commission website. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do? uri5CELEX:52008DC0689:EN:NOT. Published November 4, 2008. Accessed July 2013. 9. Perera PN, Armstrong EP, Sherrill DL, Skrepnek GH. Acute exacerbations of COPD in the United States: inpatient burden and predictors of costs and mortality. COPD. 2012;9(2): 131-141. Commentary
10. Holguin F, Folch E, Redd SC, Mannino DM. Comorbidity and mortality in COPD-related hospitalizations in the United States, 1979 to 2001. Chest. 2005;128(4):2005-2011. 11. Smith SM, Elkin SL, Partridge MR. Technology and its role in respiratory care. Prim Care Respir J. 2009;18(3):159-164. 12. Bernocchi P, Scalvini S, Tridico C, et al. Healthcare continuity from hospital to territory in Lombardy: TELEMACO project. Am J Manag Care. 2012;18(3):e101-e108. 13. Ure J, Pinnock H, Hanley J, et al. Piloting tele-monitoring in COPD: a mixed methods exploration of issues in design and implementation. Prim Care Respir J. 2012;21(1):57-64. 14. Paré G, Jaana M, Sicotte C. Systematic review of home telemonitoring for chronic diseases: the evidence base. J Am Med Inform Assoc. 2007;14(3):269-277. 15. Rogers A, Kirk S, Gately C, May CR, Finch T. Established users and the making of telecare work in long term condition management: implications for health policy. Soc Sci Med. 2011;72(7):1077-1084. 16. Antoniades NC, Rochford PD, Pretto JJ, et al. Pilot study of remote telemonitoring in COPD. Telemed J E Health. 2012;18(8):634-640. 17. Roberts A, Garrett L, Godden DJ. Can telehealth deliver for rural Scotland? Lessons from the Argyll & Bute Telehealth Programme. Scott Med J. 2012;57(1):33-37. 18. De San Miguel K, Smith J, Lewin G. Telehealth remote monitoring for community-dwelling older adults with chronic obstructive pulmonary disease. Telemed J E Health. 2013; 19(9):652-657. 19. Fairbrother P, Pinnock H, Hanley J, et al; TELESCOT Programme Team. Continuity, but at what cost? The impact of telemonitoring COPD on continuities of care: a qualitative study. Prim Care Respir J. 2012;21(3):322-328. 20. Dinesen B, Haesum LKE, Soerensen N, et al. Using preventive home monitoring to reduce hospital admission rates and reduce costs: a case study of telehealth among chronic obstructive pulmonary disease patients. J Telemed Telecare. 2012;18(4):221-225. 21. Sicotte C, Paré G, Morin S, Potvin J, Moreault MP. Effects of home telemonitoring to support improved care for chronic obstructive pulmonary diseases. Telemed J E Health. 2011; 17(2):95-103. 22. Gellis ZD, Kenaley B, McGinty J, Bardelli E, Davitt J, Ten Have T. Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: a randomized controlled trial. Gerontologist. 2012;52(4):541-552. 23. Haesum LK, Soerensen N, Dinesen B, et al. Cost-utility analysis of a telerehabilitation program: a case study of COPD patients. Telemed J E Health. 2012;18(9):688-692. 24. Lewis KE, Annandale JA, Warm DL, Hurlin C, Lewis MJ, Lewis L. Home telemonitoring and quality of life in stable, optimised chronic obstructive pulmonary disease. J Telemed Telecare. 2010;16(5):253-259. 25. Trappenburg JCA, Niesink A, de Weert-van Oene GH, et al. Effects of telemonitoring in patients with chronic obstructive pulmonary disease. Telemed J E Health. 2008;14(2):138-146. 26. Vitacca M, Bianchi L, Guerra A, et al. Tele-assistance in chronic respiratory failure patients: a randomised clinical trial. Eur Respir J. 2009;33(2):411-418. 27. Sund ZM, Powell T, Greenwood R, Jarad NA. Remote daily real-time monitoring in patients with COPD—a feasibility study using a novel device. Respir Med. 2009;103(9):1320-1328. 28. Vontetsianos Th, Giovas P, Katsaras Th, et al. Telemedicineassisted home support for patients with advanced chronic obstructive pulmonary disease: preliminary results after ninemonth follow-up. J Telemed Telecare. 2005;11(suppl 1):86-88. 29. Davey J. How collaborative care is becoming a reality in COPD management. Prim Health Care. 2007;17(9):36-39. journal.publications.chestnet.org
30. Jarad NA, Sund ZM. Telemonitoring in chronic obstructive airway disease and adult patients with cystic fibrosis. J Telemed Telecare. 2011;17(3):127-132. 31. Paré G, Sicotte C, St-Jules D, Gauthier R. Cost-minimization analysis of a telehomecare program for patients with chronic obstructive pulmonary disease. Telemed J E Health. 2006;12(2): 114-121. 32. Dang S, Ma F, Nedd N, Aguilar EJ, Roos BA. Differential resource utilization benefits with Internet-based care coordination in elderly veterans with chronic diseases associated with high resource utilization. Telemed J E Health. 2006;12(1):14-23. 33. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS; GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med. 2001;163(5):1256-1276. 34. Bolton CE, Waters CS, Peirce S, Elwyn G; EPSRC and MRC Grand Challenge Team. Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD. J Eval Clin Pract. 2011;17(6):1216-1222. 35. Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K. Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes Obes Metab. 2009;11(10):913-930. 36. Jaana M, Paré G. Home telemonitoring of patients with diabetes: a systematic assessment of observed effects. J Eval Clin Pract. 2007;13(2):242-253. 