Telemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial Home telemonitoring and quality of life in stable, optimised chronic obstructive pulmonary disease Prognostic factors for clinical failure of exacerbations in elderly outpatients with moderate-to-severe COPD Home intervention and predictor variables for rehospitalization in chronic obstructive pulmonary disease exacerbations. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial External validation of a COPD diagnostic questionnaire Efficacy of a whole-body vibration intervention to effect exercise tolerance and functional performance of the lower limbs of people with chronic obstructive pulmonary disease Efficacy of multiparametric telemonitoring on respiratory outcomes in elderly people with COPD: a randomized controlled trial Effectiveness of Telemonitoring in Patients with Chronic Obstructive Pulmonary Disease in Taiwan-A Randomized Controlled Trial Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: a qualitative study embedded in a randomized controlled trial. Simulated case management of home telemonitoring to assess the impact of different alert algorithms on work-load and clinical decisions Predictors of Outcome After Exacerbation of Chronic Obstructive Pulmonary Disease Study Design and Outcomes of Korean Obstructive Lung Disease (KOLD) Cohort Study Functional and psychosocial effects of health qigong in patients with COPD: a randomized controlled trial. Effectiveness and cost-effectiveness of early assisted discharge for Chronic Obstructive Pulmonary Disease exacerbations: the design of a randomised controlled trial A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease Evidence Base for Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Rationale : Early detection of chronic obstructive pulmonary disease ( COPD ) exacerbations using telemonitoring of physiological variables might reduce the frequency of hospitalization . Objectives : To evaluate the efficacy of home monitoring of lung mechanics by the forced oscillation technique and cardiac parameters in older patients with COPD and comorbidities . Methods : This multicenter , r and omized clinical trial recruited 312 patients with Global Initiative for Chronic Obstructive Lung Disease grade s II to IV COPD ( median age , 71 yr [ interquartile range , 66‐76 yr ] ; 49.6 % grade II , 50.4 % grade s III‐IV ) , with a history of exacerbation in the previous year and at least one nonpulmonary comorbidity . Patients were r and omized to usual care ( n = 158 ) or telemonitoring ( n = 154 ) and followed for 9 months . All telemonitoring patients self‐assessed lung mechanics daily , and in a subgroup with congestive heart failure ( n = 37 ) cardiac parameters were also monitored . An algorithm identified deterioration , triggering a telephone contact to determine appropriate interventions . Measurements and Main Results : Primary outcomes were time to first hospitalization ( TTFH ) and change in the EuroQoL EQ‐5D utility index score . Secondary outcomes included : rate of antibiotic/corticosteroid prescription ; hospitalization ; the COPD Assessment Tool , Patient Health Question naire‐9 , and Minnesota Living with Heart Failure question naire scores ; quality ‐adjusted life years ; and healthcare costs . Telemonitoring did not affect TTFH , EQ‐5D utility index score , antibiotic prescriptions , hospitalization rate , or question naire scores . In an exploratory analysis , telemedicine was associated with fewer repeat hospitalizations ( −54 % ; P = 0.017 ) . Conclusions : In older patients with COPD and comorbidities , remote monitoring of lung function by forced oscillation technique and cardiac parameters did not change TTFH and EQ‐5D . Clinical trial registered with www . clinical trials.gov ( NCT 01960907 ) Objective To test the effectiveness of telemonitoring integrated into existing clinical services such that intervention and control groups have access to the same clinical care . Design Research er blind , multicentre , r and omised controlled trial . Setting UK primary care ( Lothian , Scotl and ) . Participants Adults with at least one admission for chronic obstructive pulmonary disease ( COPD ) in the year before r and omisation . We excluded people who had other significant lung disease , who were unable to provide informed consent or complete the study , or who had other significant social or clinical problems . Interventions Participants were recruited between 21 May 2009 and 28 March 2011 , and central ly r and omised to receive telemonitoring or conventional self monitoring . Using a touch screen , telemonitoring participants recorded a daily question naire about symptoms and treatment use , and monitored oxygen saturation using linked instruments . Algorithms , based on the symptom score , generated alerts if readings were omitted or breached thresholds . Both groups received similar care from existing clinical services . Main outcome measures The primary outcome was time to hospital admission due to COPD exacerbation up to one year after r and omisation . Other outcomes included number and duration of admissions , and vali date d question naire assessment s of health related quality of life ( using St George ’s respiratory question naire ( SGRQ ) ) , anxiety or depression ( or both ) , self efficacy , knowledge , and adherence to treatment . Analysis was intention to treat . Results Of 256 patients completing the study , 128 patients were r and omised to telemonitoring and 