Telemedicine Chapter 1: Telemedicine and Asthma
Systematic Reviews
This study aimed to evaluate the current evidence on Web- or mobile-based interventions designed for adolescents and young adults (AYAs). Owing to the lack of intervention efficacy trials, no conclusion can be drawn if an intervention delivered via a mobile app is better than that delivered via a website. However, through this systematic review, it is confirmed that AYAs were receptive to receiving medical information electronically.
The aim of this study was to identify, appraise, and synthesize available qualitative evidence on users’ experiences of mHealth technologies for NCD management in young people. Slater et al explored the perspectives of both end users [young people] and implementers [health policy makers, clinicians, and researchers]. A systematic review and meta-synthesis of qualitative studies was conducted. Themes derived for end users of mHealth included: 1. experiences of functionality that supported self-management; 2. acceptance [technical usability and feasibility]; 3. importance of co-design; and 4. perceptions of benefit [self-efficacy and empowerment]. For implementers, derived themes included: 1. characteristics that supported self-management [functional, technical, and behaviour change]; 2. implementation challenges [systems level, service delivery level, and clinical level]; 3. adoption considerations for specific populations [training end users; specific design requirements]; and 4. co-design and tailoring to facilitate uptake and person-centred care. The authors conclude that synthesizing available data revealed both complementary and unique user perspectives on enablers and barriers to designing, developing, and implementing mHealth technologies to support young people’s management of their chronic NCDs.
This study examined the effectiveness of telemedicine in relieving asthma symptoms. A systematic review of databases was conducted until December 31, 2013. Inclusion criteria were randomized controlled trial, a diagnosis of asthma, the majority of the patients ³18 years of age and intervention involved any format of telemedicine. A meta-analysis of eligible studies was conducted with the primary outcome being change of asthma symptoms. Telemedicine interventions do not appear to improve asthma function scores, but other benefits may be present.
Randomised Controlled Trials
Apter, AJ et al (2020) [Randomised Controlled Trial] Patient portal usage and outcomes among adult patients with uncontrolled asthma[4]
The objective of this study was to describe portal activities and association with 12-month outcomes among low-income patients with asthma formally trained in portal use. In a longitudinal observational study within a randomized controlled trial, 301 adults with uncontrolled asthma were taught 7 portal tasks: reviewing upcoming appointments, scheduling appointments, reviewing medications, locating laboratory results, locating immunization records, requesting refills, and messaging. Patients with uncontrolled asthma used the portal irregularly if at all, despite in-person training. Usage was not associated with regular appointments or with clinical outcomes. Patient portals need modification to accommodate low-income patients with uncontrolled asthma.
Bender, BG et al (2020) [Randomised Controlled Trial] Adults with asthma experience no increase in asthma-related exacerbations when digital communication technology tools are employed to offset provider workload: a pragmatic randomized trial[5]
The objective of this study was to test whether digital communication technology tools (DCTs), compared with usual care, can reduce health care clinician burden without increasing asthma-related exacerbations among patients with asthma in a large integrated health care system. Primary outcome measures included asthma-related health care resource utilization [eg asthma nurse contacts], medication use, and exacerbations. DCT tools can successfully contact adult asthma patients to screen for symptoms and facilitate intervention. The absence of differences in medication fills and health care utilization indicates that the strategic replacement of nursing interventions by digital outreach did not reduce treatment adherence or compromise health care outcomes.
Khusial, RJ et al (2020) [Randomised Controlled Trial] Effectiveness of myAirCoach: a mHealth self-management system in asthma[6]
Khusial et al assessed the clinical effectiveness and technology acceptance of myAirCoach-supported self-management on top of usual care in patients with asthma using inhalation medication. The myAirCoach system consisted of an inhaler adapter, an indoor air-quality monitor, a physical activity tracker, a portable spirometer, a fraction exhaled nitric oxide device, and an app. The primary outcome was asthma control; secondary outcomes were exacerbations, quality of life, and technology acceptance. In study 1, 30 participants were randomized to either usual care or myAirCoach support for 3 to 6 months; in study 2, 12 participants were provided with the myAirCoach system in a 3-month before-after study. Using the myAirCoach support system improves asthma control and quality of life, with a reduction in severe asthma exacerbations. Well-validated mHealth technologies should therefore be further studied.
