Telemedicine for Asthma Care: Benefits and Drawbacks
Telemedicine can make frequent specialist appointments more accessible and, often, more affordable. Nonetheless, remote asthma management remains a work in progress.
Managing asthma can require frequent doctor visits to gain control over the condition, monitor your control to determine whether your current treatment is working, and make adjustments in your treatment plan, as necessary.
According to the guidelines developed by the National Asthma Education and Prevention Program’s expert panel, such visits may need to take place every two to six weeks for people who are newly diagnosed and still learning to use their medications, and every one to six months to monitor those with stable control of their asthma.
Can that intensity of treatment be maintained when most of it is taking place over telemedicine?
Some research suggests that it can. In fact, studies have backed up the value of telemedicine services for asthma care even before the COVID-19 pandemic put a stop to most in-person medical visits.
A study published in September 2016 in the Annals of Allergy, Asthma & Immunology compared 100 kids with asthma who were seen in a doctor’s office with 69 kids who saw their doctors via telemedicine. Six months after the initial appointment, both groups were doing equally well at managing the condition, which affects close to 7 million children in the United States.
A meta-analysis published in January 2019 in The Journal of Allergy and Clinical Immunology: In Practice yielded similar findings on the effects of telemedicine on asthma control and the quality of life in adults. “Combined telemedicine involving tele-case management or tele-consultation appear to be effective telemedicine interventions to improve asthma control and quality of life in adults,” the authors write.
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Facilitated vs. Nonfacilitated Virtual Asthma Visits
According to Jennifer Shih, MD, an assistant professor in pediatrics and medicine at Emory University in Atlanta, there are two types of asthma-related telemedicine visits: facilitated, in which a third party, or facilitator, such as a nurse, is with the patient during the session with the doctor; and nonfacilitated, in which the patient is alone.
A facilitated visit can take place in a clinic or hospital, or in the patient’s home. The locale doesn’t matter as much as the fact that another person is there to get the patient’s background information, including past medical, social, and family history. The facilitator might also take vital signs like body temperature, pulse rate, and breathing rate; measure blood pressure; listen to the sounds of the heart and lungs with a stethoscope; and administer a lung function test known as spirometry.
During the COVID-19 pandemic, most appointments have been nonfacilitated, which means the patient is alone, usually at home, communicating with their doctor by phone or videoconference.
Prior to a nonfacilitated asthma visit, Dr. Shih typically orders a type of lung function test called plethysmography, in which a person sits in an airtight room and breathes into a mouthpiece as instructed by a technician. Getting a plethysmography requires a person to go to a medical facility that has the necessary equipment; the test itself typically takes about an hour.
“This would be like going to a facility to obtain an X-ray,” Shih says. Once a person has their plethysmography, the rest of the asthma appointment can be done virtually.
Nonfacilitated appointments may also be just for checking in, with no lung function testing ahead of time. Karen Bloomfield, 53, lives in New York City and was diagnosed with asthma in her twenties. Normally, she visits her doctor in person every few months, but since the pandemic started, she’s been seeing her doctor online instead — and she loves it.
“Usually I just need to refill my inhaler, and it’s quick and easy,” Bloomfield says. “I didn’t want to risk going to my doctor’s office during the pandemic. Seeing my doctor online was the obvious solution.”
At-Home Devices and Apps Help in Asthma Monitoring
One of the results of the COVID-19 pandemic is that it has motivated many people — even those without asthma — to purchase pulse oximeters, which let you know your heart rate and how well your lungs are oxygenating your blood. “You can also get vital signs this way without a facilitator,” says Shih.
That being said, use of a pulse oximeter to monitor asthma is not included in the guidelines set out by the Global Initiative for Asthma in its 2020 Pocket Guide for Asthma Management and Prevention. You should speak to your doctor about whether and how to use a pulse oximeter if you have one.
There are also apps and some remote monitoring devices that may help some individuals manage their asthma treatment. Some devices — like Aluna, a portable spirometer that syncs with an iPhone game to keep young users engaged — are able to transmit data on a person’s lung function to a physician’s office via Wi-Fi or a cellular network.
