Use of Ecological Momentary Assessment to Measure Dyspnea in COPD

Dyspnea is an unpredictable and distressing symptom of chronic obstructive pulmonary disease (COPD). Dyspnea is challenging to measure due to the heterogeneity of COPD and recall bias associated with retrospective reports. Ecological Momentary Assessment (EMA) is a technique used to collect symptoms in real-time within a natural environment, useful for monitoring symptom trends and risks of exacerbation in COPD. EMA can be integrated into mobile health (mHealth) platforms for repeated data collection and used alongside physiological measures and behavioral activity monitors. The purpose of this paper is to discuss the use of mHealth and EMA for dyspnea measurement, consider clinical implications of EMA in COPD management, and identify needs for future research in this area.

Economic evaluation of remote patient monitoring and organizational analysis according to patient involvement: a scoping review

BACKGROUND

A literature review concerning the economic evaluation of telemonitoring was requested by the authority in charge of health evaluation in France, in a context of deployment of remote patient monitoring and identification of its financing. Due to the heterogeneity of existing telemonitoring solutions, it was necessary to stratify the evaluation according to patient involvement. Three levels of patient involvement are considered: weak (automated monitoring), medium (monitoring supported by a professional), and strong (active remote participation).

OBJECTIVES

We performed a scoping review to provide a comprehensive overview of different systems of telemonitoring and their reported cost-effectiveness.

METHODS

Following PRISMA-ScR guidelines, a search was performed in four databases: PubMed, MEDLINE, EMBASE, and Cochrane Library between January 1, 2013 and May 19, 2020. Remote patient monitoring should include the combination of three elements: a connected device, an organizational solution for data analysis and alert management, and a system allowing personalized interactions, and three degrees of involvement.

RESULTS

We identified 61 eligible studies among the 489 records identified. Heart failure remains the pathology most represented in the studies selected (n = 24). The cost-utility analysis was chosen in a preponderant way (n = 41). Forty-four studies (72 percent) reported that the intervention was expected cost-effective. Heterogeneity has been observed in the remote monitoring solutions but all systems are reported cost-effective. The small number of long-term studies does not allow conclusions to be drawn on the transposability.

CONCLUSIONS

Remote patient monitoring is reported to be cost-effective whatever the system and patient involvement.

Cost-effectiveness of personalised telehealth intervention for chronic disease management: A pilot randomised controlled trial

OBJECTIVE

The study aims to assess the cost-effectiveness of a personalised telehealth intervention to manage chronic disease in the long run.

METHOD

The Personalised Health Care (PHC) pilot study was a randomised trial with an economic evaluation alongside over 12 months. From a health service perspective, the primary analysis compared the costs and effectiveness of PHC telehealth monitoring with usual care. An incremental cost-effectiveness ratio was calculated based on costs and health-related quality of life. The PHC intervention was implemented in the Barwon Health region, Geelong, Australia, for patients with a diagnosis of COPD and/or diabetes who had a high likelihood of hospital readmission over 12 months.

RESULTS

When compared to usual care at 12 months, the PHC intervention cost AUD$714 extra per patient (95%CI -4879; 6308) with a significant improvement of 0.09 in health-related quality of life (95%CI: 0.05; 0.14). The probability of PHC being cost-effective by 12 months was close to 65%, at willingness to pay a threshold of AUD$50,000 per quality-adjusted life year.

CONCLUSION

Benefits of PHC to patients and the health system at 12 months translated to a gain in quality-adjusted life years with a non-significant cost difference between the intervention and control groups. Given the relatively high set-up costs of the PHC intervention, the program may need to be offered to a larger population to achieve cost-effectiveness. Long-term follow-up is required to assess the real health and economic benefits over time.

Economic Evaluations of Remote Patient Monitoring for Chronic Disease: A Systematic Review

OBJECTIVES

This study aimed to systematically review and summarize economic evaluations of noninvasive remote patient monitoring (RPM) for chronic diseases compared with usual care.

METHODS

A systematic literature search identified economic evaluations of RPM for chronic diseases, compared with usual care. Searches of PubMed, Embase, CINAHL, and EconLit using keyword synonyms for RPM and economics identified articles published from up until September 2021. Title, abstract, and full-text reviews were conducted. Data extraction of study characteristics and health economic findings was performed. Article reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

This review demonstrated that the cost-effectiveness of RPM was dependent on clinical context, capital investment, organizational processes, and willingness to pay in each specific setting. RPM was found to be highly cost-effective for hypertension and may be cost-effective for heart failure and chronic obstructive pulmonary disease. There were few studies that investigated RPM for diabetes or other chronic diseases. Studies were of high reporting quality, with an average Consolidated Health Economic Evaluation Reporting Standards score of 81%. Of the final 34 included studies, most were conducted from the healthcare system perspective. Eighteen studies used cost-utility analysis, 4 used cost-effectiveness analysis, 2 combined cost-utility analysis and a cost-effectiveness analysis, 1 used cost-consequence analysis, 1 used cost-benefit analysis, and 8 used cost-minimization analysis.