Nemanic, T et al (2019) [Randomised Controlled Trial] Telemonitoring in asthma control: a randomized controlled trial[7]
The aim of this project was to test the applicability and potential effects of a 12-month telemonitoring of patients with asthma supported by information and communication technologies. 100 patients with asthma were followed in the outpatient pulmonary clinic in a randomized controlled clinical trial. The patients’ data were collected by study questionnaires and lung function tests at the inclusion and at the end of interventional period. In the interventional group, asthma control test (ACT) and peak expiratory flow measurements (PEF) were stimulated to be regularly reported by Short Message Service (SMS). As a response to reported values, the patients automatically received a preformed text or a call from a study nurse in case of detected predefined critical values. The compliance of reporting PEF and ACT values was higher than 80% in 96% of patients. Although we did not detect significant differences in ACT score improvement between the two study groups, we found more prominent improvement of ACT score in the subgroup of patients with two or more exacerbations prior to inclusion in the interventional group, compared to the control group. 40 (78%) patients in the interventional group listed at least one positive effect of telemonitoring on management of asthma. The developed program for home monitoring of patients with asthma was applicable and offered the patients support in managing their disease. Further studies with more selected patients are needed to confirm its usefulness in improving asthma control.
Van De Hei, SJ et al (2019) [Randomised Controlled Trial] Effectiveness and acceptability of a smart inhaler asthma self-management programme: A cluster RCT study protocol[8]
This study aims to investigate the effectiveness of a smart inhaler asthma self-management program on medication adherence and clinical outcomes, to investigate who would benefit most based on patient characteristics, and to evaluate its acceptability. An open-label cluster randomized controlled trial of 12 months will be conducted in general practices in the Netherlands. Practices will be randomly assigned to intervention or control. The intervention consists of: 1 an electronic monitoring device (EMD) attached to the patients’ inhaler that measures medication use; 2 a smartphone application to set medication reminders, receive motivational messages and track asthma symptoms; and 3 a portal for healthcare professionals to view data on medication use. The control group will receive an EMD for measuring medication adherence objectively that can only be viewed by the researchers. Eligible patients are adults with partially controlled or uncontrolled asthma with evidence of non-adherence. The primary outcome is change in medication adherence over time. Other outcomes include asthma control, quality of life, SABA use, exacerbations, medication beliefs, eHealth literacy, acceptance and cost-effectiveness. This study will provide insight in the long-term benefits of a smart inhaler program on medication adherence and clinical outcomes in a real-world clinical setting and inform future studies on use and acceptance of eHealth self-management interventions.
Cao, Y et al (2018) [Randomised Controlled Trial] WeChat public account use improves clinical control of cough-variant asthma: a randomized controlled trial[9]
WeChat is a convenient and popular social medium, and it may be an appropriate platform for education and management of patients. This study sought to identify usefulness in clinical control of cough-variant asthma (CVA). A randomized controlled trial was conducted among 80 CVA patients. After being assigned to either the traditional group or the WeChat group, they received the same inhalation therapy, but patients in WG received additional education and instruction via our public account on the WeChat application. Questionnaires on asthma and chronic cough, data on pulmonary function, blood-related items, follow-up adherence, and Emergency Department (ED) visits were collected at the initial visit and at 3 months. Cao et al conclude that using WeChat as part of treatment and management of CVA can help patients learn about their disease and medications, as well as improve disease control and therapy outcomes.
Beydon, N et al (2017) [Randomised Controlled Trial] Digital action plan for asthma exacerbations (PANAME)[10]
A written action plan (WAP) reduces emergency visits for asthma exacerbations. However, a WAP is underused and often focused on asthma control. The innovation is an AppWeb that includes expert software aimed at diagnosing the level of severity of asthma exacerbations and delivering a personalized digital action plan (DAP) when patients are in urgent need of medical advice. The main objective of the study is to evaluate the effect of the DAP on the frequency of urgent medical attendance. Secondary objectives are to evaluate adherence to the DAP compared to a WAP and the qualitative satisfaction of patients using the DAP. Expected results are a decrease in the number of urgent medical attendances and better adherence in the WAP + DAP group compared to the WAP group.
