Moving pulmonary rehabilitation in primary care for patients with COPD using telemedicine
by Shakila Perumal
Pulmonary Rehabilitation, a comprehensive program of exercise, education, and psycho-social intervention designed for COPD patients to manage their health beyond the duration of the program. PR is known to reduce COPD-related emergency hospitalizations, unscheduled doctor visits, and lessens patient’s dependence on healthcare resources. Yet, it is underutilized and under-resourced, most likely as a consequence of the perceived impracticalities for both patient and healthcare providers. In this millennium, as the health care system shifts from volume- to value-based care, it is practical for health systems to offer PR services in primary care and adopt telemedicine to bridge the gaps between patient, healthcare interventions, and providers.
Pulmonary rehabilitation (PR) is known as a comprehensive, cost-effective intervention for long-term management of patients with chronic obstructive pulmonary disease (COPD). It is explicit PR is more effective than conventional pharmacological management. Nevertheless, dearth of evidence confirms there is logistical challenge from geographic, demographic and socioeconomic factors for implementation of PR. Major barrier is attributed to insufficient PR capacity, missing the core principle of integrated care closer to patients’ home. In addition, recruitment and retention of healthcare providers is a significant problem. Recently, telemedicine is venturing wider avenues of healthcare transformations with creative solutions to optimize health inequalities. As we continue to move into a new age of healthcare, we need to focus to build in a health system that may need to integrate virtual and in-person services with the varying degrees to which patients takes the ownership of their health.
The educational aim of this short review is two-folded:
- To recommend primary care as a best venue to bring PR closer to patients’ home for long term management
- To use telemedicine to bridge the gaps between patient, healthcare interventions and providers.
Pulmonary Rehabilitation (PR) has been endorsed as an evidence based "Gold Standard" management for COPD (Spruit et al 2013). PR is a comprehensive intervention, which includes 2 SDP
patient assessment, patient-tailored therapies, such as exercise training, education, behaviour change, and self-management support to intervene physical, psychological and social wellbeing for patients with chronic respiratory disease (Nice et al 2006, Rise et al 2007, Spruit et al 2013). This demands integration of biopsychosocial practice in PR programmes. Evidence persists PR is a cost- effective in peri exacerbation of COPD and superior to pharmacological interventions with reduced length of hospital bed days (Lacasse et al 2006, Rise et la 2007) and readmission within 90 days post discharge (BTS 2013, Maddocks 2015, Puhan et al. 2016).
Practically, wider challenges persist in implementation of PR in terms Accessibility, Enrolment, Engagement, Adherence and Sustainability. Major reasons are attributed to personal and social factors such as advancing age, being female, being from a minority ethnic group, being a current smoker, having greater breathlessness, living alone, transport, experiencing financial hardship, long term oxygen use, having anxiety and depression, and having a reduced baseline health‐related quality of life are major barriers compliance of PR programme (Young et al. 2017). This posits a challenge to quality, effectiveness and commissioning of PR, thus demanding innovative methods to deliver PR.
What can be a pragmatic solution
World health organization has endorsed primary care as an accessible, collaborative and cost-effective setting for sustained management of all non -communicable disease (WHO 2009). Most of PR interventions could be provided in primary care improving timely accessibility, enrolment and engagement for patients with COPD. This would activate a dynamic and collaborative engagement among the patient, family and healthcare provider to promote successful sustainable outcomes (Nici et al 2006). This allures policymakers to reform national and local PR policies to advocate an integrated PR care in every primary care and provision of universal coverage through social insurance. This should be complimented with the reform of national primary care services in wider UK and inclusion of pulmonary rehab module in curriculum of General Practice (GP). This would address the gaps in accessibility and enrolment by enabling direct PR referrals by GP’s, there by optimizing existing services to offer high-quality, collaborative and rewarding care for COPD population.
How to address the sustainability of PR in primary care 3 SDP
Telemedicine is becoming an appealing and promising application replacing face to face healthcare delivery and possibly be creative solution to tackle this challenge of PR implementation in primary care. (Bernocchi et al 2018, Tsai et al 2017). Generally, telemedicine interventions connect remote patients with healthcare professionals via E-health platforms. Various forms E-health platforms persists such as video telephone consultations (Liu et al 2011), videoconferencing (Yardley et al 2010, Zanaboni et al 2016), telemonitoring (Burgos et al 2012) or remote monitoring (Ekeland et al 2010).
According to a recent report by absolute market insights (2020), with surge in aging population, UK telemedicine market has generated USD 139.4 million in the year 2019 and forecasted to reach USD 322.8 million by the year 2027, with compound annual growth rate (CAGR) of 11.04% per annum. In UK, England holds a major telemedicine market share and predicted to grow at a CAGR of over 11.3% by 2027, reaching USD 265 million. Telehealth consultation and remote monitoring majorly in chronic orthopaedic conditions has been observed as major revenue generating segments of telemedicine. There is little information regarding the delivery of PR using telemedicine in COPD population.
Few studies have confirmed home telehealth programme has positive benefits in physical outcomes, dyspnoea, reduction in frequency of exacerbations, outpatient visits, hospitalization or general practitioner calls, and healthcare costs in moderate to severe COPD patients (Lundell et al 2015, Vitacca et al 2016, Vitacca et al 2009, Segrelles et al 2014, Koff et al 2009). To sustain benefits of telemedicine, it is recommended to tailor personalized telehealth intervention based on individual’s social support (Harst et al 2019). A recent review and meta-analysis have confirmed telehealth has great value by reduction in hospitalization cost by €1060 and additional saving of €898 per patient (Boland et al 2013). Real time video communications have proven to be cost-effective for collaborative services between secondary and primary care (Wade et al 2010). Internet-mediated cognitive behavioral therapy (iCBT) system has proven effective to treat depression remotely in primary care (Holst et al. 2017).
Recently, telemedicine using virtual reality (VR) application for PR delivery was non-inferior to a conventional model delivered in face-to-face sessions in terms of effects on 6MWT distance, symptoms score and quality of life. However, the practical application and cost-effectiveness is obscure. In addition, the application of VR headset would be a concern for patients with claustrophobia. Hence, the advancement in telemedicine is focused in augmented reality (AR) which is based on the concept of interaction with real time with no barriers and added with self-rewards. AR differs from VR by creating a physical, real-world environment in real time using 4 SDP computer-generated sensory input such as sound, video, graphics or GPS data while the latter detaches the contact with reality. Recent advances in telemedicine are directed to design built-in AR feature in a glass, headset or digital contact lens. These typical features recommend AR to become a driving force in the future of diagnostic and interventional medicine (medical futurist 2019). Presently, there is limited evidence of use of AR for effectiveness in rehabilitation (Al-Issa, Regenbrecht & Hale, 2012), education and training (Lee 2012). This puts out a profound call to explore and recommend use of AR to integrate PR in primary care setting, closer to patients’ home.
Nevertheless, telemedicine has promising future, there is mixed results on its effectiveness and concerns pertaining to data security, confidentiality, interoperability, health professionals’ responsibilities and potential obligations for long term management have restraining effects on telemedicine market (Gregersen et al 2016). European commission task force has suggested reform of legislation to address legal, ethical, regulatory, technical and administrative standards of e-health platforms for healthcare delivery (European Commission, 2012). More studies on telemedicine is warranted in areas of clinical effectiveness, health services and resources utilization in patients with COPD (Ambrosino et al. 2016)
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