▢ 연구 배경

2015년 통계청에서 발표한 사망원인 분석 결과를 보면, 지속적인 관리가 필요한 만성 질환과 심뇌혈관 질환이 대부분을 차지하는 것을 볼 수 있다. 천식, 만성폐쇄성폐질환(Chronic Obstructive Pulmonary Disease, COPD)과 같은 만성질환자는 매일의 증상, 치료 효과, 합병증 발병 여부 등에 대해 관찰․기록하고 이를 의료진에게 보고하여 정확한 진단과 치료가 이루어지도록 해야 하며, 스스로의 약물 복용이나 생활습관 교정 등에 대한 적극적인 태도가 필요하다. 최근에는 접근 용이성 증가, 정보통신기술(Information and Communication Technology, ICT)의 발달과 낮은 비용으로 인해, 가정 원격모니터링 중재를 이용하여 환자들을 관리하는 것에 대한 관심이 높아지고 있다(Bolton, 2010). 거리가 떨어진 곳에 보건의료서비스를 제공하고 지원하기 위해 환자 정보가 전자적으로 전송되는 원격의료(telehealth, telemedicine 등)가 활발하게 발전하고 있으며 이와 더불어 전화기, 컴퓨터, 또는 착용형과 비착용형 장치 등을 사용하는 다수의 원격의료 앱도 지속적으로 개발되고 있다. 원격모니터링 시스템으로 전송되는 정보는 대체로 의사나 간호사 같은 의료 전문가들에 의해 평가되며, 비정상적 측정값이 나온 경우나 예정된 측정값이 빗나갔을 때, 미리 지정된 프로토콜을 실행할 수 있도록 돕는다. 또한, 이러한 기술의 활용은 환자의 건강 상태에 대한 주기적인 기록 및 전송을 통하여 질환을 적절히 관리할 수 있도록 도우며, 특히, 천식 및 COPD 환자에서 약물 순응도를 높일 수 있고, 악화 사건의 예방 및 초기부터 질환의 악화로 인한 위협적인 상황을 신속하게 감지하여 더 적절한 시기에 치료하도록 돕는 역할을 할 수 있다(McKinstry, 2013). 따라서 본 연구에서는 원격모니터링 중재의 임상적 효과에 대해 2015년에 기평가한 당뇨병, 고혈압, 심부전 및 우울장애 다음으로 많이 적용되고 있는 천식 및 COPD에서의 원격모니터링 중재의 임상적 효과를 분석하고자 한다. 

▢ 연구 목적

본 연구는 천식 및 COPD 관리를 위한 원격모니터링 중재의 세부 특성을 파악하고 원격모니터링 중재의 임상적 효과에 대한 문헌적 근거를 체계적으로 고찰하여 원격의료 정책 의사결정시 도움이 되는 객관적인 근거를 제시하고자 한다. 

▢ 연구 방법

1. 신속 문헌고찰

최신 선행 체계적 문헌고찰에서 제시하는 원격모니터링 중재법 세부내용 및 임상 효과를 파악하고, 원격모니터링 중재 적용 관련 요약 결과를 제시하기 위해 천식 및 만성폐쇄성폐질환 관리를 위한 원격모니터링 중재에 대한 선행 체계적 문헌고찰을 검토(Overview of Systematic Reviews)를 수행하였다. 국외 3개 데이터베이스(Ovid-MEDLINE, Ovid-Embase, Cochrane Library)와 SIGN(Scottish Intercollegiate Guidelines Network) SR 필터를 사용하여 검색하였고, 2010년 이후 출판된 영어 및 한국어 문헌을 대상으로 검토하였다. 

2. 체계적 문헌고찰 

천식 및 만성폐쇄성폐질환 관리를 위한 원격모니터링 중재의 세부내용 파악 및 임상적 효과를 확인하기 위해 문헌적 근거를 검토하는 체계적 문헌고찰을 수행하였다. 문헌검색은 국외 4개 데이터베이스(Ovid-Medline, Ovid-EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature)와 국내 5개 데이터베이스(KoreaMed, KMbase, KISS, RISS, KISTI) 및 수기검색을 병행하였으며, 출판연도 및 언어에 제한을 두지 않았다. 문헌 선택은 2명의 연구자가 독립적으로 검토한 뒤 의견 일치를 통하여 최종 문헌을 선택하였다. 최종 선택문헌들의 비뚤림 위험 평가는 Cochrane RoB 도구를 사용하였으며 가능할 경우, 임상 결과변수에 대한 메타분석을 수행하였고, 양적합성을 수행할 수 없는 경우 질적으로 기술하였다. 

