Determining If COPD Self-Management Televisit-Based Interventions Are Evaluated Among and Equitably Effective Across Diverse Patient Populations to Reduce Acute Care Use

Abstract

Topic Importance

With telemedicine’s expansion during the COVID-19 pandemic, it has become critical to evaluate whether patients have equitable access to and capabilities to use televisits optimally for improved COPD outcomes such as reduced hospitalizations. This scoping review evaluated whether televisit-based interventions are evaluated among and equitably effective in improving health care use outcomes among diverse patient populations with COPD.

Review Findings

Using a systematic search for televisit-based COPD self-management interventions, we found 20 studies for inclusion, all but one of which were published before the COVID-19 pandemic. Most (11 of 20) were considered good-quality studies. Most studies (19 of 20) reported age and sex; few provided race (3 of 20) or income (1 of 20) data. The most frequently used televisit-based methods were in-person plus phone (6 of 20), video only (6 of 20), and phone only (4 of 20). Most studies (12 of 20) showed a significant reduction in at least one health care use metric; nine studies found hospitalization-related reductions. Effective interventions typically used two methods (eg, in-person plus televisits), video methods, or both.

Summary

Most studies failed to report on participants’ race or income, leading to a lack of data on the equity of interventions’ effectiveness across diverse patient populations. Multimethod televisit-based interventions, particularly with an in-person component, most commonly were effective; no associations were seen with study quality or size. With the increasing reliance on telemedicine to provide chronic disease care, the lack of data among diverse populations since the COVID-19 pandemic began limits generalizability of these findings for real-world clinical settings. More comprehensive evaluations of televisit-based interventions are needed in the era after the pandemic within and across diverse patient populations.

Given the widespread uptake of telemedicine since the COVID-19 pandemic began,¹ it is imperative to evaluate televisits for their accessibility and effectiveness. Within the context of COPD, televisits have the potential to provide virtual clinical care, self-management education, and even pulmonary rehabilitation, reducing high-resource burdens such as travel time and costs. However, barriers, preferences, or both may affect some populations inequitably, such as differential access to technology through limited broadband or Wi-Fi connectivity, low electronic health literacy levels, and cost barriers (eg, data).²

Regarding COPD self-management education, televisits increase options to address in-person clinic visit time limitations,³ as a care transition approach to reduce readmissions, or both. However, patients with COPD may face the same general televisit barriers noted above and additionally may not recognize the importance of self-management education, such that they may not prioritize self-management televisits.

Therefore, a better understanding is needed of the role of televisits in delivering COPD self-management education to reduce hospitalizations, with attention to understanding potential inequities in access and use of technology-based interventions, across diverse patient populations.^{1,4, 5, 6} Other reviews have evaluated the effectiveness of televisit-based interventions for patients with COPD, although their focus primarily has been on remote monitoring^7,8 and mobile applications,⁹ with less of a focus on diverse patient populations and synchronous televisit-based self-management education specifically. Therefore, the objective of this scoping review was to evaluate whether televisit-based self-management interventions are evaluated among and equitably effective in improving health care use outcomes among diverse patients with COPD.

Literature Search

The review followed scoping review reference frameworks^{10, 11, 12} and was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.¹³ The focus on synchronous visits related to ability to bill for televisits, broadening dissemination potential,^15,16 and to fill gaps in existing published telemedicine reviews.^{7, 8, 9} The primary focus on hospitalizations and rehospitalizations was the result of Medicare’s Hospital Readmissions Reduction Program.¹⁷

Scoping Review Question

Are televisit-based self-management interventions evaluated among and equitably effective in improving health care use and other outcomes among diverse patients with COPD?

Eligibility Criteria, Information Sources, and Search Strategy

Original research articles written in English and meeting the following population, intervention, comparator, outcome criteria were included: the population comprised adult patients with COPD; the intervention was synchronous televisit-based interventions for COPD self-management; the comparators were before and after, usual care, other intervention; the primary outcome was hospitalization or rehospitalizations; and the secondary outcomes were ED visits, length of stay or hospital days, and clinical and self-management outcomes.

Searches were conducted by independent reviewers (M. A., M. N., and V. G. P.) in consultation with a medical librarian for relevant English-language publications in PubMed, the Cumulative Index to Nursing and Allied Health database, PsycINFO, and Google Scholar without date restrictions including for the following terms: telemedicine, ehealth, COPD, education, self-management, hospitalizations, and readmissions and synonyms (e-Fig 1); references lists also were reviewed. The finalized search strategy was reviewed (F. O., V. G. P.) using a modified Peer Review of Electronic Search Strategies evidence-based checklist.¹⁴

Screening, Data Extraction, and Data Analysis and Synthesis

All identified studies were uploaded into Zotero (Corporation for Digital Scholarship); duplicates were removed. Study titles and abstracts were screened by two reviewers (M. A., M. N.), followed by full-text reviews (M. A., M. N.) using separate extraction forms in a REDCap (Vanderbilt University) database¹⁸; disagreements between reviewers were resolved in discussion with the senior author (V. G. P.) (Table 1, Fig 1). Extracted data included study design, quality, and location; participant demographic data; televisit method; self-management components; and health care use (hospitalizations, ED visits, and length of stay). Study quality was assessed using the 14-point National Institutes of Health Study Quality Assessment of Controlled Intervention Studies tool (good, 11-14; fair, 6-10; and poor, 0-5).¹⁹ Data were analyzed and synthesized according to study quality, timing (before vs after the COVID-19 pandemic), diversity-related factors such as participant demographic features (eg, age, sex, income, and race) and study location data (ie, continent, country, setting [urban, suburban, or rural]); televisit method (in-person plus phone or video, phone only, video only, other); focus of health care use population (COPD related vs all cause); and timing of outcomes (eg, 30 days, 90 days, 12 months, and so forth).

Table 1.

