Researchers from Washington University School of Medicine and Saint Louis University School of Medicine found that an automated COPD telemedicine intervention delivered via phone caught and alerted providers to patients experiencing poor breathing helping prevent one hospitalization for every nine patients using the system. The Journal of Telemedicine and Telecare recently published the findings.

Patients with unmanaged chronic obstructive pulmonary disease (COPD) often show up in the hospital or ED struggling to breathe. The visits are costly to the patient and hospital, yet many are preventable if poor breathing is caught early and the provider is notified.

To address this challenge, medical researchers at Washington University School of Medicine and Saint Louis University School of Medicine tested EpxCOPD, a phone and text-message based intervention to track daily breathing status among patients with a high risk for readmission. Researchers enrolled 168 patients with a recent diagnosis of COPD to receive the intervention in an eight month, double-blinded randomized-controlled-trial.

The treatment group received daily phone messages from an automated system asking them to report if they were breathing better than, worse than, or the same as the day prior. Patients reported their breathing status by responding to the text message or call. If a patient reported breathing worse, an alert was sent directly to that patient’s provider within the clinic. The control group received the same daily phone messages as the treatment group. When a subject in the control group reported breathing worse, no alert was generated to inform their provider to provide follow-up care.

The primary outcome was the subjects’ time-to-first-COPD-related hospitalization following the start of messages. The treatment group’s time-to-hospitalization was significantly different than the control group’s with a hazard ratio of 2.36 (p=0.04). The number needed to treat (NNT) to prevent 1 hospitalization was 8.62. For every nine patients enrolled in EpxCOPD, one hospitalization can be prevented.

Given the importance of fitting into the provider’s existing workflow, providers received convenient email and text message alerts when one of their patients reported breathing worse. Lead author Eric Sink  said, “Providers largely said that it was very easy for them to incorporate into their daily clinic practice.”

Ensuring patients could use the technology was critical given the average age of patients was 60 with an average annual income below $12,000. The patient engagement rate ranged from 60-75%. Patient feedback was positive and focused on how the text messaging tool helped them feel connected to their provider. One patient said, “I love feeling like my physician knows how I’m doing with my breathing at all times. It makes feel more safe and secure.” Another patient said, “When I started breathing really poorly, I told the system that I was breathing “worse” than previous days. My doctor called me soon after and helped me get more medication delivered to my home so I didn’t have to go to the hospital.”

Patient Story
Meet Jackie Jones, a fictionalized patient whose experience is typical of a patient in the study.
She is a 68 year old resident of North Saint Louis City. She has lived her entire life in the same neighborhood of North Saint Louis. She has been smoking a pack of cigarettes per day since she was 16. She receives her outpatient care for her diabetes, hypertension, and COPD at the hospital close by. However, it is very difficult for her to arrange transportation to and from clinic visits. Last year, she was admitted three separate times for six days at a time because she ran out of her respiratory inhaler medications. Her provider enrolled her in EpxCOPD to help monitor her day to day breathing status. Since being placed on EpxCOPD, her doctor can closely monitor her respiratory condition and intervene if she ever says she is breathing worse. Last week, Ms. Jones reported she was breathing “worse” and her physician called her within hours to ask her what was wrong. She had run out of her home oxygen and needed her home health company to come bring her a new tank. Her physician was able to arrange this and prevent Ms. Jones from calling an ambulance to take her to the emergency room, and potentially being admitted to the hospital again. Ms. Jones feels highly satisfied with EpxCOPD and enjoys receiving the daily text message to her cell phone, asking her how she is feeling that day. She says this makes her feel like her doctor is always close by.

“EpxCOPD fills a significant gap in COPD care by making it possible for providers to care for their COPD patients at a distance. The goal remains the same—to keep patients out of the hospital. However, EpxCOPD can increase the number of touchpoints that patients have with the care team and allow them to receive earlier notice of changes in patients’ breathing status. This enables timely changes in the patients’ care plan—prescribe a new medication, change a medication, provide oxygen, or provide other support—before the patient needs to be hospitalized," said Eric Sink.

The researchers concluded that the intervention is both effective and efficient saying, “The number of patients needed to treat to prevent one COPD hospitalization was 8.62 patients; this is an extremely economically efficient alternative to both alternative COPD telemedicine interventions and certainly less expensive than the cost of a COPD hospitalization.”

“This study is one of the first, if not the first, randomized controlled trial of a COPD telemedicine system to demonstrate a statistically significant clinical outcome among a large patient population with many participating providers. No other trial has used simple text messages or phone calls to reach a more underserved population with as many different participating providers,” researchers said.