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Background: The World Health Organization and the European Commission predict increased use of health technologies in the future care for patients in Europe. Studies have shown that services based on telehealth, which includes components of education, as well as rehabilitation initiatives can support the self-management of individuals living with COPD. This raises an interest in how virtual and in-person interactions and roles can best be organized in a way that suits people living with COPD in relation to their treatment and rehabilitation., Objective: This study aims to investigate how individuals living with COPD experience different combinations of virtual and in-person care, to help us better understand what aspects are valued and how to best combine elements of these services in future care., Methods: Two rounds of semistructured interviews were conducted with 13 and 4 informants, respectively. The individuals were all recruited in relation to a research project led by the telehealth initiative Epital Health. The first round of interviews included 11 informants, as 2 dropped out. Of these, 7 received the telemedicine service provided by Epital Health, 3 participated in a 12-week COPD program provided by their respective municipality, and 1 did not receive any supplementary service besides the usual care. In the second round, which included 4 informants, all had at one point received the telemedicine service and participated in a municipality-based rehabilitation program. A content analysis of the interviews was performed based on deductive coding with 4 categories, namely, (1) Self-management, (2) Health-related support, (3) Digital context, and (4) Well-being., Results: Medical and emotional support from health care professionals is a key aspect of care for individuals with COPD. Acute treatment with at-home medicine, monitoring one's own condition through technology, and having easy access and close contact with health care professionals familiar to them can promote self-management and well-being, as well as provide a feeling of security. Having regular meetings with a network of peers and health care professionals provides education, support, and tools to cope with the condition and improve own health. Furthermore, group-based activity motivates and increases the activity level of the individuals. Continued offers of services are desired as many experience a decrease in achieved benefits after the service ends. More emphasis is placed on the importance of the therapeutic and medical elements of care compared with factors such as technology. The identified barriers related to optimal utilization of the virtual service were related to differentiation in levels of contact depending on disease severity and skills related to the practical use of equipment., Conclusions: A combination of virtual and in-person services providing lasting medical and social support is suggested for the future. This should build upon the preferences and needs of individuals living with COPD and support relationships to caregivers and peers., (©Thea Krag, Emma Højgaard Jørgensen, Klaus Phanareth, Lars Kayser. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 14.08.2023.)

Background: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and is characterized by a progressive loss of pulmonary function over time with intermittent episodes of exacerbations. Rapid and proactive interventions may reduce the burden of the condition for the patients. Telehealth solutions involving self-tracking of vital parameters such as pulmonary function, oxygen saturation, heart rate, and temperature with synchronous communication of health data may become a powerful solution as they enable health care professionals to react with a proactive and adequate response. We have taken this idea to the next level in the Epital Care Model and organized a person-centered technology-assisted ecosystem to provide health services to COPD patients., Objective: The objective is to reveal the nature of COPD by combining technology with a person-centered design aimed to benefit from interactions based on patient-reported outcome data and to assess the needed kind of contacts to best treat exacerbations. We wanted to know the following: (1) What are the incidences of mild, moderate, and severe exacerbations in a mixed population of COPD patients? (2) What are the courses of mild, moderate, and severe exacerbations? And (3) How is the activity and pattern of contacts with health professionals related to the participant conditions?, Methods: Participants were recruited by convenience sampling from November 2013 to December 2015. The participants' sex, age, forced expiratory volume during the first second, pulse rate, and oxygen saturation were registered at entry. During the study, we registered number of days, number of exacerbations, and number of contact notes coded into care and treatment notes. Each participant was classified according to GOLD I-IV and risk factor group A-D. Participants reported their clinical status using a tablet by answering 4 questions and sending 3 semiautomated measurements., Results: Of the 87 participants, 11 were in risk factor group A, 24 in B, 13 in C, and 39 in D. The number of observed days was 31,801 days with 12,470 measurements, 1397 care notes, and 1704 treatment notes. A total of 254 exacerbations were treated and only 18 caused hospitalization. Those in risk factor group D had the highest number of hospitalizations (16), exacerbations (151), and contacts (1910). The initial contacts during the first month declined within 3 months to one-third for care contacts and one-half for treatment contacts and reached a plateau after 4 months., Conclusions: The majority of COPD patients in risk factor group D can be managed virtually, and only 13% of those with severe exacerbations required hospitalization. Contact to the health care professionals decreases markedly within the first months after enrollment. These results provide a new and detailed insight into the course of COPD. We propose a resilience index for virtual clinical management making it easier to compare results across settings., (©Klaus Phanareth, Astrid Laura Dam, Martin A B C Hansen, Signe Lindskrog, Søren Vingtoft, Lars Kayser. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 19.10.2021.)

