Intervention

The intervention program consisted of: 1) the provision of educational material about COPD (general information about the disease, its treatment, focusing on tobacco and inhaled medication, healthy lifestyle habits, and warning signs of eCOPD) by a respiratory nurse in two 30-minute sessions with the patient and caregiver, once on inclusion in the program, and again 1 year later; 2) training in using the device (smartphone) used for the telemonitoring; and 3) daily phone calls to enhance patient self-confidence during the first week of telemonitoring, and further calls as considered appropriate, progressively extending the interval between them, according to the capacity of the patient to manage on their own. Generally speaking, throughout the 2 years of the program, patients were given some advice on daily healthy habits, especially physical activity, in every phone call.

Written information about how the program ran and how to use the smartphone, as well as a contact telephone number, was provided to every patient and caregiver. Self-management plans related to eCOPDs were not included as part of the program, nor were any home visits. The implementation of this program had been previously explained to all primary care doctors involved in two general meetings.

The program was supported by a specialized respiratory nurse working full-time in Galdakao-Usansolo Hospital and two part-time respiratory specialists working on the program from Monday to Friday. During the evening and at weekends, a centralized call center (run by nonspecialized respiratory nurses) was in charge of the program.

The device used for the telemonitoring was a smartphone with specific software for the program. This software has two parts: 1) a questionnaire about the increase or not of the symptoms of the disease (cough, sputum, and dyspnea), plus a question about health status in the last 24 hours, from the last information sent (“In general, how would you characterize your health today?”; the three answers possible were “better”, “as usual”, and “worse”); and 2) physiological variables, ie, oxygen saturation and heart rate, which were sent by Blue-tooth from the pulsioximeter to the smartphone. Temperature, steps/day, and respiratory rate were measured and typed into the smartphone program by the patient or carer.

Patients included in the telEPOC program were asked to submit information about their clinical condition on a daily basis. The daily data were sent by a secure Internet connection to a password-protected server and transferred to the Respiratory Department at Galdakao Hospital, where a nurse analyzed all the information from every patient. Baseline levels of each of the clinical measurements studied were established on a case-by-case basis, considering the patient’s stable clinical condition at the time of inclusion in the program. These baseline data constituted the reference threshold for the daily measurements.

Once the patient’s daily measurements had been received, they were automatically classified into one of three color-coded levels (traffic lights), depending on the extent of deviation from the baseline values. The three levels were established by consensus among the research team, depending on the different combinations of measurements sent each day by a given patient: for example, a green alarm was cough increase or new appearance of mucus sputum; an orange alarm was a deterioration of every symptom or physiological measurement, including change of the sputum to “yellow”; a red alarm was any combination of deterioration of the variables recorded daily.

Once the patient data had been received, there were several possible courses of action. If all the data were classified as normal with respect to the previously established personalized thresholds, no action was taken. If the established threshold was exceeded an alarm was activated and a corresponding action plan was triggered. The first step was a nurse telephoning the patient or the caregiver. This phone call was used to confirm the alarm and its level of priority and attempt to resolve associated problems. If this action was not considered sufficient to address these problems and/or there were remaining concerns, the nurse had two options, depending on the severity of the alarm: waiting for the daily assessment of the patients by respiratory specialists (equivalent to a ward round) or contacting one of the respiratory specialists directly. At this point, it was the respiratory specialist who decided whether the patient should be referred to their primary care doctor, be assessed by a respiratory specialist of the program, or be sent to the hospital ED.

If it were decided that a patient should be assessed by a doctor in primary or specialized care, the program nurse contacted the doctor to arrange an appointment. An alert system warned the monitoring team if daily measurements had not been submitted.