128 to usual care ;  baseline characteristics of each group were similar . The number of days to admission did not differ significantly between groups ( adjusted hazard ratio 0.98 , 95 % confidence interval 0.66 to 1.44 ) . Over one year , the mean number of COPD admissions was similar in both groups ( telemonitoring 1.2 admissions per person ( st and ard deviation 1.9 ) v control 1.1 ( 1.6 ) ; P=0.59 ) . Mean duration of COPD admissions over one year was also similar between groups ( 9.5 days per person ( st and ard deviation 19.1 ) v 8.8 days ( 15.9 ) ; P=0.88 ) . The intervention had no significant effect on SGRQ scores between groups ( 68.2 ( st and ard deviation 16.3 ) v 67.3 ( 17.3 ) ; adjusted mean difference 1.39 ( 95 % confidence interval −1.57 to 4.35 ) ) , or on other question naire outcomes . Conclusions In participants with a history of admission for exacerbations of COPD , telemonitoring was not effective in postponing admissions and did not improve quality of life . The positive effect of telemonitoring seen in previous trials could be due to enhancement of the underpinning clinical service rather than the telemonitoring communication . Trial registration IS RCT N96634935 . Funding : The trial was funded by an NHS applied research programme grant from the Chief Scientist Office of the Scottish government ( ARPG/07/03 ) . The funder had no role in study design and the collection , analysis , and interpretation of data and the writing of the article and the decision to su bmi t it for publication . NHS Lothian supported the telemonitoring service and the clinical services We conducted a six-month r and omised controlled trial of home telemonitoring for patients with chronic obstructive pulmonary disease ( COPD ) . A total of 40 stable patients with moderate to severe COPD who had completed pulmonary rehabilitation took part . They were r and omised to receive st and ard care ( controls ) or st and ard care plus home telemonitoring ( intervention ) . During the monitoring period , patients in the telemonitoring group recorded their symptoms and physical observations twice daily . The data were transmitted automatically at night via the home telephone line . Nurses could access the data through a website and receive alerting email messages if certain conditions were detected . The patients completed the St George 's Respiratory Question naire , Hospital Anxiety and Depression and the EuroQoL EQ-5D quality of life scores before and after pulmonary rehabilitation , and then periodically during the trial . There were significant and clinical ly important improvements in the scores immediately following pulmonary rehabilitation , but thereafter there were no differences in quality of life scores between the groups at any time , or consistently within either group over time . The study showed that telemonitoring was safe but , despite being well used , it was not associated with changes in quality of life in patients who had stable COPD Background Acute exacerbations represent a significant burden for patients with moderate-to-severe chronic obstructive pulmonary disease . Each exacerbation episode is frequently associated with a lengthy recovery and impaired quality of life . Prognostic factors for out patients that may predict poor outcome after treatment with antibiotics recommended in the guidelines , are not fully understood . We aim ed to identify pretherapy factors predictive of clinical failure in elderly ( ≥60 years old ) out patients with acute Anthonisen type 1 exacerbations . Trial registration NCT00656747 . Methods Based on the moxifloxacin in AE COPD s ( acute exacerbations of chronic obstructive pulmonary disease ) trial ( MAESTRAL ) data base , this study evaluated pretherapy  demographic , clinical , sputum bacteriological factors  using multivariate logistic regression analysis , with internal validation by bootstrap replicates , to investigate their possible association with clinical failure at end of therapy ( EOT ) and 8 weeks posttherapy . Results The analyses found that the independent factors predicting clinical failure at EOT were more frequent exacerbations , increased respiratory rate and lower body temperature at exacerbation , treatment with long-acting anticholinergic drugs , and in vitro bacterial resistance to study drug . The independent factors predicting poor outcome at 8 weeks posttherapy included wheezing at preexacerbation , mild or moderate ( vs extreme ) sleep disturbances , lower body temperature at exacerbation , forced expiratory volume in 1 second < 30 % , lower body mass index , concomitant systemic corticosteroids for the current exacerbation , maintenance long-acting β2-agonist and long-acting anticholinergic treatments , and positive sputum culture at EOT . Conclusion Several bacteriological , historical , treatment-related factors were identified as predictors of early ( EOT ) and later ( 8 weeks posttherapy ) clinical failure in this older outpatient population with moderate-to-severe chronic obstructive pulmonary disease . These patients should be closely monitored and sputum cultures considered before and after treatment BACKGROUND Chronic obstructive pulmonary disease ( COPD ) exacerbation increases mortality and re sources used associated with hospitalization . We studied whether early home monitoring reduces the rate of readmission and if there are any predictor variables . PATIENTS AND METHODS We performed a prospect i ve , controlled , parallel-group