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The prevalence and mortality rates of chronic obstructive pulmonary disease (COPD) are increasing worldwide. Therefore, COPD remains a major public health problem. There is a growing interest in the use of smartphone technology for health promotion and disease management interventions. However, the effectiveness of smartphones in reducing the number of patients having a COPD exacerbation is poorly understood.
To summarize and quantify the association between smartphone interventions and COPD exacerbations through a comprehensive systematic review and meta-analysis.
A comprehensive search strategy was conducted across relevant databases (PubMed, Embase, Cochrane, CINHA, PsycINFO, and the Cochrane Library Medline) from inception to October 2015. We included studies that assessed the use of smartphone interventions in the reduction of COPD exacerbations compared with usual care. Full-text studies were excluded if the investigators did not use a smartphone device or did not report on COPD exacerbations. Observational studies, abstracts, and reviews were also excluded. Two reviewers extracted the data and conducted a risk of bias assessment using the US Preventive Services Task Force quality rating criteria. A random effects model was used to meta-analyze the results from included studies. Pooled odds ratios were used to measure the effectiveness of smartphone interventions on COPD exacerbations. Heterogeneity was measured using the
Of the 245 unique citations screened, 6 studies were included in the qualitative synthesis. Studies were relatively small with less than 100 participants in each study (range 30 to 99) and follow-up ranged from 4-9 months. The mean age was 70.5 years (SD 5.6) and 74% (281/380) were male. The studies varied in terms of country, type of smartphone intervention, frequency of data collection from the participants, and the feedback strategy. Three studies were included in the meta-analysis. The overall assessment of potential bias of the studies that were included in the meta-analysis was “Good” for one study and “Fair” for 2 studies. The pooled random effects odds ratio of patients having an exacerbation was 0.20 in patients using a smartphone intervention (95% CI 0.07-0.62), a reduction of 80% for smartphone interventions compared with usual care. However, there was moderate heterogeneity across the included studies (
Although current literature on the role of smartphones in reducing COPD exacerbations is limited, findings from our review suggest that smartphones are useful in reducing the number of patients having a COPD exacerbation. Nevertheless, using smartphones require synergistic strategies to achieve the desired outcome. These results should be interpreted with caution due to the heterogeneity among the studies. Researchers should focus on conducting rigorous studies with adequately powered sample sizes to determine the validity and clinical utility of smartphone interventions in the management of COPD.
Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that includes chronic bronchitis and emphysema. Often, the occurrence of COPD is associated with smoking [
Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients [
The prevalence and mortality rates of COPD are increasing worldwide. Therefore, COPD remains a major public health problem. One of the major effects of COPD is a reduced physical activity level in the affected patients [
GOLD defines a COPD exacerbation as an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication [
Current advances in smartphones have allowed for opportunities to provide effective health promotion and disease management interventions. Several published studies indicate that smartphones can deliver effective interventions among various age groups and diseases [
Recent improvements in smartphones suggest a potential for integration into COPD management. Effective COPD management could delay disease progression, reduce acute exacerbations, and improve quality of life [
A thorough review of the literature is necessary to understand the gaps and challenges in the current use of smartphones in COPD management. It will inform the design of future smartphone apps that aim to limit COPD exacerbations. Therefore, we conducted a systematic review and meta-analysis to answer the following question:
In patients diagnosed with COPD, will using smart phone interventions, compared with not using smart phone interventions, reduce the number of patients that have at least one exacerbation?
We included randomized controlled trials and quasi-randomized studies that used smartphone interventions in patients with COPD. A smartphone was defined as a mobile phone that performs many of the functions of a computer, typically having a touchscreen interface, Internet access, and an operating system capable of running downloaded applications. Some smartphone interventions can also include the use of medical devices that transfer data to the smartphone or a Web-based platform for monitoring and analysis. Studies define COPD exacerbations differently due to the lack of a universally accepted objective definition of a COPD exacerbation. Some investigators define COPD based on drug use, reported symptoms, or emergency admission. As a result, we based our definition of exacerbation according to the GOLD criteria:
COPD exacerbation is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication [
Studies that included additional medical conditions as well as COPD were retained if the outcomes specific to the COPD group were reported separately. All English and non-English language studies identified during the search were considered. Non-English language studies included an English abstract. The abstract was sufficient to apply the eligibility criteria. Observational studies, abstracts, and reviews were excluded. Studies without a control group were also excluded. Smartphones are carried everywhere, have constant Internet connections, and are used as communication devices. Therefore, studies that used only a tablet or Web-based intervention and not specifically a smartphone intervention were excluded.
