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Meta-Analysis
. 2016 Aug 3;2016(8):CD011714.
doi: 10.1002/14651858.CD011714.pub2.

Home telemonitoring and remote feedback between clinic visits for asthma

Kayleigh M Kew  1 , Christopher J Cates
Affiliations
Meta-Analysis

Home telemonitoring and remote feedback between clinic visits for asthma

Kayleigh M Kew et al. Cochrane Database Syst Rev. .

Abstract

Background: Asthma is a chronic disease that causes reversible narrowing of the airways due to bronchoconstriction, inflammation and mucus production. Asthma continues to be associated with significant avoidable morbidity and mortality. Self management facilitated by a healthcare professional is important to keep symptoms controlled and to prevent exacerbations.Telephone and Internet technologies can now be used by patients to measure lung function and asthma symptoms at home. Patients can then share this information electronically with their healthcare provider, who can provide feedback between clinic visits. Technology can be used in this manner to improve health outcomes and prevent the need for emergency treatment for people with asthma and other long-term health conditions.

Objectives: To assess the efficacy and safety of home telemonitoring with healthcare professional feedback between clinic visits, compared with usual care.

Search methods: We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to May 2016. We also searched www.clinicaltrials.gov, the World Health Organization (WHO) trials portal and reference lists of other reviews, and we contacted trial authors to ask for additional information.

Selection criteria: We included parallel randomised controlled trials (RCTs) of adults or children with asthma in which any form of technology was used to measure and share asthma monitoring data with a healthcare provider between clinic visits, compared with other monitoring or usual care. We excluded trials in which technologies were used for monitoring with no input from a doctor or nurse. We included studies reported as full-text articles, those published as abstracts only and unpublished data.

Data collection and analysis: Two review authors screened the search and independently extracted risk of bias and numerical data, resolving disagreements by consensus.We analysed dichotomous data as odds ratios (ORs) while using study participants as the unit of analysis, and continuous data as mean differences (MDs) while using random-effects models. We rated evidence for all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach.

Main results: We found 18 studies including 2268 participants: 12 in adults, 5 in children and one in individuals from both age groups. Studies generally recruited people with mild to moderate persistent asthma and followed them for between three and 12 months. People in the intervention group were given one of a variety of technologies to record and share their symptoms (text messaging, Web systems or phone calls), compared with a group of people who received usual care or a control intervention.Evidence from these studies did not show clearly whether asthma telemonitoring with feedback from a healthcare professional increases or decreases the odds of exacerbations that require a course of oral steroids (OR 0.93, 95% confidence Interval (CI) 0.60 to 1.44; 466 participants; four studies), a visit to the emergency department (OR 0.75, 95% CI 0.36 to 1.58; 1018 participants; eight studies) or a stay in hospital (OR 0.56, 95% CI 0.21 to 1.49; 1042 participants; 10 studies) compared with usual care. Our confidence was limited by imprecision in all three primary outcomes. Evidence quality ratings ranged from moderate to very low. None of the studies recorded serious or non-serious adverse events separately from asthma exacerbations.Evidence for measures of asthma control was imprecise and inconsistent, revealing possible benefit over usual care for quality of life (MD 0.23, 95% CI 0.01 to 0.45; 796 participants; six studies; I(2) = 54%), but the effect was small and study results varied. Telemonitoring interventions may provide additional benefit for two measures of lung function.

Authors' conclusions: Current evidence does not support the widespread implementation of telemonitoring with healthcare provider feedback between asthma clinic visits. Studies have not yet proven that additional telemonitoring strategies lead to better symptom control or reduced need for oral steroids over usual asthma care, nor have they ruled out unintended harms. Investigators noted small benefits for quality of life, but these are subject to risk of bias, as the studies were unblinded. Similarly, some benefits for lung function are uncertain owing to possible attrition bias.Larger pragmatic studies in children and adults could better determine the real-world benefits of these interventions for preventing exacerbations and avoiding harms; it is difficult to generalise results from this review because benefits may be explained at least in part by the increased attention participants receive by taking part in clinical trials. Qualitative studies could inform future research by focusing on patient and provider preferences, or by identifying subgroups of patients who are more likely to attain benefit from closer monitoring, such as those who have frequent asthma attacks.

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Conflict of interest statement

Kayleigh Kew: none.

Christopher Cates: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 1 Exacerbations requiring oral corticosteroids (subgrouped by age).
1.2
1.2. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 2 Exacerbations requiring ED visit (subgrouped by age).
1.3
1.3. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 3 Exacerbations requiring hospital admission (subgrouped by age).
1.4
1.4. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 4 Asthma control (ACQ).
1.5
1.5. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 5 Asthma control (ACT).
1.6
1.6. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 6 ACT > 19 (well controlled).
1.7
1.7. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 7 Asthma‐related quality of life (AQLQ).
1.8
1.8. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 8 Lung function (trough FEV1).
1.9
1.9. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 9 Lung function (change in PEF L/min).
1.10
1.10. Analysis
Comparison 1 Home telemonitoring with feedback vs usual monitoring, Outcome 10 Unscheduled healthcare visits.
2.1
2.1. Analysis
Comparison 2 Type of technology subgroups, Outcome 1 Exacerbations requiring oral corticosteroids.
2.2
2.2. Analysis
Comparison 2 Type of technology subgroups, Outcome 2 Exacerbations requiring ED visit.
2.3
2.3. Analysis
Comparison 2 Type of technology subgroups, Outcome 3 Exacerbations requiring hospital admission.
See this image and copyright information in PMC

Update of

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NCT00964301 {published data only}
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Osman 1997 {published data only}
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Zairina 2015 {published data only}
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References to studies awaiting assessment

Ricci 2001 {published data only}
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References to ongoing studies

Ahmed 2011 {published data only}
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References to other published versions of this review

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Publication types