Study Characteristics

Author (Year) Recruitment Period Location	Study Design Study Quality No. (Enrolled)/ (Analyzed)	Targeted Patient Population Modality	Age, mean (SD)	Sex, No. (%)	Race, No. (%)	Education, No. (%)	Income	Smoking Status, No. (%)	COPD GOLD Status
Wong et al29 (2005) Not specified Hong Kong	RCT Good 60 (30 intervention, 30 control)/56	COPD diagnosis, admitted to acute care hospital Phone	73.6 (7.8)	Male: 47 (78.3)	NR	No education: 20 (33.3) No formal education: 17 (28.3) Primary education: 16 (26.7) Secondary education or higher: 7 (11.7)	NR	Current: 10 (16.7)	NR
Casas et al27 (2006) Not specified Spain and Belgium (2 hospitals: 1 in Spain and 1 in Belgium)	RCT Good 155 (65 intervention, 90 control)/6 mo: 131 (55 intervention, 76 control) 12 mo: 120 (48 intervention, 72 control)	Admitted because of AE of COPD episode lasting > 48 h In-person plus phone	70 (9) intervention, 72 (9) control	Female: 15 (23) intervention, 11 (12) control	NR	Education less than primary: 16 (25) intervention, 20 (22) control	NR	Current: 21 (32) intervention, 19 (21) control	NR
Rice et al25 (2010) Not specified United States (5 VA health centers)	RCT Good 743 (372 intervention, 371 control)/659 (336 intervention, 323 control)	VA patients at high risk for hospitalization based on COPD hospital admission or ED visit, long-term home oxygen use, or course of systemic corticosteroids for COPD in the past year In-person plus phone	69.1 (9.4) intervention, 70.7 (9.7) control	Male: 363 (97.6) intervention, 365 (98.4) control	NR	NR	NR	NR	NR
Sorknaes et al20 (2011) June 2007-March 2008; August 2008-January 2009 Denmark	Quasi-experimental Poor 102 (52 intervention, 50 control)/100 (50 intervention, 50 control)	Admitted with AE of COPD Phone plus video	NR	NR	NR	NR	NR	NR	NR
Sorknaes et al20 (2013) May 2010-October 2011 Denmark (2 hospitals)	RCT Good 266 (132 intervention, 134 control)/242 (121 intervention, 121 control)	Admitted with AE of COPD Video	71 (10) intervention, 72 (9) control	Female: 79 (60) intervention, 83 (56) control	NR	Completed an education/training: 41 (59) intervention, 35 (70) control	NR	Current: 60 (37) intervention, 63 (34) control Former: 78 (60) intervention, 85 (63) control Never: 4 (3) intervention, 3 (2) control	NR
Blumenthal et al21 (2014) January 2009-May 2013 (study period) United States (2 hospitals: 1 in North Carolina, 1 in Ohio)	RCT Good 326 (162 intervention, 164 control)/326 for ITT analysis (162 intervention, 164 control)	Patients with COPD diagnosis and caregiver willing to participate Phone	66.1 (8.3)	Male: 199 (61)	White: 285 (87)	Education ≥ high school: 280 (86)	Income > $50,000: 111 (34)	Current: 58 (18) Former: 253 (78) Never: 13 (4)	A: 29 (9) B: 93 (29) C: 15 (5) D: 184 (57)
Wei et al30 (2014) February 2012-January 2014 (study period) China	RCT Fair 117 (58 intervention, 59 control)/ completed intervention: 104 (51 intervention, 53 control) Completed 1 y follow-up: 87 (42 intervention, 45 control)	Patients nonadherent with stable COPD and at least 2 consecutive COPD hospitalizations In-person plus phone	65.2 (8.1) intervention, 63.9 (6.2) control	Female: 20 (34.5) intervention, 19 (32.2) control	NR	< 6 y of education: 31 (53.4) intervention, 27 (45.8) control	NR	Current: 17 (29.3) intervention, 21 (35.6) control	NR
Dyrvig et al39 (2015) January 2009-December 2013 (retrospective chart review covering 5-y period) Norway	Before and after Fair 11,303/11,303	Admitted with AE of COPD Video	Before RCT: 72.85 (9.31) intervention, 71.68 (11.72) control	Female, before RCT: 113 (54.85) intervention, 2,804 (51.12) control	NR	NR	NR	NR	NR
Saleh et al32 (2014) April 2010-December 2011 (retrospective observational study of this pilot period) Norway	Before and after Fair 99/99	Patient with COPD monitored after discharge or as part of outpatient treatment Video	70.6 (0.95)	Male: 45 (45.9)	NR	NR	NR	Current: 27 (27.3) Former: 69 (69.7)	GOLD 4 (very severe): 27 (27.3)
Billington et al33 (2015) May-November 2012 (study period) England	RCT Good 73 (35 intervention, 38 control)/71 (34 intervention, 37 control)	On the COPD register, living in community, and managed in primary care Phone	72.09 (9.24) intervention, 71.97 (11.04) control	Male: 18 intervention, 17 control	NR	NR	NR	Current: 20(57) intervention, 19(50) control Former: 10(29) intervention, 11(29) control Never: 5(14) intervention, 8(21) control	Mild: 12 intervention, 18 control Moderate: 23 intervention, 20 control
Benzo et al24 (2016) September 2010-August 2014 (study period) United States (2 hospitals in Minnesota)	RCT Good 215 (108 intervention, 107 control)/214 (108 intervention, 106 control)	Admitted with COPD In-person plus phone	67.9 (9.8) intervention, 68.1 (9.2) control	Male: 46 (43) intervention, 51 (48) control	NR	Post-secondary education: 55 (54) intervention, 48 (48) control	NR	NR	NR
Lavesen et al34 (2016) December 2010-May 2012 Denmark	RCT Good 244 (122 intervention, 122 control)/day 30: 190 (105 intervention, 85 control) Day 84: 178 (101 intervention, 77 control)	Admitted and received a diagnosis of AE of COPD or COPD with pneumonia Phone	69.72 (10.3) intervention, 70.90 (9.79 control)	Male: 46 (38.7) intervention, 37 (39.4) control	NR	NR	NR	Current: 49 (41.2) intervention, 35 (37.6) control Former: 66 (55.4) intervention vs 57 (61.3) control	NR
Vasilopoulou et al35 (2017) December 2013-July 2015 (when patients completed initial PR) Greece	RCT Good 150 (50 virtual maintenacne rehab, 50 in-person maintenance rehab, 50 usual care)/147 (47 virtual maintenacne rehab, 50 in-person maintenance rehab, 50 usual care)	Patients with a COPD diagnosis, optimal medical treatment according to GOLD standards, and AE of COPD 1 y before study. Patients with difficulty using electronic devices and patients with nonoptimal pharmacotherapy were excluded. In-person plus phone or video	66.9 (9.6) virtual maintenance rehabilitation, 66.7 (7.3) in-person maintenance rehabilitation, 64.0 (8.0) usual care	Female: 3 virtual maintenance rehab, 12 in-person maintenance rehabilitation, 13 usual care Male: 44 virtual maintenance rehabilitation, 38 in-person maintenance rehabilitation, 37 usual care	NR	NR	NR	Current: 7 virtual maintenance rehabilitation, 4 in-person maintenance rehabilitation, 3 usual care Former: 40 virtual maintenance rehabilitation, 46 in-person maintenance rehabilitation, 47 usual care	NR
Zanaboni et al31 (2017) January 2012 to May 2012; follow-up visits held in June 2013 and May 2014 Norway	Before and after Poor 10/10	Patients with moderate-severe COPD who completed 4 wk of inpatient pulmonary rehabilitation. Patients whose home environments were not compatible with the intervention (eg, lacked internet connection, lacked space) were excluded. In-person plus video	55.2 (6.1)	Female: 5 (50) Male: 5 (50)	NR	Secondary: 1(10) High school: 7(70) University/university college: 2(20)	NR	NR	NR
Rose et al26 (2018) August 2012-March 2015 Canada	RCT Fair 475 (237 intervention, 238 control)/398 completed (207 intervention, 191 control)	At least 1 ED visit or hospital admission in past y and at least 2 prognostically important COPD comorbidities In-person plus phone	71 (9.2) intervention, 71 (9.7) control	Male: 117 (50) intervention, 103 (44) control	NR	Education less than high school: 89 (39) intervention, 86 (39) control Limited or simple reading level: 46 (20) intervention, 55 (24) control	NR	Current: 53 (23) intervention, 59 (26) control Former: 176 (75) intervention, 159 (69) control	NR
Kessler et al38 (2018) September 2010-March 2015 (study period) Europe (33 sites: 12 sites in France, 8 sites in Germany, 7 sites in Spain, and 6 sites in Italy)	RCT Good 345 (172 intervention, 173 control)/319 (157 invervention, 162 control)-ITT analysis	At least 1 severe AE of COPD in the past year In-person plus phone	66.9 (9.3)	Female: 97 (30.4) Male: 222 (69.6)	NR	NR	NR	Current: 68 (21.3)	A: 9 (2.9) B: 9 (2.9) C: 43 (14.0) D: 246 (80.1)
Locke et al22 (2019) January 2014-March 2016 (chart review of program that occurred during this period) United States (Seattle, Washington)	Before and after Fair 74/69	Rural VA patients who participated in video inhaler teaching Video	69.2 (8.5)	Male: 74 (100)	White: 69 (93.2)	NR	NR	NR	NR
Bhatt et al23 (2019) March 2015 - not specified United States (Alabama)	Quasi-experimental Fair 240 (80 intervention, 160 control)/240 (80 intervention, 160 control)	Patients hospitalized with a COPD exacerbation Video	64.5 (10.1) intervention, 63.4 (11.8) control	Female: 49 (61.3) intervention vs 92 (57.5) control	Black or African American: 26 (32.5) intervention vs 57 (35.6) control	NR	NR	Current: 21 (26.3) intervention vs. 60 (37.5) control	NR
Hansen et al36 (2020) March 2016 - October 2017 Denmark (8 respiratory departments)	RCT Good 134 (67 intervention vs 67 control)/134 (67 intervention vs 67 control)-ITT analysis	Patients from 8 university respiratory departments who had a COPD diagnosis Video	74 (55)	Female: 55 (74)	NR	NR	NR	Current: 30 (23) Former: 99 (75) Never: 3 (2)	Severe: 61% Very severe: 39%
Howard et al37 (2022) January 2021-June 2021 Spirometry testing to confirm COPD diagnosis could not be completed because of COVID-19 restriction. This was the biggest reason for exclusion (n=16) United States (Tennessee Valley)	Before and after Poor 18/11	Patients with COPD treated at the VA assigned to a primary care team Phone or video	67(5)	Male: 11 (100)	NR	NR	NR	Current: 5 (45)	1: 0 (0) 2: 4 (36) 3: 2 (18) 4: 1 (9)

