myCOPD to self-manage chronic obstructive pulmonary disease

Evidence suggests myCOPD has clinical benefits but this is uncertain

4.1 The committee noted that evidence from 4 comparative studies, including 3 randomised controlled trials, showed that myCOPD had clinical benefits. These included improved chronic obstructive pulmonary disease (COPD) assessment test scores, 6-minute walk test and inhaler technique. The committee accepted that there were trends towards clinical benefits, but all the studies had small sample sizes. Populations included in the studies were likely to be heterogeneous in terms of the severity of COPD and the eligibility for different health services such as pulmonary rehabilitation. In particular, RESCUE showed encouraging results but it was designed as a feasibility study. Therefore, the committee concluded that more good-quality evidence is needed (see section 4.10 about further research).

Evidence on the effect of myCOPD on healthcare resource use is needed

4.2 The committee noted the evidence on myCOPD's effect on healthcare resource use is limited. RESCUE showed that there were fewer hospital readmissions for acute exacerbation of COPD in people using myCOPD compared with people having usual care. But the difference was not statistically significant. There was evidence from the local evaluation (NHS Grampian suggesting fewer hospital admission but it was based on patient self-reported data (n=23) and potential for selection bias. There was no evidence on the number of consultations with healthcare professionals in primary and secondary care with myCOPD. The committee agreed that more evidence is needed to assess the effect of myCOPD on healthcare resource use.

Evidence on the longer-term benefits of using myCOPD is needed

4.3 The evidence from the peer-reviewed studies was relatively short-term follow-ups, mostly up to 3 months. The clinical experts advised that COPD is a chronic condition and on average people have 2 exacerbations every year. Therefore, 90 days may not be long enough to capture the potential benefits of using myCOPD. The committee considered that strong evidence on the longer-term benefits of using myCOPD was not available and concluded that further research is needed to explore this.

Usability and patient experience are key to myCOPD's success as a self-management tool

4.4 The committee heard from a commissioning expert from NHS Dorset Clinical Commissioning Group that the evaluation of digital health technologies is complex, and considerations should not only focus on the clinical benefits of the technology, but also the user experience and the usability of the technology. NICE's patient involvement programme survey showed that many people with COPD (83%, n= 297 of 359 people who responded) found the technology easy to use. However, the patient expert suggested there could be improvements, for example, the technology could include nudge messages to remind users to do pulmonary rehabilitation. The committee concluded that the usability and patient experience of the technology for both patients and the healthcare system are fundamental to its success. It considered that more data on patient experience using myCOPD would be valuable (see section 4.12).

Understanding why only some people continue using the app is important

4.5 The committee understood that myCOPD uptake varied widely across services and with people's preferences. The evidence showed that adherence to using myCOPD declines over time. The clinical expert noted that only 20% of people in their region still used the app after 2 years. The expert explained that the reason for the decrease remains unclear but people who tend to be motivated are likely to be engaged and continually use the app. The committee noted the subgroup analysis of NHS Highland data where people with the greatest degree of myCOPD engagement showed a reduction in bed days, and the EAC's comments that the most important aspect of improving the app's functionality going forward revolves around improving patient use and adherence. The committee understood that the nature of technology means that there are regular updates and refinements to the user experience, and it concluded an improved understanding of people's behaviour when using myCOPD is be important in future iterations to help improve engagement with and adherence to myCOPD.

myCOPD use in clinical practice for remote COPD monitoring requires integration with NHS software systems

4.6 The clinical expert explained that in their local evaluation, people used myCOPD as a self-management tool to collect and store all their COPD-related information in one place. The patient survey highlighted some general frustrations with users over a lack of integration with the healthcare system, including some confusion about whether healthcare practitioners were aware of the data, and whether they could access and respond to it. The company stated the technology can be integrated with systems using SystmOne (a software system used in the NHS that includes a person's health data, which has the capacity to integrate with other NHS software systems). Information can be shared with the patient's consent, but it is unclear to what extent such data is routinely used in clinical practice, and at present, there is no evidence on using myCOPD as part of shared care. The committee considered there needs to be a better understanding of how myCOPD should be integrated with the healthcare system to help with a supported self-management approach and improve understanding of using the technology in the NHS.

