**2. Chronic obstructive pulmonary diseases**

It is now consensually agreed that an estimated number of 328 million people have COPD worldwide, that is, 168 million men and 160 million women. Moreover, COPD causes the death of 2.9 million people annually and it is projected to be the third cause of mortality by 2020 [23]. Whereas the three most important factors in individual patients that determine the economic and social costs of COPD are disease severity, presence of frequent exacerbations of disease and the presence of comorbidities, which are common (30–57%) in COPD patients [24], the current short-term and long-term strategies to reduce the burden of COPD comprise the triad of smoking cessation, minimizing acute exacerbations and management and prevention of comorbidities [25].

by Johnston et al. [17] and by Nakamura et al. [18]. Johnston determined a reduction of 17% of home visits as well as a 27% reduction of costs in the telemedicine group. Moreover, Nakamura reported an improvement of daily activities in the telemedicine group. Recent studies have used videoconference to improve adherence to a telerehabilitation program [19], to follow-up patients with bipolar disorder [20] or to monitoring tuberculosis therapy com‐ pliance [21], among other topics. According to these studies, in our view the videoconference is a remarkable technology, facilitating the follow-up of patients to improve their adherence

*Telephone*. Mainly, studies have focused in the telephone as a device to follow-up of patients but Balas et al. [22] described five possible actions that we could also do via telephone: (1) follow-up, (2) videoconsultation due to interactive telephone, (3) telephonic reminders of taking a medicine or doing an exercise, (4) calling health professionals if case of clinical

*E-mail*. Email is a rather quick tool for the patients to communicate with health professionals, making it easier for the latter to perform questionnaires so any given doubt of the patient or

It is now consensually agreed that an estimated number of 328 million people have COPD worldwide, that is, 168 million men and 160 million women. Moreover, COPD causes the death of 2.9 million people annually and it is projected to be the third cause of mortality by 2020 [23].

to treatment.

62 Mobile Health Technologies - Theories and Applications

**Figure 2.** Telemedicine platform.

caregiver could be cleared up.

deterioration, and (5) clinical investigation.

**2. Chronic obstructive pulmonary diseases**

Hence, a high priority should be given to interventions aimed at delaying the progression of disease, preventing exacerbations and reducing the risk of comorbidities in order to alleviate the clinical and economic burden of COPD in Western countries [26]. Among these interven‐ tions, telemedicine has shown some promising results although no conclusive evidence has been accomplished. The effects of telemedicine in COPD have been addressed in previous systematic reviews [27, 28]; however, their conclusions are not consistent since the types of tested interventions have been rather heterogeneous. These interventions range from simple telephone or video interviews to daily telemonitoring of physiological parameters or symp‐ toms data, and that is why comparativeness of one study to the other does not come along easily.

So far, there is moderate evidence of the benefit of telemedicine in COPD, in terms of increasing quality of life and reducing hospital admissions. Basically, the problem has been that in previous years the studies included in systematic reviews were underpowered, had hetero‐ geneous populations and had lack of detailed intervention descriptions and of the care processes that accompanied telemonitoring [29]. Another issue is the clinical scenario where patients are usually recruited. For instance, telemedicine can be offered to those patients prone to exacerbations that are in stable condition [30], or right after admission regardless of the number of previous exacerbations or FEV1 obstruction severity [31].