AE = acute exacerbation; GOLD = Global Initiative for Chronic Obstructive Lung Disease; ITT = intention-to-treat; NR = not reported; PR = pulmonary rehab; RCT = randomized controlled trial; VA = Veterans Affairs.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews flow diagram. Of the total 643 records (502 + 141) that were removed after screening, nine records were excluded because they were not written in English, 191 records were excluded because they did not measure a health care use outcome, 106 records were review articles, 89 records were excluded because they were editorials, 191 records were excluded because the intervention studied was not a televisit, 27 records were excluded because they did not study COPD-specific populations, and 30 records were excluded for other reasons.

Evidence Review

Selection of Sources of Evidence

Of 941 articles screened, 880 were excluded, leading to extraction of 161 full-text articles with an additional 141 articles excluded, resulting in 20 included studies (Fig 1). Primary reasons for exclusion were duplicates (n = 309) and not meeting inclusion criteria (n = 191), being an intervention study (n = 195), assessing televisit-related interventions (n = 191), not being focused on COPD populations (n = 27), or a combination thereof.

Population Demographics

All but one study²⁰ reported age and sex. Only three studies reported race (two study populations were majority White, ranging from 87% to 93%^21,22; one study population was one-third African American²³). Only one study reported on income (34% with income > $50,000 in the United States) (Table 1).²¹ Most studies reported age and sex of participants; only four studies reported subgroup analyses by age, sex, or both,^{20,24, 25, 26} and only one study reported on readmissions among age or sex subgroups.²⁵ The mean age of patients ranged from 55 to 74 years. The sex distribution varied across studies, although it tended to skew male (ranging from 26% to 100%). Nine studies reported education level^{21,27, 28, 29, 30, 31, 32, 33}; one study reported on literacy.²⁴ Fourteen studies reported smoking status,^{21,23, 24, 25,29, 30, 31, 32,34, 35, 36, 37, 38, 39} and six studies reported Global Initiative for Obstructive Lung Disease classification.^{21,25,34,37, 38, 39} Two studies targeted high-risk patients.^24,28 Studies were distributed geographically across three continents and > 10 countries. Most (n = 11) studies were conducted in Europe (Denmark, n = 4; Norway, n = 2; Spain, n = 1; Belgium, n = 1; England, n = 1; Greece, n = 1; and multiple Europe sites, n = 1),^{20,25,26,29,30,33, 34, 35, 36, 37,39} followed by seven studies in North America (United States, n = 6; Canada, n = 1)^{21, 22, 23, 24,27,28,38} and two studies in Asia (China, n = 1; Hong Kong, n = 1).^31,32 We identified seven types of televisit methods for self-management televisit-based interventions: in-person plus phone (n = 6),^{24,27, 28, 29,32,39} video only (n = 6),^{22,23,25,26,30,37} phone only (n = 4),^21,31,34,35 in-person plus phone or video (n = 1),³⁶ in-person plus video (n = 1),³³ both phone and video methods (n = 1),²⁰ and phone or video (n = 1) (Table 1).³⁸

Quality Assessment

Most studies (11/20) were of good quality,^{21,27,29, 30, 31,34, 35, 36, 37,39} including most randomized controlled trials (n = 11/14) (Table 1). Six studies were graded as fair,^{22, 23, 24, 25, 26,32} including three randomized controlled trials, two before and after studies, and one cohort or cross-sectional study. Three studies (two before and after studies and one cross-sectional study) were graded as poor.^20,33,38 Study quality did not seem to be associated with intervention method, study effectiveness, or types of self-management intervention components.

Types of Self-Management Interventions

Intervention Components

The televisit-based interventions were led by nurses (n = 10; quality: good, n = 7; fair, n = 2; and poor, n = 1; methods: video only, n = 4; phone only, n = 3; in-person plus phone, n = 2; and phone plus video, n = 1), pharmacists (n = 3; quality: fair, n = 2; poor, n = 1; methods: video, n = 1; in-person plus phone, n = 1; and phone or video, n = 1), physiotherapists (n = 3; quality: good, n = 2; and poor, n = 1; methods: video, n = 2; in-person or video, n = 1), respiratory therapists (n = 2; both good quality and in-person plus phone methods), or was other or not specified (n = 4) (Table 2).^{20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39} All interventions included more than one session (total number range, two to unspecified); session timing varied from daily, weekly, or monthly cadence or other types of schedules. Session-related content included general COPD education (eg, symptoms, physiology), knowledge and skill-based education (eg, action plans, symptom tracking, adherence, medication management, inhaler technique, self-efficacy, smoking cessation), activity-based training (eg, exercise), physiologic measurements, and care management.

Table 2.

