There is strong evidence that home telehealth can reduce COPD exacerbations significantly more than usual care.
The ability of home telehealth to significantly improve other measures of physiological function, such as response to exertion, is supported by moderate evidence. The paucity of studies reporting on this particular outcome means that the generalizability of these results cannot yet be determined. However, the evidence available is encouraging. In one case, home telehealth was used to support delivery of a home exercise program. Significant improvements in exercise habits and ability were seen. Furthermore, this improvement persisted after the telehealth support had ceased. In another recent study, patients using a home telehealth service for pulmonary rehabilitation demonstrated improvements that were comparable to those of patients in the usual care program, but not significantly greater. As this study was retrieved in a final scan of 2011-2012 literature and was not subject to the same level of analysis as the other studies included in this review, we will not attempt to extrapolate beyond the conclusions provided by its authors. See Stickland (2011) for more details.
There is moderate evidence that home telehealth can improve the day-to-day symptoms of COPD (as opposed to those accompanying acute exacerbations) significantly more than usual care. However, caution is advised: since only one study reported on this outcome, the generalizability of this finding is unknown.
There is also moderate evidence that home telehealth can improve quality of life, but the reproducibility of this finding is questionable. It more frequently has no effect, and we found one example of a negative effect.
There is weak evidence that home telehealth can lead to more appropriate pattern of medication use. Again, the generalizability of this result is unknown.
At present, there is no evidence that home telehealth reduces mortality rates among COPD patients.
Satisfaction with care is generally high among COPD patients using home telehealth interventions. Most patients appear to be comfortable with remote monitoring systems and with appointments being delivered through videoconferencing. The extent to which this is reflected in levels of patient engagement is unclear; rates of use are rarely reported. One recent study did measure uptake, and found that it was low. Its more concerning findings, however, pertain to those who did use the system. The authors report that users became ‘obsessed’ and anxious about normal variations in vital signs. Some also demonstrated an unhealthy level of device dependence. This study suggests that educating patients in interpreting the values that they are asked to measure is highly advisable. As this study was retrieved in a final scan of 2011-2012 literature and was not subject to the same level of analysis as the other studies included in this review, we will not attempt to extrapolate further. See Roberts & Robinson (2011) for more details.
Uptake and Use of Technology
Summary: Uptake and use of technology outcomes were reported in 7 studies. Satisfaction was generally high, but rates of use varied.
Study Details: In de Toledo et al. (2006), 61% of patients actually contacted the available call centre. In a similar intervention described in Vitacca et al. (2009), the total number of calls per COPD patient over the 1-year study period was 821±537. Interestingly, this was higher than the average number of calls made by the sample as a whole, which included patients with several other chronic conditions. In Lewis et al. (2010b), patients uploaded anywhere from 50 to 100% of the data that the protocol required, with a median of 97%.
Lewis et al. (2010b), Mair et al. (2005) and Whitten and Mickus (2007) reported on patients’ experiences with the telehealth application. In all of these studies, a majority of patients expressed satisfaction with the intervention. These positive patient experiences were in response to interactions with both consultation-based management, conducted through videoconferencing (Mair et al., 2005; Whitten and Mickus, 2007), and monitoring-based management (Lewis et al., 2010a, b). Patients using videoconferencing generally reported being very satisfied with telehealth visits, found the equipment easy to use, and notably, felt secure about the comprehensiveness of care they were receiving. Mair et al. (2005) also note that patient experiences with videoconferencing diverged from provider experiences (see C.3.3.2: Provider Outcomes – Uptake and Use of Technology for more details).
Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 article that addressed uptake and use of technology outcomes (Roberts & Robinson, 2011). In this study, patients used a home telehealth device to measure and transmit data to their providers. Uptake was low, and those who did use the system became ‘obsessed’ and anxious about normal variations in vital signs. Some also demonstrated an unhealthy level of device dependence. This study suggests that educating patients in interpreting the values that they are asked to measure is advisable. As this study was not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See Roberts & Robinson (2011) for more details.
|And on the qualitative side . . .The study by Rahimpour et al. (2008) was a prospective study involving patients with COPD and/or congestive heart failure. Participants were asked to consider the idea of using a patient telehealth unit to manage their condition from home and what benefits, concerns, and challenges they perceived. Overall, patients viewed the units positively, most stating that they would be likely to use it. Empowerment, education, and convenience were among the cited advantages.In Huniche et al. (2010), patients were interviewed about their experiences with a home-telemonitoring device (TELEKAT) that was used to collect and transmit physiological data to a provider-monitored web portal. Patients were provided with feedback throughout the 4 month intervention. While a few participants did not engage with the data and viewed it as something best managed by the health professionals, most participants viewed TELEKAT as useful in helping them understand how to better manage their condition.Mair et al. (2008) reported that patients were very pleased with the telehealth system; they appreciated having the nurse there to talk to them and liked having increased control over their disease. Patient perceptions were markedly more positive than those of providers (for more details, see C.3.3.2: Provider Outcomes – Uptake and Use of Technology).|
Self-Management, Self-Efficacy, and Behaviour Change
Summary: Self-management, self-efficacy, and behaviour change outcomes were reported in 2 studies: one Level 2 evidence (Liu et al., 2008), and one Level 3 evidence (Trappenburg et al., 2008). There is moderate evidence that home telehealth can lead to significant improvements in walking endurance and exercise habits, and weak evidence associating telehealth with significant changes in patterns of bronchodilator use. Note that each of these outcomes was measured in only 1 study (Liu et al., 2008, and Trappenburg, 2008, respectively). Therefore, the robustness and generalizability of these findings cannot be determined.
