Chronic Obstructive Pulmonary Disease: Intervention Design and Implementation


Home telehealth for patients with chronic obstructive pulmonary disease (COPD) usually emphasizes remote monitoring.  Patients send their providers regular health updates, including symptom reports and measurements of lung function.  The feedback that they receive assists them in determining how to adjust their medication and daily activity.  The provider may also contact the patient if a COPD exacerbation appears imminent.



Basic Model

The basic model for home telehealth in COPD management was designed to enable remote monitoring. The patient was generally equipped with a device through which they transmitted clinical measurements and/or symptom information. The exact mechanism of transmission varied. In 2 interventions, patients were given hand-held monitoring devices through which they completed a ‘disease dialogue’: a set series of daily questions on health status, symptoms, and medication use (Lewis et al., 2010a, b; Trappenburg et al., 2008). In Lewis et al. (2010a, b), there was a further requirement for self-measured temperature and oximeter readings. In another study, transmission was done through a home telephone line (Vitacca et al., 2009, 2010). In Liu et al. (2008), patients used a cellular telephone.

Patients’ answers and clinical data were sent to a provider-accessible server and reviewed by a nurse, who could then contact patients by phone if results indicated a possible exacerbation. In some cases, an algorithm generated an immediate feedback message to patients upon receipt of answers (Trappenburg et al., 2008). Providers responsible for monitoring often received critical alerts when out-of-range values were identified.

There was a considerable amount of variation within this structure. Noteworthy aspects of particular interventions are described in more detail in Departures from Basic Model, below.


Human Resource Requirements

Multi-disciplinary teams and an integrated care approach were used to deliver the home telehealth intervention in the majority of the studies retrieved (Lewis et al., 2010a, b; de Toledo et al., 2006; Trappenburg et al., 2008; Vitacca et al., 2009, 2010). However, nurses tended to have primary responsibility for case management and daily monitoring of patient data transmissions (de Toledo et al., 2006; Trappenburg et al., 2008; Vitacca et al., 2009, 2010). An exception is Lewis et al. (2010a, b) where the server could be reviewed at any point by a member of the chronic disease management team (made up of specialist nurses, a respiratory physiotherapist, and a nurse manager), a respiratory consultant, or a specialist hospital nurse.

Only 2 studies reported on the provider time required for intervention delivery. Transmission of self-measured biometric values to the provider occurred during a scheduled weekly phone call in Vitacca et al. (2010). Each new patient enrolled in the study required 73 minutes per month for nurse consultations, and 27 minutes per month for consultations with the physician. Trappenburg et al. (2008), which used a hand-held “dialogue box” with transmission capability rather than scheduled phone calls, reported that nurses needed 13.70 ± 0.60 minutes per patient per week to review telemonitoring data.


Technical Requirements

Some technical requirements were common to all interventions. Landline telephones were invariably used for patient-provider contact, and healthcare providers monitored patient data through internet-enabled personal computers. In most studies, patients had hand-held monitoring devices through which they answered a series of questions about health status, symptoms, and disease management at set intervals (Lewis et al., 2010a, b; Vitacca et al., 2009, 2010; Trappenburg et al., 2008).

Algorithms were used in all of the interventions that fit the basic model. Functions included: 1) Generating critical alerts to providers when patients’ values or responses were out of range (Lewis et al., 2010a, b; Trappenburg et al., 2008); 2) Sending immediate feedback in response to patients’ data transmissions (Trappenburg et al., 2008); and 3) Steering dialogue in patient-provider consultations and provide decision-support to providers (Vitacca et al., 2009, 2010).

Telemonitors with screens and buttons for entering responses were featured in 2 studies (Trappenburg et al., 2008; Lewis et al., 2010a, b). The “dialogue box” in Lewis et al. (2009, 2010) had an attached pulse oximeter from which self-measured values were downloaded. Patients entered self-measured temperature values manually. The intervention in Vitacca et al. (2009, 2010) required a pulse oximetry device and a modem system for transmission.

Videoconferencing was the main component of consultation-based monitoring interventions used in Mair et al. (2005) and Whitten and Mickus (2007). Patients had the necessary videconferencing equipment installed in their homes.


Departures from Basic Model

Four interventions departed from the basic model in that they were not designed to provide monitoring-based COPD management.

Videoconferencing technology was used in the consultation-based monitoring interventions studied in Mair et al. (2005), and Whitten and Mickus (2007). The patients had the necessary telehealth equipment at home. In Mair et al. (2005), multiple videoconferencing sessions were held over a 2-week period; in Whitten and Mickus (2007), sessions occurred at least once per week.

In de Toledo et al. (2006), a call centre was available to patients during regular workday hours. An operator connected patients with the appropriate healthcare provider from the multidisciplinary team. If this was not available, a message was stored for later review. Each member of the multidisciplinary team had access to their patients’ individualized electronic chronic care patient records (ECPRs), which included work plans, mental health information, treatment and clinic visit reports, logs of phone calls to the call centre, and an educational component for providers. An expanded version of this intervention included ECPR access for patients at home, with a patient-targeted educational component. This version had not yet been used or tested.

Trappenburg et al. (2008) appeared to be the only intervention that incorporated a direct educational component. The home telehealth unit used in this study presented patients with COPD trivia and facts as well as transmitting patient data to providers.

Liu et al. (2008) was unique in its focus on lifestyle support. Patients received cell phones with software that prompted them to complete daily walking exercises. This software also provided a musical tempo that was personalized to match the patient’s exercise endurance goals. If patients missed their daily exercise the software notified the nurse, who then phoned the patient. 

And on the qualitative side . . .Mair et al. (2008) examined a videophone intervention for acutely ill COPD patients. The service consisted of a video connection to a nurse, and attachments that permitted remote physiological monitoring of blood pressure, pulse, temperature and pulse oximetry.Huniche et al. (2010) explored patient perspectives on the use of a home telemonitoring device (TELEKAT) that collected and transmitted physiological patient data to a web-based portal. Both patients and health care providers reviewed the data and patients were given advice throughout the 4 month intervention, which also included physiotherapist visits and a home exercise program. A home telehealth unit was also used in Rahimpour et al. (2008).



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