Telehealth interventions: remote monitoring and consultations for people with chronic obstructive pulmonary disease (COPD).

BACKGROUND: Chronic obstructive pulmonary disease (COPD, including bronchitis and emphysema) is a chronic condition causing shortness of breath, cough, and exacerbations leading to poor health outcomes. Face-to-face visits with health professionals can be hindered by severity of COPD or frailty, and by people living at a distance from their healthcare provider and having limited access to services. Telehealth technologies aimed at providing health care remotely through monitoring and consultations could help to improve health outcomes of people with COPD. OBJECTIVES: To assess the effectiveness of telehealth interventions that allow remote monitoring and consultation and multi-component interventions for reducing exacerbations and improving quality of life, while reducing dyspnoea symptoms, hospital service utilisation, and death among people with COPD. SEARCH METHODS: We identified studies from the Cochrane Airways Trials Register. Additional sources searched included the US National Institutes of Health Ongoing Trials Register, the World Health Organization International Clinical Trials Registry Platform, and the IEEEX Xplore Digital Library. The latest search was conducted in April 2020. We used the GRADE approach to judge the certainty of evidence for outcomes. SELECTION CRITERIA: Eligible randomised controlled trials (RCTs) included adults with diagnosed COPD. Asthma, cystic fibrosis, bronchiectasis, and other respiratory conditions were excluded. Interventions included remote monitoring or consultation plus usual care, remote monitoring or consultation alone, and mult-component interventions from all care settings. Quality of life scales included St George's Respiratory Questionnaire (SGRQ) and the COPD Assessment Test (CAT). The dyspnoea symptom scale used was the Chronic Respiratory Disease Questionnaire Self-Administered Standardized Scale (CRQ-SAS). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. We assessed confidence in the evidence for each primary outcome using the GRADE method. Primary outcomes were exacerbations, quality of life, dyspnoea symptoms, hospital service utilisation, and mortality; a secondary outcome consisted of adverse events. MAIN RESULTS: We included 29 studies in the review (5654 participants; male proportion 36% to 96%; female proportion 4% to 61%). Most remote monitoring interventions required participants to transfer measurements using a remote device and later health professional review (asynchronous). Only five interventions transferred data and allowed review by health professionals in real time (synchronous). Studies were at high risk of bias due to lack of blinding, and certainty of evidence ranged from moderate to very low. We found no evidence on comparison of remote consultations with or without usual care. Remote monitoring plus usual care (8 studies, 1033 participants) Very uncertain evidence suggests that remote monitoring plus usual care may have little to no effect on the number of people experiencing exacerbations at 26 weeks or 52 weeks. There may be little to no difference in effect on quality of life (SGRQ) at 26 weeks (very low to low certainty) or on hospitalisation (all-cause or COPD-related; very low certainty). COPD-related hospital re-admissions are probably reduced at 26 weeks (hazard ratio 0.42, 95% confidence interval (CI) 0.19 to 0.93; 106 participants; moderate certainty). There may be little to no difference in deaths between intervention and usual care (very low certainty). We found no evidence for dyspnoea symptoms or adverse events. Remote monitoring alone (10 studies, 2456 participants) Very uncertain evidence suggests that remote monitoring may result in little to no effect on the number of people experiencing exacerbations at 41 weeks (odds ratio 1.02, 95% CI 0.67 to 1.55). There may be little to no effect on quality of life (SGRQ total at 17 weeks, or CAT at 38 and 52 weeks; very low certainty). There may be little to no effect on dyspnoea symptoms on the CRQ-SAS at 26 weeks (low certainty). There may be no difference in effects on the number of people admitted to hospital (very low certainty) or on deaths (very low certainty). We found no evidence for adverse events. Multi-component interventions with remote monitoring or consultation component (11 studies, 2165 participants) Very uncertain evidence suggests that multi-component interventions may have little to no effect on the number of people experiencing exacerbations at 52 weeks. Quality of life at 13 weeks may improve as seen in SGRQ total score (mean difference -9.70, 95% CI -18.32 to -1.08; 38 participants; low certainty) but not at 26 or 52 weeks (very low certainty). COPD assessment test (CAT) scores may improve at a mean of 38 weeks, but evidence is very uncertain and interventions are varied. There may be little to no effect on the number of people admitted to hospital at 33 weeks (low certainty). Multi-component interventions are likely to result in fewer people re-admitted to hospital at a mean of 39 weeks (OR 0.50, 95% CI 0.31 to 0.81; 344 participants, 3 studies; moderate certainty). There may be little to no difference in death at a mean of 40 weeks (very low certainty). There may be little to no effect on people experiencing adverse events (very low certainty). We found no evidence for dyspnoea symptoms. AUTHORS' CONCLUSIONS: Remote monitoring plus usual care provided asynchronously may not be beneficial overall compared to usual care alone. Some benefit is seen in reduction of COPD-related hospital re-admissions, but moderate-certainty evidence is based on one study. We have not found any evidence for dyspnoea symptoms nor harms, and there is no difference in fatalities when remote monitoring is provided in addition to usual care. Remote monitoring interventions alone are no better than usual care overall for health outcomes. Multi-component interventions with asynchronous remote monitoring are no better than usual care but may provide short-term benefit for quality of life and may result in fewer re-admissions to hospital for any cause. We are uncertain whether remote monitoring is responsible for the positive impact on re-admissions, and we are unable to discern the long-term benefits of receiving remote monitoring as part of patient care. Owing to paucity of evidence, it is unclear which COPD severity subgroups would benefit from telehealth interventions. Given there is no evidence of harm, telehealth interventions may be beneficial as an additional health resource depending on individual needs based on professional assessment. Larger studies can determine long-term effects of these interventions.