Regarding telemonitoring (understood as retrieving periodically clinical data such as oxygen saturation, heart rate, symptoms, etc.), recent data including randomized clinical trials of good quality are now available; however, some of them are still underpowered. In terms of hospital admissions, one of the latest systematic reviews on the matter, which included eight studies with 486 patients randomized to home telemonitoring or usual care, determined a significant lower risk of hospitalizations in the telemonitoring group. However, healthcare utilization in general was similar in both groups, since it was not clear whether the utilization was due to respiratory events specifically, and the lower range of compliance to telemonitoring reported by some studies may have influenced the ability of detecting clinical deterioration [32]. Moreover, even between this data retrieved on a daily basis there were different clinical features measured, which end up inevitability in being quite difficult to integrate quantitative variables because of missing or noncomparative data. Thus, the extrapolation of these results to the general population should be carried out with absolute caution. The usual problem with these systematic reviews is that, due to the heterogeneity of outcomes and the way the studies have assessed them, it is troublesome to determine the true effect of telemonitoring on COPD patients. For instance, adding a closer approach to patients with videoconsultations to the usual telemonitoring, which would be ideal in order to obtain higher rates of compliance or reduction of the use of healthcare resources in general, failed to demonstrate differences in hospital admissions or time to first admission or all-cause hospital admissions [33].

Detection and management of COPD exacerbations in early stages is an important step in order to reduce hospital admissions and the consequent increase of quality of life and reduction of health costs in general. So far, telemedicine has proven to be a useful tool to achieve this.

Physical activity, one of the strong mortality predictors in COPD patients, if not the strongest, has not been properly issued. Although no conclusive evidence of telemedicine benefit exists on this regard, the use of telehealthcare may lead to increased physical activity level [34]. A recent study that evaluated the feasibility of a telerehabilitation program compared to a regular outpatient program, showed an increase of physical activity measured by steps/day in the telerehabilitation group, with acceptable rates of satisfaction with the service, although no differences were found when the 6-minute walking test, dyspnea measured by the Medical Research Council or quality of life measured by the St. George's Respiratory Questionnaire were compared [35].

The cost-effectiveness of telemedicine in COPD is yet to be determined. In fact, a recent study carried out in the United Kingdom, which recruited 3230 patients where both at baseline and follow-up participants with COPD made up the largest telehealth intervention group, showed that costs of self-reported service use, combined with telehealth intervention costs, were greater for the group randomized to telehealth in addition to standard care than for the group randomized to usual care alone [36]. However, the validity of this conclusion may be biased for two reasons. First, the trial recruiters had foreknowledge of the allocation groups in many cases [37], and second, its transferability to other healthcare systems was not taken in consid‐ eration since the trial did not include all community and healthcare resources. Thus, a recent Danish trial (TeleCare North) will determine the real benefit of telemedicine in COPD in terms of health-related quality of life and the incremental cost-effectiveness ratio through a largescale, pragmatic, cluster-randomized trial with nested economic evaluation [38].

Quality of life, a paramount feature in COPD and a strong predictor of mortality, has been analyzed irregularly. Once again, the instruments used to determine the health related quality of life vary greatly among the telemedicine studies (i.e., Chronic Respiratory Disease Ques‐ tionnaire, Chronic Respiratory Questionnaire, St. George's Respiratory Questionnaire (SGRQ), Clinical COPD Questionnaire, EURO-QOL-5D Questionnaire, Medical Outcome Study Short-Form 36 Questionnaire), so comparative data is deficient. Overall, no significant differences have been found between a home telemonitoring group and the usual care group [32].

The aim of telemedicine toward COPD patients should be to keep this population outside the hospital or the emergency rooms. Although there is evidence that this aim has been achieved in some studies, we are still in need of larger clinical trials which include a rigorous costeffectiveness analysis in terms of use of healthcare resources separated by respiratory diseases or not, quality of life, and mortality. Furthermore, a 6- or 12-month follow-up is insufficient to determine conclusive differences in favor of telemedicine.

## **3. Asthma**

reduction of the use of healthcare resources in general, failed to demonstrate differences in

Detection and management of COPD exacerbations in early stages is an important step in order to reduce hospital admissions and the consequent increase of quality of life and reduction of health costs in general. So far, telemedicine has proven to be a useful tool to achieve this.

