Chronic lung diseases are among the most common medical conditions in the world, with estimates of up 24 million people in the U.S. suffering from chronic obstructive pulmonary disease (COPD) alone.
A report by investigators at Temple University’s Temple Lung Center in Philadelphia, Pennsylvania, published in the journal Telemedicine and eHealth, finds that a digital health application for reporting symptoms of Chronic Obstructive Pulmonary Disease (COPD) enables early detection and treatment of COPD exacerbation symptoms.
According to the Centers for Disease Control and Prevention, chronic lung disorders are the third leading cause of death in America (149,205) after heart disease (611,105) and cancers (584,881). The American Lung Association notes that COPD is also a major cause of disability, with symptoms including reduced airflow, inflammation and flare-ups, called exacerbations, in which the patient may experience increased coughing, mucus, shortness of breath, wheezing, and a feeling of tightness in their chest. And while some 12 million Americans have a formal COPD diagnosis, an estimated 12 million more people may have the disease and go undiagnosed.
Even with optimum COPD treatment, few patients are totally symptom free, and worsening symptoms (i.e., exacerbations) often lead to unscheduled office visits, emergency room interventions, and hospitalizations.
In an Open Access article published online in the journal Telemedicine and eHealth entitled “Use of a SmartPhone/Tablet-Based Bidirectional Telemedicine Disease Management Program Facilitates Early Detection and Treatment of COPD Exacerbation Symptoms” (Telemedicine and eHealth, 2015; DOI: 10.1089/tmj.2015.0135), the co-authors, Heidi S. Smith, RN, Gerard J. Criner, MD, Dolores Fehrle, RN, and Carla L. Grabianowski, all of the Temple University School of Medicine BSN Department of Thoracic Medicine and Surgery; Andrew J. Criner of HGE Healthcare Solutions, LLC, in Philadelphia; and Michael R. Jacobs, PharmD of the Temple University School of Pharmacy, note that early treatment of COPD exacerbations speeds recovery, improves quality of life, and reduces need for hospitalization. While shortening the time from symptom onset to treatment reduces the severity of these events, it requires that patients recognize worsening symptoms, contact a healthcare provider, and start an appropriate treatment regimen — all of which can be a challenge, as patients may fail to recognize worsening symptoms, leading to delays in treatment.
The Temple Lung Center research team led by Gerard J. Criner, MD, FACP, FACCP, founding chair of the new Department of Thoracic Medicine and Surgery at the Temple Lewis Katz School of Medicine, and director of the Temple Lung Center, observe that a telemedicine application could facilitate detection and treatment of worsening symptoms, but in order to work, the software would require consistent use by patients, with monitoring and timely responses from healthcare providers.
The Lung Center offers a telecommunication option to its patients for COPD symptom reporting, and reports can be made using a smartphone application or by logging in to a restricted-access website through a home computer. Both the smartphone application and website are encrypted, and Health Insurance Portability and Accountability Act (HIPAA) compliant. The patient’s only responsibility is to report his or her symptoms on a daily basis. The application consists of eight screens where patients record their respiratory symptoms (dyspnea, sputum [quantity, color, and thickness], coughing, wheezing, nasal congestion, fever, and sore throat) and peak flow. Three peak flow measurements are obtained using a hand-held peak flow meter and entered into the smartphone application. Three measurements are obtained to ensure they do not vary by more than 20%, and the best of the three measurements is used to compare with the patient’s initial value.
The application compares the patient’s daily COPD symptom report with symptoms recorded based on their usual state of health. If worsening symptoms are detected, the application informs the patient and places an alert in the queue for review by a nurse. Based upon the symptoms reported, the nurse suggests an evidence-based treatment recommendation and forwards it to a pulmonologist for approval. Once the pulmonologist signs off, the nurse transmits the recommendation to the patient via text or email.
As part of their continuous quality improvement program, in order to determine the effectiveness of this program, the researchers conducted a 320-day assurance assessment of patient compliance with daily COPD symptom reporting, as well as the Lung Center’s ability to provide timely responses to worsening COPD symptoms, as reported by the digital application, to evaluate whether they were meeting the target goals.
For the assessment, 30 patients were provided with a COPD daily symptom reporting smartphone application. Reports logged between November 2012 and September 2013 were reviewed, and symptoms reports and interventions were time-stamped by the application. Adherence reporting was calculated as the number of reports made divided by the number of days each patient was enrolled in the program, and time to intervention was calculated as the interval between the time a report was submitted to the time a treatment recommendation was sent to the patient.
There were 4,434 symptom reports created over 5,178 patient-days of observation for an average reporting compliance of 85.6 percent. Median reporting compliance was 90.7 percent and 475 symptom reports resulted in an alert being issued. Average response time for all alerts was 6.64 hours, with a median response time of 5.75 hours. The researchers conclude from this quality assessment that patient adherence to the reporting system exceeded 90 percent for over half of the participants, and that over 50 percent of worsening COPD symptom reports were responded to in less than six hours with patient-specific treatment recommendations.
“Given a general lack of awareness among patients of small day-to-day symptom changes and the pace of symptom worsening in COPD, daily COPD tele-monitoring is an attractive approach to facilitate early intervention, provided that the system is used and that the health care provider responds in a timely manner,” said Dr. Criner in a press release. “Patient adherence to daily symptom reporting system using this application exceeded 90 percent for more than half of the participants, and 90 percent of worsening COPD symptom reports were responded to in less than 11 hours with patient-specific treatment recommendations. That’s substantially better than response times reported in recent COPD research literature.”
Publication of the findings follows up a Temple-led study published by Telemedicine and eHealth on August 10, which revealed that patients who used the application to report their daily symptoms and received same-day treatment recommendations experienced fewer and less severe COPD exacerbation symptoms, leading to an improvement in daily symptom control, lung function and activity status.
“Early interventions for worsening COPD symptoms shortens their duration and reduces their severity, says Michael R. Jacobs, PharmD, lead author of the analysis, a professor of Clinical Pharmacy at Temple University School of Pharmacy, and director of Clinical Research for the Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine. “This digital health application is an example of how emerging technology can help facilitate early intervention and treatment by the health care team.”
The researchers observe that there were limitations to the findings, including the small number of patients who were enrolled. Moreover, all of the patients who participated in the assessment were quite ill — a factor that may have provided them with greater motivation to make daily symptom reports than would have possibly been the case if they were less ill. Also, because of the small sample size, lack of a control group and limited follow-up duration, the team is unable to comment on whether healthcare utilization was impacted.
The technology used in the quality improvement program is a precursor to the solution currently offered by HGE Health Care Solutions, a spin-off company of Temple University founded by Dr. Gerard Criner and exclusive licensee to certain Temple University intellectual property. Both Temple University and Dr. Criner are minority owners in the company. HGE’s application is also supported by Temple’s recently launched Center for Digital Health.
You can read the entire analysis in Telemedicine and e-Health at: http://bit.ly/1GlvHfx
Temple University Health System (TUHS)
Temple Lung Center
Telemedicine and e-Health
The Lewis Katz School of Medicine
HGE Health Care Solutions, LLC
Centers for Disease Control and Prevention
American Lung Association