CONCLUSIONS

RPM was highly cost-effective for hypertension and may achieve greater long-term cost savings from the prevention of high-cost health events. For chronic obstructive pulmonary disease and heart failure, cost-effectiveness findings differed according to disease severity and there was limited economic evidence for diabetes interventions.

Exploring community members' perceptions to adopt a Tele-COPD program in rural counties

Background

Patients diagnosed with COPD residing in rural areas report a lower quality of life. Telehealth addresses geographic barriers by offering routine, technology-based visits, and remote patient monitoring.

Objective

The study objective was to explore adoption perceptions of a tele-COPD program among community members in rural Western North Carolina (WNC) counties.

Methods

A convenience sample of 17 community members were recruited to participate in one of five 45-min focus groups. Before the focus group, all participants completed a brief demographic survey. Focus groups were digitally recorded, transcribed verbatim, imported into MAXQDA v10, and analyzed thematically using established qualitative coding procedures. SPSS v22 was used to calculate descriptive statistics.

Results

Participants were primarily Non-Hispanic White (100%), male (59%), insured (100%), and had at least a high school education (80%). Only 25% of participants had any prior knowledge of telehealth programs. The majority (94%) of participants expressed interest in receiving a tele-COPD program due to convenience factors. Yet, most participants expressed a lack of interest and comfort in using Internet-capable devices (e.g., mobile devices, tablets, computers). Participants noted that to be successful, telehealth visits must be described and shown to them by their own provider or other trusted individual(s), such as a pharmacist. Privacy and cost were also expressed as telehealth concerns.

Conclusion

Interest in a tele-COPD program was high among community residents in rural WNC. However, to increase patient willingness to adopt a tele-COPD program, patients' providers must overcome challenges, such as patients' awareness and knowledge of telehealth, privacy and cost concerns, and access to and comfort with using new technologies. Pharmacists may mitigate these challenges by increasing patients' trust and comfort with telehealth programs.

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Telehealth offers video-based visits and remote patient monitoring in rural areas.

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Participants expressed concerns about privacy, cost, and using Internet-capable devices.

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Participants stated successful, telehealth visits must be described and shown by provider(s) or other trusted individual(s).

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Pharmacists may mitigate these concerns by increasing patients' trust and comfort with telehealth programs.

Short Term Economic Evaluation of the Digital Platform "Support, Monitoring and Reminder Technology for Mild Dementia" (SMART4MD) for People with Mild Cognitive Impairment and their Informal Caregivers

BACKGROUND

A randomized controlled trial of the SMART4MD tablet application was conducted for persons with mild cognitive impairment (PwMCI) and their informal caregivers to improve or maintain quality of life.

OBJECTIVE

The objective was to conduct economic evaluation of SMART4MD compared to standard care in Sweden from a healthcare provider perspective based on a 6-month follow-up period.

METHODS

Three hundred forty-five dyads were enrolled: 173 dyads in the intervention group and 172 in standard care. The primary outcome measures for PwMCI and informal caregivers were quality-adjusted life years (QALY). The results are presented as incremental cost-effectiveness ratios, and confidence intervals are calculated using non-parametric bootstrap procedure.

RESULTS

For PwMCI, the mean difference in total costs between intervention and standard care was € 12 (95% CI: -2090 to 2115) (US$ = € 1.19) and the mean QALY change was -0.004 (95% CI: -0.009 to 0.002). For informal caregivers, the cost difference was - € 539 (95% CI: -2624 to 1545) and 0.003 (95% CI: -0.002 to 0.008) for QALY. The difference in cost and QALY for PwMCI and informal caregivers combined was -€ 527 (95% CI: -3621 to 2568) and -0.001 (95% CI: -0.008 to 0.006). Although generally insignificant differences, this indicates that SMART4MD, compared to standard care was: 1) more costly and less effective for PwMCI, 2) less costly and more effective for informal caregivers, and 3) less costly and less effective for PwMCI and informal caregivers combined.

CONCLUSION

The cost-effectiveness of SMART4MD over 6 months is inconclusive, although the intervention might be more beneficial for informal caregivers than PwMCI.

