ABSTRACT

Objective: A substantial number of people with COPD suffer from exacerbations, which are defined as an acute worsening of respiratory symptoms. To minimize exacerbations, telehealth has emerged as an alternative to improve clinical management, access to health care, and support for self-management. Our objective was to map the evidence of telehealth/telemedicine for the monitoring of adult COPD patients after hospitalization due to an exacerbation. Methods: Bibliographic search was carried in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus, Biblioteca Virtual de Saúde/LILACS and Cochrane Library databases to identify articles describing telehealth and telemonitoring strategies in Portuguese, English, or Spanish published by December of 2021. Results: Thirty-nine articles, using the following concepts (number of articles), were included in this review: telehealth (21); telemonitoring (20); telemedicine (17); teleconsultation (5); teleassistance (4); telehomecare and telerehabilitation (3 each); telecommunication and mobile health (2 each); and e-health management, e-coach, telehome, telehealth care and televideo consultation (1 each). All these concepts describe strategies which use telephone and/or video calls for coaching, data monitoring, and health education leading to self-management or self-care, focusing on providing remote integrated home care with or without telemetry devices. Conclusions: This review demonstrated that telehealth/telemedicine in combination with telemonitoring can be an interesting strategy to benefit COPD patients after discharge from hospitalization for an exacerbation, by improving their quality of life and reducing re-hospitalizations, admissions to emergency services, hospital length of stay, and health care costs.

Keywords: Pulmonary disease, chronic obstructive; Symptom flare up; Telemedicine; Patient discharge.

RESUMO

Objetivo: Um número substancial de pessoas com DPOC sofre de exacerbações, definidas como uma piora aguda dos sintomas respiratórios. Para minimizar as exacerbações, a telessaúde surgiu como alternativa para melhorar o manejo clínico, o acesso aos cuidados de saúde e o apoio à autogestão. Nosso objetivo foi mapear as evidências de telessaúde/telemedicina para o monitoramento de pacientes adultos com DPOC após hospitalização por exacerbação. Métodos: Foi realizada uma pesquisa bibliográfica nos bancos de dados PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus, Biblioteca Virtual de Saúde/LILACS e Cochrane Library para identificar artigos que descrevessem estratégias de telessaúde e telemonitoramento em português, inglês, ou espanhol, publicados até dezembro de 2021. Resultados: Trinta e nove artigos, utilizando os seguintes conceitos (número de artigos), foram incluídos nesta revisão: telessaúde (21); telemonitoramento (20); telemedicina (17); teleconsulta (5); teleassistência (4); telecuidado domiciliar e telerreabilitação (3 cada); telecomunicação e saúde móvel (2 cada); e gestão de e-saúde, e-coach, teledomicílio, cuidados de telessaúde e tele/videoconsulta (1 cada). Todos esses conceitos descrevem estratégias que utilizam chamadas telefônicas e/ou de vídeo para coaching, monitoramento de dados e educação em saúde levando à autogestão ou autocuidado, com foco na prestação de cuidados domiciliares remotos integrados, com ou sem dispositivos de telemetria. Conclusões: Esta revisão demonstrou que a telessaúde/telemedicina associada ao telemonitoramento pode ser uma estratégia interessante para beneficiar pacientes com DPOC após a alta hospitalar por exacerbação, por meio da melhora da qualidade de vida e da redução das re-hospitalizações, admissões em serviços de emergência, tempo de internação hospitalar e custos de cuidados de saúde.

Palavras-chave: Doença pulmonar obstrutiva crônica; Exacerbação dos sintomas; Telemedicina; Alta do paciente.

 
INTRODUCTION
 
COPD is one of the major causes of morbidity and mortality worldwide, causing substantial economic and social burden. People with COPD suffer from this disease for years and die prematurely from the disease or its complications.(1) The WHO has predicted that COPD will be the third leading cause of death worldwide, being responsible for approximately 6% of total deaths.(2)
 
A substantial number of people with COPD suffer from exacerbations, which are defined as an acute worsening of respiratory symptoms that require a change in treatment. Exacerbations are an important health problem and are related to worse survival.(3)
 
As a result of the high prevalence of COPD in adults and the advances in the treatment of COPD, the demand for health services has increased.(4) To alleviate the burden, telehealth has emerged as an alternative for improving clinical management in chronic respiratory diseases.(5)
 
