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Hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD) is associated with poor prognosis. eHealth interventions might improve outcomes and decrease costs.
This study aimed to evaluate the effect of an eHealth program on COPD hospitalizations and exacerbations.
This was a real-world study conducted from April 2018 to December 2019 in the Bravis Hospital, the Netherlands. An eHealth program (EmmaCOPD) was offered to COPD patients at risk of exacerbations. EmmaCOPD consisted of an app that used questionnaires (to monitor symptoms) and a step counter (to monitor the number of steps) to detect exacerbations. Patients and their buddies received feedback when their symptoms worsened or the number of steps declined. Generalized estimating equations were used to compare the number of days admitted to the hospital and the total number of exacerbations 12 months before and (max) 18 months after the start of EmmaCOPD. We additionally adjusted for the potential confounders of age, sex, COPD severity, and inhaled corticosteroid use.
The 29 included patients had a mean forced expiratory volume in 1 second of 45.5 (SD 17.7) %predicted. In the year before the intervention, the median total number of exacerbations was 2.0 (IQR 2.0-3.0). The median number of hospitalized days was 8.0 days (IQR 6.0-16.5 days). Afterwards, there was a median 1.0 (IQR 0.0-2.0) exacerbation and 2.0 days (IQR 0.0-4.0 days) of hospitalization. After initiation of EmmaCOPD, both the number of hospitalized days and total number of exacerbations decreased significantly (incidence rate ratio 0.209, 95% CI 0.116-0.382; incidence rate ratio 0.310, 95% CI 0.219-0.438). Adjustment for confounders did not affect the results.
The eHealth program seems to reduce the number of total exacerbations and number of days of hospitalization due to exacerbations of COPD.
Chronic obstructive pulmonary disease (COPD) is a treatable, preventable, chronic lung disease that accounts for years lived with disability [
eHealth interventions are promising for improving outcomes and decreasing costs in chronic diseases, including COPD [
It is thought that patients with frequent exacerbations may benefit more from eHealth programs [
This was a retrospective study with a pre-post research design using real-world data that were retrieved from the electronic record system at the Bravis Hospital and from EmmaCOPD. Data were collected between April 2018 and December 2019 from patients who agreed to participate in EmmaCOPD. Analyses were performed between January 2020 and March 2020. Due to the retrospective nature of the study and the fact that this study does not fall under the Medical Research Involving Human Subjects Act (in Dutch, Wet medisch‐ wetenschappelijk onderzoek met mensen [WMO]), there was no need for ethical approval. Patients were aware that this intervention was new in clinical practice. All patients signed informed consent to use their data for research.
Patients could be included if they were treated by a pulmonologist in the Bravis Hospital. Patients were eligible for the intervention if they had COPD and if they had at least 2 exacerbations of COPD in the previous 12 months. An exacerbation was defined as an increase in symptoms that was more than day-to-day variation combined with prescription of a course of oral corticosteroids or antibiotics. Patients could also be included if they were at increased risk of exacerbations according to their health care provider.
Patients were excluded if they used EmmaCOPD before April 2018, because these patients could already have experienced the beneficial effects of the intervention. Furthermore, patients were excluded if they did not own an Android-based smartphone since the app for the Activity coach was only compatible with Android-based smartphones.
Starting in November 2016, the Bravis Hospital (Roosendaal, The Netherlands) offered patients with COPD who are at risk for hospitalization due to an exacerbation a new eHealth program: EmmaCOPD, an app [
Questionnaire app to monitor symptoms.
Smartwatch with built-in step counter.
Flow chart with zones, based on questions.
In the program, patients could be in several zones: green, yellow, orange, or red. At the start of app use, patients were in the “green zone” (steady state). Every day, patients filled out the BASE questionnaire of the COPD action plan [
The Pebble Time, a modern programmable smartwatch that includes an accelerometer and gyrometer (Bosch Sensortec BMI160, BOSCH, Germany) was used to signal a decline in the number of steps. During the first 3 weeks, baseline activity level was assessed. Thereafter, a physiotherapist set a step goal. When patients reached this goal, patients were in the “green zone.” If there was a decline of 20% in the number of steps, patients received a signal that they entered the “orange zone”; if there was a decline of 40%, patients were in the “red zone.”