Treating COPD Patients with Inhaled Medications in the Era of COVID-19 and Beyond: Options and Rationales for Patients at Home

COVID-19 has affected millions of patients, caregivers, and clinicians around the world. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads via droplets and close contact from person to person, and there has been an increased concern regarding aerosol drug delivery due to the potential aerosolizing of viral particles. To date, little focus has been given to aerosol drug delivery to patients with COVID-19 treated at home to minimize their hospital utilization. Since most hospitals were stressed with multiple admissions and experienced restricted healthcare resources in the era of COVID-19 pandemic, treating patients with COPD at home became essential to minimize their hospital utilization. However, guidance on how to deliver aerosolized medications safely and effectively to this patient population treated at home is still lacking. In this paper, we provide some strategies and rationales for device and interface selection, delivery technique, and infection control for patients with COPD who are being treated at home in the era of COVID-19 and beyond.

Cost-effectiveness of a telemonitoring program (telEPOC program) in frequently admitted chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease is a typical disease among chronic and respiratory diseases. The costs associated with chronic disease care are rising dramatically, and this makes it necessary to redesign care processes, including new tools which allow the health system to be more sustainable without compromising on the quality of the care, compared to that currently provided. One approach may be to use information and communication technologies. In this context, we explored the cost-effectiveness of applying a telemonitoring system to a cohort of chronic obstructive pulmonary disease patients with frequent readmissions (the telEPOC programme).We conducted an intervention study with a control group. The inclusion criteria used were having chronic obstructive pulmonary disease (forced expiratory volume in the first second/forced vital capacity  < 70%) and having been hospitalised for exacerbation at least twice in the last year or three times in the last 2 years. We estimated the costs incurred by patients in each group and calculated the quality-adjusted life years and incremental cost-effectiveness ratio.Overall, 77 patients were included in the control group and 86 in the intervention group. The raw cost-effectiveness analysis showed that the cost of the telEPOC intervention was significantly lower than that of usual care, while there were no significant differences between the groups in effectiveness.The incremental cost-effectiveness ratio for the intervention was €175,719.71 per quality-adjusted life-year gained.There were no differences between the intervention group (telemonitoring) and the control group (standard care) from the cost-effectiveness point of view. On the other hand, the intervention programme (telEPOC) was less expensive than routine clinical practice.

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.

Why telehealth does not always save money for the health system

Purpose

This study aims to determine elements of telehealth that have the potential to increase costs for the health system in the short to medium term.

Design/methodology/approach

A search of PubMed, EMBASE and Scopus databases was performed in May 2018 using broad terms for telehealth and economics. Articles were included if they identified and explained reasons for an increase in cost for telehealth services. Studies were categorised by economic analysis type for data extraction and descriptive synthesis.

Findings

Fourteen studies met inclusion criteria and were included in the review. These studies identified that increased health system costs were due to implementation costs (e.g. for equipment, software or staff training), increased use of other healthcare services (e.g. pharmaceutical services) and ongoing service costs (including staff salaries) resulting from telehealth being additive to traditional service (e.g. increased frequency of contact).

Originality/value

Telehealth is often assumed to be a cost-effective method of delivering healthcare, even to the point where direct cost savings are expected by decision makers as a result of implementation. However, this investigation suggests it does not routinely reduce costs for the health system and can actually increase costs at both implementation and ongoing service delivery stages. Health services considering implementing telehealth should be motivated by benefits other than cost reduction such as improved accessibility, greater patient centricity and societal cost–benefit.

Determining if Telehealth Can Reduce Health System Costs: Scoping Review

Background

Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.

Objective

This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.

Methods

A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.

Results

The cost analyses reviewed provided evidence that telehealth reduced costs when health system–funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.

Conclusions

Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.

The Cost-Effectiveness of Mobile Health (mHealth) Interventions for Older Adults: Systematic Review

The objective of this study was to critically assess and review empirical evidence on the cost-effectiveness of Mobile Health (mHealth) interventions for older adults. We systematically searched databases such as Pubmed, Scopus, and Cumulative Index of Nursing and Allied Literature (CINAHL) for peer-reviewed economic evaluations published in English from 2007 to 2018. We extracted data on methods and empirical evidence (costs, effects, incremental cost-effectiveness ratio) and assessed if this evidence supported the reported findings in terms of cost-effectiveness. The consolidated health economic evaluation reporting standards (CHEERS) checklist was used to assess the reporting quality of the included studies. Eleven studies were identified and categorized into two groups: complex smartphone communication and simple text-based communication. Substantial heterogeneity among the studies in terms of methodological approaches and types of intervention was observed. The cost-effectiveness of complex smartphone communication interventions cannot be judged due to lack of information. Limited evidence of cost-effectiveness was found for interventions related to simple text-based communications. Comprehensive economic evaluation studies are warranted to assess the cost-effectiveness of mHealth interventions designed for older adults.

Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD

RATIONALE & OBJECTIVE

Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population.

STUDY DESIGN

Scoping review of quantitative and qualitative studies.

SETTING & POPULATION

Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes).