According to the WHO, telemedicine and telehealth can be used as synonyms to encompass a wide definition of remote care. Telemedicine is defined as the delivery of health care services by health care professionals, where distance is a critical factor, using communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, as well as for research, evaluation, and continuing education of health care providers, aiming at the interests of individuals and communities. Some authors distinguish telemedicine from telehealth by considering the former to be restricted to physicians and the latter to comprise health professionals in general.(6)
 
Telehealth/telemedicine can be delivered by different technologies such as terrestrial and wireless communication, wearable devices, videoconferencing, internet platforms, mobile applications, among others. (7) These technologies can operate synchronously (e.g., real-time video conferencing or telephone call) or asynchronously (e.g., remote consultation using e-mail, smartphone messages, notifications, and recording and communicating symptoms to health care providers).(4)
 
In people with COPD, telehealth/telemedicine has a wide range of applicability, such as to increase accessibility to health care for patients living in remote areas, to decrease the demand on hospital and health care services, to promote health education, to deliver and to manage treatment, to measure treatment adherence, and to identify disease worsening rapidly.(8)
 
The COVID-19 pandemic drew attention to the necessity of incorporating telehealth/telemedicine into the usual clinical management in chronic respiratory diseases. Special attention should be given to exacerbations in chronic respiratory diseases, which are responsible for the increased demand for health care services and are related to worse outcomes. Therefore, it is important to know which strategies have been used in telehealth/telemedicine, how they have been used, and what effects they have had on the management of a COPD exacerbation.
 
The objective of this scoping review was to map the evidence of telehealth/telemedicine for the monitoring of adult COPD patients after hospitalization due to an exacerbation.
 
METHODS
 
Search strategy and selection of telehealth/telemedicine applications
 
This scoping review is registered on Open Science Framework (https://osf.io/d8gp7). It was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Scoping Review (PRISMA-ScR10) Statement(9) and was conducted according to the Joanna Briggs Institute Manual.(10) This method allows mapping the concept and clarifying definitions used in the literature.(11)
 
The research question was defined based on the Population, Concept and Context framework(10) as follows: population—adult patients hospitalized for COPD exacerbation; concept—telehealth/telemedicine strategies; and context—discharge after hospitalization. The guiding question was: “What is the scientific evidence on telehealth/telemedicine strategies for the management of adult patients after hospital stay for a COPD exacerbation?”
 
Bibliographic search was carried in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus, Biblioteca Virtual de Saúde/LILACS and Cochrane Library databases between August and September of 2020 and later, in December of 2021. The search strategy was customized for each database, and the respective keywords, descriptors, and combinations are presented in Chart 1.
 

 
Assessment criteria
 
The eligibility criteria were studies that have used telehealth/telemedicine, describing the strategies applied in detail. The articles should describe telehealth/telemedicine strategies delivered to adult patients after hospitalization due to a COPD exacerbation, be electronically available, and have been published in Portuguese, English, or Spanish by December of 2021. Exclusion criteria were articles not available in full, and dissertations, theses, end-of-course works, texts from the Internet, editorials, theoretical essays, and reflective texts.
 
Selection and data extraction
 
Initially, the studies were compiled in the EndNote software, and two independent reviewers read the titles and abstracts. Full-text articles were reviewed using the selection criteria. The reviewers compared their selections, and disagreements were discussed and resolved by consensus.
 
Data from the included studies were extracted independently by the reviewers using a structured data extraction form. The data recorded were country of origin, study design, professionals responsible to deliver telehealth/telemedicine, study aims, and outcomes.
 
RESULTS
 
A total of 1,250 articles were selected, and 39 articles were included in this review. Reasons for exclusion were nature of publication, different populations from that investigated in this study, and lack of description of the telehealth/telemedicine intervention delivered (Figure 1).