During an onboarding session in the Bravis Hospital, patients and buddies were prepared for the use of EmmaCOPD. Their individual exacerbation plan was checked, and an Emma account was created. Furthermore, the Emma questionnaire app and the Emma activity coaching companion app were installed on the patient’s smartphone. The buddy, health care providers, physiotherapists, and the support department of Medicine Men had access to the account.
Baseline characteristics of participants were collected from the electronic health records at the Bravis Hospital. At baseline and follow-up, exacerbations were collected from the electronic records. At baseline, the number of exacerbations in the previous 12 months was collected. A mild exacerbation was defined as a “flare up of COPD symptoms with a change in COPD medication,” a moderate exacerbation as a “flare up of COPD symptoms that requires prescription of a course of corticosteroids or antibiotics,” and a severe exacerbation as a “flare up of COPD symptoms that led to hospital admission.” At baseline and follow-up, the number of hospitalizations and the number of days admitted to the hospital were collected. GOLD category (A, B, C, and D) at baseline was determined using the number of exacerbations and modified Medical Research Council score [
From previous research, it is known that of all patients with COPD GOLD stage 2, 7% was admitted to the hospital. Of all patients with COPD GOLD stage 3, 18% was admitted. Of all patients with COPD GOLD 4, 33% was admitted [
Descriptive statistics are presented as mean (SD) for continuous variables with a normal distribution, median (IQR) for continuous variables without a normal distribution, and percentages for categorical variables. We used a pre-post research design. For the postintervention period, the follow-up duration was calculated as the number of days between the date of data extraction and the date of inclusion. If a patient died, the follow-up duration was calculated as the number of days between the date of death and date of inclusion. We compared the postintervention period with a preintervention period of 365 days before inclusion in the study. We analyzed the difference between the first CCQ score and the last CCQ score using descriptive statistics. Generalized estimating equations were used to analyze CCQ change over time. For the analysis of the effect of the intervention on the number of hospital admissions and the number of hospital admission days, which can be conceptualized as count data with repeated intra-individual measurements before and after initiation of EmmaCOPD, we used generalized estimating equation models. The distribution of the data was tested first to check whether the data fitted best with a Poisson distribution or negative binomial model. Outcomes are expressed as the incidence rate ratio (IRR). As explanatory variables, we used the length of follow-up (log-transformed) and intervention (coded as 0 or 1 for the preintervention and postintervention periods, respectively). Additionally, we adjusted for potential confounders of sex and age (model 2). In a final model, we additionally adjusted for baseline severity expressed as GOLD category (model 3) and inhaled corticosteroid use (model 4).
All analyses were conducted in SPSS version 25.0.
Baseline characteristics are presented in
Baseline characteristics of patients with chronic obstructive pulmonary disease (COPD; n=29).
Patient characteristics | Results | |
Age (years), mean (SD) | 67.4 (8.0) | |
Sex (women), n (%) | 13 (45) | |
Ethnicity (Caucasian), n (%) | 26 (90) | |
BMI (kg/m2), mean (SD) | 27.3 (5.0) | |
Comorbidity (CCIa score), mean (SD) | 2.1 (1.2) | |
Asthma (yes), n (%) | 3 (10) | |
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Current | 3 (10) | |
Ex-smoker | 25 (86) | |
Never | 1 (3) | |
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ICSb mono (yes) | 2 (7) | |
LABAc mono (yes) | 6 (21) | |
LAMAd mono (yes) | 11 (38) | |
ICS/LABA in one device (yes) | 14 (48) | |
LABA/LAMA in one device (yes) | 3 (10) | |
Oral corticosteroids (yes) | 13 (45) | |
Physical activity (steps a day), median (IQR)e | 2482.5 (1394.3-4184.3) | |
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FEV1f (L)e | 1.3 (0.6) | |
FEV1 (% predicted)e | 45.5 (17.7) | |
FVCg (L)e | 2.9 (0.8) | |
FVC (% predicted)e | 82.0 (16.5) | |
FEV1/FVCe | 41.2 (14.3) | |
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Number of mild exacerbationsh in previous 12 months, median (IQR) | 0.0 (0.0-0.0) | |
Number of moderate exacerbationsi in previous 12 months, median (IQR) | 0.0 (0.0-0.0) | |
Number of severe exacerbationsj in previous 12 months, median (IQR) | 2.0 (2.0-3.0) | |
Total number of exacerbations in the previous 12 months, median (IQR) | 2.0 (2.0-3.0) | |
Number of patients with ≥2 exacerbations, n (%) | 25 (86) | |
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mMRCk scoree | 3.0 (1.1) | |
CCQl scoree | 3.0 (1.2) | |
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Ao | 0 (0) | |
Bp | 1 (3) | |
Cq | 1 (3) | |
Dr | 21 (72) | |
Days admitted to the hospital due to COPD exacerbations, median (IQR) | 8.0 (6.0-16.5) |
aCCI: Charlson comorbidity index [
bICS: inhaled corticosteroids.