SELECTION CRITERIA FOR STUDIES

MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019.

DATA EXTRACTION

Intervention and study characteristics were extracted using standardized tools.

ANALYTICAL APPROACH

Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews.

RESULTS

77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed.

LIMITATIONS

Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD.

CONCLUSIONS

Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.

Telemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial

RATIONALE

Early detection of chronic obstructive pulmonary disease (COPD) exacerbations using telemonitoring of physiological variables might reduce the frequency of hospitalization.

OBJECTIVES

To evaluate the efficacy of home monitoring of lung mechanics by the forced oscillation technique and cardiac parameters in older patients with COPD and comorbidities.

METHODS

This multicenter, randomized clinical trial recruited 312 patients with Global Initiative for Chronic Obstructive Lung Disease grades II to IV COPD (median age, 71 yr [interquartile range, 66-76 yr]; 49.6% grade II, 50.4% grades III-IV), with a history of exacerbation in the previous year and at least one nonpulmonary comorbidity. Patients were randomized to usual care (n = 158) or telemonitoring (n = 154) and followed for 9 months. All telemonitoring patients self-assessed lung mechanics daily, and in a subgroup with congestive heart failure (n = 37) cardiac parameters were also monitored. An algorithm identified deterioration, triggering a telephone contact to determine appropriate interventions.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were time to first hospitalization (TTFH) and change in the EuroQoL EQ-5D utility index score. Secondary outcomes included: rate of antibiotic/corticosteroid prescription; hospitalization; the COPD Assessment Tool, Patient Health Questionnaire-9, and Minnesota Living with Heart Failure questionnaire scores; quality-adjusted life years; and healthcare costs. Telemonitoring did not affect TTFH, EQ-5D utility index score, antibiotic prescriptions, hospitalization rate, or questionnaire scores. In an exploratory analysis, telemedicine was associated with fewer repeat hospitalizations (-54%; P = 0.017).

CONCLUSIONS

In older patients with COPD and comorbidities, remote monitoring of lung function by forced oscillation technique and cardiac parameters did not change TTFH and EQ-5D. Clinical trial registered with www.clinicaltrials.gov (NCT 01960907).

Telemonitoring to Manage Chronic Obstructive Pulmonary Disease: Systematic Literature Review

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of death throughout the world. Telemedicine has been utilized for many diseases and its prevalence is increasing in the United States. Telemonitoring of patients with COPD has the potential to help patients manage disease and predict exacerbations.

Objective

The objective of this review is to evaluate the effectiveness of telemonitoring to manage COPD. Researchers want to determine how telemonitoring has been used to observe COPD and we are hoping this will lead to more research in telemonitoring of this disease.

Methods

This review was conducted in accordance with the Assessment for Multiple Systematic Reviews (AMSTAR) and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Authors performed a systematic review of the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases to obtain relevant articles. Articles were then accepted or rejected by group consensus. Each article was read and authors identified barriers and facilitators to effectiveness of telemonitoring of COPD.

Results

Results indicate that conflicting information exists for the effectiveness of telemonitoring of patients with COPD. Primarily, 13 out of 29 (45%) articles stated that patient outcomes were improved overall with telemonitoring, while 11 of 29 (38%) indicated no improvement. Authors identified the following facilitators: reduced need for in-person visits, better disease management, and bolstered patient-provider relationship. Important barriers included low-quality data, increased workload for providers, and cost.

Conclusions

The high variability between the articles and the ways they provided telemonitoring services created conflicting results from the literature review. Future research should emphasize standardization of telemonitoring services and predictability of exacerbations.

A Remote Patient Monitoring Intervention for Patients With Chronic Obstructive Pulmonary Disease and Chronic Heart Failure: Pre-Post Economic Analysis of the Smart Program

Background

Exacerbation of chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) are associated with high health care costs owing to increased emergency room (ER) visits and hospitalizations. Remote patient monitoring (RPM) interventions aim to improve the monitoring of symptoms to detect early deterioration and provide self-management strategies. As a result, RPM aims to reduce health resource utilization. To date, studies have inconsistently reported the benefits of RPM in chronic illnesses. The Smart Program is an RPM intervention that aims to provide clinical benefit to patients and economic benefit to health care payers.

Objective

This study aims to economically evaluate the potential benefits of the Smart Program in terms of hospitalizations and ER visits and, thus, associated health care costs from the perspective of the public health care system.

Methods

Seventy-four patients diagnosed with COPD or CHF from one hospital site were included in this one-group, pre-post study. The study involved a secondary data analysis of deidentified data collected during the study period – from 3 months before program initiation (baseline), during the program, to 3 months after program completion (follow-up). Descriptive analysis was conducted for the study population characteristics at baseline, the clinical frailty score at baseline and 3-month follow-up, client satisfaction at 3-month follow-up, and number and costs of ER visits and hospitalizations throughout the study period. Furthermore, the cost of the Smart Program over a 3-month period was calculated from the perspective of the potential implementer.