study in patients who were hospitalized for COPD . Patients whose residence was within less than 15 km from the hospital were assigned to an interventional group ( home visits by nurses about 48 - 72hours after discharge ) , the remainder were assigned to a conventional care group . The rate of rehospitalization within the first month was compared between the two groups , as well as those variables that showed a predictive capability . RESULTS Seventy one patients were included : 35 in the conventional care group and 36 in the interventional group . In the latter , the treatment was modified in 13 patients ( 36 % ) . The hospital readmission rate was 17 % , which was similar in both groups ( P=.50 ) . For every 5-year increase in age , the risk for readmission was 2.54 ( 95%CI , 1.06 - 5.07 ) and for each increase of 10mmHg in PaCO(2 ) , the risk of readmission was 8.34 ( 95%CI , 2.43 - 18.55 ) . CONCLUSIONS Early home monitoring did not decrease the readmission rate during the first month . Older age and high PaCO(2 ) are factors that identify the group with a high risk for rehospitalization BACKGROUND We have previously reported the use of a hospital based respiratory nurse service ( Acute Respiratory Assessment Service , ARAS ) to support home treatment of patients with exacerbations of chronic obstructive pulmonary disease ( COPD ) . A controlled trial was undertaken to compare early discharge with home treatment supported by respiratory nurses with conventional hospital management of patients admitted with exacerbations of COPD . METHODS Patients with COPD admitted as emergencies were identified the next working day . They were eligible for inclusion in the study if the differential diagnosis included an exacerbation of COPD , but were excluded if other medical conditions or acidotic respiratory failure required inpatient investigation or management . Of 360 patients review ed , 209 were being assessed for other active medical problems and were excluded , 33 potential participants were already involved in research studies and so were ineligible , and 37 did not wish to participate in the study . Eighty one patients were r and omised to receive conventional inpatient care ( n=40 ) or to planned early discharge the next working day  ( n=41 ) . Those discharged early continued treatment at home under the supervision of specialist respiratory nurses . Outcome measures were readmission , additional hospital days , and deaths within 60 days of initial admission . Process measures included number of visits , duration of follow up by the respiratory nurse , and additional treatment provided to support early discharge . RESULTS On an intention to treat basis , a policy of early discharge reduced inpatient stay from a mean of 6.1 ( range 1–13 ) days with conventional management to 3.2 ( 1–16 ) days with an early discharge policy . Twelve patients ( 30 % conventional management , 29.3 % early discharge ) were readmitted in each group giving a mean difference in readmission of 0.7 % ( 95 % CI of the difference –19.2 to 20.6 ) . In the conventional management group readmitted patients spent a mean of 8.75 additional days in hospital compared with 7.83 days in the early discharge group , giving a mean difference of 0.92 days ( 95 % CI of the difference –6.5 to 8.3 ) . There were two deaths ( 5 % ) in the conventional management group and one ( 2.4 % ) in the early discharge group , a mean difference of 2.6 % ( 95 % CI of the difference –5.7 to 10.8 ) . CONCLUSIONS Patients with acute exacerbations of COPD uncomplicated by acidotic respiratory failure or other medical problems can be discharged home earlier than is current practice with support by visiting respiratory nurses . No difference was found in the subsequent need for readmission The aim of the present study was to determine the external validity of a recently developed question naire for the identification of patients at increased risk of airflow limitation in smokers from the general population in the provinces of Dutch and Belgian Limburg ( regions surrounding Maastricht , the Netherl and s ) . As part of a study on the early detection of airflow limitation and subsequent smoking cessation treatment ( International St and ard R and omised Controlled Trial Number : 64481813 ) , the recently developed chronic obstructive pulmonary disease ( COPD ) diagnostic question naire was used in current smokers aged 40–70 yrs , with a smoking history of ≥10 pack-yrs , who reported one or more respiratory symptom ( cough , sputum production or dyspnoea ) , but who had no diagnosis of a respiratory disease ( COPD or asthma ) .  Spirometry performed according to American Thoracic Society/European Respiratory Society criteria served as a reference test . Of the 676 subjects who entered the analyses , 398 showed normal lung function and 278 had a diagnosis of COPD ( post-bronchodilator forced expiratory volume in one second/forced vital capacity of < 0.70 ) . The ability of the COPD diagnostic question naire to discriminate between subjects with and without COPD was poor ( area under the receiver operating characteristic curve of 0.65 ) . In a high-risk population consisting of middle-aged current smokers with a smoking history of ≥10 pack-yrs , the chronic obstructive pulmonary disease diagnostic question naire is probably not useful as a diagnostic tool for the identification of patients with an increased risk of airflow limitation Background Chronic obstructive pulmonary disease ( COPD ) is a respiratory condition characterised by dyspnoea , excessive sputum production , chronic cough , bronchitis and emphysema . Functionally , exercise tolerance is poor for people with COPD and is linked to difficulty in performing daily tasks . More specifically , exercise difficulties are due partly to dyspnoea and lower limb skeletal muscle dysfunction . The benefit of exercise that does not exacerbate the disease while improving exercise tolerance is salient . Whole-body vibration ( WBV ) is a mode of physical activity known to improve muscular function of the lower limbs , yet efficacy has not been investigated for a WBV intervention conducted in a home-based setting for people with COPD . Methods / design This clinical ly registered trial is a non-r and omised placebo cross-over intervention based in the home of each participant ( ACTRN12612000508875 ) . Participants diagnosed with COPD will complete a six-week WBV intervention and then after a two-week washout period , will complete a six-week placebo training intervention . Participants will complete sessions twice a week . The duration of the trial is 14 weeks . Community-dwelling older adults with COPD will provide informed voluntary consent to participate . Outcome measures will include immediate , acute , and long-term responses to exercise . Discussion Quantifying responses to WBV among people with COPD will allow discussion of efficacy of WBV as a mode of physical activity . The skill required by the participant to perform physical activity with WBV is not dem and ing and may enhance habitual sustainability . The results of this trial could be used to support further research in both clinical and community setting s . Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR12612000508875 Background Chronic obstructive pulmonary disease ( COPD ) is a highly prevalent condition associated with a high health care re source consumption and health care expenditures , driven mainly by exacerbations-related hospitalizations . Telemedicine has been proposed as a mean for timely detection of exacerbation , but the available evidence is inadequate to provide conclusive information on its efficacy . The aim of this study is to evaluate the efficacy of a telemonitoring system in reducing COPD -related hospitalizations in an elderly population with COPD . Methods This is a parallel arms , r and omized trial including patients aged 65 or older with COPD in GOLD stages II and III enrolled in a Pulmonary Medicine outpatient facility . Patients were r and omly assigned to receive a non-invasive system able to telemonitor vital signs ( oxygen saturation , heart rate , near-body temperature , overall physical activity ) or st and ard care , and were followed up for 9 months . The outcome measures were the number of exacerbations and exacerbation-related hospitalization . Results Fifty patients were included in the telemonitoring group and 49 in the control group . The incidence rate of respiratory events was 28/100 person/years in the telemonitoring group vs. 42/100 person/years in the control group ( incidence rate ratio : 0.67 , 95 % CI : 0.32 – 1.36 ) . The corresponding figures for hospital admissions where 13/100 person/years and 20/100 person/years , respectively ( IRR : 0.66 , 95 % CI : 0.21 – 1.86 ) . Conclusions In our study , COPD patients followed up with the aid of a multiparametric remote monitoring system experienced a lower rate of exacerbations and COPD -related hospitalizations compared to patients followed up using the st and ard model of care . These results need to be replicated in larger studies before they can be applied to the general COPD population . Trial registration number : NCT01481506 ( clinical trials.gov ) . Funding : co-financed by Lazio Region and Intersistemi Chronic obstructive pulmonary disease ( COPD ) is the leading cause of death worldwide , and poses a substantial economic and social burden . Telemonitoring has been proposed as a solution to this growing problem , but its impact on patient outcome is equivocal . This r and omized controlled trial aim ed to investigate effectiveness of telemonitoring in improving COPD patient outcome . In total , 106 subjects were r and omly assigned to the  telemonitoring  ( n = 53 ) or  usual care ( n = 53 ) group . During the two months following discharge , telemonitoring group patients had to report their symptoms daily using an electronic diary . The primary outcome measure was time to first re-admission for COPD exacerbation within six months of discharge . During the follow-up period , time to first re-admission for COPD exacerbation was significantly increased in the telemonitoring group than in the usual care group ( p = 0.026 ) . Telemonitoring was also associated with a reduced number of all-cause re-admissions ( 0.23 vs. 0.68/patient ; p = 0.002 ) and emergency room visits ( 0.36 vs. 0.91/patient ; p = 0.006 ) . In conclusion , telemonitoring intervention was associated with improved outcomes among COPD patients admitted for exacerbation in a country characterized by a small territory and high accessibility to medical services . The findings are encouraging and add further support to implementation of telemonitoring as part of COPD care OBJECTIVE To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease ( COPD ) . METHODS Semi-structured interviews with patients with COPD and healthcare professionals participating in a r and omized controlled trial of telemonitoring in Lothian , Scotl and , explored experiences of using telemonitoring , and dynamics in patient-practitioner relationships . Transcribed data were analyzed using the Framework approach . RESULTS 38 patients ( mean age 67.5 years ) and 32 professionals provided 70 interviews . Patients considered that telemonitoring empowered self-management by enhancing their underst and ing of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice . Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters , but expressed concerns about promoting the sick role and creating dependence on telemonitoring . CONCLUSION Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered . A medical model of ' compliant self-management ' may paradoxically have promoted dependence on professionals . PRACTICE IMPLICATION S Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD . Care is needed , however , to minimize the risk in some patients , of telemonitoring increasing dependence on practitioner support Background Home telemonitoring ( HTM ) of chronic heart failure ( HF ) promises to improve care by timely indications when a patient ’s condition is worsening . Simple rules of sudden weight change have been demonstrated to generate many alerts with poor sensitivity . Trend alert algorithms and bio-impedance ( a more sensitive marker of fluid change ) , should produce fewer false alerts and reduce workload . However , comparisons between such approaches on the decisions made and the time spent review ing alerts has not been studied . Methods Using HTM data from an observational trial of 91 HF patients , a simulated telemonitoring station was created and used to present virtual caseloads to clinicians experienced with HF HTM systems . Clinicians were r and omised to either a simple ( i.e. an increase of 2 kg in the past 3 days ) or advanced alert method ( either a moving average weight algorithm or bio-impedance cumulative sum algorithm ) . Results In total 16 clinicians review ed the caseloads , 8 r and omised to a simple alert method and 8 to the advanced alert methods .  Total time to review the caseloads was lower in the advanced arms than the simple arm ( 80 ± 42 vs. 149 ± 82 min ) but agreements on actions between clinicians were low ( Fleiss kappa 0.33 and 0.31 ) and despite having high sensitivity many alerts in the bio-impedance arm were not considered to need further action . Conclusion Advanced alerting algorithms with higher specificity are likely to reduce the time spent by clinicians and increase the percentage of time spent on changes rated as most meaningful . Work is needed to present bio-impedance alerts in a manner which is intuitive for clinicians BACKGROUND The outcome after hospitalization for an exacerbation of chronic obstructive pulmonary disease ( COPD ) is unfavorable and uncertainty exists about factors predicting short and long-term prognosis . OBJECTIVE To identify clinical predictors of length of hospital stay ( LOS ) and three-year mortality after COPD exacerbations requiring hospitalization . DESIGN Retrospective analysis of prospect ively collected data . PARTICIPANTS AND METHODS All consecutive patients hospitalized with COPD exacerbation were enrolled . Disease severity was estimated by FEV1 , body mass index ( BMI ) , Medical Research Council ( MRC ) chronic dyspnoea scale , previous hospitalizations , need for long-term oxygen treatment ( LTOT ) , arterial oxygen and carbon dioxide partial pressures ( PaO2 and PaCO2 ) , pH and respiratory rate . Outcome was assessed by LOS and three-year mortality . MAIN RESULTS Out of 81 patients enrolled , three-year mortality data were available for 61 .  LOS was related to BMI , MRC scale and respiratory rate . Three-year mortality was related to FEV1 , BMI , MRC scale , LTOT , and PaCO2 . Multiple logistic regression analysis demonstrated that MRC scale was the only independent determinant of LOS , [ p = 0.001 , odds ratio ( OR ) 7.67 ( 95 % CI 2.50–23.41 ) ] , whereas MRC scale and BMI predicted three-year mortality , [ p = 0.001 , OR 8.28 ( 95 % CI 2.25–30.47 ) and p = 0.006 , OR 6.91 ( 95 % CI 1.74–27.48 ) , respectively ] . Cox regression analysis demonstrated identical results . Using receiver-operator-optimized thresholds for these variables ( MRC > 2 and BMI < 25 kg/m2 ) , we propose a prediction model that accurately determines three-year mortality risk . CONCLUSIONS In this study , MRC scale and BMI predicted outcome after COPD hospitalization . Pending further validation , this predictive model may contribute to identify patients with poor outcome even when spirometric data are unavailable Background The Korean Obstructive Lung Disease ( KOLD ) Cohort Study is a prospect i ve longitudinal study of patients with chronic obstructive pulmonary disease ( COPD ) , asthma , or other unclassified obstructive lung diseases . It was design ed to develop new classification models and biomarkers that predict clinical ly relevant outcomes for patients with obstructive lung diseases . Methods Patients over 18 years old who have chronic respiratory symptoms and airflow limitations or bronchial hyper-responsiveness were enrolled at 17 centers in South Korea . After a baseline visit , the subjects were followed up every 3 months for various assessment s. Results From June 2005 to October 2013 , a total of 477 subjects ( 433 [ 91 % ] males ; 381 [ 80 % ] diagnosed with COPD ) were enrolled . Analyses of the KOLD Cohort Study identified distinct phenotypes in patients with COPD , and