Background: Individuals with chronic obstructive pulmonary disease (COPD) live with the burden of a progressive life-threatening condition that is often accompanied by anxiety and depression. The severity of the condition is usually considered from a clinical perspective and characterized according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification of severity (1-4) and a risk assessment (A through D) that focuses on the patient's symptoms and number of exacerbations, but information about perceived health or ability to manage the condition are rarely included., Objective: We evaluated 3 patient-reported outcome measurements (PROMs) to examine how these can be used to report on individuals with COPD who were supported by a digitally assisted intervention that aims to increase the patient's management of their condition to improve their well-being., Methods: A total of 93 individuals with COPD were enrolled. At baseline and after 6 and 12 months, we measured self-reported self-management (Health Education Impact Questionnaire, heiQ) and health literacy (Health Literacy Questionnaire, HLQ), and physical and mental health (Short Form-36, SF-36) PROMs were collected. The scores of the 19 PROM dimensions were related to COPD severity, that is, GOLD risk assessment, pulmonary function at entry, and number of exacerbations of a period up to 12 months. The initial PROM scores were also compared with pulmonary function, exacerbations, and GOLD risk assessment to predict the number of contacts within the first 90 days., Results: At baseline, 2 dimensions from heiQ and SF-36 Physical health differed significantly between GOLD risk factor groups, indicating more distress and poorer attitudes and health status with increasing severity (GOLD risk assessment). Pulmonary function (FEV1) was negatively associated with the severity of the condition. After 6 months, we observed an increase in heiQ6 (skill and technique acquisition) and a reduction in emotional distress. The latter effect persisted after 12 months, where heiQ4 (self-monitoring and insight) also increased. HLQ3 (actively managing my health) decreased after 6 and 12 months. The number of exacerbations and the GOLD risk factor assessment predicted the number of contacts during the first 90 days. Furthermore, 2 of the PROMS heiQ6 (skill and technique acquisition) and HLQ8 (ability to find good health information) evaluated at baseline were associated with the number of contacts within the first 90 after enrollment. The pulmonary function was not associated with the number of contacts., Conclusions: Our data suggest that selected dimensions from HLQ, heiQ, and SF-36 can be used as PROMs in relation to COPD to provide researchers and clinicians with greater insight into how this condition affects individuals' ability to understand and manage their condition and perception of their physical and mental health. The PROMs add to the information obtained with the clinical characteristics including the GOLD risk factor assessment., International Registered Report Identifier (irrid): RR2-10.2196/resprot.6506., (©Signe Lindskrog, Karl Bang Christensen, Richard H Osborne, Søren Vingtoft, Klaus Phanareth, Lars Kayser. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.06.2019.)

Background: There is worldwide recognition that the future provision of health care requires a reorganization of provision of care, with increased empowerment and engagement of patients, along with skilled health professionals delivering services that are coordinated across sectors and organizations that provide health care. Technology may be a way to enable the creation of a coherent, cocreative, person-centered method to provide health care for individuals with one or more long-term conditions (LTCs). It remains to be determined how a new care model can be introduced that supports the intentions of the World Health Organization (WHO) to have integrated people-centered care., Objective: To design, pilot, and test feasibility of a model of health care for people with LTCs based on a cocreative, iterative, and stepwise process in a way that recognizes the need for person-centered care, and embraces the use of digital technology., Methods: The overall research method was inspired by action research and used an agile, iterative approach. In 2012, a living lab was established in a Danish municipality which allowed for the freedom of redesigning health care processes. As the first step, a wide group of stakeholders was gathered to create a layout for the reorganization of services and development of technology, based on established principles for innovative management of people with chronic conditions. The next three steps were (1) a proof of concept in 2012, (2) a pilot study, and (3) a feasibility study from 2013 to 2015, in which a total of 93 chronic obstructive pulmonary disease (COPD) patients were enrolled. Citizens were provided a tablet-based solution for remote follow-up and communication purposes, and access to a 24/7 response and coordination center that coordinated both virtual and face-to-face support for COPD management. In step five the initial model was extended with elements that support continuity of care. Beginning in the autumn of 2013, 1102 frail elderly individuals were included and offered two additional services: an outgoing acute medical team and a local subacute bed function., Results: Based on the findings from the iterative process, and evolving technology and workflow solutions, we propose a robust and feasible model that can provide a framework for developing solutions to support an active life with one or more LTCs. The resulting Epital Care Model (ECM) consists of six stages, and serves as a template for how a digitally-enhanced health service can be provided based on patients' medical needs. The model is designed to be a proactive, preventive, and monitoring health care system that involves individuals in the management of their own health conditions., Conclusions: The ECM is in accordance with WHO's framework for integrated people-centered health services, and may serve as a framework for the development of new technologies and provide a template for future reorganization., Competing Interests: Conflicts of Interest: Dr Klaus Phanareth and Dr Søren Vingtoft now own a company, Epital Health, which is based on the ECM insights regarding the implementation of the ECM. Mister Jørgen Svenstrup is the owner of a company, EmpowerMind, that provides coaching, including health coaching; this company has provided free health coaching for this project., (©Klaus Phanareth, Søren Vingtoft, Anders Skovbo Christensen, Jakob Sylvest Nielsen, Jørgen Svenstrup, Gro Karine Rosvold Berntsen, Stanton Peter Newman, Lars Kayser. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 16.01.2017.)