Pool, AC et al (2017) [Randomised Controlled Trial] Impact of online patient reminders to improve asthma care: a randomized controlled trial[11]
The purpose of this study is to examine the efficacy of an online tool designed to improve asthma control. This is a 12-month single blind randomized controlled trial of the online tool (IC) versus an active control tool (CC). The main outcome measure was asthma control, as assessed by the 5-question Asthma Control Test (ACT). Secondary outcomes included quality of life, medication use and healthcare utilization: eg emergency department visits. Results After 12 months, 323 participants completed follow-up measures (79.2%). Participants in the IC reported a greater mean improvement in the ACT score than participants in the CC (2.3 vs. 1.2; p = 0.02) and 9 of 11 individual asthma control survey items showed non-significant improvements favouring the IC. No differences were observed in medication adherence, number of asthma controller medications or health care utilization. Simple and brief online patient reminders improved asthma control among insured patients. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect on asthma control was similar to the addition of an additional controller medication. Given the widespread use of the Internet, simple tools such as this may be useful for improving the control of other chronic diseases as well.
Whether web-based technologies can improve disease self-management is uncertain. My Asthma Portal (MAP) is a web-based self-management support system that couples evidence-based behavioural change components (self-monitoring of symptoms, physical activity, and medication adherence) with real-time monitoring, feedback, and support from a nurse case manager. The aim of this study was to compare the impact of access to a web-based asthma self-management patient portal linked to a case-management system (MAP) over 6 months compared with usual care on asthma control and quality of life. This study supported the use of MAP to enhance asthma quality of life but not asthma control as measured by an administrative database. Implementation of MAP beyond 6 months with tailored protocols for monitoring symptoms and health behaviours as individuals’ knowledge and self-management skills improve may result in long-term gains in asthma control.
Koufopoulos, JT et al (2016) [Randomised Controlled Trial] A web-based and mobile health social support intervention to promote adherence to inhaled asthma medications: randomized controlled trial[13]
The objective is to conduct a rigorous proof-of-concept randomized controlled trial of an online community intervention for improving adherence to asthma medicine. This 9-week intervention included a sample of asthmatic adults who were prescribed an inhaled corticosteroid preventer. Based on their findings, Koufopoulos et al conclude that joining an online community did not improve adherence to preventer medication for asthma patients. Without the encouragement of greater community support or more components to sustain engagement over time, the current findings do not support the use of an online community to improve adherence.
Merchant, RK et al (2016) [Randomised Controlled Trial] Effectiveness of population health management using the Propeller Health Asthma Platform: a randomized clinical trial[14]
This pragmatic controlled study was designed to measure real-world effectiveness of the Propeller Health Asthma Platform to reduce use of SABA and improve asthma control. A total of 495 patients were enrolled in parallel arms (1:1) for 12 months of monitoring SABA use. Intervention group patients received access to and feedback from the Propeller Health system. Routine care patients were outfitted with sensors but did not receive feedback. Physicians were able to monitor the status of their patients in the intervention group and receive proactive notifications. Compared with RC, the study arm monitoring SABA use with the Propeller Health system significantly decreased SABA use, increased SABA-free days, and improved ACT scores, the latter among adults initially lacking asthma control.
Zairina, E et al (2016) [Randomised Controlled Trial] Telehealth to improve asthma control in pregnancy: A randomized controlled trial[15]
This study evaluated the efficacy of a telehealth programme supported by a handheld respiratory device in improving asthma control during pregnancy. Pregnant women with asthma (n=72) from two antenatal clinics in Melbourne, Australia, were randomized to one of two groups: 1. intervention-involving a telehealth programme (management of asthma with supportive telehealth of respiratory function in pregnancy (MASTERY©) supported by a handheld respiratory device and an Android smart phone application (Breathe-easy©) and written asthma action plan; or 2. control-usual care. The primary outcome was change in asthma control at 3 and 6months [prenatal]. Secondary outcomes included changes in quality of life and lung function, and perinatal/neonatal outcomes. There were no significant differences between groups in lung function, unscheduled health-care visits, days off work/study, oral corticosteroid use, or perinatal outcomes. Differences between groups were not significant at 3months. Telehealth interventions supporting self-management are feasible and could potentially improve asthma control and asthma-related quality of life during pregnancy.