predictors of therapeutic responses and exacerbations as well as the factors related to pulmonary hypertension in COPD . In addition , several genotypes were associated with radiological phenotypes and therapeutic responses among Korean COPD patients . Conclusion The KOLD Cohort Study is one of the leading long-term prospect i ve longitudinal studies investigating heterogeneity of the COPD and is expected to provide new insights for pathogenesis and the long-term progression of COPD CONTEXT The initial gain from a Pulmonary Rehabilitation Program ( PRP ) among patients with chronic obstructive pulmonary disease ( COPD ) begins to fade away 6 months after the completion of a rehabilitation program . One possible reason may be due to the poor compliance of the patients to the existing forms of home exercise program ( e.g. , walking , weight training activities , etc . ) . OBJECTIVES This study tested the efficacy of health qigong ( HQG ) , a traditional Chinese exercise , as an adjunct home exercise program in optimizing the gains obtained from PRP until 6 months after discharge . DESIGN This was a r and omized controlled trial ( RCT ) on a mind-body exercise intervention . PARTICIPANTS Eighty ( 80 ) patients with COPD receiving conventional PRP pulmonary rehabilitation program were r and omized to the HQG intervention  group ( n = 40 ) and control group  ( n = 40 ) . OUTCOME MEASURES Assessment s were undertaken by blinded assessors at baseline , discharge from training , and follow-up ( FU ) at 3 and 6 months . Primary outcomes involved functional capacity scales and secondary outcomes involved quality -of-life scales . RESULTS Intention-to-treat analysis identified trends of improvement in all outcome measures in the HQG group , whereas lesser improvement and trends of deteriorations were identified in the control group . Ancillary analysis using a per- protocol method , however , identified significantly better improvements in functional capacity measures among the HQG at the 6-month FU . CONCLUSIONS This RCT provided some evidence to support the positive effect of HQG as an adjunct home exercise for rehabilitation among people with COPD and to support further related research Background Exacerbations of Chronic Obstructive Pulmonary Disease ( COPD ) are the main cause for hospitalisation . These hospitalisations result in a high pressure on hospital beds and high health care costs . Because of the increasing prevalence of COPD this will only become worse . Hospital at home is one of the alternatives that has been proved to be a safe alternative for hospitalisation in COPD . Most schemes are early assisted discharge schemes with specialised respiratory nurses providing care at home . Whether this type of service is cost-effective depends on the setting in which it is delivered and the way in which it is organised . Methods / Design GO AHEAD ( Assessment Of Going Home under Early Assisted Discharge ) is a 3-months , r and omised controlled , multi-centre clinical trial . Patients admitted to hospital for a COPD exacerbation are either discharged on the fourth day of admission and further treated at home , or receive usual inpatient hospital care . Home treatment is supervised by general nurses . Primary outcome is the effectiveness and cost effectiveness of an early assisted discharge intervention in comparison with  usual inpatient hospital care for patients hospitalised with a COPD exacerbation . Secondary outcomes include effects on quality of life , primary informal caregiver burden and patient and primary caregiver satisfaction . Additionally , a discrete choice experiment is performed to provide insight in patient and informal caregiver preferences for different treatment characteristics . Measurements are performed on the first day of admission and 3 days , 7 days , 1 month and 3 months thereafter . Ethical approval has been obtained and the study has been registered . Discussion This article describes the study protocol of the GO AHEAD study . Early assisted discharge could be an effective and cost-effective method to reduce length of hospital stay in the Netherl and s which is beneficial for patients and society . If effectiveness and cost-effectiveness can be proven , implementation in the Dutch health care system should be considered . Trial registration Netherl and s Trial Register NTR1129 We conducted a systematic review of the evidence on the costs and cost-effectiveness of telehealth for patients with chronic obstructive pulmonary disease ( COPD ) . A literature search identified six relevant economic evaluations that were assessed according to the Consensus Health Economic Criteria list ( CHEC list ) . Three studies were from North America and three studies were from Europe . All studies reported the use of home monitoring devices that measured and transmitted different physical indicators to nurses who provided personalised feedback to patients during weekdays . The six studies involved a total of 559 COPD patients of whom 281 were r and omised to telehealth .  