37. Inglis SC, Clark RA, McAlister FA, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010; 4(8):CD007228. 38. Jensen MH, Cichosz SL, Dinesen B, Hejlesen OK. Moving prediction of exacerbation in chronic obstructive pulmonary disease for patients in telecare. J Telemed Telecare. 2012;18(2): 99-103. 39. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. 40. Steventon A, Bardsley M, Billings J, et al; Whole System Demonstrator Evaluation Team. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ. 2012;344:e3874. 41. Pinnock H, Hanley J, McCloughan L, et al. Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial. BMJ. 2013;347:f6070. 42. Nield M, Hoo GW. Real-time telehealth for COPD selfmanagement using Skype™. COPD. 2012;9(6):611-619. 43. Stickland M, Jourdain T, Wong EY, Rodgers WM, Jendzjowsky NG, Macdonald GF. Using Telehealth technology to deliver pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Can Respir J. 2011;18(4):216-220. 44. Tousignant M, Marquis N, Pagé C, et al. In-home telerehabilitation for older persons with chronic obstructive pulmonary disease: a pilot study. Int J Telerehab. 2012;4(1):7-14. 45. 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;19(4):222-226. 46. Shaw DK, Heggestad-Hereford JR, Southard DR, Sparks KE; American Association of Cardiovascular and Pulmonary Rehabilitation. American Association of Cardiovascular and Pulmonary Rehabilitation telemedicine position statement. J Cardiopulm Rehabil. 2001;21(5):261-262. CHEST / 145 / 5 / MAY 2014
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Commentary
Telemedicine in COPD Time to Pause Roger S. Goldstein, MBChB, FCCP; and Sachi O’Hoski, MScPT
There is increasing interest in the use of telemedicine to assist in the management of chronic diseases. Telemedicine possibilities for patients with COPD include medical consultations, in-home patient monitoring, and remote rehabilitation. Teleconsultations have been used successfully, saving time and travel costs for patients with only a few subsequently requiring face-to-face visits. Despite many reports, the impact of telemonitoring on the detection of exacerbations, reductions in health-care utilization, and cost savings is equivocal. Given the health-care costs and commitment involved in telemonitoring, well-designed longer-term multicenter studies with appropriate follow-up are required prior to its more widespread application. Emerging evidence from preliminary trials of telerehabilitation for the pulmonary patient is encouraging. It may represent a useful tool for increasing access and building capacity, especially in remote areas. CHEST 2014; 145(5):945–949 Abbreviations: AECOPD 5 acute exacerbation of COPD; CHF 5 congestive heart failure; HCP 5 health-care professional; PR 5 pulmonary rehabilitation; TM 5 telemonitoring
the last decade there has been increasing interOver est in the use of telemedicine to assist in the man-
agement of chronic diseases.1,2 Telemedicine technology and devices have been used for care of patients with COPD to provide medical consultations, in-home patient monitoring, and remote pulmonary rehabilitation. Telemedicine consultations, in which the physician and patient are connected via a video conference device rather than meeting in person, have been shown, in preliminary communications, to be feasible and acceptable for the management of patients with a variety of pulmonary conditions, including COPD.3 If a healthcare professional, such as a nurse or respiratory therapist, is present at the satellite site, then he or she can provide clinical information such as vital signs, chest
Manuscript received July 17, 2013; revision accepted December 6, 2013. Affiliations: From the West Park Healthcare Centre and University of Toronto, Toronto, ON, Canada. Funding/Support: Dr Goldstein is supported by the West Park Healthcare Centre Foundation. Correspondence to: Roger S. Goldstein, MBChB, FCCP, West Park Healthcare Centre, 82 Buttonwood Ave, Toronto, ON, M6M 2J5, Canada; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1656 journal.publications.chestnet.org
auscultation, or pulse oximetry. Raza and colleagues3 found that the technology was reliable, wait times for appointments were similar to in-person wait times, and, over a 7-year period in which 314 patients had 684 videoconference clinical encounters, only 8% of patients required a subsequent in-person visit. Most referrals were for abnormal radiology (38%) or for COPD (26%). The most frequent postconsultation diagnosis was COPD (29%) followed by benign pulmonary nodule (11%). Over the study period, patients were saved 473,340 km (294,120 miles) of travel and 748 work days, with 94% of patients receiving medical subspecialty care close to home.3 This has exciting implications for patients in terms of time and cost savings as well as for the environment and the healthcare system, as a result of which some clinicians now include telemedicine consultation within their scope of practice. Telemonitoring (TM) involves the use of equipment, sensors, and questionnaires by patients in their homes, followed by transmission of the data to a health-care professional (HCP) or team at a central location,4-6 either in real time or in a record-and-store fashion.2 There may be a range of predetermined baseline acceptable values set for each piece of information collected, causing an alert to be sent to an HCP when the data CHEST / 145 / 5 / MAY 2014
