Do digital interventions help people to improve their self-management of COPD and their health? Do they help to change their behaviour about managing their symptoms?
What is COPD?
COPD is a chronic and progressive condition affecting the airways and lungs. Typically, COPD results from prolonged exposure to harmful chemicals found in tobacco smoke, leading to inflammation of the airways, as well as abnormal expansion of the airspaces of the lungs. Owing to the highly varied nature of COPD, there is much variety in how the condition affects individuals’ lives. A persistent cough and breathlessness are characteristic symptoms of COPD, worsening during flare-ups (exacerbations) and becoming more severe over time. This makes activities of daily living more difficult and greatly impacts quality of life.
Managing COPD is complex and varies depending on the severity of the condition. Self-management techniques often play a role in relieving symptoms, such as breathing exercises, as well as a combination of medication and supplementary oxygen.
'Digital interventions' and 'telehealth' are terms used to encompass the use of technology to communicate and send information between a patient and a healthcare provider - helping to manage the patient’s condition remotely. This may involve (but is not restricted to) the use of a mobile phone or tablet computer application to log symptoms and lung function, allowing a clinician to adjust medications in real-time. It may also involve remotely training a patient in self-management techniques. There is scope for those living with COPD to greatly benefit from the use of such interventions, offering convenient and accessible healthcare provision.
Why did we do this review?
We wanted to find out if digital interventions were helpful for people with COPD in terms of managing their condition, and if these interventions played a part in changing their behaviour towards self-management. Additionally, we wanted to understand the behaviour change techniques incorporated in different digital interventions.
What evidence did we find?
Mostly, digital interventions or multi component approaches did not improve walking distance or betterment in one's own belief in managing their condition. There was small short-term improvement in quality of life with Internet-based interventions but we cannot be certain whether the improvement is seen long term. Breathing difficulties may improve with long-term use of digital interventions, but they may have little to no effect on flare-ups. Due to limited data available, we cannot say with confidence that digital interventions can be used to improve health in people with COPD, or that they reduce harm. There is little or no evidence about possible unwanted side-effects of digital interventions. More research in this field can provide more robust conclusions for their use and insight into people's behaviours towards these novel approaches.
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.
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.
To assess benefits and harms of digital interventions for managing COPD and apply Behaviour Change Technique (BCT) taxonomy to describe and explore intervention content.
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.
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.
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.
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.
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.