Lau, AY et al (2015) [Randomised Controlled Trial] “Why didn’t it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma[16]
A 12-month parallel 2-group randomized controlled trial was conducted. Participants living with asthma were recruited and randomized 1:1 to either the PCHMS group or control group [online static educational content]. The primary outcome measure was possession of an up-to-date written AAP post study. Secondary measures included 1. utilizing the AAP; 2. planned or unplanned visits to a health care professional for asthma-related concerns; 3. severe asthma exacerbation, inadequately controlled asthma, or worsening of asthma that required a change in treatment; and 4. number of days lost from work or study due to asthma. Ancillary analyses examined reasons for adoption or non-adoption of the intervention. Outcome measures were collected by online questionnaire pre-study, monthly, and post study. Despite the intervention being effective in other preventive care settings, system use was negligible and outcome changes were not seen as a result. Consumers must perceive the need for assistance with a task and assign priority to the task supported by the eHealth intervention. Additionally, the cost of adopting the intervention eg, additional effort, time spent learning the new system must be lower than the benefit. Otherwise, there is high risk consumers will not adopt the eHealth intervention.
Tamblyn, R et al (2015) [Randomised Controlled Trial] Evaluating the impact of an integrated computer-based decision support with person-centered analytics for the management of asthma in primary care: A randomized controlled trial[17]
The objective was to determine whether a personalized asthma management computer-based decision support increases the quality of asthma management and reduces the rate of out-of-control episodes. A cluster-randomized trial was conducted in Quebec, Canada among 81 primary care physicians and 4,447 of their asthmatic patients. This study evaluated the effectiveness of a novel computer-assisted ADS system that facilitates systematic monitoring of asthma control status, follow-up of patients with out of control asthma, and evidence-based, patient-specific treatment recommendations. Tamblyn et al found that physicians were more likely to use ADS for out-of-control patients, that in the majority of these patients, they were advised to add an inhaled corticosteroid or a leukotriene inhibitor to the patients’ treatment regimen, and the intervention significantly increased the mean ratio of inhaled corticosteroids to FABA during follow-up. It also reduced the rate of out-of-control episodes during follow up among patients whose asthma was out-of-control at the time of study entry. Future research should assess whether coupling patient-specific treatment recommendations, automated follow-up, and home care with comparative feedback on quality and outcomes of care can improve guideline adoption and care outcomes. They conclude that a primary care-personalized asthma management system reduced the rate of out-of-control asthma episodes among patients whose asthma was poorly controlled at the study’s onset.
Miscellaneous
Abraham, R et al (2019) [Literature Review] A targeted literature review to evaluate the impact of information technology-based interventions on patient reported outcomes among asthma patients[18]
Abraham et al reviewed the literature to evaluate digital health interventions’ impact on patient-reported outcomes (PROs). IT-based interventions included Internet-based self-report tools and electronic PRO questionnaires (n=14, 29.8%), smartphone and tablet-based apps (n=12, 25.5%), mobile electronic adherence sensors (n=5, 10.6%), electronic asthma diaries (n=5, 10.6%), multimedia educational interventions (n=4, 8.5%), mobile telehealth visits (n=3, 6.4%); four studies (8.5%) assessed more than one IT-based intervention. Studies collected asthma PRO measures including asthma control and self-management skills (n=22, 46.8%), treatment self-efficacy (n=7, 14.9%), dyspnoea severity/symptoms/functional limitations (n=4, 8.5%), quality of life (n=1, 2.1%), and lung clearance index (n=1, 2.1%). Twelve studies (25.5%) assessed more than one asthma PRO. Several IT-based health interventions have shown promise in favourably impacting PROs for asthma patients. Further studies need to prospectively evaluate these findings on a larger scale.
Bodini, R et al (2019) [Review] Digital therapy in the treatment of asthma and COPD-epidemiology of development and use of an emerging health technology in respiratory medicine[19]
The aim of this review is to analyse the current state of the art about digital therapeutics (DTx) for asthma and COPD and to provide guidelines for their development. Bodini et al state that DTx has the potential to transform treatment of asthma and COPD. Evidence-based results supporting adoption are highly variable. The authors propose guidelines to ensure that DTx manufacturers understand the evidence they need to show to meet the needs of the health and care system, patients, and users.