Recommendations following a modified UK-Delphi consensus study on best practice for referral and management of severe asthma.

INTRODUCTION: Severe asthma affects an estimated 3%-5% of people with asthma and is associated with frequent exacerbations, poor symptom control and significant morbidity from the disease itself, as well as high dose of inhaled and systemic steroids used to treat it. The introduction of specialist asthma services across the UK has attempted to improve quality of care and ensure that patients undergo a full systematic assessment prior to initiation of advanced biological therapies. However, improvements are required in the patient pathway to minimise avoidable harm. OBJECTIVES: To define standards of care in areas where the evidence base is lacking through patient and healthcare professional (HCP) consensus. METHODS: The precision UK National Working Group of asthma experts identified 42 statements formed from 7 key themes. An online four-point Likert scale questionnaire was sent to HCPs working in asthma throughout the UK to assess agreement (consensus) with these statements; a subset of the statements formed a patient questionnaire. Consensus was defined as high if ≥75% and very high if ≥90% of respondents agreed with a statement. RESULTS: A total of 117/197 responses (59.3% response rate) were received from severe asthma patients (n=15) and HCPs (n=102) including respiratory physicians, respiratory nurse specialists, respiratory pharmacists, specialist physiotherapists and general practitioners. Consensus was very high in 25 (60%) statements, high in 12 (29%) statements and was not achieved in 5 (12%) statements. Based on the consensus scores, the precision UK National Working Group derived 10 key recommendations. These focus on referrals from primary and secondary care, accessing specialist asthma services, homecare provision for severe asthma patients and outcome measures. CONCLUSIONS: Implementation of these 10 recommendations across the severe asthma pathway in the UK has the potential to improve outcomes for patients by reducing delays to assessment and initiation of advanced phenotype-specific therapies.

