Perspectives of patients and healthcare professionals on the impact of telemetrically supported patient self-management for chronic obstructive pulmonary disease (COPD): a qualitative study nested in the TELESCOT trial

Background: Early identification of exacerbations reduces hospital admissions and may slow disease progression. The TELESCOTrandomised control trial based in Lothian, Scotland, is investigating the impact of a tele-monitoring service for COPD with the primaryaim of reducing hospitalisation.Aim: The nested qualitative study explored the views of patients and professionals on models of telemetric service delivery and theimpact on self-management.Method: We undertook semi-structured interviews with patient and professional participants at different time points in the TELESCOTCOPD trial. Transcribed, coded data were analysed thematically. Interpretation was supported by multidisciplinary discussion.Results: 38 patients (47% male, mean age 67.5 years) and 32 healthcare professionals provided 70 interviews. Both patients and professionals considered that home tele-monitoring had the potential to reduce the risk of hospital admission. Patients generally appreciated being ‘watched over’ by the tele-monitoring, which gave them confidence to manage their own condition. They used tele-data to improving their understanding of COPD, determine their current state of health and influence decisions about their daily activities. Numerical data (e.g. oxygen saturations) were particularly valued. Changes in readings validated their decisions to adjust treatment or seek timely professional advice, and eased access to clinical care. Patients valued the personalised care provided by tele-monitoring staff familiar with their circumstances and state of health. Professionals emphasised the potential role of telemetry in encouraging prompt compliance with medically defined behaviours and attitudes, though some doubted whether it would be sufficient to overcome a perceived reluctance on the part of patients to acknowledge and take ownership of the disease. There was also a concern that ‘fixation’ on monitoring physiological parameters (especially oxygen saturation levels), promoted a medical model of the disease and might increase dependence on services in some patients. The GPs and community nursing or physiotherapy teams who provided the supporting services emphasised the importance of ‘knowing the patient’ and ‘knowing what’s normal for the individual’ in using their clinical skills to interpret incoming tele-monitoring data Conclusion: Enthusiasm for tele-monitoring as a means of facilitating self-management and thereby reducing admissions is tempered byconcerns about increased medicalisation and dependence on support services. Tele-monitoring provides data which can be used to support self-management decisions and acts as a channel for seeking professional support. The patient-practitioner relationship, personalisation and continuity of care were prioritised as important elements in delivering clinical support for tele-monitoring services by patients and professionals

Oximetry-supported self-management for chronic obstructive pulmonary disease: mixed method feasibility pilot project

Background: Pulse oximetry could potentially contribute to self-monitoring. NHS Lothian’s ‘Light Touch’ serviceprovided COPD patients with a self-management plan based on symptoms and oximetry. The service was overseen(though not actively monitored) by respiratory-trained community teams who were contactable by a telephonehelpline. We aimed to assess the feasibility, perceived utility and impact of the ‘Light Touch’ service.Methods: A before-and-after assessment of St George’s Respiratory Questionnaire (SGRQ), Hospital Anxiety andDepression Scale (HADS) and use of healthcare resources during the 6-month feasibility study compared to theprevious corresponding 6-months. Paired semi-structured interviews with patients at baseline and 6-months, interviewswith managers and a focus group of professionals explored perceptions of the service and self-management.Transcripts were coded, and analysed thematically.Results: We recruited 51 participants (mean age 69.7 years (SD 8.4); 21 (46 %) male). 46 participants completedquantitative follow up (2 died, 2 were unwell, 1 refused). SGRQ: 21 (46 %) participants improved by 4 or more(the minimum important difference); 12 (26 %) deteriorated by 4 or more. HADS: more participants had normalscores for anxiety (65 %) and depression (80 %) at 6-months than at baseline (51 and 64 %). More emergency therapywas prescribed during the study period compared to the previous year. Only 18 participants (39 %) contacted the LightTouch Helpline during the 6-month study.Twenty patients provided a total of 36 interviews, 8 clinicians contributed to a focus group and 6 managers wereinterviewed. Patients considered that the oximetry readings heightened awareness of their condition and gave themconfidence to make self-management decisions. Healthcare professionals valued oximetry as a tool for teaching peopleself-management skills, but were concerned that patients rarely contacted the teams for help or advice during the study.Conclusions: ‘Light Touch’ shows promise as a low-cost strategy for empowering patients’ self-management skills andreducing reliance on clinical supervision.Keywords: Chronic obstructive pulmonary disease (COPD), Self-management, Telemonitoring, Primary care,Delivery of car

The use of global positional satellite location in dementia: a feasibility study for a randomised controlled trial