A comprehensive literature search was conducted in consultation with a librarian with experience in conducting systematic reviews. The literature search was run from the inception of each database until October 14, 2015 using the methods recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [
Search terms for systematic review.
Search lines | Search terms |
Line 1 | (((((((((“obstructive lung disease”[Title/Abstract]) OR copd[Title/Abstract]) OR coad[Title/Abstract]) OR “chronic obstructive pulmonary disease”[Title/Abstract]) OR “chronic obstructive lung disease”[Title/Abstract]) OR “chronic obstructive airway* disease”[Title/Abstract])) OR (((((“Lung Diseases, Obstructive”[Mesh]) OR “Pulmonary Disease, Chronic Obstructive”[Mesh]) OR “COPD, Severe Early-Onset”[Supplementary Concept]) OR “Pulmonary Emphysema”[Mesh]) OR “Bronchitis, Chronic”[Mesh]))) |
2. AND | (((((((((((((((((((((((((((((“mobile phone”[Title/Abstract]) OR “smart phone”[Title/Abstract]) OR smartphone[Title/Abstract]) OR “cell phone”[Title/Abstract]) OR “personal digital assistant”[Title/Abstract]) OR PDA[Title/Abstract]) OR microcomputer[Title/Abstract]) OR blackberry[Title/Abstract]) OR nokia[Title/Abstract]) OR samsung[Title/Abstract]) OR “i phone”[Title/Abstract]) OR iphone[Title/Abstract]) OR symbian[Title/Abstract]) OR windows[Title/Abstract]) OR INQ[Title/Abstract]) OR ipad[Title/Abstract]) OR “i pad”[Title/Abstract]) OR ipod[Title/Abstract]) OR “i pod”[Title/Abstract]) OR mhealth[Title/Abstract]) OR “mobile health”[Title/Abstract]) OR “m health”[Title/Abstract]) OR “m-health”[Title/Abstract]) OR app[Title/Abstract]) OR HTC[Title/Abstract]) OR samsung[Title/Abstract]) OR apps[Title/Abstract])) OR ((((“Cell Phones”[Mesh]) OR “Computers, Handheld”[Mesh]) OR “Text Messaging”[Mesh]) OR “Telemedicine”[Mesh])))) |
3. AND | ((“Disease Progression”[Mesh]) OR exacerbation[Title/Abstract]) |
Two authors (MA and WA) screened titles and abstracts for each unique citation. The screening process included removing duplicates and excluding studies that were not related to COPD or telemonitoring. The remaining full-text studies were then assessed for eligibility. Full-text studies were excluded if the investigators did not use a smartphone device or did not report on COPD exacerbations. The reviewers also included studies that reported the rate of COPD exacerbations in the intervention group but were not able to report the rate in the control group.
The remaining studies were assessed for potential bias according to the US Preventive Services Task Force (USPSTF) quality rating criteria [
Data were extracted regarding the study design, study procedure, intervention, population demographics, and number of patients having an exacerbation. Two reviewers (MA and WA) extracted data independently. Data from 3 studies were pooled using Review Manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) [
The study selection process is outlined in
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of search results and study selection. COPD: chronic obstructive pulmonary disease.
Six studies were included in the qualitative analysis.
The frequency of collecting data from participants was different between studies. Symptoms and objective measurements such as spirometry and pulse oximetry were collected on a daily basis. Alternatively, physical activity data were collected weekly. The investigators assessed collected data on a daily basis. When an exacerbation was detected, patients were contacted to confirm the exacerbation. One study used an automated feedback mechanism that advised to start medication in case of an exacerbation [
Characteristics of studies using smartphone interventions with COPD patients.
