Evaluation of telehealth support in an integrated respiratory clinic

The addition of telehealth support to an exacerbation-prone population, following assessment and treatment optimisation in a MISSION-ABC clinic, proved beneficial in reducing both the frequency of exacerbations and unscheduled healthcare visits. These reductions also proved to be cost effective. This is the first report of an integrated respiratory clinic delivered in primary care that has shown that the use of telehealth using telephone triggers led to a combined reduction in unscheduled care use. Here we discuss the results of our study and the limitations.

The MISSION-ABC clinic provided patients with a multi-disciplinary assessment, including treatment optimisation, education and the development of a self-management plan. It was therefore anticipated there would be an improvement in exacerbation frequency and unscheduled GP visits, hence determining the additional benefit of a telehealth service was performed as a matched cohort study. As this is a post-hoc analysis, the control and telehealth cohorts are not identical in size, however the participants are matched by their post MISSION-ABC diagnosis alongside factors that may influence their disease trajectory and unscheduled care use including age, sex, smoking history and FEV1 percent predicted.

MISSION-ABC encompassed participatory action research (PAR) methodology to evolve the clinic interventions. This therefore raises the possibility of a population bias as participants who engage with PAR may also be more likely to engage with a telehealth service. However, both our telehealth and control cohorts had attended the MISSION-ABC clinics and were therefore likely to be similarly engaged. One advantage of MISSION-ABC is that clinics were held in multiple GP practices in South East Hampshire allowing inclusion of participants across the region from different socio-economic areas which contributes to the generalisation of results.

Comparisons were performed between 6 months pre- and post- the MISSION-ABC clinic as per study protocol. We recognise that seasonal trends could affect the outcomes for an analysis period that encompasses only 6 months follow-up for an intervention that only lasted 3 months. We believe this bias has been minimised by recruiting into MISSION-ABC over an 11-month period thereby reducing any overall impact of secular trends.

As expected following the MISSION-ABC clinic, exacerbation frequency and unscheduled GP visits improved across all groups. There was a statistical difference in the reduction of exacerbations across all participants who engaged with the telehealth service, although this is less pronounced when subdivided by disease category. Importantly, there was a significant reduction in the number of unscheduled GP visits for participants in the telehealth cohorts with both asthma and COPD. The addition of the telehealth service provided the reassurance and encouragement needed for participants to follow their self-management plan at home, whether that was to increase their inhaled corticosteroid, or to start a course of steroids and/or antibiotics.

The attrition rate for returning questionnaires was high and not consistent across the groups making data from smaller samples difficult to interpret. For example, there was an improvement in the ACQ score in the telehealth cohort, although this did not reach statistical significance. Similarly there was a reduction in the PAM score in the COPD control group. These observations would require more detailed exploration in future studies.

For just over 50% of the alerts received, a supportive phone call by a trained healthcare professional with discussion of their self-management plan was sufficient. This supportive phone call and encouragement to follow their self-management plan was provided in a timely manner, pro-actively recognising and acting upon a change in symptoms. This early detection of deterioration allowed timely intervention to prevent any further decline which may have resulted in a more severe exacerbation, unscheduled GP visit or even hospital admission. Twenty-one percent of the triggers resulted in definitive advice or action being provided, with the majority relating to medications including the need to start antibiotics or oral corticosteroids. Of the 165 triggers, a clinical review was suggested for only 12 participants (7%), indicating that most alerts can be successfully managed with remote support. Despite triggering on a telehealth service designed to recognise an increased symptom burden, 22% of participants did not respond to a subsequent telephone call. As a telehealth service requires regular engagement from the participant, there will naturally be a bias towards those who will use and subsequently benefit from a remote service. We have also considered the bias from not being able to contact participants after alerts. The study methodology did not allow us to interrogate for reasons why participants were unable to be contacted. Nevertheless, their data was included in the analysis. Given that this was a substantial proportion of alerts, future research needs to explore reasons why participants could not be reached as this is a missed opportunity for an intervention. Conceivably, our reduction in unscheduled healthcare use may have been greater had we been able to contact these participants. Following a telehealth alert, all participants received a telephone call from a specialist nurse. Some calls went unanswered and although we accept the resource implications of this, this was not included in our cost-effective analysis recognising the time required for this was at most a few minutes and no subsequent interventions were required.

We compared the telehealth group versus all other participants and predictably they had lower lung function, higher rate of exacerbations and a higher FeNO as would have been expected based on our selection criteria. This supports the rationale that our intervention is more likely to be of benefit in those with more severe disease.

Overall, the cost of the telehealth intervention per participant was low (£12) for the three months of the study. This cost compares favourably to the average cost of an inhaler for three months. This intervention led to significant reductions in unscheduled care use over and above any benefit realised from simply attending a MISSION-ABC clinic i.e. our controls. Overall, the addition of telehealth proved a cost-effective measure, saving an average £444.35 per participant, and a large part of reduction in costs was in hospital admissions and unscheduled GP visits. We accept that the cost may have been underestimated as we were unable to contact a proportion of participants triggering an alert.

The potential advantage of telehealth in respiratory disease has been recognised but its value remains unproven. In 2011, a systematic review suggested telehealth may improve quality of life and reduce the number of hospital and ED visits in COPD17. A more recently published systematic review regarding digital interventions in managing COPD further concluded that there was no evidence of harm from digital interventions, but also no clear evidence of long-term benefit either18. It is a similar story for patients with asthma; a 2016 Cochrane review of home telemonitoring for patients with asthma also concluded there was no clear evidence of benefit, or harm from this intervention19. We have, however, shown a benefit in asthma and COPD with evidence of cost effectiveness, although acknowledge this is in a small cohort.

This improvement may be explained as participants were enroled from an exacerbation-prone population, following thorough assessment and treatment optimisation in a MISSION-ABC clinic. The addition of telehealth provided additional personal and interactive support in self-management and reduced the reliance on a GP appointment. This telehealth support does not replace GP or clinical visits, and at times, participants were actively encouraged to seek GP advice, however, the addition of telehealth does empower participants to self-manage at home where appropriate. Digital health is a developing market, with an ever-increasing number of technological interventions available. Using these to support self-management at home will be key in the years to come, however identifying appropriate patients is also a crucial component. This matched cohort review shows that telehealth support can reduce the number of unscheduled GP appointments in patients with both asthma and COPD, but a large-scale randomised control trial is required to prove long-term benefit.

In conclusion, the development of a self-management plan and the use of telehealth support following treatment optimisation provides an opportunity to detect early signs of deterioration, to reassure and to encourage the use of self-management plans with a subsequent reduction in the frequency of exacerbations and unscheduled GP visits. In a post COVID-19 era, where there will be an increasing focus on the use of remote technology, this study supports the hypothesis that telehealth services can be key in chronic disease management for patients with asthma and COPD.

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