Telehealth may offer opportunities for nurses to manage COPD, but how effective is it?
In this article…
- The differences between telecare, telehealth and telemonitoring
- Benefits of telehealth
- Patients’ and providers’ views on telehealth
Joe Annandale is a respiratory nurse specialist at Hywel Dda Health Board, Prince Philip Hospital, Llanelli; Keir E Lewis , Senior Clinical Lecturer, Swansea University and Consultant Chest Physician, Hywel Dda Health Board, Prince Philip Hospital, Llanelli
Annandale J, K Lewis (2011) Can telehealth patients with help COPD? Nursing Times; 107: 15/16, early online publication.
Chronic obstructive pulmonary disease (COPD) is a growing challenge for the NHS. New technologies, such as telehealth offer opportunities for health and social care providers to look at innovative ways to manage the condition. Studies show telehealth services can reduce admissions and bed days and boost patient satisfaction. But more research is needed to establish whether these technologies are safe, efficient and economical.
- This article has been double blind peer reviewed
5 key points
- COPD is predicted to become the fifth most common cause of disability
- Seventy five per cent of COPD cases remain undiagnosed, and most people have never heard of the condition
- New technologies may offer opportunities for health and social care providers to look at innovative ways to manage COPD, such as telehealth
- Studies show telehealth services can reduce bed days and hospital admissions and increase patient satisfaction
- Nurses need to feel confident with new technology
Chronic obstructive pulmonary disease (COPD) is an increasing challenge within our health service. Despite international standardised guidelines, better pharmacotherapy, more integrated care and pulmonary rehabilitation, COPD is predicted to become the fifth most common cause of disability (Lopez, 2006). It is the second largest cause of emergency hospital admissions, accounting for more than one million bed days and 21% of all respiratory beds each year in the UK (Department of Health, 2005). Although only a small number of people with COPD are admitted to hospital, these admissions account for 54% of the total £800 million spent on COPD (DH, 2005). More worryingly, in 2007 the British Lung Foundation estimated around 75% of COPD cases remain undiagnosed, and most people have never heard of the condition.
As more people are living longer with more long-term conditions, health costs continue to rise. Our healthcare system is operating within a public sector framework experiencing a significant economic downturn. For these reasons, current models of care are unsustainable and new ones must be explored.
New technologies may offer opportunities for health and social care providers to look at innovative ways to manage COPD. For example, in a study of more than 17,000 US patients, home co-ordination and telehealth were associated with a 25% reduction in bed days, a 19% drop in hospital admissions and high levels of patient satisfaction (Darkins et al, 2008).
Terms including telecare, telehealth and telemonitoring are sometimes used interchangeably and can be confusing. These are defined in box 1.
Box 1. Definitions of terms
Telecare - helps people maintain their independence at home. Examples include pendant alarms and falls detectors that trigger an alert to a monitoring service. They are traditionally provided by social care organisations (Goodwin, 2010).
Telehealth - uses technology to transfer physiological data for diagnosis or monitoring (Goodwin, 2010)Systems can include pulse oximetry, spirometry and peak flow measurements.
Telemonitoring - is a type of telehealth, but the physiological data is transmitted to a health provider, prompting an intervention to avoid deterioration in patients’ medical condition (Jaana et al, 2009).
Between 2006 and 2008, local councils in England received £80 million in government grants to invest in telecare (DH, 2006). In 2008, the DH also identified telehealth as an important resource in managing long-term conditions. This led to considerable interest and a rapid increase in the uncritical provision of telehealth services - often led by industry or politicians - in the UK, with around 5,000 people using remote monitoring (Goodwin, 2010).
Theoretical benefits of telemonitoring
Timely transfer of clinical data will alert monitoring staff that patients with COPD are starting to exacerbate. Symptoms worsen for three to five days before an exacerbation needs treatment so this window of opportunity can lead to earlier interventions by health teams (Seemungal et al, 2000). The aim is to improve symptoms, avoiding hospital admissions or reducing length of stay. Telemonitoring may lessen the need for home visits, allowing better use of limited staff time and resources without compromising care. It can also be used to improve patients’ knowledge and motivate them to change behaviours that will help them manage their illness.
We have learned that several inter-related factors are vital to achieve these benefits. These are listed in Box 2.
Box 2. Factors influencing the success of telemonitoring
Appropriate patients should be selected for telemonitoring. Stable patients may not benefit from this technology, and those who are severely ill will need to be admitted to hospital, irrespective of home data. Patients must be able and motivated to use the equipment appropriately, particularly when they notice changes to their condition. Their home environment must be suitable for telemonitoring, for example they will need a phone connection.
Health professionals need to feel confident about working differently to their usual face-to-face assessments and not feel threatened the technology may replace them. Adequate training and staff levels are vital. Good collaboration between local authority (social care) and healthcare partners -especially for installation and technical problems – is also important. Health professionals need to be able to respond to patients in a timely way and with effective treatments.
Monitors need to be acceptable to patients and health professionals. They should also be reliable, accurate and cost-effective.
What is the evidence that telehealth/monitoring works?
The evidence must demonstrate that telehealth/telemonitoring is safe, user-friendly, efficient and cost effective. Real-time telemonitoring and remote interventions were shown to be possible in two patients with advanced respiratory failure (Koizumi, 2005).