First author, (year) | COPDa stage | FEV1b, mean (SD), % predicted | Participant age (years), mean (SD), | Male |
Sample size |
No. of patients having an exacerbation | |||||
IGc | CGd | IG | CG | IG | CG | IG | CG | IG | CG | ||
Tabak, |
All stages |
48.7 |
56.4 |
65.2 (9.0) | 67.9 |
57% | 68% | 15 |
15 |
33 | N/Re |
Pedone, (2013) [ |
II or III | 52.5 (14.9) | 55.4 |
74.1 (6.4) | 75.4 |
72% | 63% | 50 |
49 |
9 | 15 |
Jehn, |
II-IV | 50.2 |
52.6 |
64.1 |
69.1 |
81% | 73% | 32 (32) | 30 (30) | 7 | 22 |
Halpin, (2011) |
All stages | 48 (4) | 54 (3) | 68.5 (1.5) | 70.2 (1.6) | 74% | 73% | 40 (39) | 39 (38) | 23 | 26 |
Nguyen, |
All stages | 49.0 (16.8) | 50.3 (17.6) | 68.0 (8.3) | 70.9 (8.6) | 61% | 55% | 26 (20) | 24 (19) | 10 | N/R |
Liu, |
II or III | 45.2(3.2) | 46 (2.8) | 71.4 (1.7) | 72.8 (1.3) | 100% | 100% | 30 (24) | 30 (24) | 2 | 10 |
aCOPD: Chronic Obstructive Pulmonary Disease.
bFEV1: Forced Expiratory Volume in one second.
cIG: Intervention Group.
dCG: Control Group.
eN/R: not reported.
Summary of the methodology in studies using smartphone interventions with COPD patients.
First author, (year) | Design |
Intervention (Frequency) | Control |
Tabak, |
RCTa |
Short respiratory symptoms questionnaires, exercise program and self-management recommendations on the Web portal (Daily); |
Usual care |
Pedone, (2013) |
RCT |
Heart rate, physical activity, near-body temperature, and galvanic skin response via wristband coupled with a smartphone (Every 3 hours); |
Usual care |
Jehn, |
RCT |
COPD Assessment Test on the smartphone (Daily); |
Usual care |
Halpin, (2011) |
RCT |
The Exacerbations of Chronic Pulmonary Disease Tool (EXACT) questionnaire on the smartphone (Daily); |
EXACT questionnaire on the smartphone |
Nguyen, (2008) |
RCT |
Exercise training program via smartphone (Daily); |
Usual care |
Liu, |
Home-based endurance exercise training program via smartphone (Daily); |
Usual care |
aRCT: Randomized Controlled Trial.
bNRCT: Nonrandomized Controlled Trial.
Three studies were included in the meta- analysis [
A summary of the assessment of potential bias of studies selected for inclusion, using USPSTF Quality Rating Criteria, can be found in
Effects of smartphone interventions on the number of patients having a COPD exacerbation.COPD: Chronic Obstructive Pulmonary Disease.
Assessment of potential bias of studies selected for inclusion using USPSTF Quality Rating Criteria [
Study | Assembly of comparable groups | Maintenance of comparable groups | No important differential loss to follow-up or overall high loss to follow-up | Measurements: equal, reliable, valid (includes masking of outcome assessment) | Clear definition of interventions | All-important outcome considered | Analysis: adjustment for potential confounders | Overall assessed quality |
Nguyen (2008) |
Good | Fair | Good | Fair | Good | Good | Poor | Fair |
Halpin (2011) |
Good | Good | Fair | Fair | Poor | Fair | Fair | Fair |
Pedone (2013) |
Fair | Good | Good | Fair | Good | Fair | Good | Fair |
Liu (2008) |
Fair | Good | Fair | Fair | Good | Good | Fair | Fair |
Jehn et (2013) |
Fair | Good | Good | Fair | Good | Good | Good | Good |
Tabak (2014) |
Poor | Fair | Poor | Fair | Good | Good | Fair | Poor |
The existing literature indicated that there is a potential for smartphone interventions in reducing the frequency of COPD exacerbations. Although most COPD patients were older than 65 years, they were able to use smartphones to monitor their symptoms. Rates of COPD exacerbations among participants receiving a smartphone intervention during the trials proved to be less compared with the participants not receiving a smartphone intervention. The main objective for using a smartphone is early identification of COPD exacerbations. Early identification allows the patient and health care team to intervene successfully, thus improving the management of COPD and reducing COPD exacerbations. As stated previously, Najafzadeh et al indicate that any intervention that reduces the number of exacerbations has a substantial impact on morbidity and costs of COPD [
Our finding that smartphones could be useful in reducing COPD exacerbations replicates the findings of 3 cohort studies. Jarad and Sund coupled a smartphone with a portable spirometer and indicated that it reduced the number of hospitalizations for COPD exacerbations [
Although the included studies reported promising results, there was moderate heterogeneity (
In many studies, the smartphone intervention was combined with different variations of symptoms diaries, physiological monitoring, and educational elements directed at patients. Patients used the smartphone to report daily symptoms [