 
Characteristics of included studies
 
The studies included comprised 21 clinical trials, 14 observational studies, 2 qualitative studies, and 2 feasibility studies. The concepts used were telehealth, in 21 studies; telemonitoring, in 20; telemedicine, in 17; telecare, in 4; teleconsultation, in 5; teleassistance, in 4; tele homecare, in 3; telerehabilitation, in 3; telecommunication, in 2; mobile health in 2; e-health-management, in 1; e-coach, in 1; tele home, in 1; telehealth care, in 1; and tele-video-consultation, in 1. The objectives and outcomes of each study are summarized in Chart 2.(8,12-49)

 

 
Variation among terms used to deliver remote care
 
The most commonly used terms to describe the delivery of remote health care were “telehealth”(13,17,19,21,22,23,29,31,32,33,34,36,37,38,39,40,42,43,44,46,48) and “telemonitoring.”(15,16,18,21,22,24,25,29,30,32,33,34,35,37,38,40,41,42,43,48) The terms “telemedicine”,(8,12,13,14,16,17,18,20,23,24,26,28,30,37,38,47,48) “telecare,” “teleassistance,” “tele homecare,” “teleconsultation,” or “telecommunication” were used as interchangeable terms. All of these concepts were used in order to describe strategies that use telephone and/or video calls for coaching, data monitoring, and health education leading to self-management or self-care. “Telemonitoring” was used with the terms “home monitoring”, “monitoring intervention,” and “monitoring system” to refer to the monitoring of signs and symptoms for prevention of exacerbations. The term “telerehabilitation” was specifically used for pulmonary rehabilitation.(19,28) The term “mobile health” (mHealth) referred to medical or health care interventions delivered through mobile technology (e.g., smartphones) in the studies.(45,49)
 
Remote care interventions
 
The most common interventions were health education to support self-management improvement, rehabilitation, and monitoring of signs/symptoms by treatment management, counseling, motivation, and prevention of exacerbations. The main key concepts related to remote consultations of COPD patients after discharge focused on providing remote integrated home care with or without the use of telemetry devices (Figure 2).
 

 
Professionals responsible to deliver remote care
 
The professionals majorly involved in telehealth delivery were nurses (in 35 studies) alone or together with multidisciplinary teams (Chart 2).
 
Remote applications and frequency of delivery of remote care
 
Most studies that described the remote monitoring of COPD patients after discharge from hospitalization for a COPD exacerbation used multiple strategies, different frequencies, and different applications. These strategies were organized into four groups: telephone calls, video calls, telemetry (alone or in combination with interactive voice response), and text messages (Figure 2). In the study by Wang et al.,(46) the patient, whenever necessary, used an application installed in the smartphone (Chart 2).
 
Effectiveness of remote care
 
The outcome investigated in 27 articles was hospital readmissions. Of these, 18 showed a reduction in the number of re-hospitalizations,(12,13,16,17,18,19,21,22,24,25,27,32,34,37,43,44,48,49) although no significant differences in the number of re-hospitalizations were found in 13 studies using telehealth/telemedicine strategies.(20,23,24,29,30,33,34,36,39,40,41,42,47) Quality of life was an outcome investigated in 13 studies, 9 of which showing favorable results with the use of telehealth/telemedicine.(12,13,17,21,37,38,39,42,46) In addition, factors associated with health literacy were pointed out as positively affecting the health of COPD patients.(13,17,42) Feasibility of home monitoring for self-management was reported in 2 studies (Chart 2).(15,45)
 
DISCUSSION
 
The main findings of this scoping review were as follows: i) the great majority of strategies demonstrated a positive effect on improving health care and quality of life in patients after hospitalization for COPD; ii) remote care involved an extensive variety of health service practices for different purposes, such as exchange of information, treatment, and exacerbation prevention; iii) most studies used two or more strategies, and phone calls and devices with or without telemetry were the most common ones; and iv) a substantial number of terms described the use of remote care, and the most common terms were telehealth, telemonitoring, and telemedicine.
 
It was observed that telehealth/telemedicine was effective for early detection and proactive intervention in patients at home after an acute exacerbation of COPD. It seems likely that adopting telehealth/telemedicine in everyday clinical practice could substantially improve the care of chronically ill patients.(13) Telehealth/telemedicine is a type of remote intervention that involves the delivery of care through various communication modalities, aiming at connecting patients to a health care professional and exchanging information to support self-management programs, which has shown to be effective in improving health-related quality of life and self-management behavior in patients with COPD.(46) For COPD patients, the use of telehealth/telemedicine may offer an opportunity to improve disease management and access to pulmonary rehabilitation programs.(2,8,12,17,26,45)
 