Introduction: The urokinase-type plasminogen activator receptor (uPAR) and its ligand (suPAR) are involved in numerous physiological and pathological pathways. Previous studies have shown that an elevated plasma suPAR level is associated with disease severity and mortality. The aim of this prospective observational study was to determine if the suPAR level was associated with readmission and mortality in the acute medical setting., Methods: Plasma suPAR levels were measured in 1,036 patients at admission. Follow-up ranged 3-10 months. Cox proportional hazards model was used to assess the relative contribution of different risk factors to mortality and readmission. The ANOVA test and Pearson's chi-squared test were used to compare suPAR tertile level with various variables., Results: The highest suPAR tertile level was significantly associated with mortality within 30 days after discharge, with a 6.66 hazard ratio (HR). Similar associations were found with readmission within the maximum observation period (HR = 2.26) and within 30 days (HR = 2.08), although the latter became insignificant when covariates were included., Conclusions: This study confirms previous findings of increased mortality and adds the finding that increased long-term readmission rates are associated with elevated suPAR levels. The present data do, however, not indicate that suPAR may serve as an independent biomarker for increased risk of short-term readmission in the acute medical setting., Funding: This study was funded by a grant from ViroGates A/S, the company that produces the suPARnostic assay., Trial Registration: No: H-B-2009-075.

Background: Substantial healthcare resources are spent on chronic obstructive pulmonary disease (COPD). In addition, the involvement of patients in monitoring and treatment of their condition has been suggested. However, it is important to maintain a view of self-care that takes differences in cognitive ability into account. The aim of this study was to determine the occurrence and severity of cognitive dysfunction in COPD patients, and to assess the association between severity of COPD and the level of cognitive function., Methods: We conducted a systematic review, and a search in the following databases: Medline, PsychINFO, Cochrane Library, EMBASE, CINAHL, and SweMed up to July 2010. The articles were included if participants were patients with COPD, relevant outcome was cognitive function investigated by a neuropsychological test battery, and the severity of COPD had been assessed., Results: Fifteen studies were included, involving 655 COPD patients and 394 controls. Cognitive function was impaired in COPD patients as compared to healthy controls, but the level of functioning was better than in patients with Alzheimer's disease. There was a significant association between severity of COPD, as measured by lung function and blood gases, and cognitive dysfunction, but only in patients with severe COPD., Conclusions: Cognitive impairment can be detected in severe COPD patients, but the clinical relevance of the cognitive dysfunction is not yet known. Future studies should concentrate on the consequences of cognitive dysfunction for daily living in these patients, and solutions involving a high degree of self-care might require special support., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Lung function is a strong predictor of overall mortality in asthma and chronic obstructive pulmonary disease (COPD). FEV1 is considered to be the "gold standard," whereas peak expiratory flow (PEF) is mostly used in absence of FEV1 measurements. We compared the predictive power of PEF and FEV1, measured after maximal bronchodilation, which included a short course of oral corticosteroids. The study population comprised 491 asthmatics and 1,095 subjects with COPD. Pulmonary function tests were performed between 1983 and 1988, and survival data were obtained by September 1997, when 127 asthmatics and 723 subjects with COPD had died. Predictors of survival were examined by Cox proportional hazards analyses. After controlling for age, smoking, sex, and body mass index, we found best PEF to be at least equal to best FEV1 as predictor of overall mortality in subjects with COPD. The predictive power of best PEF was in part maintained after controlling for best FEV1. In asthma, best FEV1 seemed to be a better predictor of mortality than best PEF. Despite close correlation to FEV1, PEF apparently provides independent prognostic information in patients with COPD. This may be due to PEF and FEV1 reflecting different components of COPD, i.e., chronic bronchitis, small airways disease, and emphysema. Furthermore, extrapulmonary components such as muscle mass and general "vigour" probably affect PEF to a greater extent than they affect FEV1.

The importance of reversible airflow obstruction to the prognosis of asthma and chronic obstructive pulmonary disease (COPD) is not clear. We tested the hypothesis that reversibility to corticosteroid and bronchodilator is not an independent predictor of prognosis, but merely reflects a component of the maximal attainable lung function, which is the best spirometric predictor of survival. During a 6-yr period (1983-1988), 1,586 subjects with asthma or COPD underwent standardized bronchodilator and corticosteroid reversibility tests at a chest clinic in Copenhagen. The vital status was obtained by September 1997. The relationship between mortality and age, gender, smoking, FEV1, and reversibilities was examined by Cox proportional hazards analyses. Of 1,586 subjects, 850 had died before September 1997. Age, smoking, and FEV1 were significant predictors of mortality. After controlling for baseline FEV1, bronchodilator and corticosteroid reversibility were significantly associated with better survival. However, after controlling for best FEV1 all reversibilities became nonsignificant and nonpredictive. The combined use of corticosteroid and bronchodilator reversibility in survival analyses is a novel approach, and we have shown that both contribute to survival prediction to the extent that they modify FEV1. However, reversibility per se does not influence survival in subjects with moderate to severe asthma or COPD.