Results

The baseline characteristics of the study population (N=74) showed that the majority of patients had COPD (50/74, 68%), were female (42/74, 57%), and had an average age of 72 (SD 12) years. Using the Wilcoxon signed-rank test, the number of ER visits and hospitalizations, including their associated costs, were significantly reduced between baseline and 3-month follow-up (P<.001). The intervention showed a potential 68% and 35% reduction in ER visits and hospitalizations, respectively, between the 3-month pre- and 3-month postintervention period. The average cost of ER visits reduced from Can $243 at baseline to Can $67 during the 3-month follow-up, and reduced from Can $3842 to Can $1399 for hospitalizations.

Conclusions

In this study, the number and cost of ER visits and hospitalizations appeared to be markedly reduced for patients with COPD or CHF when comparing data before and after the Smart Program implementation. Recognizing the limitations of the one-group, pre-post study design, RPM requires an upfront investment, but it has the potential to reduce health care costs to the system over time. This study represents another piece of evidence to support the potential value of RPM among patients with COPD or CHF.

A Scoping Review of Economic Evaluations Alongside Randomised Controlled Trials of Home Monitoring in Chronic Disease Management

Many countries have considered telemedicine and home monitoring of patients as a solution to the demographic challenges that health-care systems face. However, reviews of economic evaluations of telemedicine have identified methodological problems in many studies as they do not comply with guidelines. The aim of this study was to examine economic evaluations alongside randomised controlled trials of home monitoring in chronic disease management and hereby to explore the resources included in the programme costs, the types of health-care utilisation that change as a result of home monitoring and discuss the value of economic evaluation alongside randomised controlled trials of home monitoring on the basis of the studies identified. A scoping review of economic evaluations of home monitoring of patients with chronic disease based on randomised controlled trials and including information on the programme costs and the costs of equipment was carried out based on a Medline (PubMed) search. Nine studies met the inclusion criteria. All studies include both costs of equipment and use of staff, but there is large variation in the types of equipment and types of tasks for the staff included in the costs. Equipment costs constituted 16-73% of the total programme costs. In six of the nine studies, home monitoring resulted in a reduction in primary care or emergency contacts. However, in total, home monitoring resulted in increased average costs per patient in six studies and reduced costs in three of the nine studies. The review is limited by the small number of studies found and the restriction to randomised controlled trials, which can be problematic in this area due to lack of blinding of patients and healthcare professionals and the difficulty of implementing organisational changes in hospital departments for the limited period of a trial. Furthermore, our results may be based on assessments of older telemedicine interventions.

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Background

Cold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.

Objectives

To determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.

Design

A mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.

Setting

Low-income areas across Wales.

Participants

Residents who received energy efficiency measures through the intervention programme and matched control groups.

Main outcome measures

Primary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.

Methods

Anonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.

Data sources

The Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.

Results

The study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.

Limitations

This was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.

Conclusion

Although there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.

Future work

Our research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.

Funding

The National Institute for Health Research Public Health Research programme.

Oxygen saturation measurements in telemonitoring of patients with COPD: a systematic review

INTRODUCTION

Telemonitoring applications are expected to become a key component in future healthcare. Despite the frequent use of SpO₂ measurements in telemonitoring of patients with chronic obstructive pulmonary disease (COPD), no profound overview is available about these measurements. Areas covered: A systematic search identified 71 articles that performed SpO₂ measurements in COPD telemonitoring. The results indicate that long-term follow-up of COPD patients using daily SpO₂ spot checks is practically feasible. Very few studies specified protocols for performing these measurements. In many studies, deviating SpO₂ values were used to raise alerts that led to immediate action from healthcare professionals. However, little information was available about the exact implementation and performance of these alerts. Therefore, no firm conclusions can be drawn about the real value of SpO₂ measurements. Future research could optimize performance of alerts using individualized, time-dependent thresholds or predictive algorithms to account for individual differences and SpO₂ baseline changes. Additionally, the value of performing continuous measurements should be examined. Expert commentary: Standardization of the measurements, data science techniques and advancing technology can still boost performance of telemonitoring applications. All these opportunities should be thoroughly explored to assess the real value of SpO₂ in COPD telemonitoring.

Health-economic evaluation of home telemonitoring for COPD in Germany: evidence from a large population-based cohort

INTRODUCTION

Telemonitoring for COPD has gained much attention thanks to its potential of reducing morbidity and mortality, healthcare utilisation and costs. However, its benefit with regard to clinical and economic outcomes remains to be clearly demonstrated.