Intervention Descriptions

Authors (Year)	Intervention	Session No./Interventionist	In-Person	Phone	Video	Self-Management Education	Exercise Advice	Remote Monitoring	Care Coordination	Significance: Use/Clinical/Self-Management
Wong et al (2005)29a	2 Nurse-led self-efficacy self-management follow-up phone calls 3-7 d and 14-20 d after discharge	2 sessions/nurse led	None	Self-efficacy self-management follow-up phone calls; protocol consisted of assessment, management options, and evaluation	None	Self-efficacy, self-management education	None reported	None reported	None reported	Mixed significant and nonsignificant/NR/significant
Casas et al (2006)27a	Integrated care: 1.In-person comprehensive assessment of patient at discharge 2.Nurse-led in-person self-management education at discharge 3.Tailored care plan shared between nurse case manager and primary care team 4.Weekly self-management phone calls with a nurse for 1 mo through call center	2 in-person sessions (1 in hospital; 1 at home by nurse) plus 1 mo of weekly calls/nurse led	2-h education session on discharge and 1 home visit with nurse and primary care team 72 h after discharge (only at 1 of the 2 study sites)	Weekly phone calls for 1 mo after discharge to reinforce self-management strategies; nonscheduled visits could be initiated through call center	None	Self-management empowerment, strategies to adopt during future exacerbations, in-person assessment of inhaler technique	None reported	None reported	Comprehensive assessment at discharge and individualized care plan shared between nurse case manager and primary care team	P < .05 across all analyses/mixed significant and nonsignificant/NR
Rice et al (2010)25a	1.1 60-90 min group education session with RT case manager 2.Monthly RT case manager-initiated disease management phone calls for 12 mo; patients could initiate calls during working hours	1 group session plus monthly phone calls/RT led	60-90 group education session with RT case manager consisting of disease education, inhaler education, medication education, smoking cessation counseling, exercise encouragement, and written action plan	Monthly disease management phone calls	None	Action plan, inhaler technique education, medication education, smoking cessation education, exercise encouragement	None reported	None reported	None reported	Mixed significant and nonsignificant/nonsignificant/NR
Sorkna es et al (2011)20b	1.Daily nurse-led video consultations for 1 wk after discharge 2.At least 1 follow-up phone call during study period and phone hotline access	7 calls (daily over 1 wk)/nurse led	None	At least 1 follow-up phone call and hotline access	Nurse made clinical observations, measured lung function and oxygen saturation, and provided self- management education during video visit	Medication education, education on preventing exacerbations	None reported	Manual symptom tracking: nurse made clinical observations and measured lung function and oxygen saturation during video consultations	Nurse could confer with an in-house consultant and instruct patient to make appointment with primary care physician or contact home health nurse	Mixed significant and nonsignificant/NR/NR
Sorkna es et al (2013)28a	5-9 (depending on patient preference) daily nurse-led self-management video consultations for 1wk	5-9 sessions (daily over 1 wk; per patient preference/nurse led	None	None	Nurse provided self- management education and collected remote monitoring data	Treatment education, exacerbation prevention, and how to live with COPD	None reported	Manual symptom tracking: patients measured pulse, saturation, and spirometry independently or with nurse instruction while nurse collected and recorded measurements electronically during video consultations	Nurse could consult with respiratory physician, patient’s PCP, or home health system to organize rapid treatment if needed	Nonsignificant across all measured metrics/NR/NR
Blumenthal et al (2014)21a	CST plus education vs COPD education only; both arms received 12 weekly and 2 biweekly phone calls over 16 wk	14 total calls over a total of 16 wk/clinical psychologist (CST), health educator (COPD education only)	None	CST protocol included four components: 1.Education about stress and pulmonary health 2.CST 3.Promotion of physical activity and personalized recommendations 4.Maintenance and generalization COPD education only included: 1.Discussion of the patient's current treatment and symptoms 2.A different COPD management topic each week	None	CST included education about stress and pulmonary health, coping skills training, and exercise promotion. COPD education group received education on different topics related to COPD including pulmonary physiology, medication use, nutrition, and symptom management.	None reported	None reported	None reported	Nonsignificant across all measured metrics/mixed significant and nonsignificant/mixed significant and nonsignificant
Wei et al (2014)30c	1.In-person education disease, inhaler, and medication education during clinic visit 2.10-min pharmacist-led medication education phone calls (frequency of calls dependent on patient) for 6 mo	In-person clinic session plus unspecified number of calls over 6 mo/pharmacist led	5-6 sessions (20-30 min per session) presented in structured, stepwise fashion during clinic visit (100-180 min total) and comprising disease, inhaler, and medication education)	10-min pharmacist-led medication education phone call, frequency dependent on patient	None	Inhaler education, disease education, medication education	None reported	None reported	None reported	Significant across all metrics measured/NR/mixed significant and nonsignificant
Dyrvig et al (2015)39c	Daily 30-min nurse-led self-management video consultations for 1 wk after discharge	7 sessions (daily over 1 wk)/nurse led	None	None	Nurse provided self-management education and collected remote monitoring data	Treatment education, exacerbation prevention, and how to live with COPD	None reported	Manual symptom tracking: patients measured pulse, saturation, and spirometry independently or with nurse instruction while nurse collected and recorded measurements electronically during video consultations	Nurse could consult with respiratory physician, patient’s PCP, or home health system to organize rapid treatment if needed	Significant across all metrics measured/mixed significant and nonsignificant/NR
Saleh et al (2014)32c	Daily nurse-led self-management video consultations (except for weekends) for 2 wk (10 total)	10 total sessions over 2 wk/nurse led	None	None	Nurse made clinical observations, measured oxygen saturation, and provided self- management and medication education and exercise advice during video visits	Medication education, coping with COPD symptoms, maintaining daily activity, and physical activity	None reported	Manual symptom tracking: patient measured oxygen saturation and pulse and performed spirometry during nurse video visits	Patients could press a button to trigger immediate video consultation when needed. Nurse could consult with doctor, physiotherapist, or occupational therapist.	Mixed significant and nonsignificant/NR/NR
Billington et al (2015)33a	Self-management plan and at least 2 nurse phone visits during a 6-wk period	Minimum 2 sessions over 6 wk/nurse led	None reported	Patients received two 25-min nurse phone calls 3 and 5 wk after baseline	None reported	Nurse provided self-management education including: 1.Answering questions about COPD 2.Advice on using action plan 3.Advice on medication adherence 4.Encouragement	None reported	None reported	Nurse could offer an appointment if the patient’s health was worsening	Nonsignificant across all metrics measured/nonsignificant/NR
Benzo et al (2016)24a	In-person self- management education, written action plan, and written education booklet after discharge 12-weekly then 9-monthly health coaching phone calls (21 total over 12 mo); patients provided with elliptical trainer and written instructions in booklet	One in-person session plus 21 phone calls over 12 mo/RT or nurse led	2 h after discharge visit consisting of self-management education, instruction on slow pursed lip breathing, and goal setting. Patients were provided with a written action plan and “Living a Healthy Life with Chronic Conditions” booklet.	12-weekly and then 9-monthly (21 total over 12 mo) self-management motivational interviewing phone calls	None	General self- management, action plan, goal setting, written booklet	Patients were provided with breathing exercise advice, written instructions on how to perform exercises, and an elliptical trainer	None reported	None reported	Mixed significant and nonsignificant/nonsignificant/NR
Lavesen et al (2016)34a	At least 2 nurse-initiated after discharge self-management follow-up calls for 30 d	Minimum of 2 calls over 30 d/nurse led	None	Phone calls occurred day 2, day 30, and as needed. Day 2 phone call focused on patient’s hospitalization; patients were encouraged to ask questions related to COPD self-management	None	Self-management education during phone calls	None reported	None reported	Nurse could consult with pulmonary specialist or contact PCP when necessary	Nonsignificant across all metrics measured/nonsignificant/P < .05 across all analyses (except one)
Vasilopoulou et al (2017)35a	Virtual maintenance pulmonary rehabilitation 3 d/wk for 12 mo including: 1.Individualized exercise program 2.Remote monitoring using tablet provided by study team 3.Weekly self-management televisits 4.Call center in case of complications	In-person pulmonary rehabilitation plus up to 52 calls (weekly over 12 mo)/physiotherapist led	Both virtual and in-person maintenance rehabilitation groups attended in person, outpatient pulmonary rehabilitation 3 d/wk for 2 mo. In-person rehabilitation consisted of exercise, dietary advice from dietician, and breathing control and self-management techniques from RT.	Patients were given the option to conduct weekly televisits via phone instead of video	Patients received scheduled weekly visits with a physiotherapist, an exercise scientist, a dietician, and a physician via video visit. Visits consisted of dietary and self-management education.	Patients received self-management education via video or phone visits, handouts, and videos installed on tablets. Self-management education included self-efficacy skills, instructions to adhere to medications, breathing techniques, exercises, disease education, and anxiety and depression symptom management.	Patients received exercise training through asynchronous videos on tablets	Vital sign measurements (HR, oxygen saturation), lung function (spirometry), daily steps, home exercise vital sign data (HR plus oximetry), symptoms of SOB and leg discomfort after exercise. Data were transmitted to health professionals who used it to tailor exercise plan.	None reported	Significant across all metrics measured/mixed significant and nonsignificant/NR
Zanaboni et al (2017)31b	Virtual maintenance pulmonary rehabilitation consisting of: 1.Individualized exercise program (recommended 3 times/wk) using treadmill provided by study team 2.Weekly video visits with a physiotherapist, an exercise scientist, dietician, and a physician 3.Remote monitoring 4.Self-management education via web page	Weekly video visits for 1 y/exercise scientist led	Patients were recruited after attending 4 wk of inpatient pulmonary rehabilitation	None reported	Weekly video visits (average 1.7 visits/wk for 2 y) with a physiotherapist who remotely observed the patient exercising, provided self-management education focused on exercise and activity, and emphasized self-efficacy strategies	Clinicians provided self-management education focused on exercise and activity and emphasized self-efficacy strategies	Patients had access to an individualized exercise program via web page and physiotherapist could observe patients via video visit. Exercise was recommended 3 d/wk.	Patients were provided with pulse oxygen and asked to record oxygen saturation at rest, breathlessness, cough, and sputum scale in an electronic form daily	None reported	Significance not reported/significance not reported/Significance not reported
Rose et al (2018)26c	Integrated care: 1.In-person self- management and action plan education during enrollment at ED visit, inpatient admission, or at outpatient appointment 2.12-weekly then 9-monthly self- management phone calls (21 total over 12 mo) with case manager 3.Priority access to outpatient clinic, individualized care plan, case manager, and primary care team communication	One in-person session plus 21 phone calls over 12 mo/case manager-led (not specified if nurse or RT)	40-min standardized education session based on “Living Well with COPD” at study enrollment	12-weekly and then 9-monthly phone calls (21 total over 12 mo) with case manager consisting of self-management counselling, action plan teach-back, symptom assessment, and problem-solving strategies	None	Self-management education, action plan education, problem-solving strategies	None reported	Manual symptom tracking: case managers assessed symptoms during phone calls	Patients had priority access to clinics and case manager communicated with family physicians and hospital specialists	Mixed significant and nonsignificant/mixed significant and nonsignificant/NR
Kessler et al (2018)38a	Home based disease-management program consisting of: 1.Self-management education based on “Living Well With COPD” program 2.Remote monitoring 3.Telephone or web platform	12 phone calls over 12 mo/case manager led (not specified if nurse or RT)	4 individual home sessions during 3-wk to 5-wk run-in period	Patients could receive monthly follow-up self-management phone visits during 12-mo follow-up period. Patients also received a case manager phone call when they reported worsening symptoms.	None reported	Patients received self-management education at four individual home sessions during 3-wk to 5-wk run-in period and then from monthly group sessions or individual phone sessions during 12-mo follow-up period	None reported	Patients report symptoms once weekly, every day, or both via phone questionnaire when they experience worsening symptoms. Their responses were transmitted automatically to a web platform that triggered standardized interventions, including patient measurements of pulse oxygen and spirometry and a case manager phone call.	Major alerts could be transmitted to hospital physician for same-day treatment	Nonsignificant/mixed significant and nonsignificant/mixed significant and nonsignificant
Locke et al (2019)22c	3-4 monthly pharmacist-led inhaler education video visits	3-4 sessions over 3-4 mo/pharmacist led	None	None	3-4 monthly inhaler education pharmacist-led video visits (initially 4 visits, but reduced to 3 based on patient feedback)	3-4 TTG inhaler training sessions. During TTG sessions, patients demonstrated inhaler use and pharmacists assessed technique based on a standardized checklist. The pharmacist then demonstrated correct use and reassessed patient technique until the patient mastered the technique.	None reported	None reported	None reported	Nonsignificant across all metrics measured/nonsignificant/P < .05 across all analyses (except one)
Bhatt et al (2019)23c	Virtual pulmonary rehabilitation consisting of: 1.Individualized exercise program (36 tailored exercise sessions over 12 wk) 2.Self-management education via video call (smoking cessation, inhaler technique, disease education, self-efficacy) 3.Remote monitoring	36 exercise sessions over 12 wk/exercise/physiologist led; unclear who was providing the education; timing of the education also unclear	Patients learned how to use the device at a regularly scheduled outpatient follow-up visit 10-12 d after discharge.	None reported	Self-management education video visits consisting of smoking cessation, inhaler techniques, disease education, and self-efficacy education	Self-management education was delivered via video visit and included smoking cessation, inhaler techniques, disease education, and self-efficacy education	Patients received a tailored exercise plan that consisted of 36 sessions over 12 wk (3 sessions/wk)	Patients were provided with automatic sphygmomanometers to measure BP before and after exercise sessions. They also received pulse oxygen to measure HR and oxygen saturation.	None reported	P < .05/NR/NR
Hansen et al (2020)36a	Virtual pulmonary rehabilitation consisting of: 1.Group-based exercise program via video call (3 35-min sessions/wk for 10 wk) supervised by physiotherapist 2.Self-management education via video call (3 20-min sessions/wk for 10 wk) led by nurse	30 sessions over 10 wk/physiotherapist and nurse led	None reported	None reported	Video visits consisted of 35-min of group-based exercise and 20-min of self-management education.	Self-management education was delivered via video visit and covered medication education, inhaler techniques, disease education, smoking cessation education, diet advice, and anxiety management.	30 group-based exercise via video visits over 10 wk (3 sessions/wk)	None reported	None reported	Nonsignificant/nonsignificant/NR
Howard et al (2022)37b	Pharmacist-led video visit (or phone visit if patients did not have access to video visit technology) consisting of medication reconciliation and optimization, inhaler education, smoking cessation (counseling plus offer pharmacotherapy), scheduled follow-up visits if necessary (eg, if laboratory test required). Additional visits scheduled if necessary. Patients were discharge from program if no pharmacotherapy changes needed or if patients reported symptom satisfaction.	At least 1 session; additional sessions as needed up to 6 mo/pharmacist led	None	Phone visits were offered if patients did not have access to video visit technology	Initial visit consisted of clinical assessment, medication optimization, inhaler education, smoking cessation education	Inhaler technique education, smoking cessation education, medication optimization and reconciliation	None reported	None reported	Pharmacist would schedule clinic follow-up appointment or video visit appointment if necessary	Nonsignificant across all measured metrics/NR/NR