The review demonstrated a potential for cost savings . All six studies reported a lower average cost per patient with telehealth plus usual care compared with usual care alone . However , the quality of the economic evidence was poor . Five studies were evaluated as low quality and one study was evaluated as moderate quality , with CHEC list scores of 21–68 % . Caution is advised for healthcare decision-makers seeking large-scale implementation of telehealth in routine clinical practice . The clinical effectiveness of such implementations with follow-up exceeding 12 months has not yet been demonstrated The American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) and the American College of Chest Physicians ( ACCP ) developed this evidence -based clinical practice guideline in collaboration . A joint expert panel examined the evidence and developed recommendations . The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper , Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease : A Summary and Appraisal of Published Evidence , which is part 2 of this guideline ( see pages 600 - 620 ) . The guideline and background paper are based primarily on a systematic review compiled in an Agency for Healthcare Research and Policy evidence report prepared by the Evidence -Based Practice Center at Duke University ( 1 ) . Our target audience is primary care physicians and specialists who care for patients with chronic obstructive pulmonary disease ( COPD ) . Although most acute exacerbations of COPD take place and are treated on an outpatient basis , research studies focus on emergency department or inpatient setting s. As a result , this guideline applies to exacerbations treated in those setting s. The guideline presents the available evidence on risk stratification for relapse and 6-month mortality rates , diagnostic testing for acute exacerbations of COPD , and current treatment options for acute exacerbations of COPD . In the United States , 16 million adults have COPD , which accounts annually for 110 000 deaths , more than 16 million office visits , 500 000 hospitalizations , and $ 18 billion in direct health care costs . The disease is characterized by chronic airflow obstruction and episodic increases in dyspnea , cough , and sputum production that are commonly called exacerbations . After an acute exacerbation , most patients experience a transitory or permanent decrease in quality of life , and nearly 50 % of patients discharged from hospitals after acute exacerbations are readmitted more than once in the following 6 months . Therefore , one of the main treatment goals for patients with COPD is reducing the number and severity of annual exacerbations . There is no widely accepted definition of acute exacerbation of COPD , but most published definitions encompass some combination of three clinical findings : worsening dyspnea , increase in sputum purulence , and increase in sputum volume . A severity scale for acute exacerbations developed by Anthonisen and colleagues ( 2 ) is based on these findings as well as others . Type 1 exacerbations ( severe ) have all three clinical findings , and type 2 exacerbations ( moderate ) exhibit two . Type 3 exacerbations ( mild ) have one of these clinical findings plus at least one of the following : an upper respiratory tract infection in the past 5 days , fever without other apparent cause , increased wheezing , increased cough , or a 20 % increase in respiratory rate or heart rate above baseline . We use this scale when referring to severity in this guideline . Acute exacerbations can be triggered by tracheobronchial infections or environmental exposures , and patients often have associated clinical conditions , such as heart failure , extrapulmonary infections , and pulmonary embolism . Therefore , acute exacerbation is mainly a clinical diagnosis . Despite the importance of this disease , the review of the evidence brings to light the paucity of high- quality studies on this subject . Nevertheless , recommendations in this guideline are based on the highest- quality evidence currently available . While the studies of highest quality were often r and omized , controlled clinical trials , these were few in number and tended to enroll small numbers of patients . The clinician must consider this fact when basing management decisions on the guideline recommendations . Current practice s for the diagnosis and management of acute exacerbations of COPD are varied . Some commonly used tests and therapies are not supported by evidence , while others are . The Panel found enough evidence to make recommendations about the use of the following diagnostic and therapeutic methods in acute exacerbations of COPD : chest radiography , acute spirometry , bronchodilators , corticosteroids , antibiotics , oxygen , mucolytic agents , mucus-clearing strategies , and noninvasive positive-pressure ventilation ( NPPV ) .  Indirect evidence shows that arterial blood gases are helpful for determining the present need for oxygen therapy and the potential need for mechanical ventilatory support . We did not find enough evidence to make recommendations regarding the use of pulse oximetry , sputum smear , and culture . Risk Stratification Prediction of Outpatient Relapse All of the studies included for analysis were performed in the emergency department . Relapse was defined as a return visit to the emergency department within 14 days of initial presentation . Identifying patients at high risk for relapse should help guide decisions about hospital admission and follow-up appointments . Several studies have confirmed what most clinicians intuitively know : Patients who have lower baseline FEV1 , low Po 2 , high Pco 2 , and low pH and who receive more bronchodilator  treatments while in the emergency department are more likely to relapse within 14 days of initial presentation . Unfortunately , none of the predictive models perform well