This review sought to collect and interpret the evidence on home telehealth for management of patients with chronic obstructive pulmonary disease. We looked at 3 areas:
- Patients: How is home telehealth used in treating people with COPD? Do patients like it? How clinically effective is it?
- Providers: What is the impact of home telehealth on health human resources? What are the roles of nurses, general practitioners, and specialists in its delivery? How do providers characterize their experiences with home telehealth?
- System: How is home telehealth incorporated into the care continuum? What is the economic impact of incorporating home telehealth into care? What policies need to be in place for home telehealth to be successful?
In order to answer these questions, we conducted a systematic search for literature published from 2005 to 2010. This search retrieved 7 studies that met our inclusion criteria. The quality of the evidence was generally strong. A final search for publications from 2011 to 2012 found 5 additional studies. Though findings from these studies were incorporated into the review, be aware that material from the 2011-2012 period was screened and analyzed in a slightly different way than the studies retrieved in our original search.
Number and Location
A search of literature published from 2005-2010 located 7 studies of home telehealth for chronic obstructive pulmonary disease (COPD) management (Lewis et al., 2010a, b; Liu et al., 2008; Mair et al., 2005; de Toledo et al., 2006; Trappenburg et al., 2008; Vitacca et al., 2009, 2010 Whitten & Mickus, 2007). This included 1 multi-part study (Lewis et al., 2010a, b) and 1 case series study (Vitacca et al., 2009, 2010).
The bulk of the studies were located in Europe, including the UK, Spain, Italy, and the Netherlands (Lewis et al., 2010a, b; and Mair et al., 2005; de Toledo et al., 2006; Vitacca et al., 2009, 2010; Trappenburg et al., 2008). The remaining 2 were located in Taiwan and the USA (Liu et al., 2008; Whitten & Mickus, 2007, respectively). There were no studies from Canada.
A scan of material from 2011-2012, a time period not covered by our initial searches, found 5 additional studies that met our inclusion criteria and filled gaps left by the first rounds of searching (Dinesen et al., 2012; Roberts et al., 2012; Roberts & Robinson, 2011; Sicotte et al., 2011; Stickland, 2011). These studies were analyzed in a slightly different way than the studies retrieved in our original search, and their findings were incorporated into this review in a limited fashion. For more details, please see Methods.
|And on the qualitative side . . .There were 3 qualitative articles found of relevance to COPD, 2 of which focused on patient experiences with COPD management using telehealth (Rahimpour et al., 2008; Huniche et al., 2010) and 1 that compared patient and provider experiences using telehealth to help manage acute COPD (Mair et al., 2008). The studies were carried out inAustralia, Denmark, and the United Kingdom.|
The Oxford 2011 Levels of Evidence were used to assess the strength of the evidence base. Studies were placed on a scale running from Level 1, considered the highest level of evidence, through to Level 5. Levels are based primarily on study design. Studies were also assigned scores for quality of execution and reporting. Low execution/reporting scores resulted in downgrading.
The Oxford 2011 Levels of Evidence are intended to provide guidance rather than absolute judgments, and do not obviate the need for careful appraisal of local needs and context. The quality of studies within a given level can vary, as can their applicability to select populations. Furthermore, this system is not suitable for all forms of assessment. In the text that follows, the Oxford 2011 Levels of Evidence are used only when discussing clinical outcomes.
The evidence base for home telehealth in the management of chronic obstructive pulmonary disease (COPD) was generally strong. In 5 instances, including part 1 of a multi-part study (Vitacca et al., 2009), a Level 2 rating was granted (Lewis et al., 2010a, b; Liu et al., 2008; Mair et al., 2005; de Toledo et al., 2006). This rating indicates use of randomization, concurrent comparison groups, and prospective measurement of exposure and outcome. Whitten & Mickus (2007), though also meeting these criteria, was downgraded to Level 3 for a low execution/reporting score. Trappenburg et al. (2008), a non-randomized controlled cohort study, also received a Level 3 rating. The second part of the multi-part study (Vitacca et al., 2010) used a historical control group and therefore qualified as Level 4 evidence.
Sample sizes tended to fall between 50 and 200. Vitacca et al. (2010) had the largest sample by a considerable margin (n=396). However, the 5-year analysis of the program under study included data from patients with chronic diseases other than COPD.
There was unusual uniformity in study duration. Data collection took place over a 12-month period in Lewis et al. (2010a, b), Liu et al. (2008), de Toledo et al. (2006), Trappenburg et al. (2008), and Vitacca et al. (2009). In 2 cases, the intervention ended roughly 6 months before the final follow-up (Lewis et al., 2010a, b; Trappenburg et al., 2008). Vitacca et al. (2010) again stood out as unusual, this time for its 5-year duration. Mair et al. (2005) was also exceptional: the intervention was designed to alleviate acute exacerbations and lasted just 2 weeks.
Population Characteristics: Demographics
The participants in most studies were seniors, with mean age hovering around 70 years. Those in Vitacca et al. (2009, 2010) were slightly younger, with mean ages of 61 and 64, respectively. However, the program studied in Vitacca et al. (2009, 2010) included patients with chronic respiratory diseases other than COPD, which skewed the results towards a younger mean age. When looking solely at those with COPD, mean age increases by roughly 10 years.
In 4 studies, the sample was overwhelmingly male (Liu et al., 2008; de Toledo et al., 2006; Vitacca et al., 2009, 2010). Whitten and Mickus (2007) was the only study to trend in the other direction, with 70% of the 67 participants being female. The remaining studies had roughly equal numbers of male and female participants (Lewis et al., 2010a, b; Mair et al., 2005; Trappenburg et al., 2008). This is interesting in light of recent Canadian prevalence statistics for COPD, which indicate that the condition affects more females than males in every province.
None of the studies provided race or ethnicity data. Only Lewis et al. (2010a, b) reported on the socioeconomic status of the participants, and in an indirect manner: they note that 25% of the sample held either managerial or professional occupations. Lewis et al. (2010a, b) was also the only study to report on participants’ technological literacy. Between 15% and 20% of participants were regular internet users. Mean computer confidence scores for the control and intervention group did not differ significantly.
Population Characteristics: Clinical Characteristics
The inclusion criteria for COPD studies were not strict when compared to those found in other chronic disease sections. As a general rule, patients with comorbidities were accepted. Three studies reported comorbidity figures for their patient population. In Lewis et al. (2010a, b), approximately 90% of subjects had a known comorbidity. In Vitacca et al., (2009), the mean number of comorbidities was 1.69 ± 1.4 per patient for the intervention group and 1.57 ± 1.24 for the control group.
A number of studies required the patient to have had a recent respiratory disease-related exacerbation and/or hospitalization (Mair et al., 2005; Trappenburg et al., 2008; Vitacca et al., 2009, 2010), and 1 limited its sample to patients who were attending outpatient rehabilitation sessions (Lewis et al., 2010a, b). Two studies included patients with other chronic respiratory diseases or congestive heart failure as well as COPD patients (Vitacca et al., 2009, 2010; Whitten and Mickus, 2007). These studies were included in this section because they included disease-specific sub-analyses.
Liu et al. (2008) was unique in excluding patients with acute COPD-related exacerbations, patients using oral corticosteroids or oxygen therapy, and patients with any comorbidities or medication use that might limit exercise capacity. This is perhaps because the study’s intervention was designed to increase physical activity levels rather than to enable remote monitoring.
 For a comprehensive overview of this system, please refer to Jeremy Howick, Iain Chalmers, Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, and Hazel Thornton. “Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document)”.
Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653
 Systematic reviews of randomized trials; n-of-1 trials.