Adherence to e-Health Self-management Tool Was High yet Inadequate for Patients With COPD and Heart Failure

Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure were adherent to an e-health self-management intervention but were often not responsive when advised to call medical personnel because of concerning symptoms.

Although patients with chronic obstructive pulmonary disease (COPD) coupled with chronic heart failure (CHF) were adherent overall with completing an e-health self-management tool, improvements are needed to ensure best practices for home-based care among patients, according to a pilot study.

The study, published in the International Journal of Chronic Obstructive Pulmonary Disease, tested an e-health tablet-based platform, finding that patients with COPD and CHF often did not take actions suggested by the self-management intervention and often used their inhaled medications incorrectly.

“This pilot study gives insight into how to further develop the eHealth self-management intervention. For this, personalizing and tailoring to an individual patient’s needs and competences are essential,” wrote the investigators.

COPD and CHF share periods of acute symptom deterioration and have similar risk factors and symptoms, including dyspnea. Between 7.5% and 31.3% of patients with COPD also have CHF. Because of overlapping symptoms, initiating treatment may be delayed, causing patients to have an increased disease burden and health care costs.

Self-management interventions typically contain multiple individualized components aimed at improving patients’ health behavior and self-management skills. Evidence has shown that self-management strategies can improve patient quality of life, respiratory- and CHF-related hospitalization rates, all-cause death rates, and dyspnea. However, previous studies have shown poor adherence rates.

e-Health platforms have the added benefits of providing tailored information, giving reminders for completing tasks and taking medications, and adapting to patient needs. Different intervention components delivered using e-health tools have not been explored previously in patients with both COPD and CHF.

The patients participated in 3 self-management training sessions in September and October 2018 prior to receiving the e-health tool for up to 4 months (early October 2018 to early February 2019). They were recruited from 2 hospitals in the Netherlands: Medisch Spectrum Twente (MST) Enschede and Ziekenhuisgroep Twente (ZGT) Almelo and Hengelo.

Patients had to have a diagnosis of both COPD and CHF, have 2 or more exacerbations or 1 or more hospitalizations between the 2 years prior and 1 week prior to the study, be 40 years or older, and be able to use a tablet.

The e-health application contained daily diaries for patients to record their symptom changes, automated messages for actions to take if symptoms reached concerning levels, and an inhaler model that monitored technique and daily adherence. The patients were trained on how to enter information into the tool and how to connect the tool to the internet.

After 50 patients from MST and 3 from ZGT met the study criteria, 11 patients were examined after exclusion. The patients had a mean (SD) age of 66.8 (2.9) years, and 55.0% (n = 6) had moderate COPD and 45.0% (n = 5) had severe COPD. Five (46%) patients had midrange left ventricular function (LVF) and 3 (27.0%) had reduced LVF.

The 11 patients produced 1148 daily diaries. Seven patients received a total of 24 advised actions because increased symptoms did not subside after 2 days. Only 11 (46%) advised actions were followed up on. Among the 13 (54%) unperformed actions, 6 were “call the case manager” for dizziness. Investigators said that patients may not have felt that their dizziness was serious enough to warrant a case manager call.

Adherence to inhaled medications was high (98.4%). However, 51.9% of inhalations were done incorrectly. “Inhaling too shortly” (<1.25 s) was the most frequent error, accounting for 79.6% of errors.

“In the future, prompt, specified and correct information about individual inhalations that is recorded by the sensor, may be helpful to improve inhalation technique,” said the investigators.

Limitations of the study included the limited generalizability due to the small sample size and technical issues with the e-health tool, such as connection problems, low batteries, diary entry duplication, and absent messages advising patients to take medication for chest pain symptoms. Although no adverse events occurred during the study, technical issues did lead to patient frustration and distrust in the application.

“In follow-up studies, the technology should therefore be intensively tested upfront together with its end users…ensure its suitability for larger scale summative evaluation,” the investigators noted.

The investigators said that future studies should assess patient willingness to change behaviors, increase adjustability of e-health self-management interventions to account for baseline health literacy and cognitive impairment, identify adherence barriers, and analyze the effects of the intervention on health outcomes.


Sloots J, Bakker M, van der Palen, et al. Adherence to an eHealth self-management intervention for patients with both COPD and heart failure: results of a pilot study. Int J Chron Obstruct Pulmon Dis. 2021;2021(16):2089-2103. doi:10.2147/COPD.S299598

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