In order to improve telemonitoring effectiveness in COPD, parameters need to be well defined, easily available, and associated with COPD symptomatology.(40) Therefore, it is essential to identify the target populations among which telehealth is accepted and identify feasible interventions.(50) Defining parameters, as well as identifying and knowing the target population, leads to patient and physician satisfaction and, consequently, to the effectiveness of the proposed telemonitoring strategies.(8,40)
 
It is important to highlight that telemonitoring can be carried out and analyzed with or without telemetry. A telemetry system allows monitoring of physiological parameters with the use of smart wearable device systems to monitor health. A smart wearable device system may include a wide range of wearable or implantable devices, such as sensors, actuators, smart fabrics, power supplies, and wireless communication networks.(51)
 
Data transmitted by the devices were, in general, physiological measures (vital signs, SpO2, lung function parameters, temperature, and weight) and reported symptoms, such as shortness of breath; aspect, quantity, and color of sputum; wheezing; and cough. In this regard, telemedicine has the potential to enhance the detection of true deterioration in clinical state.(44)
 
Among the terms identified to refer to remote care, telehealth was used for electronic technologies that transmit or receive data.(52) Telemedicine can be effective for detecting the worsening of clinical status and reducing morbidity, mortality, and health costs due to exacerbations.(53-55)
 
Telehealth is a term used interchangeably with telemedicine. Telemedicine uses e-health networks to provide health services and health education at a distance.(56) The term e-health refers to a self-management web platform designed to support patients to improve self-management of exacerbations at an early stage.(47) Tele-education utilizes web-based platforms to deliver information and services that pertain to the management of patient conditions.(52) Education intervention through telehealth/telemedicine is characterized by interventions to achieve a healthy lifestyle through the practice of physical activities, correct use of medications, smoking cessation, and emotional control, as well as to enhance patient self-management.(6,14,25,26,28,34) Telehealth/telemedicine showed positive effects on COPD patients after a hospitalization for an exacerbation, playing a central role in self-management. The intangible benefits of the program include improvement in quality of life and in hospitalization rates.(44) These positive results support the importance of guidance and use of educational materials and methods to back a telephone call intervention. Teleconsultation might be used to change or adjust the pharmacological therapy, refer the patient to an emergency department, or even identify the need of a face-to-face home consultation.(50)
 
Teleconsultation, in which care is provided by videoconference and webcams connecting the healthcare practitioner with the patient, makes it possible to assess, diagnose, or treat patients remotely in addition to monitoring exercises and functional capacity in pulmonary rehabilitation.(52) Telemedicine consultations are agreed upon between the patient and the telemedicine nurse day to day. The nurse could advise the patient to consult with a general practitioner or contact a home care nurse.(18) Nurse telemedicine consultation seems to prevent early readmission and is associated with high patient and nurse satisfaction.(18)
 
Telerehabilitation by teleconsultation has a great potential for reducing the use of health care services, combining physical training at home, remote monitoring, health education, and promotion of self-management.(51) Telerehabilitation programs seem to be as effective as face-to-face sessions, which stimulates their use since they might solve the need for increasing access to health care.(53) The study by Rosenbek Minet et al.(28) showed that home-based supervised training and counseling via videoconference is safe and feasible and that telemedicine can help ensure more equitable access to supervised training in patients with severe COPD.
 
This review also highlights programs for the transition of care with the use of mobile health technologies to ensure safe coordination and continuity of care for patients with different health needs.(22,34) Transition of care is one of the pillars for integration of health systems, reducing hospitalizations, readmissions, and costs of health services, and it improves the quality of life of patients and their families.(57) Also, interventions capable of detecting and intervening on exacerbation signs at an early stage can minimize the need for emergency hospitalizations.(52) The combination of several strategies has better results. In addition, the integration of interactive telephone calls may result in higher rates of adherence to health care plans among patients with an exacerbation.(54)  Telehealth/telemedicine interventions should consider individual factors that affect the usability, acceptability, and efficacy of the intervention.(45)
 
The limitations of the present review are related to the languages in which the studies were published, since we limited the research to those published in English, Portuguese, or Spanish. In addition, the fact that all of the studies included were carried out in developed countries might not reflect the reality in less developed countries.
 
FINAL CONSIDERATIONS
 
Telehealth/telemedicine strategies seek to accompany and encourage COPD patients to self-manage their disease by identifying signs and symptoms that can lead to an exacerbation.
 
