Digital technologies to support self-management of COPD: early value assessment

COPD is a long-term and progressive respiratory condition that can cause breathlessness, a persistent chesty cough, persistent wheezing, and frequent chest infections. The incidence of COPD in the UK is increasing (see section 3.2). COPD is a common cause of emergency hospital admissions, accounting for 1 in 8 UK hospital admissions. The National Asthma and COPD Audit Programme (NACAP) COPD clinical audit 2017 to 2018 (PDF only) reports that 23.9% of people are readmitted within 30 days and 43.2% within 90 days after discharge, highlighting the importance of effective self-management to prevent exacerbations and readmissions.

In 2020 to 2021, NHS Digital reported that about 1.17 million people (1.9% of the population) in England were diagnosed with COPD. It is estimated that a further 2 million people remain undiagnosed. Incidence of diagnosed COPD has risen from 1.7% to 1.9% of the population over the last 10 years. Chronic lower respiratory diseases were reported as the third most common cause of death in England and Wales in 2023 (Office for National Statistics, 2023). COPD is much more common in areas of high deprivation. People living in these areas have a lower life expectancy than the general population, and COPD is responsible for 8% of this difference in men and 12% in women. Managing COPD in the UK costs the NHS over £800 million a year.

The clinical experts and patient experts explained that barriers to implementation of the digital technologies would include:

• integration of the technology between care providers across the care pathway

• digital literacy and setting up the technology for users

• language and cultural considerations

• social and environmental factors

• additional resources needed in terms of healthcare professionals' time

• ensuring data that is captured is beneficial to users and healthcare professionals

• usability of the technologies.
  
  The clinical experts also explained that an additional barrier to implementing these technologies is ensuring that staff are not overburdened. The likelihood of this occurring likely depends on the amount and format of clinical information being shared, which may be difficult and time consuming for healthcare professionals to interpret. But clinical experts suggested that, because the technologies are to support self-management, less input may be needed from staff. Users should be better equipped to manage their condition themselves, seeking medical advice only if needed.

Patient experts explained that they thought that digital technologies were predominantly focused on supporting healthcare professionals, rather than people with COPD. One of the patient experts also emphasised that COPD management should be a partnership between healthcare professionals and the person with COPD (as well as carers, when applicable).

Although the patient experts had not used the technologies, they agreed that there may be potential benefits for the user that may be captured through getting user feedback. The patient experts suggested that the technologies should provide advice on triggers, like environmental factors, and tracking of routine symptoms that may cause a person's health to deteriorate and lead to an exacerbation. They suggested that having this information was equally as important as the general health monitoring aspects of the technologies.

Although the evidence base predominantly included people with more severe and established COPD, the patient experts stated that people with COPD should have access to these technologies early in the care pathway, from the point of diagnosis. They suggested that earlier intervention with supported self-management using digital technologies could delay the worsening of COPD. This would not only benefit people with COPD (and their carers, when applicable), but could also be cost saving to the NHS.

The patient experts suggested that these technologies could supplement routine primary care appointments, but not completely replace them, because they felt that there should still be clinical oversight from healthcare teams.

The committee discussed the potential of digital technologies to improve COPD care through effective self-management and to address the unmet need of people who are unable to access appointments with their healthcare team.

Clinical experts explained that digital technologies to support self-management can provide timely education and individualised COPD plans. This includes exacerbation action plans for people at risk of exacerbations, in line with NICE's guideline on COPD in over 16s: diagnosis and management. These technologies can also improve other aspects of COPD care, including inhaler technique and recognising exacerbations. The clinical experts emphasised that people with COPD would still need face-to-face reviews at least annually, even when using digital technologies for self-management. They explained that people with COPD should be on the primary care COPD register and should attend a follow-up review in primary care at least once a year, and more often if needed. Both patient experts and clinical experts thought that these technologies may help provide information for the annual review, ideally through an integrated system that is accessible by patients, carers and healthcare professionals. The committee agreed that digital technologies to support self-management would provide another option for people with COPD, but they would not completely replace all appointments in the care pathway.