Background: Getting lost outside is stressful for people with dementia and their caregivers and a leading cause oflong-term institutionalisation. Although Global Positional Satellite (GPS) location has been promoted to facilitate safewalking, reduce caregivers’ anxiety and enable people with dementia to remain at home, there is little high qualityevidence about its acceptability, effectiveness or cost-effectiveness. This observational study explored the feasibilityof recruiting and retaining participants, and the acceptability of outcome measures, to inform decisions about thefeasibility of a randomised controlled trial (RCT).Methods: People with dementia who had been provided with GPS devices by local social-care services and theircaregivers were invited to participate in this study. We undertook interviews with people with dementia, caregiversand professionals to explore the perceived utility and challenges of GPS location, and assessed quality of life (QoL)and mental health. We piloted three methods of calculating resource use: caregiver diary; bi-monthly telephonequestionnaires; and interrogation of health and social care records. We asked caregivers to estimate the time spentsearching if participants became lost before and whilst using GPS.Results: Twenty people were offered GPS locations services by social-care services during the 8-month recruitmentperiod. Of these, 14 agreed to be referred to the research team, 12 of these participated and provided data. Eightpeople with dementia and 12 caregivers were interviewed. Most participants and professionals were very positiveabout using GPS. Only one person completed a diary. Resource use, anxiety and depression and QoL questionnaireswere considered difficult and were therefore declined by some on follow-up. Social care records were timeconsuming to search and contained many omissions. Caregivers estimated that GPS reduced searching timealthough the accuracy of this was not objectively verified.Conclusions: Our data suggest that a RCT will face challenges not least that widespread enthusiasm for GPSamong social-care staff may challenge recruitment and its ready availability may risk contamination of controls.Potential primary outcomes of a RCT should not rely on caregivers’ recall or questionnaire completion. Timespent searching (if this could be accurately captured) and days until long-term admission are potentially suitableoutcomes

The impact of supported telemetric monitoring in people with type 2 diabetes: study protocol for a randomised controlled trial

BackgroundDiabetes prevalence is increasing and current methods of management are unsustainable. Effective approaches to supporting self-management are required. The aim of this randomized controlled trial is to establish whether supported telemetric monitoring of glycemic control and blood pressure results in reductions in glycosylated hemoglobin (HbA1c; the primary outcome of a measure of long-term glycemic control) and secondary outcomes of blood pressure and weight among people with poorly controlled diabetes compared to a control group receiving usual care.Methods/DesignDesign: multi-center, randomized controlled trial with embedded qualitative study.Setting: primary care in Lothian, Kent, Glasgow and Borders regions in the UK.Participants: people with type 2 diabetes and confirmed HbA1c >7.5% (58 mmol/mol).Intervention/comparison: randomization to intervention or control groups will be performed by the Edinburgh Clinical Trials Unit. Participants in the intervention group will be shown how to use blood glucose and blood pressure monitors and weighing scales which use Bluetooth wireless technology to transmit readings via modem to a remote server. These participants will be asked to provide at least twice weekly measurements of morning and evening blood glucose and weekly measurements of weight and blood pressure. Measurements will be checked at least weekly by practice nurses who will contact the patients to adjust therapy according to guidelines and reinforce lifestyle advice. Participants in the control group will receive usual care. All participants will receive an individual education session.ollow-up: measurements will be performed at practices 9 months after randomization by research nurses blinded to allocation. The primary outcome measure is HbA1c and secondary outcomes measure are daytime systolic and diastolic blood pressure, weight and cost per quality-adjusted life year.Analysis: intention-to-treat analyses will be performed. The sample size of 320 participants allows for 20% drop-out and has 80% power at 5% significance to detect a 0.5% absolute (6 mmol/mol) fall in HbA1c in the intervention group. The qualitative study will explore the experiences of patients and professionals using the intervention

Qualitative study of telemonitoring of blood glucose and blood pressure in type 2 diabetes.

Objectives To explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of blood glucose, blood pressure (BP) and weight telemonitoring in type 2 diabetes supported by primary care, and identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice. Design Qualitative study adopting an interpretive descriptive approach. Participants 23 patients, 6 nurses and 4 doctors who were participating in a RCT of blood glucose and BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought. Setting 12 primary care practices in Scotland and England. Method Data were collected via recorded semistructured interviews. Analysis was inductive with themes presented within an overarching thematic framework. Multiple strategies were employed to ensure that the analysis was credible and trustworthy. Results Telemonitoring of blood glucose, BP and weight by people with type 2 diabetes was feasible. The data generated by telemonitoring supported self-care decisions and medical treatment decisions. Motivation to self-manage diet was increased by telemonitoring of blood glucose, and the ‘benign policing’ aspect of telemonitoring was considered by patients to be important. The convenience of home monitoring was very acceptable to patients although professionals had some concerns about telemonitoring increasing workload and costs. Conclusions Telemonitoring of blood glucose, BP and weight in primary care is a promising way of improving diabetes management which would be highly acceptable to the type of patients who volunteered for this study

Application of Mixed Effects Limits of Agreement in the Presence of Multiple Sources of Variability: Exemplar from the Comparison of Several Devices to Measure Respiratory Rate in COPD Patients