This review demonstrated that there is a growing body of evidence showing that telehealth/telemedicine and telemonitoring can be an interesting strategy to benefit COPD patients after discharge from hospitalization for an exacerbation after being discharged by improving their quality of life and reducing re-hospitalizations, admissions to emergency services, hospital length of stay, and health care costs.
 
The terms to describe telehealth/telemedicine were varied and sometimes specific for different situations. The goals, the frequency of use, and the strategies adopted were also varied. Notwithstanding the differences, the great majority of studies showed that telehealth/telemedicine was beneficial regarding readmissions, quality of life, health literacy, and costs. The scope of this study is summarized in Figure 3.
 
AUTHOR CONTRIBUTIONS
 
LCR, EGR, LCP, RAG, GMR, AFC, TBC, LPSM, VMA, and KLS: study conception, protocol design, and reference management. LCR, EGR, LCP, LPSM, VMA, and KLS: drafting of the manuscript. TBF, LPSM, VMA, and KLS: critical review of intellectual content of the manuscript. All of the authors approved the final version of the manuscript.
 
CONFLICTS OF INTEREST
 
None declared.
 
REFERENCES
 
1.            Global Initiative for Chronic Obstructive Lung Disease [homepage on the Internet]. Bethesda: GOLD [cited 2020 Apr 4]. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. [Adobe Acrobat document, 141p.] Available from: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
2.            World Health Organization [homepage on the Internet]. Geneva: WHO; [cited 2020 Apr 4]. Chronic obstructive pulmonary disease (COPD). Available from: https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)
3.            Viniol C, Vogelmeier CF. Exacerbations of COPD. Eur Respir Rev. 2018;27(147):170103. https://doi.org/ https://doi.org/10.1183/16000617.0103-2017
4.            Ding H, Fatehi F, Maiorana A, Bashi N, Hu W, Edwards I. Digital health for COPD care: the current state of play. J Thorac Dis. 2019;11(Suppl 17):S2210-S2220. https://doi.org/10.21037/jtd.2019.10.17
5.            Blakey JD, Bender BG, Dima AL, Weinman J, Safioti G, Costello RW. Digital technologies and adherence in respiratory diseases: the road ahead. Eur Respir J. 2018;52(5):1801147. https://doi.org/10.1183/13993003.01147-2018.
6.            World Health Organization. Telemedicine: opportunities and developments in Member States: report on the second global survey on eHealth. Global Observatory for eHealth series. Geneva: WHO; 2010. Available from: https://apps.who.int/iris/bitstream/handle/10665/44497/9789241564144_eng.pdf?sequence=1&isAllowed=y
7.            Barbosa MT, Sousa CS, Morais-Almeida M, Simões MJ, Mendes P. Telemedicine in COPD: An Overview by Topics. COPD. 2020;17(5):601-617. https://doi.org/10.1080/15412555.2020.1815182
8.            Vitacca M, Montini A, Comini L. How will telemedicine change clinical practice in chronic obstructive pulmonary disease?. Ther Adv Respir Dis. 2018;12:1753465818754778.  10.1177/1753465818754778
9.            Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141-146.  10.1097/XEB.0000000000000050
10.          Peters MDJ, Godfrey C, Mclnerney P, Munn Z, Tricco AC, Khall H. Chapter 11: Scoping reviews. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI: JBI; 2020.  Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews.
11.          Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-473.  https://doi.org/10.7326/M18-0850.
12.          Ratner D, Louria D, Sheffet A, Fain R, Curran J, Saed N, et al. Wealth from Health: an incentive program for disease and population management: a 12-year project. Lippincotts Case Manag. 2001;6(5):184-204. 10.1097/00129234-200109000-00002
