Preventative telehealth supported services for early stage chronic obstructive pulmonary disease: Lessons from a pilot

randomised controlled trial

Deborah A. Fitzsimmons1

Claire Bentley2, Gail A. Mountain2 Jill Kenny2, Kinga Lowrie2, Stuart G Parker2, Mark S Hawley2

1 School of Health Studies, University of Western Ontario, London, ON, Canada 4 School of Health and Related Research, University of Sheffield, Sheffield, UK

Faculty/Presenter Disclosure• Faculty: Deborah A. Fitzsimmons PhD

• Relationships with commercial interests: None

• This program has received financial support from:

The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care, South Yorkshire (CLAHRC SY) in the form of grant funding for the research team.

• This program has received in-kind support from: NHS Barnsley and Barnsley Metropolitan Council in the form of staff time and the procurement of the devices.

UK trial - Barnsley

Barnsley characteristics

• Aging Population– 2008 – 2031: Population increase by 16%

65 – increase by 67%75 – increase by 80.5%

• History of coal mining history

• One of most deprived areas– Adverse lifestyle factors (diet, smoking)

• High incidence of COPD– 2.5% vs. UK avg. of 1.5%

 

ᬅ Patient uses Doc@HOMEtechnology to take daily readings

ᬅ�Readings are sent via telephone line to the

Doc@HOME secure server

ᬇ PCT staff access the server daily to check patient data and prioritise their workloadᬇ�PCT staff will contact

patients if an alert is triggered by the doc@HOME system

ᬉ doc@HOME system provides patient education through feedback of their readings

The Technology

COPD RCT

Time Line

Standard COPD

Service

(Control)

Tele-health

Supported COPD

Service

First home visit after hospital

discharge (Baseline (time 0)

Home visit Home visit

3 days Home visit Home visit

5 days Home visit Telehealthequipment

installed

2 weeksHome visit Remote review of

telehealthparameters

6 weeksHome visit

8 weeksDischarge Home

visitDischarge Home

visit

8 months Measurement of outcomes

Outcome measures

• Re-admitted to hospital with COPD

• Change in self-reported health status and quality of life at baseline, 8 weeks and eight months after start of service

• Requiring unscheduled healthcare support

• Cost effectiveness through quality adjusted life years (QALYs)

Innovative Partnership

Barnsley HospitalBarnsley Primary

Care Trust

Barnsley Metropolitan

Borough Council

Care Pathway

Patient admitted to hospital with COPD

Patient discharged from hospital

Patient accepted on COPD service

Patient discharged from service

8 week service

Equipment removed

Equipmentinstalled

Patient referred to COPD service

HOSPITAL PCT COUNCIL

Repairs / replacement

Equipment maintained /

cleaned

Standard Service WorkloadPATIENT CLINICAL INPUT ADMIN INPUT

Initial Assessment 1 hour 10 min phone triage40 mins clinical admin

2nd visit 1 hour 20 mins clinical admin

3rd visit 1 hour 20 mins clinical admin

4th visit 30 min 20 mins clinical admin

5th visit 30 mins 20 mins clinical admin

6th visit 1 hour 30 mins clinical admin

5 HOURS 2 HOURS 40 MINS

10% tolerance for cancellations

45 MINS

TOTAL WORKLOAD 8 HOURS 25 MINS

UNIT CAPACITY 371 PATIENTS p.a.

Telehealth Service WorkloadPATIENT CLINICAL INPUT ADMIN INPUT

Initial Assessment 1 hour 10 min phone triage40 mins clinical admin

2nd visit 30 mins 20 mins clinical admin

20 mins clinical admin to check parameters

10 mins p/w (*8) to check patient status online

3rd visit 1 hour 30 mins clinical admin

2.5 HOURS 3 HOURS 20 MINS

10% tolerance for cancellations

35 MINS

TOTAL WORKLOAD 6 HOURS 25 MINS

UNIT CAPACITY 487 PATIENTS p.a. 31.2% increase

40s 50s 60s 70s 80s 90s0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Patient Profile

Age

What do users really think of tele-health

monitoring? Quotes from interviews with users

with COPD

“It became a bit of a chore”

“I’m lost without it”

“I can stay at home and feel

safe”

“It didn’t do anything for me – it

didn’t build my confidence or anything like

that”

“It’s like having someone to

turn to”

“I knew someone was watching and any indication

that I was getting ill or anything, they’d get in

touch”

“I knew somebody was keeping an eye on me

which was the main thing – there’s somebody there

for you

“I haven’t been back to hospital since that machine

came in”

“It’s one of the best things... I showed it to the chap who lives two doors away... They are going to

put him on it”

“The best service I’ve ever had”

“It was quite simple to use...It’s not rocket

science is it?”

“The questions, they were a bit puzzling sometimes... The (answers) ought to be more in-between instead of

black and white”

Patient Views of Tele-health

RCT Eligibility Criteria

• Male or female over age of 16• Discharged from hospital with COPD as

primary or secondary diagnosis• 1 – 3 hospital admissions in prior 12 months

for COPD including this discharge– PCT definition of early stage COPD

• Willing to use telehealth • Home landline in place• Able to read English (technology requirement)

Reasons for exclusion from trial

Other Reasons* (n=132) Number

Backlog on telephone referral waiting list 69

Not seen within adequate trial timeframe 15

Readmitted to hospital straightaway 11

Discharged over Christmas holiday period 10

Disruptions to trial visiting schedule 6

Unable to contact 5

Patient does not believe they have COPD 4

Other 12

EXPECTATION REALITY

Care pathways devised by the clinical team were in place

No documented care pathways in place. Development of care pathways was difficult and time-consuming, delayed the research and contributed to later issues in the nursing team

(Relatively) stable NHS environment with a team that had been in place for some years

Continually shifting structures within the NHS and internal politics between teams (e.g. new COPD community nursing service perceived as threatening existing service)

Issues Encountered

EXPECTATION REALITY

Technical procedures and necessary resources for the service were in place

Resources/routines between the partners delivering the service to manage de/installation and cleaning of units took time to establish

Readings can be automatically sent via telephone line to the secure server

Technical issues prevented use of the device with certain landline companies

EXPECTATION REALITY

All patients discharged from hospital with COPD will be suitable for the technology

Of 450 referrals, 180 (40%) of patients failed to meet the inclusion criteria for the study

Most patients offered it will accept the technology

The term ‘early stage COPD’ can be misleading and does not fully reflect the state of ill health experienced by this patient population. Many participants were simply too ill to take part at the time that they were provided with information about the services

EXPECTATION REALITY

Most homes are suitable for the installation of the technology

Dispute over potential Health and Safety issues took time to resolve and a larger than expected number of patients did not have home landlines

Systems for sharing data and identifying patients were in place

Conflicts arose over how patient data should be shared between organizations

Common language base

Miscommunications occurred between different teams, possibly due to different vocabularies, priorities and team changes

EXPECTATION REALITY

Working with a small team would facilitate training and operationalizing the trial

Staff illness and absence had a higher impact in terms of capacity and morale

Outcomes of the Pilot

• Planned to recruit 60 patients in 3 months (30 per arm)

• Recruited 63 (randomized 5 with no/unsuitable landline) so needed to recruit 65 patients in total but this took 12 months

• Lack of funding and support for full trial– Staff to be reassigned in organization shuffle– Testing alternate technology / approach introduced

by new department management

References

Telehealth RCT protocol:Fitzsimmons, D.A., Thompson, J., Hawley, M., Mountain, G.A.,

http://www.trialsjournal.com/content/12/1/6.

Thank you

Any questions?