IntroductionThe Bland-Altman limits of agreement method is widely used to assess how well the measurements produced by two raters, devices or systems agree with each other. However, mixed effects versions of the method which take into account multiple sources of variability are less well described in the literature. We address the practical challenges of applying mixed effects limits of agreement to the comparison of several devices to measure respiratory rate in patients with chronic obstructive pulmonary disease (COPD). MethodsRespiratory rate was measured in 21 people with a range of severity of COPD. Participants were asked to perform eleven different activities representative of daily life during a laboratory-based standardised protocol of 57 minutes. A mixed effects limits of agreement method was used to assess the agreement of five commercially available monitors (Camera, Photoplethysmography (PPG), Impedance, Accelerometer, and Chest-band) with the current gold standard device for measuring respiratory rate. ResultsResults produced using mixed effects limits of agreement were compared to results from a fixed effects method based on analysis of variance (ANOVA) and were found to be similar. The Accelerometer and Chest-band devices produced the narrowest limits of agreement (-8.63 to 4.27 and -9.99 to 6.80 respectively) with mean bias -2.18 and -1.60 breaths per minute. These devices also had the lowest within-participant and overall standard deviations (3.23 and 3.29 for Accelerometer and 4.17 and 4.28 for Chest-band respectively). ConclusionsThe mixed effects limits of agreement analysis enabled us to answer the question of which devices showed the strongest agreement with the gold standard device with respect to measuring respiratory rates. In particular, the estimated within-participant and overall standard deviations of the differences, which are easily obtainable from the mixed effects model results, gave a clear indication that the Accelerometer and Chest-band devices performed best

Electronic prescribing systems in hospitals to improve medication safety: a multimethods research programme.

Electronic prescribing (ePrescribing) systems allow health-care professionals to enter prescriptions and manage medicines using a computer. We set out to find out how these ePrescribing systems are chosen, set up and used in English hospitals. Given that these systems are designed to improve medication safety, we looked at whether or not these systems affected the number of prescribing errors made (mistakes such as ordering the wrong dose of medication). We also tried to see whether or not the systems were good value for money (or more cost-effective). Finally, we made recommendations to help hospitals choose, set up and use ePrescribing systems. We found that setting up ePrescribing systems was very difficult because there is a need to take into consideration how different pharmacists, nurses and doctors work, and the different work that needs to be carried out for different diseases and medical conditions. We recorded a link between the implementation of ePrescribing systems and a reduction in some high-risk prescribing errors in two out of three study sites. Given that the error reductions corresponded to the warnings triggered by the system, we concluded that the system is likely to have caused the error reduction. Prescribing errors may lead to adverse events that lead to death, impaired quality of life and longer hospital stays. The cost of an ePrescribing system increased in proportion to reduced errors, reaching £4.31 per patient per year for the site that experienced the greatest reduction in prescribing errors (i.e. site S). This estimate is based on assumptions in the model and how much a health service is willing to pay for a unit of health benefit. To help professionals choose, set up and use ePrescribing systems in the future, we produced an online ePrescribing Toolkit (www.eprescribingtoolkit.com/; accessed 21 December 2019) that, with support from NHS England, is becoming widely used internationally

Promoting healthy teenage behaviour across three European countries through the use of a novel smartphone technology platform, PEGASO fit for future: study protocol of a quasi-experimental, controlled, multi-Centre trial

BackgroundBehaviour change interventions targeting physical activity, diet, sleep and sedentary behaviour of teenagers show promise when delivered through smartphones. However, to date there is no evidence of effectiveness of multicomponent smartphone-based interventions. Utilising a user-centred design approach, we developed a theory-based, multi-dimensional system, PEGASO Fit For Future (PEGASO F4F), which exploits sophisticated game mechanics involving smartphone applications, a smartphone game and activity sensors to motivate teenagers to take an active role in adopting and maintaining a healthy lifestyle. This paper describes the study protocol to assess the feasibility, usability and effectiveness (knowledge/awareness and behavioural change in lifestyle) of the PEGASO system.MethodsWe are conducting a quasi-experimental controlled cluster trial in 4 sites in Spain, Italy, and UK (England, Scotland) over 6 months. We plan to recruit 525, in a 2:1 basis, teenagers aged 13–16 years from secondary schools. The intervention group is provided with the PEGASO system whereas the comparison group continues their usual educational routine. Outcomes include feasibility, acceptance, and usability of the PEGASO system as well as between and within group changes in motivation, self-reported diet, physical activity, sedentary and sleeping behaviour, anthropometric measures and knowledge about a healthy lifestyle.DiscussionPEGASO F4F will provide evidence into the cross-cultural similarities and differences in the feasibility, acceptability and usability of a multi-dimensional smartphone based behaviour change intervention for teenagers. The study will explore facilitating factors, challenges and barriers of engaging teenagers to adapt and maintain a healthy lifestyle when using smartphone technology. Positive results from this ICT based multi component intervention may have significant implications both at clinical level, improving teenagers health and at public health level since it can present an influential tool against the development of chronic disease during adulthood.Trial registrationhttps://clinicaltrials.gov Registration number: NCT02930148, registered 4 October 2016