▢ 연구 결과

1. 신속 문헌고찰 결과

1) 천식

천식환자에서 원격모니터링 중재의 효과를 확인하기 위해 최종 선정된 선행 체계적 문헌고찰 연구는 8편이었다. 

임상적 결과지표인 천식 증상 조절, 삶의 질, 의료 이용, 폐기능, 부작용, 순응도에서 일관성 있는 결과 개선을 제시한 문헌은 없었다. 포함된 문헌 수의 부족으로 인해서 주로 질적으로 합성하였고, 양적 합성을 수행한 경우에도 통계적으로 유의하지 않았다.

중재 적용 측면의 결과지표에 대해서 보고한 문헌은 접근성 및 진료횟수 및 비용, 의료자원 활용과 약물 사용, 원격모니터링 중재의 적용 가능성에 대해서 보고하였다. 접근성 측면에서 원격모니터링 중재의 접근성이 통상적 관리에 비해 좋았으며, 진료횟수 및 비용은 원격모니터링 중재군의 진료횟수가 더 많고, 비용은 더 낮았다. 의료자원 활용과 약물 사용에 대해서 인터넷 중재군과 일반 진료군을 비교한 결과, 두 군에 차이가 나타나지 않았으며 예약하지 않은 진료횟수의 경우 인터넷 중재군이 더 높게 나타났다.

경제적 측면 결과지표에 대해서 보고한 문헌은 건당 의료비용, 원격모니터링의 비용-효과성 등에 대해서 보고하였다. 건당 의료비용을 살펴본 결과, 원격모니터링군의 의료비용이 더 낮았고, 연간 의료비용은 원격모니터링 군의 의료비용이 낮게 나타났다. 원격모니터링의 비용-효과성 결과, 성인의 경우 원격모니터링 군의 의료비용이 $695.54 높고 효과는 0.03QALY 높게 나타나 점증적 비용효과비는 42,520$/QALY이었고, 어린이는 의료비용이 $829.56 높고 효과는 0.01QALY 높게 나타났다.

2) 만성폐쇄성폐질환

만성폐쇄성폐질환 환자에서 원격모니터링 중재의 효과를 확인하기 위해 최종 선정된 체계적 문헌고찰은 총 13편이었다. 

임상적 결과지표 중 증상 악화, 의료이용, 사망률, 신체활동 정도 및 신체능력 관련 분석 결과, 일관성 있는 결과 개선을 제시한 문헌은 없었다. 다만, 최근 문헌들에서 입원율의 유의한 감소 효과와 삶의 질 향상, 신체활동 정도의 개선 효과가 있는 것으로 보고되었다. 그러나 여전히 확정적 결과를 도출하기에 근거가 부족하고 이질성이 존재하여 결과 해석에 주의를 요하고 있다. 

경제적 측면 결과지표에 대해서 보고한 문헌은 의료관련 비용 및 절감, 일인당 평균비용에 대해서 보고하였다. 의료관련 비용 결과, 원격모니터링군이 대조군에 비해 의료비용이 감소하는 경향을 보였고 이는 입원 횟수 감소 등이 주요한 원인으로 제시되었으며, 일인당 평균 비용도 원격모니터링 군의 평균 비용이 더 낮은 것으로 보고되었다. 

2. 체계적 문헌고찰 결과

1) 천식

천식 환자에서 원격모니터링 중재의 임상 효과를 평가하기 위해 최종 선정된 무작위배정 비교임상연구는 21편(17개 연구)이었다. 원격모니터링 중재와 통상적 관리를 비교한 결과, 통계적으로 유의한 결과를 나타낸 지표는 없었다. 

