Building a patient-centered, comprehensive digital
network for COPD
SGK/SGHC/SGP 16.06.16 Lausanne
Dr. med. Frank Rassouli
Clinic for Pulmonology and Sleep Medicine
Cantonal Hospital St. Gallen
Building a patient-centered, comprehensive digital
network for COPD
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Structure of the talk
1. Goals of telemedicine for COPD
2. What’s the evidence?
3. Summary of main findings
4. What did / do we do in St. Gallen?
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
1. Goals of telemedicine for COPD
- Improve QoL
- Reduce hospitalisations due to AECOPD
- Reduce ED visits due to AECOPD
- Reduce and better allocate healthcare activities
- Reduce healtcare costs
Building a patient-centered, comprehensive digital network for COPD
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Pubmed (last 5 years):
«telemedicine COPD» 193
«telehealthcare COPD» 12
«telehealth COPD» 221
«telemonitoring COPD» 58
• 8 relevant RCTs (2013-2016)
• Thorax
• Respirology
• Int J COPD (2)
• BMJ
• J Telemed Telecare
• Scientific Reports
• BMC Health Services Research
2. What’s the evidence?
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
2. What’s the evidence?
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
3. Summary of main findings
- Inconsistent results in all mentioned goals!
- Likely contributing factors
- Different healthcare settings (6 countries)
- Different inclusion criteria
- Different interventions
- Different intervention intervals (daily to every 2 weeks!
Tendency: negative studies had rather longer reaction intervals)
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
4. What did / do we do in St. Gallen?
Pilot study: «Telehealthcare in COPD – a feasibility trial»
(PP-135)
- Objective: test the feasibility and patient acceptance of telehealthcare
for COPD in our healthcare setting
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Methods
- THC-platform was integrated in a comprehensive electronic patient
data repository has to be available for all patients in Switzerland by
law by 2017
- We use Evita by Swisscom
Patient General practitioner
Specialist
Decides who has access
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Methods
Phone call, if red signal
(suspected AECOPD)
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Results
• Data completeness 88%
• Patient acceptance 94%
• 230 phone calls in 38 patients
• 60 AECOPD in 22 patients confirmed
• 3 AECOPD in 3 patients missed
• Sensitivity 95% / PPV 26% / NPV 99.9%
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Results
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Conclusions
• Adding THC to state-of-the-art COPD management is feasible in a selected subgroup
of patients
• Up to 50% of COPD patients could be eligible for a THC strategy
• Patient compliance, acceptance and satisfaction were very high
• With the proposed approach we missed only very few AECOPD events
• However, a telephone-based verification of THC alerts was required
• Overall, in this proof-of-concept study we experienced a positive effort-to-benefit ratio
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
What’s an adequate primary endpoint for a RCT in this area?
ED visits / hospitalisations for AECOPD?
- 6/8 trials negative
- Probably underpowered
- Rare event in our pilot study
- Not adequate
Number of exacerbations?
- 4/5 trials negative: plausible (higher sensitivity)!
- Pilot study: higher than expected
- Not adequate
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
What’s an adequate primary endpoint for a RCT in this area?
QoL parameters?
- Mixed results in RCTs
- Pilot study: CAT score
- 28% improved (>MCID of 2), 66% improved or stable
- Overall slope: -0.45 points per year (rather increase expected!)
improved worsenedstable
examples
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Currently ongoing (started May 2016)
- Multicenter crossover RCT
- Centers (until now): KSSG / USB / USZ / Glarus / Wangen (D)
- Primary endpoint: change of CAT score (slope)
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Supplemental material…
Efficacy of multiparametric telemonitoring on respiratory outcomes in elderly people with COPD: a
RCT (Italy)Pedone et al. BMC Health Services Research 2013
Intervention: Wristband (heart rate, physical activity, temperature) + pulse oxymeter
Bluetooth Smartphone Server
Daily analysis by pulmonologist phone call when suspected deterioration
«events»: 50% hospital admission
50% AECOPD outpatient
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for
exacerbation of COPD: researcher blind, multicentre, RCT (UK)Pinnock et al. BMJ 2013
Intervention: Daily online questionnaire (symptoms and treatment use) + SpO2
phone call when suspected deterioration
Results: n = 256
No difference: time to first AECOPD admission
number of AECOPD admissions
QoL (SGRQ)
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
A telehealth program for self-management of COPD exacerbations and promotion of an active
lifestyle: a pilot RCT (Netherlands)Tabak et al. Int J COPD 2014
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
High adherence and satisfaction
A randomised clinical trial of the effectiveness of home-based health care with telemonitoring in
patients with COPD (Ireland)McDowell et al. (only abstract available) J Telemed Telecare 2015
Intervention: «Home telemonitoring» + standard care vs. standard care
Results: n = 100 (48 telemonitoring, 52 control)
SGRQ and HADS anxiety score sig. improved
No difference: GP activity
ED visits
Hospital admissions
Exacerbations
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Telemedicine, the effect of nurse-initiated telephone follow up, on health status and health-care
utilization in COPD patients: a RT (Netherlands)Berkhof et al. Respirology 2015
Intervention: Medical call center (nurses): phone call every 2 weeks: «Clinical COPD
Questionnaire» (CCQ)
If deterioration: phone call by pulmonologist
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Effect of tele health care on exacerbations and hospital admissions in patients with COPD: a RCT
(Denmark)Ringbaek et al. Int J COPD 2015
Intervention: - Tablet + camera + microphone / spirometer / pulse oxymeter
- Report changes in dyspnea, sputum color, volume and purulence
- Measurements 3 times per week (4 weeks), then once weekly +
video consultation once weekly (4 weeks), then once monthly
- Phone call (study nurse), if deterioration suspected (pulmonologist as backup)
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Randomized crossover trial of telemonitoring in chronic respiratory patients (TeleCRAFT trial) (UK)Chatwin et al. Thorax 2016
Intervention: - Daily questionnaire on dyspnoea, wheeze, sputum production, sleep quality,
therapy alterations
- Daily heart rate + SpO2
- Results reviewed daily by study team (nurse; pulmonologist if needed)
advice to patient by phone or online
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Hospitalisations for exacerbations
(1° endpoint)
QoL: no difference
Effectiveness of Telemonitoring in Patients with COPD in Taiwan: A RCT (Taiwan)Ho et al. Scientific Reports 2016
SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli
Building a patient-centered, comprehensive digital network for COPD
Daily for 2 months after discharge
Review by pulmonologist
Phone call when deemed necessary