CST = coping skills training; HR = heart rate; NR = not reported; PCP = primary care physician; RT = respiratory therapist; SOB = shortness of breath; TTG = teach to goal.

^aGood study quality.

^bPoor study quality.

^cFair study quality.

Self-Management Education Components

All 20 studies provided self-management education, including self-efficacy (n = 8)^{21,23,26,28,29,31,33,36}; medication reconciliation (n = 1)³⁸; general medicine education (n = 9),^{20,21,25,26,28,30,32,34,36} specific inhaler education (n = 7),^{22,23,28,29,32,37,38} or both; adherence (n = 2)^32,34; action plans (n = 4)^24,27,28,34; exercise or activity (n = 5)^{23,27,33,36,37}; symptom avoidance (n = 6)^{20,21,24, 25, 26,30}; smoking cessation (n = 4)^23,28,37,38; general self-management education (n = 11)^{23,24,27,29,33,34, 35, 36, 37,39}; depression, anxiety, or stress (n = 3)^21,36,37; nutrition (n = 1)²¹; or a combination thereof.

Other Intervention Components (Exercise or Activity Training, Remote Monitoring, and Care Coordination)

Five studies incorporated activity-based interventions,^{23,27,33,36,37} nine studies used remote monitoring,^{20,23,24, 25, 26,30,33,36,39} and 10 studies used some level of care coordination.^{20,24, 25, 26,29,30,34,35,38,39}

Impact of Televisit-Based Interventions on Health Care Use

Overall Health Care Use

Two-thirds of studies (12/20) showed significant reduction in at least one health care use metric across multiple methods and time points (Table 3).^{20,23,25, 26, 27, 28, 29,31,32,36,39} Health care use was reduced across studies that incorporated several different components of self-management televisit-based interventions, including self-efficacy adherence (1/1),³¹ action plans (3/4),^24,27,28 exercise (3/5),^25,27,28 medication education (5/9),^{20,24,25,28,32} preventing exacerbations or symptoms (3/6),^20,25,30 smoking cessation education (2/4),^28,39 general self-management (5/11),^{24,29,31,36,39} and inhaler instruction (3/7).^28,29,32 The only two studies reporting on race or income were conducted in North America (n = 1 each for phone only or video only).^21,23 The only study published after the pandemic was conducted in North America (phone or video).³⁸ Study quality was not found to be associated with health care use outcomes (Table 3).

Table 3.