주요 결과변수별로 살펴보면, 천식조절점수에 대한 메타분석 결과(연구 7개, 중재법 기준 8개), 원격모니터링 중재군과 대조군 간의 차이가 통계적으로 유의하지 않았다(SMD 0.15, 95% CI –0.07 ~ 0.38). 또한, 문헌 간 이질성이 높게 나타나(I2=74%) 하위군 분석을 시행하였으나, 이질성을 설명하는 요인을 확인할 수 없었다. 천식 악화율을 보고한 연구(연구 6개, 중재법 기준 7개)의 통합분석 결과, 원격모니터링 중재군과 대조군 간의 차이가 유의하지 않았다(RR 0.75, 95% CI 0.51 ~ 1.10). 무증상 일수의 메타분석 결과(연구 4개), 두 군 간 차이가 통계적으로 유의하지 않았다(WMD 3.92, 95% CI –4.96 ~ 12.80). 의료 이용과 관련하여 메타분석 결과, 입원율(5편 합성, RR 2.34, 95% CI 0.82 ~ 6.62), 응급실 방문율(6편 합성, RR 0.77, 95% CI 0.43 ~ 1.39), 계획되지 않은 외래 방문율(2편 합성, RR 0.90, 95% CI 0.34 ~ 2.35) 모두에서 두 군 간 유의한 차이는 확인되지 않았다. 삶의 질(연구 6개, 중재법 기준 7개)의 통합분석 결과에서도 두 군 간 유의한 차이가 없었다(SMD 0.10, 95% CI –0.10 ~ 0.31). 폐기능(FEV1)을 보고한 문헌은 총 10편으로 양적 합성이 가능한 문헌은 4편이었다. 메타분석 결과, FEV1은 두 군 간 유의한 차이가 없었다(SMD 0.07, 95% CI –0.22 ~ 0.36).

원격모니터링 중재와 기타 중재를 비교한 연구는 2편(중재법 기준 3개)으로 원격모니터링의 효과를 평가하기에는 근거가 부족하였다. 다만, RCT 1개(중재법 기준 2개)의 결과를 이용하여 탐색적으로 통합한 메타분석 결과, 천식 악화율(RR 0.13, 95% CI 0.07 ~ 0.25), 삶의 질(WMD 0.55, 95% CI 0.18 ~ 1.02)에서 통계적으로 유의한 차이를 나타냈다.

2) 만성폐쇄성폐질환

만성폐쇄성폐질환 환자에서 원격모니터링 중재의 임상적 효과를 분석하기 위하여 최종 선정된 문헌은 무작위배정 비교임상연구 24편(n=2,014명)이었다. 연구에는 경증부터 매우 중증의 질환 중증도를 갖는 만성폐쇄성폐질환 환자를 모두 포함하였다. 

원격모니터링군과 대조군을 비교한 결과, 통계적으로 유의한 차이를 보인 결과지표는 없었다. 악화율에 대한 메타분석 결과(문헌 6편), 원격모니터링군과 대조군 간의 차이가 통계적으로 유의하지 않았다(RR 0.67, 95% CI 0.31 ~ 1.42). 또한, 문헌 간 중등도 수준의 이질성이 나타나(I2=67%) 하위군 분석을 시행한 결과, 중재기간이 이질성을 설명하는 요인일 수 있는 것으로 확인되었다. 악화 기간에 대한 메타분석 결과(문헌 6편), 원격모니터링군과 대조군 간의 차이가 유의하지 않았다(MD 0.12, 95% CI –1.18 ~ 1.43, I2=7%). 악화 횟수에 대한 메타분석 결과(문헌 6편), 원격모니터링군과 대조군 간의 차이가 유의하지 않았다(MD –0.12, 95% CI -0.32 ~ 0.07, I2=0%). 

삶의 질 또는 건강상태를 보고한 결과 전체를 합성할 경우(문헌 10편), 원격모니터링군과 대조군 간의 차이가 유의하지 않았다(SMD -0.17, 95% CI –0.41 ~ 0.07, I2=51%). 전체 사망률에 대한 메타분석 결과(문헌 5편), 두 군 간 유의한 차이는 확인되지 않았다(RR 0.80, 95% CI 0.48~1.35, I2=0%). 