enough to justify their uniform use in clinical practice [ 2.1.1 ] . Prediction of 6-Month Mortality The Study to Underst and Prognoses and Preferences for Outcomes and Risks of Treatments ( SUPPORT ) found a 180-day mortality rate of 33 % in its cohort . Significant predictors of 180-day mortality were worse Acute Physiology and Chronic Health Evaluation ( APACHE ) III score , lower body mass index , older age , worse functional status 2 weeks before admission , lower ratio of Po 2 to fraction of inspired oxygen , history of congestive heart failure , lower serum albumin level , and presence of cor pulmonale . Other studies reported similar associations . Although these studies suggest that certain physiologic characteristics are associated with a higher likelihood of inpatient mortality , we conclude that there is currently no reliable method for identifying patients at high risk ( > 90 % ) for inpatient or 6-month mortality . Therefore , these measures should not influence decisions about instituting , continuing , or withdrawing life-sustaining therapies but should prompt a discussion regarding patient preferences for end-of-life care [ 2.1.2 ] . Diagnostic Testing : Chest Radiography and Spirometry Three observational studies showed substantial rates of abnormalities in chest radiography among patients admitted for acute exacerbation of COPD . In one prospect i ve study , which included patients with asthma , chest radiography results prompted change in management in 23.5 % of patients , mostly because of new infiltrates . Observational studies showed that spirometric assessment at presentation or during treatment is not useful in judging severity or guiding management of patients with acute exacerbations of COPD . When measured at the time of an exacerbation , FEV1 showed no significant correlation with Po 2 and only a weak ( although statistically significant ) correlation with Pco 2 . Peak expiratory flow rate is often used in the clinic to approximate FEV1 . One study found a correlation between peak expiratory flow rate and FEV1 . The clinical implication of this finding is not clear , however , because FEV1 is a poor predictor . Despite this fact , many studies use changes in FEV1 as the primary outcome rather than other , more clinical ly pertinent measures ( such as degree of dyspnea or sputum production and quality ) , probably because the latter are much more difficult to quantify and evaluate [ 2.2.2 , 2.2.3 ] . Therapeutic Interventions Bronchodilators Fourteen r and omized trials show that inhaled short-acting 2 agonists , such as albuterol , and anticholinergic bronchodilators , such as  ipratropium  , are equally efficacious in patients with acute exacerbations of COPD . They are also superior to all parenterally administered bronchodilators , including methylxanthines and sympathomimetic agents . Furthermore , some patients may experience additional benefit when a second inhaled bronchodilating agent is administered after the maximal dose of the initial agent is reached . Several studies examined patients receiving a short-acting 2 agonist plus an anticholinergic bronchodilator . In general , patients in these studies had marginally shorter lengths of stay and proportionally larger increases in FEV1 , but hospital admission rates were similar to those of patients receiving one bronchodilator . Since anticholinergic bronchodilators are associated with fewer and milder side effects , it is advisable to start with them and then add a short-acting 2 agonist . Studies are equivocal on the addition of a methylxanthine , such as aminophylline , to inhaled bronchodilators . More important , the potentially serious side effects of the methylxanthines make their use more problematic . In addition , some evidence shows that the efficacy of wet nebulization and dry aerosol delivery systems ( metered-dose inhaler plus a spacer ) are clinical ly equivalent . Therefore , the choice of a specific delivery method should be determined on an individual basis , depending on each patient 's ability to use the different methods ( 3 ) [ 2.3.1 ] . Corticosteroids Six r and omized , placebo-controlled trials showed that for patients hospitalized with acute exacerbation of COPD , systemic corticosteroids given for up to 2 weeks are helpful . Dosage , length of treatment , administration , and setting varied greatly among the studies evaluated . In the largest trial ( Systemic Corticosteroids in Chronic Obstructive Pulmonary Disease Exacerbations ) , patients received a 2-week or 8-week course . The 2-week course consisted of 3 days of intravenous methylprednisolone , 125 mg every 6 hours , followed by oral prednisone for 2 weeks ( 60 mg/d on days 4 to 7 , 40 mg/d on days 8 to 11 , and 20 mg/d on days 12 to
Only then will telemonitoring achieve the aim of preventing hospital admissions , contributing to the reduction of health re source utilization and improving the quality of life of patients
Major reported factors associated with the limited effectiveness of home telemonitoring interventions in chronic respiratory conditions include the lack of useful early predictors , poor patient compliance and the poor performance of conventional algorithms for detecting deteriorations .
This article provides a systematic review of existing algorithms and the factors associated with their performance in detecting exacerbations and supporting clinical decisions in patients with chronic obstructive pulmonary disease ( COPD ) or asthma .