Summary of Health Care Use Outcomes by Method, Study Size, Population Characteristics, Study Quality, and Location

Authors (Year)	Method	Continent	Study Sizea	Characteristics (Age, Sex, Race, Income)	Study Quality	Hospitalization		ED		LOS/Hospital Days
						Outcomes	Results	Outcomes	Results	Outcomes	Results
Wong et al (2005)29	Phone	Asia	Small	Age, sex	Good	•1-mo all-cause hospital readmissions •1-mo COPD-related readmission days •3-mo all-cause readmissions	•Nonsignificant •Nonsignificant •Nonsignificant	3-mo all-cause ED visits	P < .05	NR	NR
Casas et al (2006)27	In-person plus phone	Europe	Medium	Age, sex	Good	1-y all-cause hospital readmissions	P < .05 across all analyses	NR	NR	NR	NR
Rice et al (2010)25	In-person plus phone	North America	Large	Age, sex	Good	12-mo COPD-related, cardiac- or non-COPD pulmonary-related, all-cause hospital readmissions	Mixed significant and nonsignificant	NR	NR	•Total all-cause hospital days •Total all-cause ICU days	•P < .05 •Nonsignificant
Sorknaes et al (2011)20	Phone plus video	Europe	Medium	None	Poor	•28-d COPD related readmissions •28-d all-cause readmissions	•Mixed significant and nonsignificant •Nonsignificant	NR	NR	•Cumulative COPD-related days of readmissions •Cumulative all-cause days of readmissions	•NR •Nonsignificant
Sorknaes et al (2013)28	Video	Europe	Medium	Age, sex	Good	•4-wk, 8-wk, 12-wk, and 26-wk COPD-related readmissions •4-wk, 8-wk, 12-wk, and 26-wk all-cause readmissions	•Nonsignificant •Nonsignificant	NR	NR	•4-wk, 8-wk, 12-wk, 26-wk COPD-related admission days •4-wk, 8-wk, 12-wk, 26-wk COPD-related admission days	•Nonsignificant •Nonsignificant
Blumenthal et al (2014)21	Phone	North America	Large	Age, sex, race, income	Good	Time to COPD-related hospitalization up to 4.4 y	Nonsignificant	NR	NR	NR	NR
Wei et al (2014)30	In-person plus phone	Asia	Medium	Age, sex	Fair	•12-mo COPD-related admissions •12-mo COPD-related readmissions	•P < .05 •P < .05	NR	NR	12-mo COPD-related LOS	P < .05
Dyrvig et al (2015)39	Video	Europe	Large	Age, sex	Fair	5-y study risk of all-cause hospitalization before RCT, during RCT, after RCT	P < .05 across all analyses	NR	NR	Days spent admitted	P < .05
Saleh et al (2014)32	Video	Europe	Small	Age, sex	Fair	•6-mo COPD-related readmissions •12-mo COPD-related readmissions	•Nonsignificant •Nonsignificant	NR	NR	•6-mo readmission LOS •12-mo all-cause readmission LOS	•Mixed significant and nonsignificant •P < .05 across all analyses
Billington et al (2015)33	Phone	Europe	Small	Age, sex	Good	3-mo all-cause ED visits or hospitalization	Nonsignificant	3-mo ED visits or hospitalization	Nonsignificant	NR	NR
Benzo et al (2016)24	In-person plus phone	North America	Medium	Age, sex	Good	•1-mo COPD-related readmissions •1-mo all-cause readmissions •3-mo COPD-related readmissions •3-mo all-cause readmissions •6-mo COPD-related readmissions •6-mo all-cause readmissions •9-mo COPD-related readmissions •9-mo all-cause readmissions •12-mo COPD-related readmissions •12-mo all cause readmissions	•P < .05 across all analyses •Nonsignificant •P < .05 across all analyses •Mixed significant and nonsignificant •P < .05 •P < .05 •Nonsignificant •Nonsignificant •Nonsignificant •Nonsignificant	NR	NR	•1-mo COPD-related no. of hospital days •3-mo COPD-related no. of hospital days •6-mo COPD-related no. of hospital days	•P < .05 •P < .05 •P < .05
Lavesen et al (2016)34	Phone	Europe	Medium	Age, sex	Good	•30-d all-cause readmissions •84-d all-cause readmissions	•Nonsignificant •Nonsignificant	NR	NR	NR	NR
Vasilopoulou et al (2017)35	In-person plus phone or video	Europe	Medium	Age, sex	Good	12-mo COPD-related hospitalizations	P < .05	12-mo all-cause ED visits	P < .05	NR	NR
Zanaboni et al (2017)31	In-person plus video	Europe	Small	Age, sex	Poor	2-y COPD-related hospitalizations	NR	NR	NR	Average LOS	NR
Rose et al (2018)26	In-person plus phone	North America	Large	Age, sex	Fair	12-mo all-cause hospitalizations	Mixed significant and nonsignificant	12-mo all-cause ED visits	Mixed significant and nonsignificant	12-mo all-cause LOS risk ratio	P < .05
Kessler et al (2018)38	In-person plus phone	Europe	Large	Age, sex	Good	12-mo all-cause hospital admissions	NR	NR	NR	•Unplanned AE of COPD hospital days •Unplanned all-cause hospital days	•Nonsignificant •Nonsignificant
Locke et al (2019)22	Video	North America	Small	Age, sex, race	Fair	6-mo all-cause ED/hospital visits	Nonsignificant	6-mo ED/hospital visits	Nonsignificant	NR	NR
Bhatt et al (2019)23	Video	North America	Medium	Age, sex, race	Fair	•30-d COPD readmissions •30-d all-cause readmissions •Time to first readmissions	•P < .05 •P < .05 •P < .05	NR	NR	NR	NR
Hansen et al (2020)36	Video	Europe	Medium	Age, sex	Good	•10-wk COPD hospitalizations •22-wk COPD hospitalizations	•Nonsignificant •Nonsignificant	NR	NR	NR	NR
Howard et al (2022)37	Phone or video	North America	Small	Age, sex	Poor/poor	6-mo COPD-related ED visits, hospital visits, or ED and hospital visits	Nonsignificant	6-mo ED visits, hospital visits, or ED and hospital visits	Nonsignificant	NR	NR

AE = acute exacerbation; LOS = length of stay; NR = not reported; RCT = randomized controlled trial.

^aSmall < 100; medium, 100-300; large > 300.

Participant Diversity and Study Location

Four studies included subgroup analyses of age and sex.^{20,24, 25, 26} One found that age (hazard ratio, 3.94; 95% CI, 1.46-10.60) and male sex (hazard ratio, 2.97; 95% CI, 0.99-8.87) were associated with high hazard of readmissions.²⁰ Another found that age (OR, 1.11; 95% CI, 1.01-1.22; P = .043) and male sex (OR, 5.12; 95% CI, 1.18-22.22; P = .029) were predictive of readmission in a multiple regression model.²⁵ They also found that readmitted patients tended to be older than those who were not readmitted (mean ± SD, 72.4 ± 1.29 readmitted vs 68.5 ± 1.36 not readmitted). Similarly, another study demonstrated that younger age reduced risk of ED visits (risk ratio, 0.99; 95% CI, 0.98-1.00; P = .04), although male sex did not affect risk of ED visit (risk ratio, 0.98; 95% CI, 0.83-1.15; P = .78).²⁴ Finally, one study also found that higher age was associated significantly with risk of readmission (OR, 1.022-1.03; P < .0001) and that female patients were more likely to be readmitted. This difference was not statistically significant before the trial portion of the study period (OR, 1.11; 95% CI, 0.99-1.26; P = .09), but was significant during the trial period (OR, 1.25; 95% CI, 1.08-1.45; P = .003) and after the trial period (OR, 1.15; 95% CI, 1.01-1.31; P = .04).²⁶ None of the three studies reporting on participants’ race included subgroup analyses based on race. These studies also reported demographic data for only one racial category (two reported White, 87% and 93%; one reported Black or African American, 32.5% in the intervention group and 35.6% in the control group) (Table 1).^{21, 22, 23}