The frequency of data collection from participants and feedback strategy also differed between the studies. Liu et al collected data from participants every day [
Only 2 studies reported on metrics related to user experience [
The frequency of data collection from the participant was also dependent on the type of data being collected. Symptoms were collected daily while exercise progress was assessed weekly. Collecting data from participants frequently could yield more accurate data; nevertheless, it must not compromise the participant’s adherence to the intervention. There are many factors that could have caused the reduction in COPD exacerbation. Early detection of symptoms and timely treatment could be possible by the use of smartphones or due to phone contact by the research team. Currently, we are uncertain whether the reduction in the number of patients having an exacerbation is caused by the smartphone intervention or merely due to bias among the studies. Additional investigations are required before large-scale implementation of smartphone interventions.
Aside from the methodological heterogeneity among studies, there are several limitations with this systematic review. There are a limited number of studies using smartphones in the management of COPD exacerbations, each with relatively small samples, less than 100 participants each. A comprehensive search strategy was used, but studies utilizing smartphones in the management of COPD exacerbations that are still in progress or provided only an abstract were excluded. All investigators provided a smartphone to participants. This could have caused highly motivated participants who are familiar with smartphones to contribute data. Another limitation is that studies did not clearly define exacerbations (recognized and unrecognized) and how to identify it (eg, drug use, reported symptoms, and emergency admission). Tabak used a self-management Web portal to measure exacerbations, which could have yielded many false positive results. The review favored smartphone interventions across all studies, thus overall findings do indicate that smartphone interventions may reduce the number of patients having COPD exacerbations across a wide variety of contexts.
Implementing a mixed methods research design to investigate the validity and clinical utility of smartphone interventions could help to understand why a particular component is successful and how patients will use smartphone interventions for a long-term. There is limited research regarding smartphone interventions among COPD patients. Although the studies in this review have a small sample size and a relatively short follow-up period, current literature supports the potential of smartphones in reducing COPD exacerbations. There is a need for more studies evaluating smartphone interventions, including studies using smartphones as the main intervention. This will assist in determining whether smartphones can be effective in the management of COPD. Investigators should include participants with different stages of COPD severity and age spans to minimize the risk of bias and enhance the generalizability of the study results.
Although the current literature on the role of smartphones in reducing COPD exacerbations is limited, our results suggest that smartphone interventions may reduce COPD exacerbations. Nevertheless, using smartphones require synergistic strategies to achieve the desired outcome. The results should be interpreted with caution due to the heterogeneity among the studies, risk of small study bias, and limitations in study quality. Researchers should focus on conducting rigorous randomized controlled trial (RCT) studies with adequately powered sample sizes to determine the validity and clinical utility of smartphone interventions in the management of COPD.
Control Group
Chronic Obstructive Pulmonary Disease
Forced Expiratory Volume in one second
Global initiative for chronic Obstructive Lung Disease
Intervention Group
Not Reported
Nonrandomized Controlled Trial
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
US Preventive Services Task Force
We acknowledge the assistance and feedback we received from Dr. Marshall Godwin and Dr. Douglas Dorward. We would like to thank Mrs. Michelle Swab for her assistance in designing the search strategy. JMG holds a New Investigator Award from the Canadian Institute of Health Research and a Clinician Scientist Award from the Canadian Diabetes Association.
None declared.