*4.3.2 Medication adherence*

Only 3 studies out of the 11 evaluated the effectiveness of telemonitoring on compliance by patients with their treatment and adherence to medication. The study in [40] reported no significant difference, whereas [41] reported improved compliance with treatment in the telemonitoring group.

#### *4.3.3 Quality of life*

The eight studies evaluating quality of life of patients reported no statistically significant general improvement for patients from the intervention. However some studies did report certain aspects of awareness were improved. For example, [42], using SF-36 and MLHF, reported that knowledge about CHF was significantly higher among patients in the intervention group (P < .001). The study in [43] reported significant difference on the vitality subscale of SF-36 at 1 month (P = 0.022), 3 months (P = 0.017) and a year (P = 0.009). Similarly, [44] noted that improvement was achieved over time by using MLHF. [41] reported significant difference in health perception score of SF-36 (P = 0.046). Only two studies assessed anxiety and depression scores. The Minnesota Living with Heart Failure (MLHF) and Short Form (SF-36) Questionnaire were used in all studies to measure Quality of Life.

#### *4.3.4 Managing blood pressure*

Blood pressure must be carefully managed in patients with CHF. **Figure 10** shows how telehealth was used to manage reduction of the blood pressure in a patient to an appropriate level [45]. However the blood pressure and pulse rate became erratic. Further investigation determined the patient had atrial fibrillation. Recent blood pressure devices now provide an indication if they determine erratic pulse rate.

**Figure 10.** *Daily blood pressure and pulse rate [45].*

#### *4.3.5 Monitoring weight*

Weight is often monitored in patients with CHF. During exacerbation patients will develop oedema with a corresponding gain in weight. The gain in weight is relatively rapid, over the period of a few days, and the change may be easily detected to generate an alert.

#### **4.4 Clinical benefits in patients with COPD**

Chronic obstructive pulmonary disease (COPD), which is characterized by a chronic irreversible airflow limitation, is a leading cause of mortality and morbidity globally and results in substantial costs and healthcare utilisation. Several diseases are categorised as COPD, including asthma, lung disease, and pulmonary fibrosis; each has its own characteristics, progression, and approaches to telehealth have differed accordingly.

#### *4.4.1 Physical activity*

Early telehealth approaches concentrated on rehabilitation and used education and intervention via telephone and messaging to encourage patients to perform exercises to improve pulmonary function and increase tolerance to physical activity. Meta-analysis of studies using intervention [46] showed positive outcome for telehealth to increase the duration of physical activity (**Figure 11**), tolerance to 6 minute walk (**Figure 12**), and reduce episodes of dyspnoea (**Figure 13**).

#### *4.4.2 Progression of disease*

While effective, such approaches could be considered labour-intensive, especially when continuing to contact patients who are responding. Recent efforts in