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submitted by the patient falls outside of these values.6 The patient is then contacted by the central site and provided with health-care assistance. TM has recently been introduced to assist with the management of patients with COPD. Given the progressive nature of the condition, the dominant symptoms of dyspnea, and the clinical course punctuated by acute exacerbations of COPD (AECOPDs), it has been suggested that daily TM of patients’ signs and symptoms will detect changes in their clinical status sufficiently early to improve care and decrease health-care resource utilization by decreasing unscheduled visits to the family physician or specialist, home visits, ED visits, and hospitalizations.7,8 Despite plentiful communications on this topic, the benefits of TM in regard to its impact on clinical outcomes and cost-effectiveness remain to be clearly demonstrated. COPD is one of the most expensive chronic diseases in the developed world, mainly due to its increasing prevalence, with attendant exacerbation rates and hospitalizations as the condition progresses. In the United States in 2006, there were . 1.25 million hospitalizations due to AECOPD, with an average length of hospital stay of 5.9 (⫾6.1) days resulting in a total inpatient cost of $11.98 billion US dollars.9 Regardless of the reason for hospitalization, the prevalence of COPD even as a comorbidity increases the incidence of in-hospital mortality.10 Patient and HCP satisfaction with TM is generally positive.1,11-14 Patients report that the equipment is easy to use,1,12,15-18 despite the fact that the majority of the patients are . 65 years of age and may have limited exposure to technology. This is likely due to the training they receive when the equipment is installed. They also report that they feel safe knowing they are being monitored regularly13,15,17,18 and that home monitoring is convenient13 and makes medical care more accessible.19 They report satisfaction and empowerment from being involved in self-managing their condition.20 However, some patients are equally satisfied when their care includes regular home visits and telephone calls. Only a few studies have suggested added benefit to quality of life when home monitoring is compared with home care21 or usual care.22,23 Not only have studies shown no between-group differences resulting from the addition of TM,18,24,25 some HCPs have expressed concern that, in addition to increasing their workload,13,17,19 it creates the potential for overtreatment13 and increased dependency on technology,21 which varies in accuracy and reliability. To interpret the symptoms and signs in context, it is preferable for the same HCP to be monitoring the same patients on an ongoing basis. Patients have indicated that this consistency adds to their comfort level with TM.13,15,19 Given the cost of TM in human resources, equipment, and patients’ time, firm evidence of cost-effectiveness 946
is required, especially regarding the impact of earlier detection of AECOPD. Both randomized and nonrandomized trials have reported fewer exacerbations in the TM intervention group compared with control participants,25,26 with one study noting that regular monitoring of oxygen saturation, heart rate, and symptoms resulted in exacerbation prediction by an HCP 73% of the time.27 Although one randomized trial concluded that TM decreased ED visits compared with a control group receiving home care22 and two other studies reported a decrease in visits within the intervention group,17,28 one study observed a small increase in ED visits in the intervention group25 and another reported no betweengroup differences.21 Hospital admissions have been reported to decrease when a period of TM was compared with the time prior to the intervention,17,27-30 or when patients receiving TM were compared with those receiving usual care18,20,25,26 or home care.21,31 However, other randomized controlled trials have concluded that there were no between-group differences in hospital admissions,16,24 and, in one pre-to-post study, admissions increased in the 6 months following the intervention.32 The impact of TM on the length of hospital stay is also inconclusive with reports of a decrease,18,29,32 no within-group change or betweengroup difference,16,21,24 and an increase in the TM group.31 The impact of TM on home-care visits and visits to primary care is also inconsistent with reports of decreased contact,17,28,31 no between-group differences,22,24 and increased visits in the TM group.18,21 This outcome is of concern if, instead of fostering self-management and independence,33 intensive monitoring of symptoms and vital signs encourages requests for clarification of symptoms or increased care for comorbidities as well as dependence on repeated coaching from a case manager. Of the few studies evaluating the cost-effectiveness of adding TM to care of patients with COPD, both no cost benefit20 and reduced costs among the intervention group have been reported.18,23,26,31 Crist and colleagues,7 in a retrospective chart review following a home health-care strategy for patients with a variety of chronic conditions, estimated a projected savings of $216 to $681 per patient per week in home-care costs. These savings were among patients with wounds, IV therapies, diabetes, and stroke, rather than for those with a respiratory diagnosis. Details of adherence to TM in COPD are lacking. However, as in most chronic disease management programs, patient adherence to TM has been shown to be .77% in the mediumterm,16,17,27 but markedly decreases over time.14 The absence of conclusive evidence of benefit from TM in COPD should not be taken as evidence of absence of benefit as many studies have suffered from Commentary