13.          Vontetsianos T, Giovas P, Katsaras T, Rigopoulou A, Mpirmpa G, Giaboudakis P, et al. Telemedicine-assisted home support for patients with advanced chronic obstructive pulmonary disease: preliminary results after nine-month follow-up. J Telemed Telecare. 2005;11 Suppl 1:86-88. 10.1258/1357633054461697
14.          Finkelstein SM, Speedie SM, Potthoff S. Home telehealth improves clinical outcomes at lower cost for home healthcare. Telemed J E Health. 2006;12(2):128-136. 10.1089/tmj.2006.12.128
15.          Vitacca M, Assoni G, Pizzocaro P, Guerra A, Marchina L, Scalvini S, et al. A pilot study of nurse-led, home monitoring for patients with chronic respiratory failure and with mechanical ventilation assistance. J Telemed Telecare. 2006;12(7):337-342. 10.1258/135763306778682404
16.          Trappenburg JC, Niesink A, de Weert-van Oene GH, van der Zeijden H, van Snippenburg R, Peters A, et al. Effects of telemonitoring in patients with chronic obstructive pulmonary disease. Telemed J E Health. 2008;14(2):138-146. 10.1089/tmj.2007.0037
17.          Cardozo L, Steinberg J. Telemedicine for recently discharged older patients. Telemed J E Health. 2010;16(1):49-55. 10.1089/tmj.2009.0058
18.          Sorknaes AD, Madsen H, Hallas J, Jest P, Hansen-Nord M. Nurse tele-consultations with discharged COPD patients reduce early readmissions--an interventional study. Clin Respir J. 2011;5(1):26-34. 10.1111/j.1752-699X.2010.00187.x
19.          Dinesen B, Haesum LK, Soerensen N, Nielsen C, Grann O, Hejlesen O, et al. Using preventive home monitoring to reduce hospital admission rates and reduce costs: a case study of telehealth among chronic obstructive pulmonary disease patients [published correction appears in J Telemed Telecare. 2018 Jan;24(1):3]. J Telemed Telecare. 2012;18(4):221-225. 10.1258/jtt.2012.110704
20.          Sorknaes AD, Bech M, Madsen H, Titlestad IL, Hounsgaard L, Hansen-Nord M, et al. The effect of real-time teleconsultations between hospital-based nurses and patients with severe COPD discharged after an exacerbation. J Telemed Telecare. 2013;19(8):466-474. 10.1177/1357633X13512067
21.          Bentley CL, Mountain GA, Thompson J, Fitzsimmons DA, Lowrie K, Parker SG, et al. A pilot randomised controlled trial of a Telehealth intervention in patients with chronic obstructive pulmonary disease: challenges of clinician-led data collection. Trials. 2014;15:313. 10.1186/1745-6215-15-313
22.          Segrelles Calvo G, Gómez-Suárez C, Soriano JB, Zamora E, Gónzalez-Gamarra A, González-Béjar M, et al. A home telehealth program for patients with severe COPD: the PROMETE study. Respir Med. 2014;108(3):453-462. 10.1016/j.rmed.2013.12.003
23.          Gottlieb M, Marsaa K, Andreassen H, Strømstad G, Godtfredsen N. Feasibility of a telecare solution for patients admitted with COPD exacerbation: screening data from a pulmonary ward in a university hospital. Eur Clin Respir J. 2014;1:10.3402/ecrj.v1.24193. https://doi.org/10.3402/ecrj.v1.24193
24.          Saleh S, Larsen JP, Bergsåker-Aspøy J, Grundt H. Re-admissions to hospital and patient satisfaction among patients with chronic obstructive pulmonary disease after telemedicine video consultation - a retrospective pilot study. Multidiscip Respir Med. 2014;9(1):6. 10.1186/2049-6958-9-6
25.          Davis C, Bender M, Smith T, Broad J. Feasibility and Acute Care Utilization Outcomes of a Post-Acute Transitional Telemonitoring Program for Underserved Chronic Disease Patients. Telemed J E Health. 2015;21(9):705-713. 10.1089/tmj.2014.0181
26.          Dyrvig AK, Gerke O, Kidholm K, Vondeling H. A cohort study following up on a randomised controlled trial of a telemedicine application in COPD patients. J Telemed Telecare. 2015;21(7):377-384. 10.1177/1357633X15572202
27.          Mierdel S, Owen K. Telehomecare Reduces ER Use and Hospitalizations at William Osler Health System. Stud Health Technol Inform. 2015;209:102-108. https://doi.org/10.3233/978-1-61499-505-0-102
