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A Digital Health Tool Aimed at COPD in High-Risk Individuals Reduces All-Cause Hospitalization via Effect on Other Co-Morbidities: A Randomized, Controlled Trial
Authors: Shivakumar N1, Xu R1, Sink E2, Kim E2, Patel K2, Groenendyk J1, Javaherian K1, Peters R1, Shifren A1, Polites G1 , Blanchard M1, Ross W1+, 1Washington University School of Medicine, St. Louis, MO, 2Saint Louis University School of Medicine, St. Louis, MO, +Corresponding Author
Introduction: Due to its capacity to perform remote assessments, telemedicine is rising as a new force in COPD management. Patients with COPD often have multiple comorbidities, including heart failure, diabetes, hypertension. The effect of a text messaging digital health tool, EpxCOPD, on all cause hospitalization has not yet been assessed. We conducted a six-month randomized-controlled-trial to study the effect of an automated telemedicine intervention on patients' all-cause hospitalizations for a population of actively engaged patients at the resident clinic at Washington University in St. Louis.
Methods: We randomized 149 patients with a diagnosis of COPD in the past 24 months enrolled to receive intervention at a primary care clinic who are actively followed by residents, defined as having made at least one appointment in the past year. The treatment group received daily phone messages from an automated system asking them to report if they were breathing better, worse, or the same 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. However, no proactive breathing alerts were ever generated to the provider for these subjects and instead subjects were directed to make an appointment using the main line. The primary outcome was number of patients hospitalized due to COPD-related cause or any cause during the trial period.
Results: The absolute risk reduction (ARR) in percentage of patients with all-cause hospitalizations was 11.55% between treatment and control groups. The absolute difference comparing all-cause hospitalization reduction and COPD hospitalization reduction was 7.88% (1.47-14.57). The hazard ratio comparing treatment and control group's time to all-cause hospitalization was 1.917 (0.9439-3.892). Subject engagement averaged 82% (78-93%) and 73% (75-85%) for control and treatment groups respectively.
Conclusion: In this analysis, we find that a telehealth tool, EpxCOPD, has a strong effect on all-cause hospitalization. Although the tool was primarily focused on COPD symptomatology, in this actively followed group, we find the intervention actually having a significantly greater than expected change in all-cause hospitalizations as compared to placebo, suggesting a broader effect of the intervention on comorbidities. Connecting patients with providers outside the bedside, e.g. telephonic contact, may give better care than the existing standard, especially for high-risk patients with multiple co-morbidities. The use of non-smartphone interventions reduces barriers to care presented by more complicated and expensive technologies. The intervention represents a simple, innovative, and inexpensive tool for improved management of care for patients with COPD and other comorbidities. Further study is necessary to understand the mechanism by which this effect occurs.