design flaws and only one systematic review has focused solely on studies in patients with COPD.34 Bolton and colleagues,34 in a review that included six studies, reported reduced exacerbations and hospital admissions in the TM group. However, the small sample sizes, lack of consistency in study design, lack of detailed intervention descriptions, lack of economic evaluations, and diverse outcome measures used, led them to conclude that large, well-designed trials are required before broader application of TM can be recommended. Although systematic reviews that have included participants with a mixed variety of chronic conditions (such as COPD, heart failure, diabetes, and stroke) have reported benefits of TM (such as decreased ED visits and hospitalizations),4-6,14 poor research quality with inconsistencies in design and outcomes meant that their findings were very qualified and difficult to generalize.1,2,4-6,14 TM is a complex intervention that includes both the electronic transmission of patient information as well as a follow-up response by a healthcare professional. Other components such as telephone support,2,4-6,11,14 increased contact and attention,2,24,27 better care coordination,6,14,32 and increased education25,27 are sometimes included. As some of these other components are also provided to the control group, it can be difficult to isolate and evaluate a single variable. The conclusions regarding the use of TM in COPD are consistent with studies of its application in other chronic diseases. For example, in studies in diabetic patients investigating the impact of TM on glycemic control and hospitalizations, authors have noted the lack of subject homogeneity, small sample sizes, short follow-up periods, variation in treatments, and differing outcome measures.35,36 In contrast, in patients with congestive heart failure (CHF) with whom TM and telephone support were used, all-cause mortality, heart failure-related hospitalizations, length of stay, and resource utilization were reduced as well as quality of life improved, such that a review concluded that further randomized trials of TM in the CHF population were not warranted for proof of concept but more research was required to establish the most effective models of care, optimal duration, and cost benefit.37 One of the challenges to TM in people with COPD is that there is no concrete symptom or sign that separates a period free of exacerbation from a period of exacerbation.38 This might well be one of the contributors to the reported success in CHF where weight gain from fluid retention is a reliable sign. Given the equivocal evidence of effectiveness of TM in COPD11 as well as most other chronic diseases, more robust clinical trials to provide methodologically sound clinical evidence are required before recommending more widespread application of this technology.4-6,14,20 Unfortunately, in some jurisdictions, payers are rushjournal.publications.chestnet.org
ing to introduce TM in response to the pressures for reducing hospitalization among patients with COPD. This is occurring despite the paucity of good evaluative research. It may be that treating COPD as a single disease misses the important effects of attendant conditions.39 Many of the reported studies have considered the impact of comorbidities other than cognitive or physical impairments that would alter the clinical course, the likelihood of hospitalization, and the patient’s ability to use the technology.12,13,18,20,21,31 It is inconclusive whether TM in COPD is effective. If it is the play of chance with some poorly designed trials being positive and others negative, then better designed trials with more power and longer follow, or meta-analysis, may provide the necessary evidence. Although many studies have included patients with severe disease (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stage III or IV)12,20,21,25,31 they have varied in terms of their inclusion and exclusion criteria regarding the exacerbation history25,27,30 and the previous use of healthcare services such as home visits, hospitalizations, or rehabilitation,21,24,31,32 as well as requirements for supplemental oxygen.12,18 Whereas a small group of severely affected patients with severe symptoms, frequent exacerbations, multiple comorbidities, and limited community support might well benefit from TM, the absence of standardized interventions, such as controlled trials with a minimum of one year of follow-up, that include a costbenefit analysis