의료이용도에 있어 전체 입원기간에 대한 메타분석 결과(문헌 5편), 두 군간 차이가 유의하지 않았다(MD 0.54, 95% CI –1.49 ~ 2.58, I2=9%). 전체 입원 횟수(문헌 5편),  전체 응급실 방문 횟수(문헌 2편), 전체 외래 방문 횟수에 대한 메타분석 결과(문헌 2편), 두 군간 차이가 유의하지 않았다(각각, MD -0.13, 95% CI –0.58 ~ 0.32, I2=58%; MD -0.16, 95% CI –0.38 ~ 0.05, I2=0%; MD -0.16, 95% CI –2.05 ~ 1.74, I2=62%).

호흡곤란점수인 CRQ 점수에 대한 메타분석 결과(문헌 3편), 원격모니터링군과 대조군 간의 차이는 유의하지 않았다(MD 0.60, 95% CI –2.75 ~ 3.96, I2=60%). 신체활동 정도 및 신체 능력에 대한 결과도 원격모니터링군과 대조군 간에 통계적으로 유의한 차이가 없었다. 6분 보행 거리에 대한 메타분석 결과(문헌 5편), 두 군간 차이가 유의하지 않았다(MD 38.32, 95% CI –2.04 ~ 78.68, I2=44%). FEV1%에 대한 메타분석 결과(문헌 2편), 두 군간 차이가 유의하지 않았다(MD -3.25, 95% CI –10.08 ~ 3.57, I2=0%). 

▢ 결론

본 연구는 체계적 문헌고찰 방법을 통해 천식 환자에서 원격모니터링 중재의 임상적 효과를 평가하였다. 통상적 관리와 비교 시, 원격모니터링 중재가 천식 환자 관리에 있어 증상을 조절하고, 천식 악화의 감소 및 삶의 질 향상에 효과적이라는 결론을 내릴 만한 근거는 확인되지 않았다. 향후 추가 연구를 통해 천식 환자에서의 원격모니터링 중재의 효과 및 어떤 특성의 중재가 더 효과적인지에 대한 지속적 규명이 이루어질 필요가 있다.

만성폐쇄성폐질환 환자에서 원격모니터링 중재는 통상적 관리에 비해 만성폐쇄성폐질환 악화 감소, 삶의 질 또는 건강상태의 향상, 사망의 감소에 효과적이라는 명확한 근거는 확인되지 않았다. 다만, 중재기간이 6개월을 초과하는 경우 악화율의 유의한 감소 효과가 나타났고 문헌간 이질성이 유의하지 않았다. 전체적으로 연구마다 대상자 특성(질환중증도), 원격모니터링 중재의 세부내용, 결과지표측정에 사용된 지표가 다양하다는 제한점이 있으므로 향후 추가 연구를 통하여 만성폐쇄성폐질환에서 원격모니터링 중재 효과와 함께 어떤 중재유형이 효과적인지에 대한 지속적인 규명이 이루어질 필요가 있다.

▢ Background

As a result of analysing cause of death announced by Statistics Korea in 2015, it was found that chronic diseases and cardiovascular diseases requiring continuous care account for the largest part of it. The prevalence of chronic disease is growing due to bad eating habits of modern people and decline of physical activities, etc. as well as aging of modern society, but, despite the development of medical technology, the treatment rate of chronic disease such as asthma and COPD (Chronic Obstructive Pulmonary Disease) is remarkably low (Choi et al., 2009). 

Patients with chronic disease such as asthma and COPD should make accurate diagnosis and treatment conducted by observing and recording daily symptoms and treatment effects, and complication occurrence status and reporting them to medical team, and the active attitude for taking medicine or life style correction is required of them.

Nowadays, owing to an increase in accessibility, ICT (Information and Communication Technology) development and low cost, the patient care utilizing a home telemonitoring intervention is drawing massive interest (Bolton, 2010). Telehealth or telemedicine may be defined as the use of information and communication technologies to deliver healthcare at a distance and to support patient self-management through remote monitoring and personalised feedback. Telemonitoring for asthma or COPD involves patients regularly recording and transmitting their symptoms and physiological measurements to supervising clinicians. These symptoms are scored and if the total score breaches an agreed level or if a physiological measure is out-with preset parameters, then clinicians are alerted and can respond promptly to changes which may be interpreted as significant worsening of the patients’ clinical condition. In this way it is hoped that exacerbations can be identified at an early stage and treatment instituted to prevent serious deterioration and hospital admission (McKinstry, 2013). Therefore, in this study, we tried to analyse clinical effects of the telemonitoring intervention in chronic diseases such as asthma and COPD which are most applied to this intervention after diabetes, hypertension, heart failure and depressive disorder already assessed in 2015. 