OBJECTIVE

To analyse the effect of Europe's largest COPD telemonitoring pilot project on direct medical costs, health resource utilisation and mortality at 12 months.

METHODS

We evaluated a population-based cohort using administrative data. Difference-in-difference estimators were calculated to account for time-invariant unobservable heterogeneity after removing dissimilarities in observable characteristics between the telemonitoring and control group with a reweighting algorithm.

RESULTS

The analysis comprised 651 telemonitoring participants and 7047 individuals in the standard care group. The mortality hazards ratio was lower in the intervention arm (HR 0.51, 95 % CI 0.30-0.86). Telemonitoring cut total costs by 895 € (p < 0.05) compared to COPD standard care, mainly driven by savings in COPD-related hospitalisations in (very) severe COPD patients (-1056 €, p < 0.0001). Telemonitoring enrolees used healthcare (all-cause and COPD-related) less intensely with shorter hospital stays, fewer inpatient stays and smaller proportions of people with emergency department visits and hospitalisations (all p < 0.0001). Reductions in mortality, costs and healthcare utilisation were greater for (very) severe COPD cases.

CONCLUSION

This is the first German study to demonstrate that telemonitoring for COPD is a viable strategy to reduce mortality, healthcare costs and utilisation at 12 months. Contrary to widespread fear, reducing the intensity of care does not seem to impact unfavourably on health outcomes. The evidence offers strong support for introducing telemonitoring as a component of case management.

Subgroup analysis of telehealthcare for patients with chronic obstructive pulmonary disease: the cluster-randomized Danish Telecare North Trial

PURPOSE

Results from the Danish cluster-randomized trial of telehealthcare to 1,225 patients with chronic obstructive pulmonary disease (COPD), the Danish Telecare North Trial, concluded that the telehealthcare solution was unlikely to be cost-effective, by applying international willingness-to-pay threshold values. The purpose of this article was to assess potential sources of variation across subgroups, which could explain overall cost-effectiveness results or be utilized in future economic studies in telehealthcare research.

METHODS

First, the cost-structures and cost-effectiveness across COPD severities were analyzed. Second, five additional subgroup analyses were conducted, focusing on differences in cost-effectiveness across a set of comorbidities, age-groups, genders, resource patterns (resource use in the social care sector prior to randomization), and delivery sites. All subgroups were investigated post hoc. In analyzing cost-effectiveness, two separate linear mixed-effects models with treatment-by-covariate interactions were applied: one for quality-adjusted life-year (QALY) gain and one for total healthcare and social sector costs. Probabilistic sensitivity analysis was used for each subgroup result in order to quantify the uncertainty around the cost-effectiveness results.

RESULTS

The study concludes that, across the COPD severities, patients with severe COPD (GOLD 3 classification) are likely to be the most cost-effective group. This is primarily due to lower hospital-admission and primary-care costs. Telehealthcare for patients younger than 60 years is also more likely to be cost-effective than for older COPD patients. Overall, results indicate that existing resource patterns of patients and variations in delivery-site practices might have a strong influence on cost-effectiveness, possibly stronger than the included health or sociodemographic sources of heterogeneity.

CONCLUSION

Future research should focus more on sources of heterogeneity found in the implementation context and the way telehealthcare is adopted (eg, by integrating formative evaluation into cost-effectiveness analyses).

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01984840.

Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: results from the Danish 'TeleCare North' cluster-randomised trial

OBJECTIVES

To investigate the cost-effectiveness of a telehealthcare solution in addition to usual care compared with usual care.

DESIGN

A 12-month cost-utility analysis conducted alongside a cluster-randomised trial.

SETTING

Community-based setting in the geographical area of North Denmark Region in Denmark.

PARTICIPANTS

26 municipality districts define randomisation clusters with 13 districts in each arm. 1225 patients with chronic obstructive pulmonary disease were enrolled, of which 578 patients were randomised to telehealthcare and 647 to usual care.

INTERVENTIONS

In addition to usual care, patients in the intervention group received a set of telehealthcare equipment and were monitored by a municipality-based healthcare team. Patients in the control group received usual care.

MAIN OUTCOME MEASURE

Incremental costs per quality-adjusted life-years gained from baseline up to 12 months follow-up.

RESULTS

From a healthcare and social sector perspective, the adjusted mean difference in total costs between telehealthcare and usual care was €728 (95% CI -754 to 2211) and the adjusted mean difference in quality-adjusted life-years gained was 0.0132 (95% CI -0.0083 to 0.0346). The incremental cost-effectiveness ratio was €55 327 per quality-adjusted life-year gained. Decision-makers should be willing to pay more than €55 000 to achieve a probability of cost-effectiveness >50%. This conclusion is robust to changes in the definition of hospital contacts and reduced intervention costs. Only in the most optimistic scenario combining the effects of all sensitivity analyses, does the incremental cost-effectiveness ratio fall below the UK thresholds values (€21 068 per quality-adjusted life-year).