Physical activity, one of the strong mortality predictors in COPD patients, if not the strongest, has not been properly issued. Although no conclusive evidence of telemedicine benefit exists on this regard, the use of telehealthcare may lead to increased physical activity level [34]. A recent study that evaluated the feasibility of a telerehabilitation program compared to a regular outpatient program, showed an increase of physical activity measured by steps/day in the telerehabilitation group, with acceptable rates of satisfaction with the service, although no differences were found when the 6-minute walking test, dyspnea measured by the Medical Research Council or quality of life measured by the St. George's Respiratory Questionnaire

The cost-effectiveness of telemedicine in COPD is yet to be determined. In fact, a recent study carried out in the United Kingdom, which recruited 3230 patients where both at baseline and follow-up participants with COPD made up the largest telehealth intervention group, showed that costs of self-reported service use, combined with telehealth intervention costs, were greater for the group randomized to telehealth in addition to standard care than for the group randomized to usual care alone [36]. However, the validity of this conclusion may be biased for two reasons. First, the trial recruiters had foreknowledge of the allocation groups in many cases [37], and second, its transferability to other healthcare systems was not taken in consid‐ eration since the trial did not include all community and healthcare resources. Thus, a recent Danish trial (TeleCare North) will determine the real benefit of telemedicine in COPD in terms of health-related quality of life and the incremental cost-effectiveness ratio through a large-

scale, pragmatic, cluster-randomized trial with nested economic evaluation [38].

determine conclusive differences in favor of telemedicine.

Quality of life, a paramount feature in COPD and a strong predictor of mortality, has been analyzed irregularly. Once again, the instruments used to determine the health related quality of life vary greatly among the telemedicine studies (i.e., Chronic Respiratory Disease Ques‐ tionnaire, Chronic Respiratory Questionnaire, St. George's Respiratory Questionnaire (SGRQ), Clinical COPD Questionnaire, EURO-QOL-5D Questionnaire, Medical Outcome Study Short-Form 36 Questionnaire), so comparative data is deficient. Overall, no significant differences have been found between a home telemonitoring group and the usual care group [32].

The aim of telemedicine toward COPD patients should be to keep this population outside the hospital or the emergency rooms. Although there is evidence that this aim has been achieved in some studies, we are still in need of larger clinical trials which include a rigorous costeffectiveness analysis in terms of use of healthcare resources separated by respiratory diseases or not, quality of life, and mortality. Furthermore, a 6- or 12-month follow-up is insufficient to

hospital admissions or time to first admission or all-cause hospital admissions [33].

were compared [35].

64 Mobile Health Technologies - Theories and Applications

Asthma is a worldwide disease affecting 300 million of people, and its economic and social costs are mostly related to emergency visits and hospital admissions. Self-monitoring of symptoms and peak flow, following a written action plan and attending regular visits to their physician, have demonstrated to improve asthma control [39], and that is why approaches through telemedicine have been done to increase its control and follow-up. It has been hypothesized that providing self-monitoring tools such as easy-to-use handheld electronic monitoring devices or symptom questionnaires, patients can gain insight into their level of asthma control which gives them suggestions for subsequent treatment adjustment [40]. This is why telemedicine for asthma appears to be a promising tool to achieve this so wished for self-control and management of the disease.

However, there are some pitfalls regarding telemedicine for asthma. If noncomparative data due to the different sort of interventions is a main issue for COPD, the problem is probably more serious for asthma. One of the most relevant systematic reviews in the matter included 21 studies, of which nine consisted in telephone calls, two in videoconferences, two in using the Internet, one in short text messaging, one in a combination of short text and Internet, and six more using other networked communications. This study demonstrated no improvement of quality of life and even a nonsignificant increase of emergency room visits in the telemedi‐ cine group, although a significant reduction of hospitalizations was observed [41]. However, some authors have stated some concerns about these meta-analysis conclusions. First of all, there were only few examples of a comprehensive telemanagement approach in asthma (defined as a treatment plan, self-monitoring of lung function by FEV1 and asthma control with feedback and e-communication with a professional to support this self-management), and second, patients in the control strategies often received an enhanced form of usual care, which makes it difficult to draw final conclusions on the effectiveness of telemanagement in asthma [40]. A more recent meta-analysis of 20 trials involving 10,406 asthmatic patients where common outcomes employed were healthcare utilization, quality of life and symptoms, concluded that the median effect of telemedicine was weakly positive, and that there were not differences between the types of interventions (telemonitoring, routine voice contact or videoconferencing). But the problem with this positive effect is that a publication bias exists due to the tendency of more positive results reported in earlier studies, which contained heterogeneous outcomes measurement and assessment [42].