▢ Objective

This study aims to provide objective basis which is of help in making a decision for the telemedicine policy figuring out detailed characteristics of telemonitoring intervention for managing asthma and COPD and contemplating systematically documentary basis on clinical effects of it. 

▢ Methods

1. Rapid review

We conducted the overview of systematic reviews about telemonitoring intervention for asthma and COPD management. Relevant systematic reviews of telemonitoring interventions were identified through searches in Ovid-MEDLINE, Ovid-EMBASE, Cochrane Library using SIGN (Scottish Intercollegiate Guidelines Network)  systematic review filter. We included the systematic reviews that were published in English and Korean from 2010. The reviews were finally selected by an agreement of opinions following an individual examination of 2 investigators. Appropriate literatures were selected examining original texts in accordance with selection/exclusion criteria. For all literatures finally selected, these materials were agreed after one investigator extracted them and then other investigator examined independently the extracted results. Research country, targeted disease, intervention characteristics, literature search period and number of selected literatures, and outcome indicator, etc. were included as a general characteristic, and the results of clinical effects were presented in order of major outcome indicators defined in this study. 

2. Systemic review

We searched Ovid-MEDLINE, Ovid-EMBASE, CENTRAL (the Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and 5 domestic databases (KoreaMed, KMbase, KISS, RISS, KISTI) up to March 2016. We included randomized controlled trials (RCT). Two review authors independently extracted data and assessed the risk of bias. Data was synthesized quantitatively or qualitatively depending on type of extracted data.

▢ Results

1. Results of rapid review

1) Asthma

We included 8 systematic reviews to examine the effect of telemonitoring intervention in patients with asthma. There was no literature presenting the improvement of consistent results in asthma symptom control which is a clinical outcome indicator, quality of life, use of medical service, pulmonary function, side effect and compliance. Owing to an insufficiency of number of included literatures, these were mainly qualitatively synthesized, and even in case the quantitative synthesis was conducted, it was not statistically significant. 

The literatures presenting outcome indicators of the intervention application side reported for accessibility and the expense and number of medical treatment, utilization of medical sources and drug use, and applicability of telemonitoring intervention. In terms of accessibility, the accessibility of telemonitoring intervention was better than that of usual care, and, for the number and expense of medical treatment, even if the number was more in telemonitoring intervention, and the expense was less. As a result of comparing the internet intervention group with the normal treatment group for application of medical sources and drug use, there was no difference between the two groups. In case of the number of treatment not reserved, the internet intervention group was shown to be higher.

The literatures described for outcome indicators in the economic views reported for medical expense per case, expense-effectiveness of the telemonitoring, etc. Upon examination of medical expense per case, the medical expense of telemonitoring group was lower, and annual medical expense appeared also to be less. As a result of the expense-effectiveness of telemonitoring, in case of adults, it was shown that the medical expense of telemonitoring group was $695.54 high and the effectiveness was 0.03QALY high, and thus the ratio of the gradual expense-effectiveness was 42,520$/QALY. In case of children, it is found that the medical expense was $829.56 high and the effectiveness was 0.01QALY high.

2) COPD (Chronic Obstructive Pulmonary Disease)

13 documents were finally selected to conduct the systemic review in literatures investigating the effect of telemonitoring intervention in patients with COPD.

As a result of the clinical outcome indicators such as deteriorated symptoms, healthcare usage, mortality, degree of physical activity, and physical performance, there was no literature presenting consistent improvement of outcomes. With regard to quality of life outcomes, it was found that quality of life improvement was statistically consistent.

The literatures stated for outcome indicators in terms of economics reported for healthcare-related expense and its reduction, and average expense per each person. As a result of the expense relevant to medical treatment, the decreasing tendency appeared in the telemonitoring group compared to the control group, indicating that the reduction of the number of hospitalization, etc. was main cause. As a result of analysing average expense per each person, the average expense of the telemonitoring group was found to be lower.