CONCLUSIONS

Telehealthcare is unlikely to be a cost-effective addition to usual care, if it is offered to all patients with chronic obstructive pulmonary disease and if the willingness-to-pay threshold values from the National Institute for Health and Care Excellence are applied.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01984840, 14 November 2013.

Cost-Utility Analysis of Telemonitoring Interventions for Patients with Chronic Obstructive Pulmonary Disease (COPD) in Germany

BACKGROUND

Chronic obstructive pulmonary disease (COPD) poses major challenges for health care systems. Previous studies suggest that telemonitoring could be effective in preventing hospitalisations and hence reduce costs.

OBJECTIVE

The aim was to evaluate whether telemonitoring interventions for COPD are cost-effective from the perspective of German statutory sickness funds.

METHODS

A cost-utility analysis was conducted using a combination of a Markov model and a decision tree. Telemonitoring as add-on to standard treatment was compared with standard treatment alone. The model consisted of four transition stages to account for COPD severity, and a terminal stage for death. Within each cycle, the frequency of exacerbations as well as outcomes for 2015 costs and quality adjusted life years (QALYs) for each stage were calculated. Values for input parameters were taken from the literature. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

In the base case, telemonitoring led to an increase in incremental costs (€866 per patient) but also in incremental QALYs (0.05 per patient). The incremental cost-effectiveness ratio (ICER) was thus €17,410 per QALY gained. A deterministic sensitivity analysis showed that hospitalisation rate and costs for telemonitoring equipment greatly affected results. The probabilistic ICER averaged €34,432 per QALY (95 % confidence interval 12,161-56,703).

CONCLUSION

We provide evidence that telemonitoring may be cost-effective in Germany from a payer's point of view. This holds even after deterministic and probabilistic sensitivity analyses.

Qualitative investigation into a wearable system for chronic obstructive pulmonary disease: the stakeholders' perspective

OBJECTIVES

To ascertain the stakeholders' views and devise recommendations for further stages of the Wearable Sensing and Smart Cloud Computing for Integrated Care to Chronic Obstructive Pulmonary Disease (COPD) Patients with Co-morbidities (WELCOME) system development. This system aims to create a wearable vest to monitor physiological signals for patients concerned incorporating an inhaler adherence monitoring, weight, temperature, blood pressure and glucose metres, and a mobile health application for communication with healthcare professionals (HCPs).

DESIGN

A study of qualitative data derived from focus groups and semistructured interviews.

SETTING

4 participating clinical sites in Greece, the UK, Ireland and the Netherlands.

PARTICIPANTS

Purposive sampling was used to recruit 32 patients with COPD with heart failure, diabetes, anxiety or depression, 27 informal carers and 23 HCPs from 4 European Union (EU) countries for focus groups and interviews.

RESULTS

Most patients and HCPs described the WELCOME system as 'brilliant and creative' and felt it gave a sense of safety. Both users and HCPs agreed that the duration and frequency of vest wear should be individualised as should the mobile application functions. The parameters and frequency of monitoring should be personalised using a multidisciplinary approach. A 'traffic light' alert system was proposed by HCPs for abnormal results. Patients were happy to take actions in response.

CONCLUSIONS

WELCOME stakeholders provided valuable views on the development of the system, which should take into account patient's individual comorbidities, circumstances and concerns. This will enable the development of the individualised system in each member state concerned.

Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement

The estimated prevalence of ventilator-dependent individuals in Europe is 6.6 per 100 000 people. The increasing number and costs of these complex patients make present health organisations largely insufficient to face their needs. As a consequence, their burden lays mostly over families. The need to reduce healthcare costs and to increase safety has prompted the development of tele-monitoring for home ventilatory assistance.

A European Respiratory Society Task Force produced a literature research based statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of these patients.

Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients' needs. The legal problems associated with tele-monitoring are still controversial. National and European Union (EU) governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a “gold standard” of home care that is very variable among different European countries and within each European country.

Much more research is needed before considering tele-monitoring a real improvement in the management of these patients.

