Our study is the first to demonstrate a marked reduction in the length of hospital re-admissions in patients with COPD during a 12 month period following intervention with TVC, as compared to the last 12 months prior to TVC. Moreover, patients who had been admitted the last 6 or 12 months prior to TVC, had shorter hospital stays when re-admitted following TVC, meaning important savings in health costs for the community and improved quality of life for the patient. Only confirmation of these findings in a prospective, randomised, controlled trial could position TVC as an important new contribution to standard management of these patients.
In this retrospective pilot study we could, however, not demonstrate a reduction in the rate of hospital re-admission due to COPD exacerbations during 6 and 12 months follow up after TVC, as compared to prior to TVC. Thus, our observations are not in agreement with the Danish study using the same equipment , demonstrating 10% reduction in re-admissions due to COPD exacerbations in the TVC group as compared to a control group. However, the observational period after TVC in that study was 28 days.
A previous history of COPD exacerbation has been suggested to be the most reliable predictor of COPD exacerbations [5, 21]. Additionally, data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE)  showed that 33% with COPD stage 3 and 47% with stage 4 defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD)  had ≥ 2 exacerbations in the first year of follow up. Our patients are characterised by COPD stage 3–4, with a mean FEV1 of 36.3%, and 67.9% had been admitted the last year. In accordance with previous observations [17, 23], higher age and male gender was associated with an increased risk of re-admittance in our study.
Our main finding was the reduction in days per admission when in need of hospitalisation. Several factors could have influenced this observation. In addition to the introduction of TVC, a change in treatment or hospitalisation policies might have influenced this. There are, however, no new treatments introduced in the study period at the hospital. In addition, on-going regular medication was similar at inclusion and at discharge from index hospital stay (prior to TVC), and no change in conventional medical therapy could explain this difference. Regarding hospitalisation policies, “The new Coordination Reform”, guaranteeing immediate help from the municipality health care system when discharged from hospital, such as a place in a nursing home, came into force in Norway the 1st of January 2012. This reform does not seem to explain the shorter length of hospital stays in this study, as the patients receiving TVC in this study, were not candidates for nursing homes. Besides, more than 60% of the re-admissions occurred among the 49 first included patients whose 12 months follow up were completed before “The Coordination Reform” came into force.
We therefore believe that the observed changes in length of hospital stays were related to the introduction of the TVC. Many advances related to the TVC could contribute to the benefit of reduced length of hospital stays when re-admitted. During the TVC period, the specially trained nurse not only daily monitored and advised each patient according to personal needs to improve the actual health condition. Also, great effort was invested in advising and teaching each patient to increase the empowerment and competence for good self-care, concerning correct medication use, inhalation technique, appropriate physical activity, pulmonary drainage, dealing with stress and anxiety to prevent and to cope with future exacerbations. However, our study has not been designed to directly evaluate the influence of TVC on each of those factors.
An interdisciplinary team was available for consultation when needed, including among others a physiotherapist and an occupational therapist, who could for example easily facilitate home conditions, and thereby also enable a faster and smoother future hospital discharge. The discharge policy of the hospital, defined in the hospital’s quality criteria, has not changed before and after the TVC during the study period, ensuring a stabilised patient without need for fast-acting bronchodilators more frequently than every 4 hour, whose ability to eat and sleep is not limited by breathlessness, ensuring the patient appropriate home conditions, and that the patient, relatives and eventually nursing staff can administer the prescribed treatment, that an ambulatory patient can walk at least 20 meters, and the need of interdisciplinary rehabilitation should have been considered, all in order to guarantee that the patient will manage at home. The marked reduction after TVC of the relatively long hospital stay might therefore be related to a facilitated discharge process and safeguarding of home conditions offered by TVC. However, home nursing was equally frequent among those who were re-admitted and those who were not. Thus, home-nursing does not seem to prevent re-admissions. There was no change in the hospital’s discharge policy during the study period.
The self-perceived patient satisfaction and the increased coping skills following TVC are also of major importance for the feeling of safety at home, which was reported high in the enquiry.
The marked reduction in use of hospital resources after introduction of TVC in this pilot study gives promise for a better management of COPD patients. This could induce both a better life and feeling of safety for the patients and reduce the costs for the society. Further, the results presented in this report, are based on the experience from the early start of TVC at our site with a strict use of the equipment for 2 weeks. The accumulated experience through the development of the program indicates even better effects by applying an individualised approach with some patients with shorter follow up and longer in others, based on their individual condition and needs. It is therefore possible that a future, more flexible, individually adapted duration of TVC monitoring of patients might even contribute to increase periods free of re-admissions, rather than the strict, pre-determined period of 14 days of TVC monitoring, used in our study, irrespective of patient condition and needs.
For majority of patients the need of re-admission has been decided by occurrence of an infective exacerbation, as nearly 70% of patients re-admitted, required antibiotic therapy during the first re-admission. Thus, these re-admissions are hard to avoid, but the length of re-admission hospital stays were shortened, as already discussed.
The major limitation of this study is, of course, the retrospective design and the lack of a control group. This pilot study is, however, inspiring to perform a randomised, controlled trial evaluating the effect of TVC on re-admissions and length of hospital stays due to COPD exacerbations. Moreover, DMC was the first centre in Norway applying TVC, being a pioneer, establishing a new therapeutic approach in our region, and the concept has probably improved by time, gaining more experience. Including also the first patients participating might have influenced the results of our investigation. On the other hand, the TVC system has been user friendly both for the patients and the nurses, experiencing few technical problems, the nurses have been well skilled and trained, and both the patient confidence in the TVC service and the patient satisfaction were high.
Cost-benefit analysis has never been an aim of this pilot study, and future research is needed to confirm the cost effectiveness of TVC for COPD patients.