Telemedicine in chronic obstructive pulmonary disease: a possible transition to the patient independence

There are many offers for monitoring of the COPD patients at home. In one study Promete II, the authors tried to compare a specific telemedicine system with routine clinical practice in cases of severe COPD (5). They used for telemonitoring equipment for blood pressure, heart rate, oxygen saturation and spirometry measurements (actively or passively collected by the patients). It was not a success because, in comparison with routine practice, this telemonitoring did not reduce the admission to the emergency department and hospitalisations. It demonstrates that having only telehealth physiological monitoring of severe COPD, for a long term, will unlikely be of benefit, and focused more on the limits of telemedicine. At the opposite Promete I, after 7-month of monitoring of elderly, severe COPD patients, and follow-up showed a significant reduction of hospitalisation, a period of stay on mechanical ventilation and visits to the emergency department, confirming the practicality of telehealth assistance for these severe COPD patients (6). Also, in other meta-analyses, there are conflicting results. The Cochrane review of 10 randomised controlled trials showed different results; some of them also confirm the absence of significantly improving the quality of life by using telehealth but with some benefits related to significantly reducing the risk of emergency department attendance and hospitalisation (7). On the other hand, a more recent meta-analysis of 18 trials found no statistically significant quality-of-life benefits (8). What are the limits of every evaluation of these studies? If we look at the parameters used for monitoring the first question is: are they appropriate? Blood pressure, O2 saturation and respiratory rate are usually reflecting severe exacerbations but not an early moment of an exacerbation (3). It is difficult for the practitioner and patient to be alerted in time and to prevent further complications of the disease. Another problem of telemonitoring particularly in COPD is the substantial variability of different telemonitoring interventions and applications used. We have a variety of tools for monitoring starting with:

traditionally recording and electronic transmission of physiological parameters and vital signs (spirometry, pulse oximetry, heart rate, breathing frequency and blood pressure);

Another open window for COPD, coming from telehealth medicine is telerehabilitation (TR) (16). There are, of course, also some barriers from the staff’ perspective such as: 1) skills, 2) professional role and identity, 3) beliefs about capabilities, 4) beliefs about consequences, 5) environmental context and resources and 6) social influences. At the same time, there are two key messages for assuring the TR success: a combination between the involvement of the health professionals in the decision process with sufficient education and skill training of patients and responsible for delivering the messages. One possibility is digitalising pulmonary rehabilitation (PR) with a smartphone app. This is feasible and accepted by selected patients included in a 20-day core programme with short-term improvements of health-related quality of life (17). It also seems that the problem of safety, feasibility and effectiveness of this virtual TR is solved (18). It is another study that demonstrates that live video conferencing with a hub where 24 patients were receiving 14 sessions of standard, outpatient, multi-disciplinary PR in a hospital is improving shuttle walk test with less staffing ratios and significantly less travelling. Introduction of mHealth (personal digital assistants and monitoring) and eHealth (delivery, surveillance and management through telehealth communication) is working for elderly people but with two conditions (19): they must be guided to ensure valid and reliable online sources and to create the ability to interact with peers who had similar experiences. For therapy, telemonitoring is useful. Video telehealth inhaler training sessions using teach to goal methodology is another occasion to use telemedicine for improving patient acceptance of inhaling techniques in rural areas (20). Benefits for therapy are also evident. Enrolling patients with COPD in a digital platform to help to manage their medications and symptoms (21), receiving electronic medications monitor (and a smartphone app to track use trends and feedback), to monitor short-acting beta 2 agonists (SABA), brings a reduction of SABA use and more SABA free days.

Concerning cost evaluation, if we are looking to Chromed study (10), applying the prespecified health economic analysis the authors suggest it is possible to have a 27% reduction in the healthcare costs in the intervention (per patient per year, largely driven by a reduction in hospital costs). Even so in our days, the economic benefit of telemonitoring in COPD remains unclear (22), reflecting the difficulty in isolating the effects of telemonitoring from educational interventions (23). One condition for telemonitoring to be truly cost-effective is to have an annual cost of equipment and technical support at a price less than the annualised difference in costs between intervention and control groups

If we look at the conclusions of experts in 2019 (24), there are no differences in comparison with the round tables organised in 2018 (25). There is still much conflicting information regarding the effectiveness of telemonitoring for COPD patients with an overall improvement in more than 45% of the articles but also with the absence of this improvement in 38% (24). They defined some barriers such as low-quality data, costs, increase the workload for providers and as benefits, they underline these aspects: less in-person visits, better disease management and a better relationship-patient-provider-health assistant. Concerning patients’ opinions, these sometimes are similar to them of the healthcare providers. If we look at future mHealth interventions for patients and healthcare providers, they should focus (26) on developing self-management skills over time by providing adequate information, decision support and feedback on self-management behaviour. At the same time, mHealth should complement regular care (26).

The best telemonitoring outcomes for the future come from programmes dedicated to a certain cluster of patients with COPD (comprising aged and very sick patients, frequent exacerbators with multimorbidity and limited community support). There are also some important conditions for users. Programmes must use third-generation telemonitoring, flexible, adapted (to our diverse healthcare contexts) systems providing constant analytical and decision-making support (24 h/day, 7 days/week). We have to identify correctly who are the ideal candidates, at what time they need it and for how long (10). It seems that even for starting at home non-invasive ventilation in hypercapnic COPD patients, the use of telemedicine is noninferior to in-hospital initiation and brings over 50% of cost reduction (27). The extension of telehealth in community services is already a certainty. One example is England and Wales where one-third of the respondents are already using telehealth (28).

Despite the expansion of telemedicine in COPD, the science behind telemedicine in COPD remains underdeveloped (25). That is why it is a strong need to develop the necessary and definitive scientific basis for clarifying the role of telemedicine in the medical management of our patients.