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Suboptimal treatment adherence is common in respiratory patients and is associated with poor disease control and outcome.1–3 In patients with asthma, real-life adherence rates are as low as 8% and in some studies up to 70%,4–6 and low treatment adherence is associated with an increased risk of severe disease exacerbations.7 Similar levels are seen in patients with chronic obstructive pulmonary disease where, real-life adherence rates range between 20% to 60%,8 and low treatment adherence is associated with increased mortality.9

Digital technology

Now digital technologies may help improve adherence and the focus of current approaches have been to monitor medication use remotely in order to identify those patients poorly controlled and in need of additional attention to help achieve better disease controlled. Now such systems have both monitoring components and self-management components.10 

So if we reflect on a few studies. In a randomised controlled trial by Chan and colleagues,11 220 children aged between 6 to 15 years of age with asthma were randomised to receive a preventer inhaled corticosteroid inhaler sensor with an audio-visual function that in one group was enabled and in the other group was disabled. The authors found a significant improvement in adherence in those where the sensor was enabled, and they also observed an improvement in asthma control. The authors concluded digital interventions may be beneficial for improving asthma control where poor asthma control is related to poor adherence.

In the STARR trial,12 electronic adherence monitoring, with reminder alarms and feedback, was investigated for poorly controlled asthma patients where 90 children aged between the ages of 6 to 16 years participated. Now, although this study missed out on its primary outcome of the Asthma Control Questionnaire, the ACQ, there was significantly fewer courses of oral corticosteroids and fewer hospital admissions. However, interestingly the approach was not liked by all, as when overtly monitored in the intervention group, patients were more likely to report broken in nearly 50%, damaged, 37%, forgotten in over 20% or lost 11% devices. So maybe this big brother approach, wasn’t appreciated by all.

Improving treatment

Improving treatment for patients with asthma and COPD is not just focused on monitoring adherence, but also inhaler technique. It has been shown that errors in inhaler technique have a significant association with poor disease outcomes and a greater health-economic burden.13 And this was undertaken in a study that we did a few years ago. So, objective measurement of inhaler technique has been undertaken to help identify the frequency of error type with electronic acoustic recording devices that are that have been attached to inhaler devices.14 Using digital technology, monitored adherence, including inhaler technique and regularity of use, with personalised biofeedback on inhaler use, has been shown to increase and sustain adherence in patients with severe uncontrolled asthma.15

Now it’s important to say that any successful digital solution requires the perspectives of the end-users, that is the patients themselves and also the healthcare professionals, on the design, the use and functionality of mobile-Health systems for asthma self-management.

So, in a study investigating a digital solution for asthma,16 the authors asked what would patients want from a mobile-Health system, and the top three responses were a system that would: 

  • help patients monitor their asthma over time
  • collect data that patients can show their healthcare professional to demonstrate how their asthma had been over time because sometimes they forget
  • and detect and alert patients and/or healthcare professionals to a deterioration in their asthma control before they, would themselves normally notice. 

Now when healthcare professionals were asked what they would want from a mobile-Health system in the same study, the top three responses were:16

  • offer advice regarding when additional medical attention should be sought, offer advice to the patients
  • detect and alert to a deterioration in their asthma so that was similar to what the patients wanted 
  • and provide instruction on how to manage their asthma in an emergency. 

And interestingly, in this study the authors found that asthma patients were less likely than healthcare professionals to believe measuring adherence, inhaler technique, and respiratory symptoms could help them achieve better control.16 So a bit of a disconcordance there.

A study on inhaler adherence during the COVID-19 pandemic reported that using the electronic medication data on controller medication they found positive increases in nearly 15% in medication adherence. The study was undertaken between January to March 2020, and in over 7500 subjects, where 77% had a diagnosis of asthma, and here an electronic inhaler sensor was used to assess adherence to the controller medication and assess at least 70% adherence. And the authors concluded that there may be two reasons for this increased adherence. One in the early period of the pandemic, patients were quite afraid of being admitted to hospital, so they increased their engagement with management of their airway disease condition. And two, they had more time because they were self- isolating to also spend on educational materials and understanding their asthma COPD and adhering to treatment. 

Challenges ahead

So, I think the challenges for digital health going forward is recognised by several authors now that we need high-quality evidence. Currently the studies we’ve seen are of moderate quality, of short term in duration, with high heterogeneity in study endpoints, and of varied study designs that makes them difficult to compare, with a lack of defining the minimal clinical difference a priori.

So, there is optimism in digital technologies to improve treatment adherence in asthma and COPD but that does require well conducted studies.

Professor Omar Usmani, professor of respiratory medicine, Imperial College London

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