Digital interventions for the management of chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with dyspnoea, cough or sputum production (or both) and affects quality of life and functional status. More efficient approaches to alternative management that may include patients themselves managing their condition need further exploration in order to reduce the impact on both patients and healthcare services. Digital interventions may potentially impact on health behaviours and encourage patient engagement. OBJECTIVES: To assess benefits and harms of digital interventions for managing COPD and apply Behaviour Change Technique (BCT) taxonomy to describe and explore intervention content. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 28 April 2020). We found other trials at web-based clinical trials registers. SELECTION CRITERIA: We included RCTs comparing digital technology interventions with or without routine supported self-management to usual care, or control treatment for self-management. Multi-component interventions (of which one component was digital self-management) compared with usual care, standard care or control treatment were included. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. Discrepancies were resolved with a third review author. We assessed certainty of the evidence using the GRADE approach. Primary outcomes were impact on health behaviours, self-efficacy, exacerbations and quality of life, including the St George's Respiratory Questionnaire (SGRQ). The minimally important difference (MID) for the SGRQ is 4 points. Two review authors independently applied BCT taxonomy to identify mechanisms in the digital interventions that influence behaviours. MAIN RESULTS: Fourteen studies were included in the meta-analyses (1518 participants) ranging from 13 to 52 weeks duration. Participants had mild to very severe COPD. Risk of bias was high due to lack of blinding. GRADE ratings were low to very low certainty due to lack of blinding and imprecision. Common BCT clusters identified as behaviour change mechanisms in interventions were goals and planning, feedback and monitoring, social support, shaping knowledge and antecedents. Digital technology intervention with or without routine supported self-management Interventions included mobile phone (three studies), smartphone applications (one study), and web or Internet-based (five studies). Evidence is very uncertain about effects on impact on health behaviours as measured by six-minute walk distance (6MWD) at 13 weeks (mean difference (MD) 26.20, 95% confidence interval (CI) -21.70 to 74.10; participants = 122; studies = 2) or 23 to 26 weeks (MD 14.31, 95% CI -19.41 to 48.03; participants = 164; studies = 3). There may be improvement in 6MWD at 52 weeks (MD 54.33 95% CI -35.47 to 144.12; participants = 204; studies = 2) but studies were varied (very low certainty). There may be no difference in self-efficacy on managing Chronic Disease Scale (SEMCD) or pulmonary rehabilitation adapted index of self-efficacy tool (PRAISE). Evidence is very uncertain. Quality of life may be slightly improved on the chronic respiratory disease questionnaire (CRQ) at 13 weeks (MD 0.45, 95% CI 0.01 to 0.90; participants = 123; studies = 2; low certainty), but is not clinically important (MID 0.5). There may be little or no difference at 23 or 52 weeks (low to very low certainty). There may be a clinical improvement on SGRQ total at 52 weeks (MD -26.57, 95% CI -34.09 to -19.05; participants = 120; studies = 1; low certainty). Evidence for COPD assessment test (CAT) and Clinical COPD Questionnaire (CCQ) is very uncertain. There may be little or no difference in dyspnoea symptoms (CRQ dyspnoea) at 13, 23 weeks or 52 weeks (low to very low certainty evidence) or mean number of exacerbations at 26 weeks (low-certainty evidence). There was no evidence for the number of people experiencing adverse events. Multi-component interventions Digital components included mobile phone (one study), and web or internet-based (four studies). Evidence is very uncertain about effects on impact on health behaviour (6MWD) at 13 weeks (MD 99.60, 95% CI -15.23 to 214.43; participants = 20; studies = 1). No evidence was found for self-efficacy. Four studies reported effects on quality of life (SGRQ and CCQ scales). The evidence is very uncertain. There may be no difference in the number of people experiencing exacerbations or mean days to first exacerbation at 52 weeks with a multi-component intervention compared to standard care. Evidence is very uncertain about effects on the number of people experiencing adverse events at 52 weeks. AUTHORS' CONCLUSIONS: There is insufficient evidence to demonstrate a clear benefit or harm of digital technology interventions with or without supported self-management, or multi-component interventions compared to usual care in improving the 6MWD or self-efficacy. We found there may be some short-term improvement in quality of life with digital interventions, but there is no evidence about whether the effect is sustained long term. Dyspnoea symptoms may improve over a longer duration of digital intervention use. The evidence for multi-component interventions is very uncertain and as there is little or no evidence for adverse events, we cannot determine the benefit or harm of these interventions. The evidence base is predominantly of very low certainty with concerns around high risk of bias due to lack of blinding. Given that variation of interventions and blinding is likely to be a concern, future, larger studies are needed taking these limitations in consideration. Future studies are needed to determine whether the small improvements observed in this review can be applied to the general COPD population. A clear understanding of behaviour change through the BCT classification is important to gauge uptake of digital interventions and health outcomes in people with varying severity of COPD. Currently there is no guidance for interpreting BCT components of a digital intervention for changes to health outcomes. We could not interpret the BCT findings to the health outcomes we were investigating due to limited evidence that was of very low certainty. In future research, standardised approaches need to be considered when designing protocols to investigate effectiveness of digital interventions by including a standardised approach to BCT classification in addition to validated behavioural outcome measures that may reflect changes in behaviour.