Regarding cost-effectiveness we are still in need of studies addressing the topic specifically, situation that withholds the use of telemedicine for asthma unquestionably. Probably the only evidence of cost-effectiveness of Internet-based self-management compared with usual care, showed no significant differences during a follow-up of one year. However, this study had several limitations, acknowledge by the authors. First, the quality adjusted life year estimates were calculated out of only two measurements throughout one year. Second, patients were inevitable conscious of the allocated group, which may have influenced their utility ratings. And third, the economic evaluation was limited to one year only [43]. Regarding a specific feature of telemedicine, another study showed that telephone consultations led by experienced nurses enabled a greater proportion of asthma patients to be reviewed at no additional cost to the health service, although these findings should not be extrapolated as a thorough costeffectiveness analysis, compared to the comprehensive telemanagement as explained before [44, 45].

Despite the similar moderate evidence either for asthma or COPD, there are some differences when telehealthcare main purposes are compared between the two diseases. While in COPD telemedicine aims to reduce exacerbations or their early detection in order to avoid emergency rooms visits or hospital admissions, in asthma these objectives are usually directed at assuring a better symptoms self-control and adherence to treatment, considering that undertreatment is the most common problem in European asthmatic subjects [46], and its usual presentation at early stages of life. A fitter control of asthma has been reported possibly secondary to the opportunity of register symptoms continually, thus, the patient obtained a more accurate picture of his disease severity and complied to treatment with a closer and efficient selfmonitoring. However, this severity awareness led to an increased number of unscheduled visits and a harmful consumption of inhaled corticosteroids, which increased their adverse effects [47]. In a similar fashion, another study revealed that 43 patients under a mobile telephone interactive self-control system and compared with a control group, presented significantly higher mean daily dosage of either inhaled or systemic corticosteroids during the study period. Nonetheless, this system also demonstrated fewer unscheduled visits to the emergency department; higher peak expiratory flows at 4, 5, and 6 moths; higher FEV1 at 6 months; and better quality of life at 3 months after inclusion [48].

Compliance to new technologies is a relevant feature of telemedicine since not all of public health systems can afford them, and there are still underprivileged groups who are not familiar to these sorts of interventions. It seems that telemedicine for asthma is feasible, although when compared to a web based self-management, patients presented higher rates of adherence to the classic paper based strategies of self-control of symptoms and action plans, though other critical feature such as lung function data was not reliable when the patient wrote it down on his own [49].

In the pediatric population there is also lacking evidence of telemedicine benefit. Telemoni‐ toring of lung function on daily home spirometry in 44 children with professional feedback did not reduce the frequency of exacerbations significantly when compared to conventional treatment, nor the number of unscheduled visits, FEV1, quality of life or use of inhaled corticosteroids [50]. This finding could be explained by the fact that a highly variable peak expiratory flow and FEV1 values at time of symptoms and a complete overlap in distributions between symptoms-free days and at times of symptoms [51], and also by the underpowered nature of the study.

In conclusion, even though telemedicine for asthma seems to be a useful and promising tool for empowering the asthmatic patients in order to guarantee the self-control of the disease, the evidence of its benefit is still unclear. The short follow-ups, the heterogeneity of subjects and the insufficient evidence of its cost-effectiveness, are paramount aspects that restrain the use of telemedicine for asthmatic patients. We advocate for the tailoring treatment to the individual needs as the cornerstone of telehealthcare, although more studies are called for so the real effect of this new technologies can be elucidated.]