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Remote Asthma Management Makes Specialists More Accessible
One of the main benefits of remote asthma care is that it eliminates the need for travel. For people with asthma who live far away from a physician — in some rural areas the nearest allergist-immunologist is hours away — telemedicine makes a lot of sense. It also gives doctors the chance to reach a wider audience.
According to a report by the American Academy of Allergy, Asthma, and Immunology, in 2009 and 2010 there were 4,446 practicing allergy-immunology physicians in the United States, or 1.43 allergist-immunologists per 100,000 people. This is slightly lower than in 1999, when there were 1.57 allergist-immunologists per 100,000 people. In addition, allergist-immunologists were unevenly dispersed across the United States, with the highest numbers per 100,000 people in New England and the lowest in the Mountain division, as defined by the U.S. Census.
It’s possible, though not proven, that increased availability of telemedicine appointments will enable more people who need the services of an allergist-immunologist to receive them.
Less Travel and Lower Costs Improve Asthma Care
Shih has personal experience working with patients who live far away from her office or who have financial struggles that limit their ability to come in for regular visits.
“A success story of mine is a patient who was deemed to be at risk of death from asthma because he had been intubated three times by the time he reached middle school,” Shih says. In intubation, a tube is placed in the throat to help air move into and out of the lungs. While the procedure can be lifesaving, it can also have numerous complications.
The patient’s family was unable to bring him in for in-person visits, so she started seeing him in her telemedicine clinic.
“I did a lot of education with him and spent a lot of time with him. Otherwise, he wouldn’t have had anyone to see where he lives,” she says. “The good thing about telemedicine is that it gave him access to specialists and reduced his costs — before, his mom would have to take off work and drive four and a half hours one way to Atlanta each month. Because of his improved access and lower costs, he showed up in clinic and therefore became more compliant with meds.”
Since working with her via telemedicine, he has not been intubated once. Even better? “He can play sports now,” she says.
The Future of Telemedicine in Asthma Care
The use of telemedicine services skyrocketed in the United States in the spring of 2020, as communities were asked to shelter in place to avoid the spread of COVID-19.
By summer 2020, however, telemedicine visits had fallen sharply, according to a report in STAT.
Patients' preferences may account for some of that. A study published in June 2020 in the Annals of Allergy, Asthma, & Immunology collected data on 518 patient visits (children and adults), including 290 telemedicine encounters, from April 13 to May 8, 2020, among four physicians at the Rochester Regional Health Allergy and Immunology practice in New York.
Of the 290 patients who had a telemedicine appointment, 177 completed a follow-up telephone survey. Nearly 97 percent of them reported being satisfied with their virtual visit, and just over 77 percent believed it was as satisfactory as an in-person encounter. Nonetheless, when asked the most important reason to prefer an in-person evaluation, 95 respondents (nearly 54 percent) offered a reason. The most frequently cited was the desire for a more personal interaction, followed by wanting a physical exam and wanting a skin test.
Providers' preferences may also account for a move back to more in-person visits: When assessing those same 177 patient visits, the treating physicians deemed 102 evaluations to be complete and 75 to be incomplete. The study report didn’t specify what was lacking in the incomplete evaluations.
Value of School-Based Telemedicine Interventions for Asthma Is Unclear
Even before the COVID-19 pandemic, the use of telemedicine in school settings has garnered interest among various stakeholders, including school health systems, who wish to find ways to reduce school absenteeism caused by asthma and other chronic illnesses.
In 2008, asthma caused 11 million missed school days in the United States, according to a report in National Health Statistics Reports.
Clearly there’s a need for better asthma management among schoolchildren, but will telemedicine be the answer to providing it?
A systemic review published in the September-October 2020 issue of Academic Pediatrics evaluated the impact of school-based telemedicine programs on improving asthma-related outcomes. The authors found few high-quality studies to review, and those they did find showed inconsistent outcomes in terms of asthma symptom-free days, asthma flare-ups, healthcare utilization, and school absences.
The authors observe: “School-based telemedicine interventions have shown promise in reducing disparities in access to care, the provision of counseling and special-needs services, and in the management of other conditions such as acute illnesses, diabetes, and ADHD.” They call for higher-quality studies of the use of telemedicine-based asthma programs that include “cost-effectiveness analyses to help schools determine whether to invest limited resources in telemedicine technologies.”
Additional reporting by Ingrid Strauch.