28.          Rosenbek Minet L, Hansen LW, Pedersen CD, Titlestad IL, Christensen JK, Kidholm K, et al. Early telemedicine training and counselling after hospitalization in patients with severe chronic obstructive pulmonary disease: a feasibility study. BMC Med Inform Decis Mak. 2015;15:3. 10.1186/s12911-014-0124-4
29.          Chatwin M, Hawkins G, Panicchia L, Woods A, Hanak A, Lucas R, et al. Randomised crossover trial of telemonitoring in chronic respiratory patients (TeleCRAFT trial). Thorax. 2016;71(4):305-311. 10.1136/thoraxjnl-2015-207045
30.          Cordova FC, Ciccolella D, Grabianowski C, Gaughan J, Brennan K, Goldstein F, et al. A Telemedicine-Based Intervention Reduces the Frequency and Severity of COPD Exacerbation Symptoms: A Randomized, Controlled Trial. Telemed J E Health. 2016;22(2):114-122. 10.1089/tmj.2015.0035
31.          Fitzsimmons DA, Thompson J, Bentley CL, Mountain GA. Comparison of patient perceptions of Telehealth-supported and specialist nursing interventions for early stage COPD: a qualitative study. BMC Health Serv Res. 2016;16(1):420. https://doi.org/10.1186/s12913-016-1623-z
32.          Ho TW, Huang CT, Chiu HC, Ruan SY, Tsai YJ, Yu CJ, et al. Effectiveness of Telemonitoring in Patients with Chronic Obstructive Pulmonary Disease in Taiwan-A Randomized Controlled Trial. Sci Rep. 2016;6:23797.10.1038/srep23797
33.          Ritchie CS, Houston TK, Richman JS, Sobko HJ, Berner ES, Taylor BB, et al. The E-Coach technology-assisted care transition system: a pragmatic randomized trial. Transl Behav Med. 2016;6(3):428-437. 10.1007/s13142-016-0422-8
34.          Vianello A, Fusello M, Gubian L, Rinaldo C, Dario C, Concas A, et al. Home telemonitoring for patients with acute exacerbation of chronic obstructive pulmonary disease: a randomized controlled trial. BMC Pulm Med. 2016;16(1):157. 10.1186/s12890-016-0321-2
35.          Crooks MG, den Brinker A, Hayman Y, Williamson JD, Innes A, Wright CE, et al. Continuous Cough Monitoring Using Ambient Sound Recording During Convalescence from a COPD Exacerbation. Lung. 2017;195(3):289-294. 10.1007/s00408-017-9996-2
36.          Kargiannakis M, Fitzsimmons DA, Bentley CL, Mountain GA. Does Telehealth Monitoring Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data. JMIR Med Inform. 2017;5(1):e8. 10.2196/medinform.6359
37.          Scalvini S, Bernocchi P, Zanelli E, Comini L, Vitacca M; Maugeri Centre for Telehealth and Telecare (MCTT). Maugeri Centre for Telehealth and Telecare: A real-life integrated experience in chronic patients. J Telemed Telecare. 2018;24(7):500-507. 10.1177/1357633X17710827
38.          Barken TL, Thygesen E, Söderhamn U. Unlocking the limitations: Living with chronic obstructive pulmonary disease and receiving care through telemedicine-A phenomenological study. J Clin Nurs. 2018;27(1-2):132-142. 10.1111/jocn.13857
39.          Fors A, Blanck E, Ali L, Ekberg-Jansson A, Fu M, Lindström Kjellberg I, et al. Effects of a person-centred telephone-support in patients with chronic obstructive pulmonary disease and/or chronic heart failure - A randomized controlled trial. PLoS One. 2018;13(8):e0203031. 10.1371/journal.pone.0203031
40.          Soriano JB, García-Río F, Vázquez-Espinosa E, Conforto JI, Hernando-Sanz A, López-Yepes L, et al. A multicentre, randomized controlled trial of telehealth for the management of COPD. Respir Med. 2018;144:74-81. 10.1016/j.rmed.2018.10.008
41.          Walker PP, Pompilio PP, Zanaboni P, Bergmo TS, Prikk K, Malinovschi A, et al. elemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial. Am J Respir Crit Care Med. 2018;198(5):620-628. 10.1164/rccm.201712-2404OC