cLABA: long-acting beta2 agonist.
dLAMA: long-acting muscarinic antagonist.
en=26, data missing for 3 participants.
fFEV1: forced expiratory volume in 1 second.
gFVC: forced vital capacity.
hMild exacerbation: change in COPD medication.
iModerate exacerbation: course of corticosteroids and/or antibiotics.
jSevere exacerbation: hospital admission.
kmMRC: modified Medical Research Council.
lCCQ: clinical COPD questionnaire.
mGOLD: Global Initiative for Chronic Obstructive Lung Disease.
nn=23, data missing for 6 participants.
oA: low symptoms, low risk for exacerbation.
pB: high symptoms, low risk for exacerbation.
qC: low symptoms, high risk for exacerbation.
rD: high symptoms, high risk for exacerbation.
Outcomes at follow-up are found in
The data for both the number of hospitalization days and total number of exacerbations fitted best within a Poisson distribution. Unadjusted analyses showed that, after initiation of the EmmaCOPD intervention, both the number of hospitalization days (IRR 0.210, 95% CI 0.116-0.382) and the total number of exacerbations (IRR 0.310, 95% CI 0.219-0.438) decreased significantly (
Follow-up at 12-18 months after initiation of EmmaCOPD (n=29).
Outcomes | Results |
Follow-up duration (days), median (IQR) | 587.0 (372.0-594.0) |
Mortality (yes), n (%) | 3 (10) |
Number of mild exacerbationsa, median (IQR) | 0.0 (0.0 to 0.0) |
Number of moderate exacerbationsb, median (IQR) | 0.0 (0.0 to 0.0) |
Number of severe exacerbationsc, median (IQR) | 1.0 (0.0 to 2.0) |
Total number of exacerbations, median (IQR) | 1.0 (0.0 to 2.0) |
Hospital admission (days), median (IQR) | 2.0 (0.0 to 4.0) |
Change in CCQd, median (IQR)e | 0.3 (–0.4 to 0.9) |
aMild exacerbation: change in COPD medication.
bModerate exacerbation: course of corticosteroids and/or antibiotics.
cSevere exacerbation: hospital admission.
dCCQ: clinical chronic obstructive pulmonary disease questionnaire.
en=28, data missing for 1 participant.
Effect of EmmaCOPD on length of hospitalization and number of exacerbations, compared between 365 days before the initiation of EmmaCOPD and 12-18 months after the initiation of EmmaCOPD.
Analytic model | Hospitalization (days), IRRa (95% CI) | Total number of exacerbations, IRR (95% CI) |
Crude analysis (model 1) | 0.210 (0.116-0.382) | 0.310 (0.219-0.438) |
Adjusted analysis (model 2)b | 0.209 (0.114-0.382) | 0.308 (0.217-0.435) |
Adjusted analysis (model 3)c | 0.225 (0.111-0.456) | 0.327 (0.211-0.506) |
Adjusted analysis (model 4)d | 0.225 (0.111-0.456) | 0.325 (0.208-0.508) |
aIRR: incidence rate ratio.
bAdjusted for sex and age.
cModel adjusted for sex, age, and Global Iniative for Chronic Obstructive Lung Disease (GOLD) stage (patients with missing GOLD stage were exluded).
dModel adjusted for sex, age, GOLD stage (patients with missing GOLD stage were excluded), and inhaled corticsteroid use.
