Do telehealth technologies help improve the health of people who have COPD?
Chronic obstructive pulmonary disease (COPD) includes a group of lung conditions that cause breathing difficulties. Symptoms include shortness of breath (dyspnoea), coughing, and increased mucus. COPD causes limited airflow in the lungs when breathing out; this can be measured by spirometry (a measure to assess how well the lungs function). The spirometer takes two measurements: volume of air when breathing out forcefully in one second, and total amount of air breathed out. When COPD gets worse over time, this leads to greater symptom severity and can reduce quality of life. Disease progression and sudden flare-ups (exacerbations) of symptoms can increase someone's risks of hospitalisation and death. Telehealth technologies could improve delivery of health care for people with COPD, which could reduce exacerbations, improve quality of life, and lower rates of hospitalisation. However, it is unclear whether providing telehealth care improves health-related outcomes for people with COPD. We wanted to explore whether telehealth technologies were helpful for people with COPD.
What are telehealth technologies?
Study investigators used a range of telehealth technologies. Some included remote monitoring technology, which requires daily use of a laptop or a tablet with monitoring equipment, with results received by the healthcare professional. Typical monitoring equipment included a stethoscope (to measure blood pressure and heart rate), a pulse oximeter (to measure oxygen levels in the blood), a spirometer (to measure lung function), a thermometer, and other devices. Interventions involved regular phone calls with healthcare professionals for patients to talk about their symptoms and completion of health questionnaires.
Identifying and selecting studies
We searched online databases up until April 2020. We searched for studies published worldwide, in any language, at any time. Two review authors looked at lists of studies separately, then agreed on which studies should be included.
To find the best answer to our question, we looked for studies that recruited people with COPD of any severity. To make the comparison fair, we looked for studies in which investigators compared remote monitoring, remote monitoring plus usual care, and multi-component treatments. People included in these studies had to have the same random chance (like the flip of a coin) to receive one of these teleheath technologies or usual care.
We found 29 studies (5654 people with moderate to very severe COPD) that were suitable for inclusion in our review. Duration of these studies ranged from 3 to 12 months.
We did not find any important benefits or harms for patients who were monitored with any of the telehealth technologies when we looked at number of exacerbations, improvement in quality of life, and reduction in breathing distress symptoms, hospitalisations, or death. However, people who were monitored through telehealth technology plus usual care had some reduction in risk of hospital re-admission. Thus, telehealth technologies that were part of a care package reduced COPD-related hospital re-admissions.
We could not be certain of any harms of stand-alone remote monitoring. We are also uncertain of any benefits or harms of stand-alone remote monitoring of patient experiences or reports of breathing distress.
Quality of evidence
Currently, no good quality evidence is available. We are very uncertain about evidence for exacerbations, quality of life, dyspnoea symptoms, hospitalisations, deaths, and side effects. However, we are moderately certain about our findings for hospital re-admissions.
We are not clear whether telehealth technologies for monitoring or consultation provide benefit, but we have not found any information on harms. Telehealth could play a role in the care and management of people with COPD. Telehealth as part of multi-component care packages may provide short-term benefit for quality of life and hospital re-admissions. Telehealth in the form of remote monitoring in addition to usual care may reduce the risk of hospital re-admission. There is little impact on exacerbations, quality of life, and death. Owing to limited information, the findings of this review should be interpreted with caution. More studies are needed to determine whether telehealth provides any long-term benefits for people with COPD of varying severity.
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.
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.
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.
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.
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).
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.
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.