42.          Bohingamu Mudiyanselage S, Stevens J, Watts JJ, Toscano J, Kotowicz MA, Steinfort CL, et al. Personalised telehealth intervention for chronic disease management: A pilot randomised controlled trial. J Telemed Telecare. 2019;25(6):343-352. 10.1177/1357633X18775850
43.          Lyth J, Lind L, Persson HL, Wiréhn AB. Can a telemonitoring system lead to decreased hospitalization in elderly patients?. J Telemed Telecare. 2021;27(1):46-53. 10.1177/1357633X19858178
44.          Arcilla D, Levin D, Sperber M. Transitioning Patients to Independence. Home Healthc Now. 2019;37(3):158-164. 10.1097/NHH.0000000000000741
45.          Bentley CL, Powell L, Potter S, Parker J, Mountain GA, Bartlett YK, et al. The Use of a Smartphone App and an Activity Tracker to Promote Physical Activity in the Management of Chronic Obstructive Pulmonary Disease: Randomized Controlled Feasibility Study. JMIR Mhealth Uhealth. 2020;8(6):e16203. 10.2196/16203
46.          Wang L, Guo Y, Wang M, Zhao Y. A mobile health application to support self-management in patients with chronic obstructive pulmonary disease: a randomised controlled trial. Clin Rehabil. 2021;35(1):90-101. 10.1177/0269215520946931
47.          Leonard R, Forte M, Mehta D, Mujahid H, Stansbury R. The impact of a telemedicine intervention on home non-invasive ventilation in a rural population with advanced COPD. Clin Respir J. 2021;15(7):728-734. 10.1111/crj.13354
48.          Marcos PJ, Represas Represas C, Ramos C, Cimadevila Álvarez B, Fernández Villar A, Fraga Liste A, et al. Impact of a Home Telehealth Program After a Hospitalized COPD Exacerbation: A Propensity Score Analysis. Arch Bronconeumol. 2022;58(6):474-481. 10.1016/j.arbres.2020.05.030
49.          Kooij L, Vos PJE, Dijkstra A, van Harten WH. Effectiveness of a Mobile Health and Self-Management App for High-Risk Patients With Chronic Obstructive Pulmonary Disease in Daily Clinical Practice: Mixed Methods Evaluation Study. JMIR Mhealth Uhealth. 2021;9(2):e21977. 10.2196/21977
50.          Sood S, Mbarika V, Jugoo S, Dookhy R, Doarn CR, Prakash N, et al. What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemed J E Health. 2007;13(5):573-590. 10.1089/tmj.2006.0073
51.          Chan M, Estève D, Fourniols JY, Escriba C, Campo E. Smart wearable systems: current status and future challenges. Artif Intell Med. 2012;56(3):137-156. 10.1016/j.artmed.2012.09.003
52.          Selzler AM, Wald J, Sedeno M, Jourdain T, Janaudis-Ferreira T, Goldstein R, et al. Telehealth pulmonary rehabilitation: A review of the literature and an example of a nationwide initiative to improve the accessibility of pulmonary rehabilitation. Chron Respir Dis. 2018;15(1):41-47. 10.1177/1479972317724570
53.          Ambrosino N, Vagheggini G, Mazzoleni S, Vitacca M. Telemedicine in chronic obstructive pulmonary disease. Breathe (Sheff). 2016;12(4):350-356. 10.1183/20734735.014616
54.          Al Rajeh A, Steiner MC, Aldabayan Y, Aldhahir A, Pickett E, Quaderi S, et al. Use, utility and methods of telehealth for patients with COPD in England and Wales: a healthcare provider survey. BMJ Open Respir Res. 2019;6(1):e000345. https://doi.org/10.1136/bmjresp-2018-000345
55.          Farias R, Sedeno M, Beaucage D, Drouin I, Ouellet I, Joubert A, et al. Innovating the treatment of COPD exacerbations: a phone interactive telesystem to increase COPD Action Plan adherence. BMJ Open Respir Res. 2019;6(1):e000379. 10.1136/bmjresp-2018-000379
56.          Talboom-Kamp EPWA, Holstege MS, Chavannes NH, Kasteleyn MJ. Effects of use of an eHealth platform e-Vita for COPD patients on disease specific quality of life domains. Respir Res. 2019;20(1):146. 10.1186/s12931-019-1110-2
57.          Zanaboni P, Dinesen B, Hjalmarsen A, Hoaas H, Holland AE, Oliveira CC, et al. Long-term integrated telerehabilitation of COPD Patients: a multicentre randomised con-trolled trial (iTrain). BMC Pulm Med. 2016;16(1):126. 10.1186/s12890-016-0288-z