makes it impossible to be confident of the role of TM in overall care of the patient with COPD. In the United Kingdom, the Department of Health released the results of a large 2-year trial of TM in which family physician practices were randomized to intervention or control groups.40 Participants included those with COPD, CHF, or diabetes who had at least one unplanned medical event in the preceding 12 months. The end point was the number of patients hospitalized during the 12-month trial. The authors reported a significantly lower proportion of admissions (OR, 0.82; 95% CI, 0.7-0.97; P 5 .017) and a lower mortality (4.6% vs 8.36%, OR 0.54 [95% CI, 0.39-0.75; P , .001]) among the intervention group over the 12-month period. Of note, the largest difference was in the first three months following the start of the trial and was due to an increase in hospitalizations in the control group. This group was composed of older patients who had a higher incidence of COPD and CHF and a lower incidence of diabetes and who had an increased length of stay as well as health-care costs prior to the trial period. Subsequently, in a multicenter primary care randomized controlled trial, Pinnock and colleagues41 reported on 256 patients with COPD who completed selfmonitoring or TM over a 1-year period. They reported CHEST / 145 / 5 / MAY 2014
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that the number of days to admission (the primary end point) did not differ between groups (adjusted hazard ratio, 0.98; 95% CI, 0.66-1.44). The mean number of COPD admissions was similar as was the mean length of stay. There was no between-group difference in health-related quality of life.41 Results of studies such as these will help provide clarity as to best indications and applications of TM. An interesting innovation in telemedicine is the provision of pulmonary rehabilitation (PR) to satellite centers. This addresses issues of access and capacity, as PR is currently available to only a small percentage of eligible patients. Nield and Hoo42 completed a randomized controlled trial in which they used teletechnology to deliver education on pursed lips breathing and coordination of breathing with physical activity. After 4 weeks, the intervention group reported increased program adherence, decreased dyspnea intensity, and no between-group differences in 6-min walk distance, dyspnea distress, or dyspnea severity. Stickland and colleagues43 delivered PR to 147 people with COPD in satellite centers across Alberta, Canada, twice a week for 8 weeks and compared results with 262 similar patients who had attended conventional institutionally based PR. The intervention group received education through a telemedicine network and then exercised with local supervision. Both groups showed similar clinically and statistically significant improvements in quality of life and 12-min walk distance. Two small proof-of-concept home telerehabilitation studies44,45 have evaluated the feasibility of home exercise, supervised from a service center over 8 weeks, on participants with COPD and reported improvements in healthrelated quality of life and 6-min walking distance. These preliminary results are sufficiently interesting to encourage funding of randomized controlled trials of satellite telerehabilitation, to include at least 1 year of follow-up to establish feasibility and cost-effectiveness for this model of care. As noted in the position statement on telemedicine by the American Association of Cardiovascular and Pulmonary Rehabilitation,46 as with all new medical innovations, the clinicians’ obligation includes an explanation of the potential benefits and risks of telemedicine services as well as the patients’ rights and responsibilities. Given the integral part played by the transmission of clinical data, there is the added obligation of ensuring the confidentiality of medical records. In conclusion, consultations using teletechnology are feasible as well as cost-effective and telerehabilitation may be as effective as conventional rehabilitation as well as increasing access to PR. The evidence for TM in COPD remains inconclusive because of issues of trial design, sample size, unstandardized intervention, and limited follow-up. Whether it is the irreversible and progressive nature of COPD that leads 948
inevitably to exacerbations and hospitalization, whether it is the lack of reliable indicators of exacerbation, or even the effectiveness of the support services once an exacerbation has been detected, TM has yet to prove its worth in the COPD population. The enthusiasm for new technology and the urgency of reducing healthcare costs notwithstanding, the resources and patient commitment involved as well as the risk of fostering dependence, requires that longer-term, robust, multicenter studies should precede more widespread use of TM. Such studies should also inform as to the most effective intervention or combinations of interventions as well as the patient phenotype most likely to benefit. It is time to pause before incorporating this modality as part of the standard of care for those with COPD. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.
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