Heaney LG et al (2019) [Review] Remotely monitored therapy and nitric oxide suppression identifies non-adherence in severe asthma[20]
Suppression of fractional exhaled nitric oxide (FeNO) with directly observed ICS therapy over 7 days can identify non-adherence to ICS treatment in difficult-to-control asthma. Heaney et al examined the feasibility and utility of FeNO suppression testing in routine clinical care within UK severe asthma centres using remote monitoring technologies. A web-based interface with integrated remote monitoring technology was developed to deliver FeNO suppression testing. They examined the utility of FeNO suppression testing to demonstrate ICS responsiveness and clinical benefit on electronically monitored treatment with standard high-dose ICS and long-acting β2-agonist treatment. They conclude that remote FeNO suppression testing is an effective means of identifying non-adherence to ICS in subjects with difficult-to-control asthma and the substantial population of subjects who derive important clinical benefits from optimized ICS/long-acting β2-agonist treatment.
Holgate, ST et al (2019) [Review] The future of asthma care: personalized asthma treatment[21]
Although once considered a single disease entity, asthma is now known to be a complex inflammatory disease engaging a range of causal pathways. The most frequent forms of asthma are identified by sputum/blood eosinophilia and activation of type 2 inflammatory pathways involving interleukins -3, -4, -5, and granulocyte-macrophage colony-stimulating factor. The use of diagnostics that identify T2 engagement linked to the selective use of highly targeted biologics has opened up a new way of managing severe disease. Novel technologies, such as wearables and intelligent inhalers, enable real-time remote monitoring of asthma, creating a unique opportunity for personalized health care.
Blakey, JD et al (2018) [Review] Digital technologies and adherence in respiratory diseases: the road ahead[22]
Outcomes for patients with chronic respiratory diseases remain poor despite the development of novel therapies. In part, this reflects the fact that adherence to therapy is low and clinicians lack accurate methods to assess this issue. Digital technologies hold promise to overcome these barriers to care. For example, algorithmic analysis of large amounts of information collected on health status and treatment use, along with other disease relevant information such as environmental data, can be used to help guide personalised interventions that may have a positive health impact, such as establishing habitual and correct inhaler use. Novel approaches to data analysis also offer the possibility of statistical algorithms that are better able to predict exacerbations, thereby creating opportunities for preventive interventions that may adapt therapy as disease activity changes. To realise these possibilities, digital approaches to disease management should be supported by strong evidence, have a solid infrastructure, be designed collaboratively as clinically effective and cost-effective systems, and reflect the needs of patients and healthcare providers. Regulatory standards for digital interventions and strategies to handle the large amounts of data generated are also needed. This review highlights the opportunities provided by digital technologies for managing patients with respiratory diseases.
Burch, J et al (2018) [Cochrane Clinical Answers] What are the benefits and harms of home telemonitoring and remote feedback between clinic visits in people with asthma?[23]
Moderate-certainty evidence shows that for adults with asthma, most often of mild to moderate severity, home telemonitoring plus remote feedback [Internet‐based device, program or website, text messaging or mobile phone software, or phone calls] reduces the number of people with exacerbations requiring hospitalization on average, 21 vs 83 per 1000 people compared with usual monitoring [educational session, personalized asthma action plan, peak flow meter, or asthma diary]. Researchers observed no clear differences between groups for exacerbations requiring hospitalization in the overall population nor for exacerbations requiring oral corticosteroids, emergency department visits, or unscheduled healthcare visits [when assessed, low‐certainty evidence]. In terms of asthma control, measured by the Asthma Control Questionnaire or the Asthma Control Test, researchers observed no clear differences between groups at 12‐month follow‐up. However, lung function was improved with home telemonitoring and remote feedback: on average, a 7.21% greater increase in forced expiratory volume in one second [FEV1] [moderate‐certainty evidence] and 13.20 L/min greater increase in peak expiratory flow. Researchers also observed improvement in quality of life, but this finding was not clinically significant. No RCT reported on adverse events.