Improving patient engagement will increase the uptake and engagement with myCOPD but is likely to be an additional cost to the health service

4.7 The commissioning expert reported that there was an improvement in the app uptake in her clinical commission group, from 43% to 65%. Such an increase is achieved through support to help people engage. She described their approach of using company-funded digital health advisers to support the implementation of the technology in primary care. The commissioning expert stated that they provided support for people to register and set up the app. On-going support from the commissioning expert's CCG is provided at different time points via text messaging, face-to-face appointments, or over the phone, to help improve patient engagement. The committee understood that uptake of and adherence using myCOPD could be improved but this may affect NHS resources such as staff time which were not included in the cost model.

myCOPD requires users to be able to use a smart device and to understand English

4.8 myCOPD is only available in English. It is difficult to use for people who have limited English language skills. It is also difficult for people not able to use a smart device easily, such as people with a visual or cognitive impairment, or limited manual dexterity, or who are hard of hearing. The company said that myCOPD users could access via any smart device such as a phone, tablet or computer. The company is also working to improve the app accessibility and people may be able to access the app via a smart TV in the future. The committee concluded that computer literacy skills and English skills are needed to use myCOPD.

Further research would help identify people who are most likely to benefit from using myCOPD

4.9 The evidence showed that 2 population groups had clinical benefits with myCOPD (people discharged from hospital with an acute exacerbation of COPD [AECOPD] and people referred for pulmonary rehabilitation). There is currently no clinical consensus on which patients should be offered face-to-face pulmonary rehabilitation or myCOPD. The clinical expert explained that, in their NHS trust, myCOPD is offered to all people with COPD, regardless of patient characteristics. The commissioning expert stated that in primary care in Dorset, the technology is offered to 2 groups of people: those with the highest risk of having exacerbations and those at risk of their COPD becoming worse. Limited evidence from the local evaluations reported an association between clinical benefits and patient characteristics including demographics, disease severity and use of the technology. The committee agreed that there is no clear evidence on who myCOPD would most benefit, and that further research would be helpful to inform patient selection.

Uncertainties about the clinical benefits of myCOPD are reflected in the cost modelling

The committee understood that clinical parameters in the AECOPD model were based on RESCUE, a feasibility trial with fewer than 50 patients. It noted that the key drivers of cost-saving in this model were the uptake of myCOPD and hospital readmissions, and these parameters were uncertain because of the limitations in the evidence. Results from TROOPER were used in the pulmonary rehabilitation model. There were 3 treatment options in the intervention arm and people were able to choose myCOPD, face-to-face pulmonary rehabilitation (PR) and a hybrid model which consists of face-to-face sessions and myCOPD. Key drivers for cost-saving in this model were the uptake of myCOPD alone and a hybrid model, the number of people eligible for pulmonary rehabilitation and the cost of face-to-face pulmonary rehabilitation. The patient and clinical expert each advised that many people would prefer a face-to-face pulmonary rehabilitation programme. They also advised that the health service is moving towards a hybrid model which combines face-to-face and remote programmes. The committee agreed that variance in the uptake and high attrition rate contributed to the uncertainties in the economic modelling. The committee concluded that to inform the cost modelling, more evidence is needed about myCOPD's benefits in clinical practice.

Further good quality evidence is needed to address uncertainties about myCOPD's clinical benefits and its effects on healthcare resources

4.10 myCOPD has potential for clinical benefits, but more evidence is needed to reduce uncertainties. The committee considered that an adequately powered randomised controlled trial is needed to show the clinical benefits of using myCOPD and its healthcare resource use in both primary and secondary care. Evaluating the long-term effects of myCOPD compared with standard care is also important. In addition to clinical outcomes such as rates of exacerbations to help inform the economic model the trial should assess the following:

4.11 Qualitative data on patient experience using myCOPD such as patient preferences, the uptake of the app and adherence.