Hospitalizations and Rehospitalizations

About one-half of studies (9/20) showed significant reductions in hospitalizations, rehospitalizations, or both (Table 3, e-Table 1).^{20,23,24,26, 27, 28, 29,32,36} Hospitalization-related reductions were found in one-half of studies evaluating COPD-related hospitalization (6/13)^{20,23,27,28,32,36} and one-third evaluating all-cause hospitalizations (6/15).^{23,27, 28, 29,32,36} All but one positive study used two methods,^{20,24,27, 28, 29,32,38,39} and all but three positive studies specifically used two methods, with most including an in-person plus televisit method.^{24,27, 28, 29,32,39} Of note, only two single-method (all video-only) interventions were successful.^25,30 Time periods for hospitalization or rehospitalization ranged from 28 days to 5 years. No common type of hospitalization (COPD vs all-cause) or time period seemed to be more likely to be successful than any other. Of the four studies reporting subgroup analyses including age, sex, or both,^{20,24, 25, 26} overall, older age was associated consistently with higher risk of hospital readmission in three studies,^20,25,26 whereas male sex was associated with higher risk of hospital readmission two studies^20,25; women showed higher risk of readmission in one study.²⁶ Only one of these studies specifically reported on a televisit intervention group, however. The other studies did not specifically report age-based or sex-based results within the televisit intervention group.

ED Visits

Of the six studies that measured ED visits,^{24,28,31,34,36,38} two studies showed reduced visits,^28,36 all using phone methods with or without other methods (both good quality). The other four studies used different methods from phone (good quality) to video only (fair quality), to in-person plus phone (fair quality), or to phone or video (poor quality).^24,31,34,38 Two of the six studies were conducted in Europe^34,36 (both of good study quality), and the rest were conducted in North America (n = 3; two of fair quality and one of poor quality)^24,28,38 and Asia (n = 1; good quality).³¹ Of the studies that reduced visits, one was in Europe³⁶ and one was in Asia.³¹ Only one study reported that both older age and male sex increased risks of ED visits,³¹ although subgroup analyses on health care use outcomes by intervention group were not reported (Table 3).

Additional Health Care Use Metrics, Clinical Outcomes, Disease-Related and Patient-Related Outcomes, and Self-Management Outcomes

Hospital days and length of stay results can be found in the e-Appendix 1, Table 3, and e-Table 1. Patient clinical outcomes, including mortality results, can be found in e-Appendix 1, Table 4,^{20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39} and e-Table 2. Disease-related results can be found in e-Appendix 1 and e-Table 3. Quality of life-related results can be found in e-Appendix 1 and e-Tables 3 and 4. Patient experience-related results can be found in e-Appendix 1 and e-Tables 3 and 4. Patient self-management results can be found in Table 4, e-Appendix 1 and e-Table 4.

Table 4.

Summary of Patient Clinical Outcomes and Self-Management Outcomes by Method, Study Size, Population Characteristics, Study Quality, and Location

Authors (Year)	Method	Continent	Study Sizea	Characteristics (Age, Sex, Race, Income)	Study Quality	Clinical		Self-Management
						Outcomes	Results	Outcomes	Results
Wong et al (2005)29	Phone	Asia	Small	Age, sex	Good	NR	NR	Self-efficacy	P < .05
Casas et al (2006)27	In-person plus phone	Europe	Medium	Age, sex	Good	All-cause mortality and survival at 30 or 84 d	Mixed significant and nonsignificant	NR	NR
Rice et al (2010)25	In-person plus phone	North America	Large	Age, sex	Good	All-cause 12-mo mortality	Nonsignificant	NR	NR
Sorknaes et al (2011)20	Phone plus video	Europe	Medium	None	Poor	NR	NR	NR	NR
Sorknaes et al (2013)28	Video	Europe	Medium	Age, sex	Good	NR	NR	NR	NR
Blumenthal et al (2014)21	Phone	North America	Large	Age, sex, race, income	Good	•All-cause time to death or first COPD exacerbation within study period •4-mo 6-min walk test results •PFT results •Activity	•Nonsignificant •P < .05 •Nonsignificant •Mixed significant and nonsignificant	Self-efficacy	Mixed significant and nonsignificant
Wei et al (2014)30	In-person plus phone	Asia	Medium	Age, sex	Fair	NR	NR	Medication adherence	Mixed significant and nonsignificant
Dyrvig et al (2015)39	Video	Europe	Large	Age, sex	Fair	All-cause risk of dying during study period	Mixed significant and nonsignificant	NR	NR
Saleh et al (2014)32	Video	Europe	Small	Age, sex	Fair	NR	NR	NR	NR
Billington et al (2015)33	Phone	Europe	Small	Age, sex	Good	3-mo AE of COPD exacerbations	Nonsignificant	NR	NR
Benzo et al (2016)24	In-person plus phone	North America	Medium	Age, sex	Good	All-cause 12-mo mortality	Nonsignificant	NR	NR
Lavesen et al (2016)324	Phone	Europe	Medium	Age, sex	Good	All-cause 30-d or 84-d mortality rate	Nonsignificant	Self-efficacy	P < .05 across all analyses (except one)
Vasilopoulou et al (2017)35	In-person plus phone or video	Europe	Medium	Age, sex	Good	•12-mo AE of COPD exacerbations •Symptoms (mMRC) •Peak work rate •6-min walk test results •Daily activity	•P < .05 •Nonsignificant •P < .05 •Nonsignificant •P < .05	NR	NR
Zanaboni et al (2017)31	In-person plus video	Europe	Small	Age, sex	Poor	•6-min walk test results •PFT results •BMI	•NR •NR •NR	NR	NR
Rose et al (2018)26	In-person plus phone	North America	Large	Age, sex	Fair	•All-cause 12-mo survival •Disease progressions	•P < .05 •Nonsignificant	•Action plan education teach-back •Medication adherence	NR
Kessler et al (2018)38	In-person plus phone	Europe	Large	Age, sex	Good	•12-mo COPD-related deaths •12-mo all-cause deaths •1-y COPD-related BODE index •Severe COPD exacerbations •6-min walk test results •BMI	•NR •P < .05 •Mixed significant and nonsignificant •Mixed significant and nonsignificant •Not significant •Not significant	•Self-management education •Smoking cessation	•NR •Mixed significant and nonsignificant
Locke et al (2019)22	Video	North America	Small	Age, sex, race	Fair	6-mo AE of COPD exacerbations	Nonsignificant	Inhaler education	P < .05 across all analyses (except one)
Bhatt et al (2019)23	Video	North America	Medium	Age, sex, race	Fair	NR	NR	NR	NR
Hansen et al (2020)36	Video	Europe	Medium	Age, sex	Good	•Deaths •6-min walk test results •Sit-to-stand results •Physical activity	•Nonsignificant •Mixed significant and nonsignificant •P < .05 •Mixed significant and nonsignificant	NR	NR
Howard et al (2022)37	Phone or video	North America	Small	Age, sex	Poor	NR	NR	NR	NR

AE = acute exacerbation; BODE = index, body mass index, airflow obstruction, dyspnea, exercise capacity; mMRC = modified medical Research Council dyspnea scale; NR = not reported; PFT = pulmonary function test.

^aSmall < 100; medium, 100-300; large > 300.

A synthesis of the results appears in e-Appendix 2.