Sumino, K et al (2018) [Meeting Abstract] Accuracy of smartphone-based spirometry (WING) use at home in asthma[24]
Sumino et al evaluated the accuracy of a new, innovative, pocket-sized, smartphone sound-based spirometry system (WING Sparo Labs), which can monitor FEV1 and PEFR on a smartphone at home using a built-in application with video instruction. They randomly assigned participants with asthma and a broad range of lung function to 3 groups: group 1: WING with in-person instruction by trained technician in outpatient office; group 2: WING with built-in video instruction viewed by the participant only in outpatient office; group 3: WING with built-in video instruction at home by the participant. They evaluated the accuracy of lung function testing with the WING device against standard spirometry [KoKo PFT spirometer, n-spire health] performed in the same setting by a single trained technician. When used for the first time, the smartphone-based spirometry system (WING) in patients with asthma provided acceptable accuracy in measuring FEV1, even if used with the built-in video instruction. Future studies are needed to evaluate if repeated use at home increases the accuracy.
Unni, E et al (2018) [Review] A review of the use and effectiveness of digital health technologies in patients with asthma[25]
A new generation of digital health technologies (DHT) offers the opportunity to improve adherence and asthma control. Recent literature was reviewed to summarize the use of technological aids and evaluate their impact on health outcomes in patients with asthma. Interactive websites were the most frequently evaluated type of DHT (50% of all studies), followed by mobile apps in adult patient cohorts. Relatively few studies assessed electronic monitoring devices, phone calls, or text messaging. Most interventions reported at least some benefit, although results varied based on the specific outcome. Overall, technology that included more interactive features, such as website-based daily diary entries and apps that provided real-time feedback, was associated with increased asthma control, as was the case for multidimensional interventions that combined the use of several complementary types of DHT.
Merchant, R et al (2017) [Conference Abstract] Digital health intervention for asthma: patient perception of usability and value for self-management[26]
The aim of this study is to assess patient’s feedback on usability of and satisfaction with an asthma digital health platform after 12 months of use. Patients reported high satisfaction and usability of a digital health platform for asthma self-management. Patients perceived value from the platform in contributing to their self-management by increasing self-awareness, identifying asthma triggers, and improving communication with their providers.
Pinnock, H et al (2016) [Review] Digital technology in respiratory diseases: promises, (no) panacea and time for a new paradigm[27]
Recent evidence suggests that telehealth may not be quite the panacea that was promised; this has led to discussions on the mechanisms and role of digital technology in respiratory care. Implementation in rural and remote settings offers significant benefits in terms of convenient access to care, but is contingent on technical and organizational infrastructure. Telemonitoring systems rely on algorithms to detect deterioration and trigger alerts; machine learning may enable telemonitoring of the future to develop personalized systems that are sensitive to clinical status whilst reducing false alerts. By providing access to information, offering convenient and flexible modes of communication and enabling the transfer of monitoring data to support professional assessment, telehealth can support self-management. At present, all too often, expensive off the shelf systems are purchased and given to clinicians to use. It is time for the paradigm to shift. Pinnock et al argue that clinicians should identify the specific challenges they face in delivering care, and expect flexible systems that can be customized to individual patients’ requirements and adapted to diverse healthcare contexts.
Van Sickle, D et al (2016) [Conference Abstract] Randomized, controlled study of the impact of a mobile health tool on asthma SABA use, control and adherence[28]
The aim of this study was to determine whether a sensor-enabled, clinically-integrated mobile health asthma quality improvement programme could reduce the frequency of short-acting beta agonist (SABA) use, and increase asthma-free days, asthma control and controller medication adherence. Adult patients with asthma and a SABA prescription were enrolled (n=125). Participants randomized to the intervention group (IG) (n=67) received electronic inhaler sensors to track their medication use, and access to smartphone and online applications that provided visualizations of their data, reminders to promote adherence, and personalized, guidelines-based education. Clinical care managers viewed IG patients’ data in an online dashboard to guide care. Participants in the control group (CG) (n=58) received sensors, but neither the patient nor the care manager received access to their data. Mixed effects regression models with random intercepts were used to compare outcomes between groups at 6 months. The IG demonstrated significant improvements compared to the CG on all clinical outcomes, including controller medication adherence, daily SABA use, asthma free days, and asthma control (all p<0.001), including a 21-point improvement in adherence for the IG. This mobile health programme, with sensor-enabled data collection and patient and provider access to the data, improved asthma outcomes, including asthma SABA use, control, and adherence in a real-world clinical setting.
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