Vontetsianos (2005) used telemonitoring via a visiting nurse in 18 “well-motivated” patients with advanced COPD with previous admissions. They reported a decrease in health service use and better patient knowledge and self-management. But the real-time video link was set up during the nurse home visits, which combined with the intensive initial education may have made the difference.
In 2010 a Danish study reported significant reductions in COPD readmissions to hospital (Sorknaes, 2010). But the study also acknowledged a lack of randomisation and the control group had no access to home nurses or to remote monitoring. It is important to question where it was the telemonitoring or the home nursing input that reduced readmissions?
In our first randomised control trial (RCT) of telemonitoring in COPD, patients were highly motivated - all had to have completed at least 12 to 18 sessions of pulmonary rehabilitation. They were prescribed optimal medication and known to our home-care COPD team (Lewis et al, 2010a; Lewis et al, 2010b). This pilot was initially designed assess whether telemonitoring was safe and feasible. It completed ahead of schedule with no adverse events with excellent use of monitors (97% compliance of twice daily uploads where patients had to take readings and answer question twice a day. We found hospital admissions were roughly halved while contact with GPs was significantly reduced. There was no increased workload on clinics or home-care teams but there were also no differences in generic or disease-specific “quality of life” scores. This was a small pilot of only 40 patients over 12 months, and was not designed for an economic costing.
The patient perspective
Patients have reported high levels of satisfaction in “before and after” studiesbut this may be influenced by patient selection. In an attempted RCT, Mair et al (2006) found 80% of patients with COPD declined telemonitoring, the main reason being fear of having a nurse visit replaced by a telemonitor.
Our RCT refusal rate was much lower, probably because we only recruited from patients who has participated in pulmonary rehabilitation and we offered telemonitoring in addition to home care (Lewis et al, 2010a). But 15% still refused because of worries about using technology and others declined or dropped-out because they were reluctant to use the machine every day. Jaana et al’s review (2009) concluded patients were less likely to use the equipment if it was not user friendly or did not include some type of prompt.
The provider perspective
Respiratory nurses have reported concerns that telehealth could potentially replace them and many believed telemonitoring was unhelpful in building the patient nurse relationship and undermined some of the core values of nursing care (Hibbert et al, 2004).
Detailed interviews with 12 COPD nurses in a Liverpool study found they sometimes saw the technology as unhelpful in establishing effective relationships with patients. According to Hibbert et al (2004) “considerable work by all participants, over a period of months was required to develop the technology in ways that minimised the risk to the stability of the specialist service and existing nurse-patient relationships …[and] interplay of new technology with existing professional practices and relationships go beyond simple issues of training”.
In 2003, May et al attempted to identify barriers to implementing telehealth into routine care, and checklists based on surveys of healthcare providers and literature reviews are rapidly being developed to guide purchasers (Joseph et al, 2011). But with so many studies related to telehealth and telemonitoring over the last decade reporting positive outcomes, why is it not recommended for all patients?
We believe the main reason is the lack of robust evidence. A systematic review of benefits in home telemonitoring in COPD concluded the number of sufficient quality studies was small (n=6), at risk of bias (small sample size, no power calculations, no randomisation, no control groups, short term follow up and access to additional health care support as well as telemonitoring) and lacking full economical evaluations (Bolton et al, 2010). Although each study was reported positively, the review found the benefits of telemonitoring in COPD were not yet proven and could not support large scale implementation. This conclusion has been supported by other systematic reviews (Polisena et al, 2010; Smith et al 2009).
Larger scale and better designed research into telehealth and telemonitoring is required. Our pilot enabled us to learn from staff concerns, training issues, work patterns, installation difficulties and patient recruitment. We used the data to power a larger ongoing RCT designed to detect differences in hospital admission rates, in less optimised patients. (www.controlled-trials.com/ISRCTN18443546).Other well-designed RCTs are also examining telemonitoring in COPD in the UK (Fitzimmons et al,2011; Pinnock et al, 2009; www.controlled-trials.com/ISRCTN68856013). Fitzimmons et al are also reporting that “implementation of this service demanded significant changes to established working patterns and has been a challenging process requiring considerable planning”.
Most importantly, the DH has invested £31 million into the Whole System Demonstrator pilot programme. This large RCT of three chronic diseases in a range of clinical settings includes nearly 1,600 patients with COPD measuring a range of outcomes, including cost-effectiveness and patient-care experiences (www.wsdactionnetwork.org.uk/).
There is a lack of robust evidence to support routine telemonitoring for patients with COPD. The impact on the nurse-patient relationship and concerns about its impact on nursing’s professional identity are also areas we know little about.
But due to population demographic changes, the reduction in health professionals and huge financial constraints, our current models of care, particularly for chronic conditions are untenable. Changes need to occur and soon.
The government is an important driver in realising telehealth’s full potential in managing patients with COPD. But patients and clinicians also need to re-design care strategies and place the technology within them, rather than letting new technology dictate the care models.
Until this promising technology undergoes the same rigorous assessment, we cannot be sure of its safety, efficacy and economical impact. We hope this day comes soon then we implement it on larger scale in mainstream COPD care.
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