A retrospective study of the impact of a telephone alert service (Healthy Outlook) on hospital admissions for patients with chronic obstructive pulmonary disease.

BACKGROUND: Healthy Outlook is a service delivered by the UK Met Office directly to patients with chronic obstructive pulmonary disease (COPD) that has been in place since 2006. Its objective is to reduce the severity and length of COPD exacerbations, hence improving the quality of life and life expectancy. AIMS: To assess the effect of the Healthy Outlook service on hospital admission rates of all general practitioners that have used the service. METHODS: Control practices were selected for each of the 661 participating practices. The number of hospital admissions for each practice was extracted from the Hospital Episode Statistics database. The differences in admission rates per practice between the first year of use of the Healthy Outlook service and the previous year were compared by paired t-test analyses. RESULTS: For admissions with a primary diagnosis of COPD, the difference between participating and control practices was -0.8% (95% confidence interval (CI)=-1.8 to 0.2%; P=0.13). For admissions with a primary or co-morbid diagnosis of COPD, the difference was -2.3% (95% CI=-4.2 to -0.4%; P=0.02). CONCLUSIONS: Participation in the Healthy Outlook service reduces hospital admission rates for patients coded on discharge with COPD (including co-morbid).

End-of-life care discussions with nonmalignant respiratory disease patients: a systematic review.

BACKGROUND: Patients with nonmalignant respiratory diseases have limited access to palliative care services and health professionals do not adequately address discussions about end-of-life care preferences. OBJECTIVE: The aim of this systematic literature review was to highlight key components and challenges for patients and health professionals discussing end-of-life care in nonmalignant respiratory disease. DESIGN: A mixed methods systematic review was conducted. Included studies were assessed for quality and data were synthesized thematically, while original data were presented in tabular form. DATA SOURCES: PubMed, CINAHL, BNI, ASSIA, PsycINFO, Science Direct, and Web of Science were searched (1999-2010) for studies on end-of-life discussions. Additional studies were identified by hand searching key journals and reference lists of included articles. RESULTS: Fourteen studies were identified. Three themes involving components and challenges in end-of-life discussions were identified: the discussion, the health professional/patient relationship, and patient perceptions. CONCLUSIONS: End-of-life discussions should be initiated by health professionals, who must be aware of patient expectations regarding palliative care and end-of-life care planning. Efforts must be made to develop relationships with patients with terminal illness and allow sufficient time to discuss the end of life during clinical encounters. Future research should address palliative care uptake in nonmalignant disease and implications for health education should be addressed.

Exploring the outcomes and implications of the latest national COPD audit.

Publication of the clinical strategy for COPD is expected at the end of the year and it is anticipated that this will provide a structure to improve management of the condition. The latest national COPD audit has shown that although services have improved since the last audit in 2003, there are key areas in COPD management that need to be improved. This article analyses the results of this audit and the implications for practice.

Illicit drug use and its effect on the lungs.

Charlotte Rayner and Samantha Prigmore describe the prevalence of illicit drug use, how these drugs are inhaled or injected and the pulmonary consequences of such drug use.

A randomised-controlled trail examining the effects of reflexology of patients with chronic obstructive pulmonary disease (COPD).

It is known that many patients with obstructive pulmonary diseases use a number of complementary and alternative medicines (CAM). There has been a great deal of interest into the CAM recently, with the House of Lords select committee for science and technology's report suggesting randomised-controlled trials are the best means of researching the area. There is very little research into the effects of reflexology specifically on the effects it has on COPD. As such a randomised-controlled trial was set up to examine the effects of reflexology treatments on COPD. Results were qualitative and quantitative and showed that there are a number of areas of possible benefit for patients with COPD, but a larger scale study with a longer time frame is needed for a full evaluation of these effects.

End-of-life decisions and respiratory disease.

Withdrawing treatment from a patient is a difficult decision. Samantha Prigmore uses an ethical framework to explore how complex clinical dilemmas can be addressed. She also provides a brief introduction to ethics and ethical principles.

Assessment and nursing care of the patient with dyspnoea.

Breathlessness is a subjective experience, which has been described as an unpleasant or uncomfortable awareness of breathing, or of the need to breathe (Gift, 1990). Patients experiencing breathlessness are often described as being dyspnoeic, or having dyspnoea. This is derived from the Greek word, which, when translated, means 'difficulty in breathing'.