Study Details: Only one study, by Liu et al. (2008), looked at a lifestyle support intervention. This intervention involved delivery of a walking exercise training program at a frequency of ~4 to 6 days per week. The authors report that the intervention group significantly improved their walking distance and their walking endurance during the 3-month monitoring period, and that this improvement lasted for the 9-month observational period that followed. No change was seen in the control group. The difference between groups was statistically significant. By the end of the self-management period, 9 months after the monitoring had ceased, 92% of intervention group patients had maintained their walking regime, while only 38% of patients in the control group reported walking regularly (p<.01).
Trappenburg et al. (2008) carried out the only study to report on changes in medication use. There was a significant change in short-acting bronchodilator use in the intervention group compared with the control group (p=.008). The percentage of patients using the bronchodilators only during acute episodes decreased (15% to 2%), while the proportion with ‘constant use’ increased (53% to 66%).
|And on the qualitative side . . .In Huniche et al. (2010), viewing the physiological data collected by the telemonitoring system seemed to affect patients’ moods: they tended to be encouraged when the data was good and depressed when the data was bad. Overall, patients seemed more conscious of their energy levels and better able to pace themselves throughout the day. The data influenced their decisions about daily activities: whether or not to go to the store, when to contact a health professional, when to worry, and so on.|
Clinical Outcomes, Symptoms, and Health Status
Outcomes related to clinical measures, health status, and symptoms were measured in 4 studies, three of them Level 2 evidence (Liu et al., 2008; Vitacca et al., 2009; de Toledo et al., 2006) and one Level 3 (Trappenburg et al., 2008).
Summary: Pulmonary function was assessed in 3 studies (Liu et al., 2008; Trappenburg et al., 2008; Vitacca et al., 2009). There is strong evidence associating home telehealth with significantly greater improvements in some measures of lung function than those seen with usual care.
Study Details: Liu et al. (2008) carried out a strongly designed study on a lifestyle support intervention involving an exercise training program. While there was no significant change in or difference between the control and intervention groups in FEV1 (Forced Expiratory Volume in 1 Second), the intervention group experienced significant improvements compared to baseline in their inspiratory capacity pre- and post-incremental shuttle walk test after 12 weeks and at the end of the observation period (p<.001 at both points). Intervention patients also showed significantly less change than controls in inspiratory capacity on exercise – indicative of dynamic hyperinflation – at 12- and 52-week follow-ups (p<.01 at both points).
Liu et al. (2008) also reported that a significantly fewer number of intervention group patients, compared to the control group, experienced acute exacerbations leading to unscheduled clinical visits (p<.01) and hospitalizations (p<.05).
An significant intervention effect was observed by Vitacca et al. (2009), in which intervention group patients were more likely than control group patients to remain free from exacerbations over the year of the study (p<.0001). Recall that this study included patients with a variety of chronic diseases. When the patients were stratified based on diagnosis, it was found that this intervention effect actually held only for the 101 participants with COPD. In a study by Trappenburg et al. (2008), the intervention group also had a decrease in the number of exacerbations. The size of the difference between interventions and controls, who experienced an increase, was significant (p=.004).
Summary: Mortality was reported in 2 studies, both Level 2 evidence (de Toledo et al., 2006; Vitacca et al., 2009). At present, there is no evidence associating home telehealth with significant reductions or increases in mortality.
Study Details: Both studies found a non-significant difference between the intervention and the control group. In the de Toledo et al. (2006) study, the difference favoured the control group; in the Vitacca et al. (2009) study, the difference favoured intervention group patients. In neither case was the difference significant.
Summary: Only 1 study reported on symptoms (Liu et al., 2008). Findings from this Level 2 study constitute moderate evidence that a home telehealth intervention can lead to significantly greater improvement that usual care in symptoms of COPD. However, caution is advised: given the size of the evidence base, the generalizability of this finding is unknown.
Study Details: Liu et al. (2008) found no significant change in either the intervention or control group in resting breathlessness at any point of data collection during the 3-month intervention or 6-month follow-period. However, there was a significant decrease in post-exercise breathlessness in the intervention group compared with the control group at the 12 week follow-up (3.0 ± 0.1 vs. 4.3 ± 0.1; p<.01), and notably, at the 52 week follow up that marked the end of the observation period (3.2 ± 0.2 versus 3.9 ± 0.2; p<.05). This indicates that the intervention group’s improvement in post-incremental shuttle walk test breathlessness was maintained throughout the self-management period, where patients did not receive telehealth support from nurses.
Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 additional article that addressed clinical outcomes, symptoms, and health status (Stickland, 2011). In this study, patients enrolled in a pulmonary rehabilitation program delivered through home telehealth demonstrated improvements that were comparable to those of patients in the usual care program, but not significantly greater. As this study was not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See Stickland (2011) for more details.
Quality of Life
Summary: Outcomes related to quality of life were reported in 4 studies: two Level 2 evidence (Lewis et al., 2010a; Liu et al., 2008) and two Level 3 evidence (Trappenburg et al., 2008; Whitten & Mickus, 2007). Although findings by Liu et al. (2008) constitute moderate evidence that home telehealth can lead to significantly greater improvements in quality of life than those seen with usual care, the balance of the evidence base indicates that home telehealth is no better than usual care in improving quality of life (Lewis et al., 2010a; Trappenburg et al., 2008; Whitten & Mickus, 2007). Furthermore, 1 study found significantly poorer intervention group scores on the general health sub-scale of the SF-36 when controlling for independent variables (Whitten & Mickus, 2007).
Study Details: See table below (Table C.3.3.1: Patient Outcomes – Quality of Life) for additional details.
Cost and Time Savings
No cost or time savings outcomes were reported.