2. Results of systemic review

1) Asthma

We included 17 Randomised controlled trials (21 articles) in this review. The effects of intervention were evaluated in accordance with asthma symptoms (asthma control score, asthma exacerbation, asthma symptom, and symptom-free days), use of medical service (hospitalization, emergency room visits, and unscheduled visit of outpatient clinic), quality of life and limited activity, pulmonary function (FEV1, FVC, PEFR), outcomes related to drug use (drug adherence, use of daily inhaled corticosteroid, use of bronchodilators, use of leukotriene modifier, and use of whole drugs), and intervention compliance and satisfaction. Also, according to the control group type, we compared them discriminating between usual care and other intervention.

Firstly, studies comparing telemonitoring intervention to usual care were found in 21 trials (17 articles) in total, and they were conducted targeting 3,025 participants: 9 in children and 8 in adults. Studies generally recruited people with mild to severe asthma and followed them for between two and 12 months. People in the telemonitoring intervention group transmitted patient information such as asthma control score, result of pulmonary function test, drug administration status using a variety of technologies (web systems, mobile phones), and such information was monitored by the medical professionals and various types of feedbacks were provided.

Upon a comparison of telemonitoring intervention and usual care, there were no indicators showing statistically significant results. In case of examining it by each major outcome variable, as a result of meta-analysis for asthma control score (7 studies, 8 arms), a difference between the telemonitoring intervention group and the control group was not statistically significant (SMD 0.15, 95% CI –0.07 ~ 0.38). Also, as the heterogeneity between literatures was shown to be high (I2=74%), subgroup analysis was performed, but we couldn’t find out any factor describing it. As a result of integrated analysis of the studies reporting the frequency of asthma exacerbations (6 studies, 7 arms), a difference between the telemonitoring intervention group and the control group was not statistically significant (RR 075, 95% CI 0.51 ~ 1.10). As a result of meta-analysis of symptom-free days (4 studies), a difference between the two groups was not statistically significant (WMD 3.92, 95% CI –4.96 ~ 12.80). As a result of meta-analysis related to use of medical service, a difference between the two groups was not found in hospitalization rate (5 studies, RR 2.34, 95% CI 0.82 ~ 6.62), emergency room visit rate (6 studies, RR 0.77, 95% CI 0.43 ~ 1.39), and unscheduled outpatient clinic visit rate (2 studies, RR 0.90, 95% CI 0.34 ~ 2.35). Also, the result of meta-analysis of quality of life (6 studies, 7 arms), there is no difference between the two groups (SMD 0.10, 95% CI –0.10 ~ 0.31). The studies reporting the pulmonary function (FEV1) was 10 trials, and the quantitative synthesis was possible in 4 studies. As a result of meta-analysis, there was no difference between the two groups in FEV1 (SMD 0.07, 95% CI –0.22 ~ 0.36).

Secondly, the studies comparing telemonitoring intervention and other intervention was 2 trials (3 arms), there was a lack of basis to evaluate the effect of telemonitoring. However, as a result of meta-analysis integrated in the manner of exploration by using 1 RCT (2 arms), there was a statistically significant difference in asthma exacerbation rate (RR 0.13, 95% CI 0.07 ~ 0.25) and quality of life (WMD 0.55, 95% CI 0.18 ~ 1.02).

2) COPD (Chronic Obstructive Pulmonary Disease)

The literatures finally selected to analyse clinical effects of telemonitoring intervention in patients with COPD were 24 randomized controlled trials, and total subjects were 2,014 people. In the studies, all COPD patients with disease severity from mild to very serious condition were included. 

For the intervention period, 5 studies were long-term (≥12months), 13 studies were mid-term (>3months, <12months), and 5 studies were short-term (≤3months). In one study, intervention period was not reported. 

For the follow-up period, 9 studies were long-term (≥12months), 12 studies were mid-term (>3months, <12months), and 3 studies were short-term (≤3months). 

