title: Exploring participant utilisation of a novel digital support service for people with COPD using a mixed methods study
Creators: name: Taylor, Anna Juliette
Publisher: name: University of Glasgow
Year: 2025

description: Background 
Chronic obstructive pulmonary disease (COPD) is a significant health concern thought to affect over 4 million people in the UK. Although not curable, effective management and treatment can minimise symptom and healthcare burden. Effective self-management - empowering patients to manage their own condition, recognise changes, and seek early intervention when needed – is a key component of value-based COPD care. There is however a mismatch between guideline-based recommendation and care resources, often exacerbated by socioeconomic disparities and quality care gaps. Digital solutions offer the opportunity to overcome service inefficiencies, widen access and increase uptake of strategies known to improve healthcare outcomes in COPD. A range of digital health solutions to support COPD management have been developed and evaluated over the last 10 years, but firm evidence of their sustained usage and utility has not yet been acquired.
COPD is a major healthcare challenge in Scotland, with notable variation in health outcomes and access to guideline-based care across the country. To address this, the Innovate UK-funded DYNAMIC project was created in 2018. The project aimed to co-develop and implement a digital intervention for people with COPD, with effectiveness testing of a digital infrastructure and associated service model to support effective delivery of supported COPD management and evidence-based care. The innovation team, in collaboration with a digital agency (StormID), co-designed and developed the COPD digital support service intervention, with the overarching goal to improve patient outcomes for those with COPD, whilst also integrating remote management and data capture.
The COPD digital support service consists of a patient-facing web application (app), where users can submit daily patient reported outcomes (PRO), access self-management info and medication information, link in Fitbit wearables and home non-invasive ventilation devices, and use patient&lt;&gt;clinician asynchronous messaging for non-urgent advice or queries. A linked support site gives access to further self-management resources. An associated clinician dashboard displays PRO responses and physiological data, and allows management of messaging and collated health record data.

Approach 
The RECEIVER trial is the implementation and effectiveness observational cohort study that evaluated the use of the COPD digital support service alongside routine care. Its planned 1-year recruitment phase commenced in September 2019, with follow-up data censored in August 2021. Patients with COPD who had access to smartphone, tablet or computer and had had a severe COPD exacerbation requiring admission to hospital, and/or had chronic hypercapnic respiratory failure on home non-invasive ventilation were eligible for the study. The primary outcome of the trial was participant usage of the support service, measured through the submission of daily PROs. Secondary outcomes included clinical events, PRO and quality of life measures.
This research for this thesis sat within the RECEIVER trial and aimed to explore utilisation of the digital support service by people with COPD using an explanatory mixed methods study design. Study participant usage data and clinical outcomes were collated and analysed. Participant admission and occupied bed days (OBD) were compared to a matched contemporary control cohort created from a deidentified dataset of patients with COPD in NHS GGC.
The results from the quantitative evaluation that warranted further exploration were identified. Qualitative semi-structured interviews were designed and conducted in a sub-cohort of study participants who were best placed to give added insight into the findings seen. Interview transcripts were coded, and thematic analysis was undertaken to develop themes reflecting the use of the service from participant’s perspectives. This sequential combining of quantitative outcome data with qualitative semi-structured interview themes provided additional perspectives and deepened the understanding of the results obtained.

Findings 
81 people with high-risk COPD were recruited to the RECEIVER study. Quantitative results showed consistent utilisation of the service, with participants submitting an average of 4 sets of PROs per week over the course of the study. There were notable reductions in hospital admissions and OBDs following enrolment, along with improvements in time to readmission and survival rates among RECEIVER participants compared to the matched contemporary controls.
To better understand the reasons behind the sustained usage of the service by some participants, semi-structured interviews were conducted with a sub-cohort of those who continued to engage with the platform. 14 interviews were performed and data from these analysed. Four themes were developed; conditions for success, added colour and detail, background care, and a means to help. These themes revealed key factors that appeared to contribute to successful use of the app and highlighted the perceived benefits experienced by participants from use of the COPD digital support service components.
The combining of qualitative and quantitative results allowed conclusions to be drawn about the practical drivers behind the persisting usage seen within the trial and identified aspects and priorities to incorporate into future service iterations and other project developments. This integration also broadened the insight into motivations behind usage and mechanisms that may have led to the improved outcomes seen. Aspects of the service that warranted further evaluation were revealed, including potential value gained from analysis of messaging patterns and physiological data.
Evaluation data from the scale-up of the COPD digital service provision during the COVID-19 pandemic (out with the RECEIVER trial) is also explored. Eligibility was extended to include any patient with COPD resident in NHS GGC. Results from the evaluation confirmed sustained utilisation and reductions in clinical events for patient users, mirroring the results from the RECEIVER trial. User feedback from this scale-up cohort group also captured similar sentiments to those recorded amongst RECEIVER trial participants.

Conclusion 
This mixed-methods RECEIVER trial evaluation and complementary data from the subsequent service scale-up confirms sustained patient utilisation, perceived participant benefits and positive impact on healthcare utilisation from development and deployment of a co-designed COPD digital service. The outcomes from this research project have contributed to the adoption and evaluation of the service in other organisations, the publication of a supportive NICE early value assessment and to the extension of the digital tools including development, deployment and evaluation of artificial intelligence-based risk prediction models and transformation of the COPD diagnostic pathway. This research project and its evaluations also provide exemplar insights for implementation-effectiveness evaluations of additional digital technologies for COPD and other long-term conditions.