Digital technologies to deliver pulmonary rehabilitation programmes for adults with COPD: early value assessment

The 2015 National COPD Audit Programme report suggested an unmet need in the provision of face-to-face rehabilitation. The clinical experts explained that this was despite face-to-face pulmonary rehabilitation being recommended by NICE and the British Thoracic Society. The clinical experts explained that digitally supported pulmonary rehabilitation would help people who cannot, or do not want to, access face-to-face pulmonary rehabilitation. The committee defined the group of people who this guidance will apply to as those who cannot have or do not want face-to-face pulmonary rehabilitation.

The committee considered information governance and NHS England's Digital Technology Assessment Criteria (DTAC) compliance. The companies and technology developer explained that the technologies were all compliant with GDPR. Some of the technologies that can only be used in research were not yet DTAC compliant, but the companies without DTAC approval were working towards this.

The clinical experts explained that barriers to implementation would include:

• digital literacy

• language and cultural considerations

• social and environmental factors

• staff training needed to deliver digital pulmonary rehabilitation

• additional resources needed, and

• usability of the technologies.
  
  The clinical experts also explained that an additional barrier to implementation of these technologies is ensuring that people who are offered them adhere to the programme. They explained that monitoring COPD remotely takes significant time and resource.

The patient experts explained that while improved exercise capacity is one of the key outcomes, the effect of pulmonary rehabilitation on people with COPD was far-reaching and holistic. They thought that any interventions that deliver potential benefits to people with COPD should be available. One explained based on their own experience without digital technologies they would not have been able to participate in pulmonary rehabilitation because of their dependence on supplemental oxygen. The other explained that participating in pulmonary rehabilitation provides a means of social support. They explained that digital technologies should not exclude the 'human touch' of the camaraderie and social aspect of pulmonary rehabilitation. A charity also emphasised the importance of the social aspect. They highlighted the social benefits of pulmonary rehabilitation, such as people learning about their condition, being able to meet others going through something similar, and sharing their experiences. These social aspects need to be considered when using digital technologies to deliver pulmonary rehabilitation.

Both patient experts acknowledged the constraints on capacity to deliver face-to-face pulmonary rehabilitation, and that these technologies could be useful in addressing this. An example was to provide pulmonary rehabilitation for people who were on a waiting list to start another course of pulmonary rehabilitation after completing a face-to-face programme.

Regarding exercise capacity measures, a patient expert questioned if using validated measures such as the 6‑minute walk test was appropriate for people with advanced COPD. But there was no consensus on an alternative measure that was more appropriate for these people.

The committee discussed the potential of digital technologies to increase access to pulmonary rehabilitation and to address the unmet need of people who are eligible for face-to-face rehabilitation but are not offered it or cannot have it. Clinical experts explained that digital technologies to deliver pulmonary rehabilitation programmes should be used to overcome barriers to participation, and not to deal with backlogs for face-to-face services. This is in line with the British Thoracic Society's 2023 clinical statement on pulmonary rehabilitation, which stated that face-to-face pulmonary rehabilitation is the preferred treatment option for people with COPD. The committee agreed that digital technologies for pulmonary rehabilitation provide another option for people with COPD, but they will not replace face-to-face pulmonary rehabilitation in the care pathway.

For SPACE for COPD, the committee was aware that this technology is being developed into a new programme that offers both pulmonary and cardiac rehabilitation. When reviewing the guidance, the committee will revisit its recommendation and assess any new evidence on the new programme.

There were multiple equality considerations noted by the committee. These included general and digital literacy, not speaking English or having English as a second language, age, access to equipment and internet access. The committee recognised that additional support and resources may be needed for people who are unfamiliar with digital technologies or people who do not have access to smart devices or the internet. Most of the companies stated that they were either making plans to develop or had developed their technology to be available in another language. A clinical expert explained that digital technologies could actually be an enabler for those with language difficulties because it would allow people to rewatch and reread instructions as much as they wanted to.

A cost-consequences analysis was done using data from the 2015 National COPD Audit Programme, with walking distance as the outcome. It suggested that Clinitouch, myCOPD, SPACE for COPD and Rehab Guru could offer potential cost savings caused by reduced healthcare professional time. This was despite these technologies being slightly less effective than face-to-face pulmonary rehabilitation.

An exploratory cost-effectiveness analysis using 2015 National COPD Audit Programme data as the comparator, suggested that Clinitouch, myCOPD, SPACE for COPD and Rehab Guru were found to be cost saving and less effective than face-to-face pulmonary rehabilitation, when considering walking distance as the outcome.

For Active+me REMOTE, a hybrid model (offer of usual care and provision of the app) was used. Depending on the number of in-person supervised sessions assumed, both cost-consequences and exploratory-cost effectiveness analyses indicated that this technology could either be cost saving or more costly, but slightly less effective than face-to-face pulmonary rehabilitation using 2015 National COPD Audit Programme data.

Economic analysis was not possible for Kaia Health and Wellinks because of a lack of cost information.

The committee noted that there were differences in effectiveness when using different comparators and difference sources of data (the trial data and the UK audit data [there were differences in how the outcome measures were generated for the UK audit data]). When taking into account licence costs and healthcare professional time for delivery only, the technologies appeared cheaper to provide than face-to-face pulmonary rehabilitation. But this did not take into account other potential costs related to staff training and implementation. The EAG agreed that the difference in effectiveness was uncertain and that the health economic evaluation was for exploratory purposes only. The committee recommended that data be collected, including comparisons with appropriate comparators, to enable a full, robust, health economic evaluation.

Evidence for Active+me REMOTE assessed a hybrid model of digital and face-to-face pulmonary rehabilitation. The committee understood that some people choose to attend a full course of in-person supervised sessions, as well as using the app to supplement these sessions, or for monitoring. Because of this, the intervention then may not address the unmet need in the NHS, of those who cannot have or do not want face-to-face pulmonary rehabilitation. The committee also understood that the hybrid model created uncertainty about if the technology was cost saving or cost incurring.

For all the technologies, the evidence gaps related to the population, comparator and outcomes.