Clinician’s Commentary on Tanguay et al.

Chronic respiratory diseases (CRDs) are a major cause of death and disability around the world.² Pulmonary rehabilitation (PR) is the cornerstone of non-pharmacological treatment of CRDs; it consists of exercise training, education, and behavioural change, and it aims to improve patients’ health status and promote their adherence to health-enhancing behaviors.³ Evidence of its benefits in treating chronic obstructive pulmonary disease is unequivocal,⁴ and evidence is growing that it is effective in improving exercise capacity and quality of life among people with other CRDs.⁵ However, if no maintenance strategy is in place, the benefits of PR tend to deteriorate over 6–12 months.^3,5

The use of information and communications technology (ICT) in managing CRDs (telehealth) has gained popularity over the years, following the rapid growth in the use of the Internet and mobile technologies. Computers, smartphones, and tablets are ubiquitous in people’s everyday lives, are easily accessible, are generally available at low cost, and allow patients to customize their experience; this makes them useful resources for patient self-management (i.e., strategies and lifestyle changes that individuals adopt to better manage their disease).⁶ Using telehealth to promote self-care among patients with CRDs may result in better patient outcomes and reduced reliance on unplanned health care. Yet, evidence for its benefits is still insufficient.⁷

Tanguay and colleagues¹ developed an innovative web platform to optimize self-management after PR among patients with CRDs and explored its usability and impact on health-related outcomes. The platform included a module of breathing exercises, which patients had to perform twice a day, 6 days per week, for 8 months. The breathing pattern was individualized and accompanied by visual support and music, and a weekly progress bar was available to motivate patients to perform the exercises. Patients also had a logbook in which they could insert the aerobic and strengthening exercises they had learned during PR, although its use was not mandatory.

The web platform seemed to be a promising solution because it included important components of self-management:⁶ goal setting, feedback on patients’ progress, and access to historical data for both the patients and their health professionals. However, when the platform was implemented with six stable patients for 8 months, the authors encountered some challenges. The first related to the patients’ adherence to the intervention. Adherence rates were high (>90%) among only half the sample, and two patients stopped using the platform for personal and health-related reasons.

Despite the growing popularity of telehealth in managing disease, it is common for users to discontinue using it or abandon a study before it is complete. This phenomenon is called the “law of attrition.”⁸ Several factors may influence attrition rates, including participants’ characteristics, the degree of innovation of the ICT solution, and the environment.⁸ Understanding the reasons for non-adherence and the key factors for adoption and continued use of ICT are fundamental to the success of these interventions.

The second challenge related to the patients’ satisfaction with the platform. Although the results were positive overall, opinions differed on how easy the platform was to use, whether to include music during the exercises, how frequent the exercises were, and how adequate and timely the responses to patients’ questions were. These findings show that one size does not fit all and reinforce the need to tailor self-management interventions to individuals’ characteristics and preferences to ensure that they suit the target population.^6,9 As a result, Tanguay and colleagues proposed improvements to future iterations of the platform.¹

User needs and preferences are generally identified through post-study user evaluations; however, they can also be defined before designing and implementing ICTs. Participatory design methods, in which users are involved in the design of technological solutions through an iterative process (i.e., using phases of evaluation and adapting the technology to consider participants’ contributions to the previous phase), can facilitate customization of the solution.¹⁰ This process should include not only patients but also health professionals to ensure that it is appropriate in clinical settings.

Tanguay and colleagues found that most patients had maintained their exercise capacity 8 months after completing PR.¹ Although the sample was small, these are encouraging results because PR benefits (particularly exercise capacity) tend to deteriorate over time.³ This finding deserves further investigation because, according to a previous review,¹¹ exercise capacity can be improved when patients carry out breathing exercises, although such exercises should not replace a comprehensive intervention such as PR.

Tanguay and colleagues’ study highlights the promising role of telehealth in supporting long-term self-management of CRDs and the need to involve end users in the design of these innovative solutions.¹ It is likely that different patients will require different levels of assistance, tailored to their specific needs (e.g., diagnosis, disease severity, comorbidities). Further work is needed to understand which interventions work best and with whom.