Because of the wide range of features in the digital technologies that contribute to self-management, the committee wanted to clarify which aspects of the technologies are most useful for self-management. The committee considered that remote patient monitoring might not be a tool used regularly because self-management of COPD should generally function independently of clinical oversight from the healthcare team. A clinical expert noted that remote monitoring may be beneficial during periods of increased risk such as after an exacerbation. The experts stated that people with more severe COPD might need additional face-to-face care rather than self-management. The committee suggested that stratification according to the severity of COPD and the features of the technologies would be useful when generating evidence to help inform practice.

Equality considerations highlighted to the committee included general and digital literacy, speaking a different language to English or having English as a second language, and access to equipment and internet. The committee recognised that additional support and resources may be needed for people who are unfamiliar with digital technologies or who do not have access to smart devices or the internet. Most of the companies stated that their technologies are available in other languages. The companies also stated that they promote engagement and digital inclusion by supporting people with onboarding and training when the technology is initially prescribed. One company indicated that socially and economically deprived areas show a higher uptake of digital health services relative to less deprived areas. The committee understood that additional support may be needed for people with accessibility needs or who are unable to read or understand English. But the digital technologies are not intended to replace face-to-face contact so usual care will still be an available option for people with COPD.

A cost-comparison model was developed to assess the potential benefits of the technologies over a 1‑year period. Limited evidence was available to model the potential impact of digital technologies to support self-management of COPD. The model focused on estimating resource use, such as GP visits, non-hospitalised exacerbations and hospitalisations. The EAG excluded costs related to mortality to avoid double-counting. The effectiveness of the digital technologies was evaluated based on potential reductions in resource use.

The results of the economic modelling suggested a potential cost saving of £337 per person when using digital technologies compared with standard care. The committee acknowledged uncertainties in the data used to inform the modelling, particularly the impact of digital technologies on healthcare resource use, such as hospitalisations because of COPD. The committee also noted that, because the data predominantly came from people with severe COPD, the results may report a higher potential benefit than may be the case for people with less severe COPD, particularly for those recently experiencing acute exacerbations. Both the committee and clinical experts agreed that the average hospital admissions used in the economic model represented a more severe COPD cohort compared to mild-to-moderate cases and this should be considered when interpreting the results.

The only difference in the economic model between the different technologies was the cost of the technology, because all other assumptions remained constant. Costs varied among companies, affecting the assessment when comparing technologies based on price alone. The EAG highlighted that one limitation of the model was pricing uncertainty because of different factors, including setup fees, licence fees varying depending on number of users, and the possibility that some technologies may offer medical devices as part of their package (which was not costed). The economically justifiable price was estimated at £620 per person, with 1 technology exceeding this cost. The results are indicative and not perfectly representative of all digital technology providers.

The committee noted that the results should be considered cautiously because of the limitations of the clinical evidence informing the modelling. The comparative effectiveness of digital interventions was unclear, particularly in mixed or unclear treatment settings. Some studies showed benefits, but others did not, reflecting the heterogeneous nature of the evidence and varied methodologies used. Potential improvements in COPD management using digital technologies were indicated by improvements in COPD Assessment Test scores, inhaler use, and reductions in exacerbations and admissions. But results were mixed and somewhat inconsistent across different patient populations and studies.

Sensitivity and scenario-based analysis indicated that digital technologies generally remained cost saving except in scenarios with the highest costs of the digital technologies, and when there was no reduction in hospitalisation rates. The cost of hospitalisation in the base case, based on the latest NHS cost data, was significantly higher than in previous iterations. So, using a lower cost for hospitalisation reduced the cost-saving potential of digital technologies.

The committee agreed that the general direction of efficacy data for digital technologies was positive, suggesting improvements over standard care. By reducing hospitalisations, exacerbations and GP visits, digital technologies to support self-management of COPD are likely to be cost saving rather than cost incurring.

For all the technologies, the evidence gaps related to the population, intervention and outcomes, including resource use and health-related quality of life.