Discussion and Future Directions

The primary impact of this scoping review was to identify that a dearth of publications describe COPD self-management televisit-based interventions, particularly after the COVID-19 pandemic, and are missing critical demographic data, leading to a lack of meaningful effectiveness outcomes for current day practice across diverse patient populations. Specifically, only one study was published after the pandemic and most of the studies failed to report race or income; even those reporting age and sex lacked subgroup analyses regarding health care use data among those in the intervention group receiving televisits. Further, the televisit-based interventions were heterogeneous with respect to methods used, the quality of the studies, the self-management intervention components, and the timing of outcomes measured. A few factors do seem to be associated with greater likelihood of televisit-based interventions’ effectiveness. These factors included multimethod televisit-based interventions, particularly with an in-person component; reducing COPD-specific hospitalizations (vs all-cause hospitalizations); and certain self-management educational components such as self-efficacy, medication topics, and disease-based information. However, no associations were seen with study quality or size. With increasing reliance on telemedicine to provide chronic disease care, the lack of data after the pandemic and among diverse populations weakens the ability to generalize these findings for current practice across US hospitals. Therefore, it is imperative that more televisit-based interventions, particularly video-based interventions, are evaluated in the era after the pandemic within and across diverse patient populations.

Despite our intended focus on increased telemedicine after the pandemic and specifically understanding how televisit-based interventions varied based on diverse populations, we were unable to draw many conclusions because of the lack of published articles after the pandemic and a dearth of demographic data. Although most studies reported age and sex data, heterogeneous factors related to study design and outcomes limited conclusions, with the exception of older age predicting readmissions broadly, with few data reported specifically about subgroups of participants by age or sex who received the televisit intervention. Further, data on race and income were significantly limited. These sparse data limited our ability to understand if and how these televisit-based interventions are generalizable across diverse patient populations. Future work is needed to elucidate better this critical aspect of televisit-based interventions’ effectiveness, given known disparities in access to technology, use of technology, and eHealth literacy levels regarding technological interventions in general,^{6,40, 41, 42} and telemedicine specifically.^43,44 One-half of studies reported educational demographic data, although only one reported on literacy.²⁶ However, the heterogeneity in the specific educational outcomes measured and the diversity in location limit generalizability, beyond components of self-efficacy and medication-based education being among the more effective self-management intervention components. Future work should study the effect of televisit-based interventions among diverse populations and settings. Of note, our review showed significant geographic diversity, with three continents and > 10 countries represented, indicating a global interest in self-management televisit-based interventions.

From a televisit method standpoint, the common method(s) that showed effective reductions in acute care use tended to have more than one method, usually including an in-person method. Few successful televisit-based interventions used phone-only or video-only approaches. Given the evidence that phone-based interventions may be more equitably accessible,^{2,45, 46, 47} it is critical that future studies of televisit-based interventions specifically evaluate video-based televisits and whether disparities are created or expanded if using video-only visits, with identification of what approaches could mitigate these disparities if found. Notably, and perhaps not surprisingly, multimethod-based interventions (eg, in-person visits plus phone visit-based interventions) were most successful at reducing acute care use. Overall, our findings suggest that a multimethod (ie, in-person plus phone) approach to self-management education may be an effective way to reduce acute care use. However, the in-person plus phone interventions included in this review tended to be robust, and given that they involved multiple methods, they could limit dissemination, sustainability, or both. Single-method interventions (eg, phone-only visit, video-only visit) may be a more feasible way to improve self-management education and quality of life, although their impact on acute care use and other clinical outcomes has been limited to date. Future research should evaluate the efficacy and feasibility of in-person plus video televisit or just televisit-based interventions and how to broaden equitable access to video-based televisits for reducing acute care use and improving self-management outcomes.

With respect to type of hospitalization or rehospitalization outcomes, COPD-related outcomes more often were successful, with about two-thirds of studies showing reductions; all-cause related outcomes were mixed, with about one-half of studies showing reductions in hospitalization metrics. This result is not surprising, given that the interventions were focused on patients with COPD for COPD-related self-management. However, the all-cause metric is salient because of the Hospital Readmissions Reduction Program penalty that confers nontrivial financial penalties for all-cause readmissions after initial hospitalization for COPD. Although the Centers for Medicare and Medicaid Services penalty is related to 30-day readmission, the published studies focused on a myriad of time points from around 1 month to up to 5 years. We found no clear indications of whether shorter-term or longer-term outcomes were more likely to be reduced by televisit-based interventions.

Although our scoping review provides a thorough summary of the published evidence to date on the effectiveness of televisit-based interventions to reduce hospitalizations and rehospitalizations, the finding with more impact was identifying the significant dearth of data across diverse populations in the era after the pandemic. This finding is also a key limitation because a central aim of this scoping review was to determine if outcomes of these interventions are equitable across diverse patient populations. In addition, the study has other noteworthy limitations. Notably, the results were too heterogeneous to conduct a meta-analysis. This heterogeneity also impacted some level of generalizability. For instance, studies ranged from small (< 20 participants) to large (> 11,000 participants), the interventions studied varied significantly with respect to intervention components, and the metrics for the acute care visits varied widely across settings (hospital, ED) and time points (30 days, 60 days, and so forth), impacting our ability to draw conclusions for specific settings or time periods. Additionally, although most studies reported the timing of the recruitment, a handful did not recruit for an entire year, potentially introducing seasonal variation-related bias into their results. Another limitation is that most of the included studies were published before the COVID-19 pandemic, with only one study published with data from after the pandemic. Therefore, current-day advances in telemedicine and specifically televisits are not represented in the published studies included in this review. Additionally, most of the articles were published > 5 years ago. The age of the publications and the lack of articles from after the pandemic raise several concerns. First, publication bias regarding innovation and positive findings may exist such that investigators may have had difficulty publishing results that do not appear innovative enough or that may have shown negative findings. Second, technology for televisits has been enhanced greatly since most of the included studies were published; results of this review would not reflect how these enhanced aid in feasibility of providing visits, accessing visits, and expanding televisits. Further, because the use of telemedicine has increased dramatically since the pandemic began, these results indicate the long delay between study implementation and publication, that televisit-based interventions are simply being implemented and not necessarily published, or both. If the latter is the case, this would be problematic because we have shown that data do not exist showing if these interventions are equitably feasible, effective, or both across diverse patient populations. Additionally, given the advantages of video over phone-based televisits, including ability to bill for video visits and expanded scope (eg, visualization), it is critical that data are published on effective video-based televisit interventions that are implemented equitably. Hence, the key call to action is to evaluate rigorously COPD self-management televisit-based interventions, particularly video-based ones, within and across diverse patient populations to ensure that critical disparities are not being created, widened, or both. Ultimately, further reviews should be conducted as evidence emerges on the effectiveness of televisit-based interventions to address gaps in care for patients across transition-of-care settings.

This scoping review indicated that although potential exists for self-management televisits, particularly those that use a multimethod approach, to improve health care use, clinical outcomes, and patient self-management, studies of current-day televisit-based interventions across diverse patient populations are critically needed. Future work should assess the impact of current self-management televisit-based, particularly video-based, interventions among diverse patient populations and settings as these data become available.

Summary

Most studies failed to report on race or income, leading to a lack of data on equity of effectiveness across diverse patient populations. Multimethod televisit-based interventions, particularly with an in-person component, most commonly were effective; no associations were seen with study quality or size. With the increasing reliance on telemedicine to provide chronic disease care, the lack of data after the pandemic and among diverse populations weakens the ability to generalize these findings for current practice across US hospitals. Therefore, it is imperative that more televisit-based interventions are evaluated in the era after the pandemic within and across diverse patient populations.

Funding/Support

This study was supported by the Agency for Healthcare Research and Quality (AHRQ) Grant R01HS027804. In addition, Drs Press and Arora both receive National Institutues of Health (NIH) funding [Press: R01HL146644 and K24HL163408; Arora: R01HD097786].

Financial/Nonfinancial Disclosures

V. G. P. reports financial support was provided by Agency for Healthcare Research and Quality and by National Institutes of Health. V. G. P. reports a relationship with Humana that includes: consulting or advisory. V. M. A. reports financial support was provided by Agency for Healthcare Research and Quality and by National Institutes of Health. J. A. reports financial support was provided by Agency for Healthcare Research and Quality. None declared (M. A., M. N., F. O., A. S., L. T.).