Data derived from EmmaCOPD are presented in
EmmaCOPD outcomes (n=29), with results categorized in zones (green, yellow, orange, or red), with each zone except green (steady state) requiring a different action.
Variables | Results | |
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Number of BASE question answered, median (IQR) | 252.0 (125.0-453.0) | |
Number of BASE questions answered as yes (yellow zoneb), median (IQR) | 26.0 (7.0-91.0) | |
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Number of PLUS questions answered, median (IQR) | 13.0 (5.0-68.0) | |
Number of PLUS questions answered with an answer in the orange zoned, median (IQR) | 1.0 (0.0-4.0) | |
Number of PLUS questions answered with an answer in the red zonee, median (IQR) | 1.0 (0.0-3.0) | |
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Number of days in the orange zoned, median (IQR) | 0.0 (0.0-25.0) | |
Number of days in the red zonee, median (IQR) | 3.0 (2.0-3.0) | |
Physical activity (steps per day), median (IQR)f | 1710.0 (1144.0-3078.0) |
aBASE question: daily question about worsening of symptoms;
bYellow zone: patient experienced worsening of symptoms (BASE question yes) and given advice to adjust medication.
cPLUS question: additional question when patient or the patient’s buddy suspected something serious.
dOrange zone: no improvements in 3 days (yes answer to the BASE for 3 days) or an orange-rated answer to a PLUS question, for which the patient is given advice to take emergency medication or contact health care provider.
eRed zone: red answer on the PLUS question, potentially life-threatening clinical situation, buddy was advised to call an ambulance.
fn=27, data missing for 2 participants.
The aim of the present study was to evaluate the effect of a new eHealth program (EmmaCOPD) on the number of hospitalized days and the total number of exacerbations in patients with COPD who are at risk for hospitalization. The present study, using real-world data, showed a significant decrease in the number of exacerbations and the number of days admitted to the hospital.
In line with the results of the present study, a Cochrane review [
In the Netherlands, several eHealth projects aiming to prevent hospital admissions have been initiated. One project is focusing on education of health care providers and patients for early detection of mild and moderate exacerbations to prevent severe exacerbations [
A strength of this study was the use of real-world data. EmmaCOPD was implemented as part of usual care in the Bravis Hospital, not as part of a study. Therefore, the risk of bias associated with participating in a study was minimized. Subgroup analysis in a systematic review has shown that telemonitoring is effective in patients with COPD, as are interventions that last more than 6 months [
This study has limitations. First, there were fewer patients included in the study than were calculated in the power calculation. The number of patients included in the study could probably have been higher if the app had also been available for iPhones. Also, eHealth interventions often face implementation challenges, including costs, that might explain why the sample size was not met [
For future studies, we recommend a study with a longer follow-up since it is known that interest in eHealth often declines over time, with fewer responses on alerts [
EmmaCOPD, an eHealth program that includes an app that signalled symptoms, a smartwatch with step counter, and provision of feedback to the patient and buddies, seems to reduce the number of total exacerbations and the number of days of hospitalization due to exacerbation of COPD in this real-world study. The effects of long-term use of EmmaCOPD should be studied further in future studies.
Charlson comorbidity index
clinical COPD questionnaire
chronic obstructive pulmonary disease
Global Initiative for Chronic Obstructive Lung Disease
incidence rate ratio
We acknowledge Bart Mertsens, Leiden University Medical Center, Leiden, the Netherlands for statistical checks. Furthermore, we acknowledge Bregje de Jong-ten Berge, Harry van Looij, and Rini Voeten from the Bravis ziekenhuis, Roosendaal, the Netherlands, for making possible the data extraction from the Bravis ziekenhuis.
OvD is founder and CEO of MedicineMen. All other authors declare that they have no conflicts of interest.