Upon a comparison of telemonitoring intervention and control group, there were no indicators showing statistically significant results. As a result of meta-analysis related to exacerbation rate (6 studies), a difference between the two groups was not found (RR 0.67, 95% CI 0.31 ~ 1.42). Also, as the moderate degree of the heterogeneity between literatures was shown to be high (I2=67%), subgroup analysis was performed, and we found that intervention period could be the factor describing it. As a result of meta-analysis of the exacerbation period (6 studies), a difference between the two groups was not statistically significant (MD 0.12, 95% CI –1.18 ~ 1.43, I2=7%). As a result of meta-analysis of the number of exacerbations (6 studies), a difference between the two groups was not statistically significant (MD -0.12, 95% CI –0.32 ~ 0.07, I2=0%). 

When meta-analysing all the studies which were reported quality of life of health status (10 studies), a difference between the two groups was not statistically significant (SMD -0.17, 95% CI –0.41 ~ 0.07, I2=51%). As a result of meta-analysis of all-cause mortality (5 studies), a difference between the two groups was not statistically significant (RR 0.80, 95% CI 0.48 ~ 1.35, I2=0%). 

Outcomes on healthcare usage were also not statistically significant between tele-monitoring group and control group. When meta-analysing total length of hospital stay (5 studies), a difference between the two groups was not statistically significant (MD 0.54, 95% CI –1.49 ~ 2.58, I2=9%). As a result of meta-analysis of total number of hospitalization (5 studies), a difference between the two groups was not statistically significant (MD -0.13, 95% CI –0.58 ~ 0.32, I2=58%). As a result of meta-analysis of total number of emergency room visiting (2 studies), a difference between the two groups was not statistically significant (MD -0.16, 95% CI –0.38 ~ 0.05, I2=0%). As a result of meta-analysis of total number of outpatient visiting (2 studies), a difference between the two groups was not statistically significant (MD -0.16, 95% CI –2.05 ~ 1.74, I2=62%). 

As a result of meta-analysis of CRQ dyspnea score (3 studies), a difference between the two groups was not statistically significant (MD 0.60, 95% CI –2.75 ~ 3.96, I2=60%). Performing meta-analysis of degree of physical activity and physical performance (6-minute walk distance, FEV1%), a difference between the two groups was not statistically significant. As a result of meta-analysis of 6-minute walk distance (5 studies), a difference between the two groups was not statistically significant (MD 38.32, 95% CI –2.04 ~ 78.68, I2=44%). As a result of meta-analysis of FEV1% (2 studies), a difference between the two groups was not statistically significant (MD -3.25, 95% CI –10.08 ~ 3.57, I2=0%). 

▢  Plain Language

As a result of this study, current evidence dose not support that the telemonitoring intervention in patients with asthma is effective in control of asthma symptom, reduction of asthma exacerbation, and improvement of quality of life compared to the usual care. As detailed contents of the telemonitoring intervention included in this study were heterogeneous, there is limitation in concluding what character of interventions is more effective, and thus it is considered that further studies are required in the future to examine the telemonitoring intervention effect of asthma patients.

As a result of this study, there were no obvious reasons that the telemonitoring intervention in patients with COPD is effective in reduction of COPD exacerbation, improvement of quality of life or health status, and reduction of death compared to the usual care. Only, when the intervention period was over 6 months, exacerbation rate was significantly reduced and synthesized studies were not heterogeneous. However, as there is limitation that the subject characteristics (disease severity), detailed contents of telemonitoring intervention, and measurement of outcome indicator are different according to each study, and therefore continued investigations should be conducted in terms of the telemonitoring intervention effect in COPD and the effective intervention type through additional studies in the future.

요약문 ⅰ

Executive Summary ⅶ

Ⅰ. 서론 1

  1. 연구의 배경 및 필요성 1

  2. 연구 목적 3

Ⅱ. 선행연구 4

  1. 천식 4

  2. 만성폐쇄성폐질환 11

Ⅲ. 연구 방법 20

  1. 신속 문헌고찰 20

  2. 체계적 문헌고찰 21

Ⅳ. 연구 결과 29

  1. 천식 29

  2. 만성폐쇄성폐질환 86

Ⅴ. 고찰 156

  1. 연구 결과 요약 156

  2. 연구의 의의 161

  3. 연구의 제한점 및 후속연구 제안 163

  4. 결론 및 제언 166

Ⅵ. 참고문헌 167

Ⅶ. 부록 172