Health State Utility Value in Chronic Obstructive Pulmonary Disease (COPD); The Challenge of Heterogeneity: A Systematic Review and Meta-Analysis

Chronic obstructive pulmonary disease (COPD) has a considerable impact on quality of life and well-being of patients. Health state utility value (HSUV) is a recognized measure for health economic appraisals and is extensively used as an indicator for decision-making studies. This study is a systematic review of literature aimed to estimate mean utility value in COPD using meta-analysis and explore degree of heterogeneity in the utility values across a variety of clinical and study characteristic. The literature review covers studies that used EQ-5D to estimate utility value for patient level research in COPD. Studies that reported utility values elicited by EQ-5D in COPD patients were selected for random-effect meta-analysis addressing inter-study heterogeneity and subgroup analyses. Thirty-two studies were included in the general utility meta-analysis. The estimated general utility value was 0.673 (95% CI 0.653 to 0.693). Meta-analyses of COPD stages utility values showed influence of airway obstruction on utility value. The utility values ranged from 0.820 (95% CI 0.767 to 0.872) for stage I to 0.624 (95% CI 0.571 to 0.677) for stage IV. There was substantial heterogeneity in utility values: I(2) = 97.7%. A more accurate measurement of utility values in COPD is needed to refine valid and generalizable scores of HSUV. Given the limited success of the factors studied to reduce heterogeneity, an approach needs to be developed how best to use mean utility values for COPD in health economic evaluation.

Oximetry-supported self-management for chronic obstructive pulmonary disease: mixed method feasibility pilot project

Background

Pulse oximetry could potentially contribute to self-monitoring. NHS Lothian’s ‘Light Touch’ service provided COPD patients with a self-management plan based on symptoms and oximetry. The service was overseen (though not actively monitored) by respiratory-trained community teams who were contactable by a telephone helpline. We aimed to assess the feasibility, perceived utility and impact of the ‘Light Touch’ service.

Methods

A before-and-after assessment of St George’s Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS) and use of healthcare resources during the 6-month feasibility study compared to the previous corresponding 6-months. Paired semi-structured interviews with patients at baseline and 6-months, interviews with managers and a focus group of professionals explored perceptions of the service and self-management. Transcripts were coded, and analysed thematically.

Results

We recruited 51 participants (mean age 69.7 years (SD 8.4); 21 (46 %) male). 46 participants completed quantitative follow up (2 died, 2 were unwell, 1 refused). SGRQ: 21 (46 %) participants improved by 4 or more (the minimum important difference); 12 (26 %) deteriorated by 4 or more. HADS: more participants had normal scores for anxiety (65 %) and depression (80 %) at 6-months than at baseline (51 and 64 %). More emergency therapy was prescribed during the study period compared to the previous year. Only 18 participants (39 %) contacted the Light Touch Helpline during the 6-month study.

Twenty patients provided a total of 36 interviews, 8 clinicians contributed to a focus group and 6 managers were interviewed. Patients considered that the oximetry readings heightened awareness of their condition and gave them confidence to make self-management decisions. Healthcare professionals valued oximetry as a tool for teaching people self-management skills, but were concerned that patients rarely contacted the teams for help or advice during the study.

Conclusions

‘Light Touch’ shows promise as a low-cost strategy for empowering patients’ self-management skills and reducing reliance on clinical supervision.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1135-2) contains supplementary material, which is available to authorized users.

Effect of tele health care on exacerbations and hospital admissions in patients with chronic obstructive pulmonary disease: a randomized clinical trial

BACKGROUND AND OBJECTIVE

Tele monitoring (TM) of patients with chronic obstructive pulmonary disease (COPD) has gained much interest, but studies have produced conflicting results. Our aim was to investigate the effect of TM with the option of video consultations on exacerbations and hospital admissions in patients with severe COPD.

MATERIALS AND METHODS

Patients with severe COPD at high risk of exacerbations were eligible for the study. Of 560 eligible patients identified, 279 (50%) declined to participate. The remaining patients were equally randomized to either TM (n=141) or usual care (n=140) for the 6-month study period. TM comprised recording of symptoms, saturation, spirometry, and weekly video consultations. Algorithms generated alerts if readings breached thresholds. Both groups received standard care. The primary outcome was number of hospital admissions for exacerbation of COPD during the study period.

RESULTS

Most of the enrolled patients had severe COPD (forced expiratory volume in 1 second <50%pred in 86% and ≥hospital admission for COPD in the year prior to enrollment in 45%, respectively, of the patients). No difference in drop-out rate and mortality was found between the groups. With regard to the primary outcome, no significant difference was found in hospital admissions for COPD between the groups (P=0.74), and likewise, no difference was found in time to first admission or all-cause hospital admissions. Compared with the control group, TM group patients had more moderate exacerbations (ie, treated with antibiotics/corticosteroid, but not requiring hospital admission; P<0.001), whereas the control group had more visits to outpatient clinics (P<0.001).

CONCLUSION

Our study of patients with severe COPD showed that TM including video consultations as add-on to standard care did not reduce hospital admissions for exacerbated COPD, but TM may be an alternative to visits at respiratory outpatient clinics. Further studies are needed to establish the optimal role of TM in the management of severe COPD.