Digital interventions to improve adherence to maintenance medication in asthma

A systematic review of users experiences of using digital interventions within psychosis: a thematic synthesis of qualitative research

PURPOSE

Although the development of digital mental health support for people with psychosis has been increasing, the development and opportunities to access this have been more limited compared to other mental health conditions. Qualitative research exploring the experiences of using digital interventions amongst people with psychosis is even less well developed; however, such research is crucial in capturing the experiences of using digital interventions to ensure they are meeting the needs of people with psychosis. This paper aimed to synthesise qualitative data related to the experiences of people with psychosis who have used digital interventions.

METHODS

A systematic literature search was conducted of articles published between 1992 and October 2023 using PubMed, MBase, PsycINFO, & OVID Medline. Two reviewers independently reviewed and screened 268 papers. Papers that met inclusion criteria were quality assessed using The Critical Appraisal Skills Programme (CASP) qualitative studies checklist. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist was used to guide the structure of the report.

RESULTS

A thematic synthesis of 19 studies revealed six overarching themes which related to different aspects and features of the digital interventions: participants' relationship with technology; the accessibility of the interventions; how the interventions could impact on individuals' awareness and management of mental health; enhanced communication and relationships; and opportunities for reflection.

CONCLUSIONS

Benefits of using digital interventions are discussed. Areas for development and improvements are highlighted. Finally, recommendations for stakeholders who develop and implement digital interventions for psychosis are made.

Digital Self-Management Platform for Adult Asthma: Randomized Attention-Placebo Controlled Trial

BACKGROUND

Asthma is one of the most common chronic conditions worldwide, with a substantial individual and health care burden. Digital apps hold promise as a highly accessible, low-cost method of enhancing self-management in asthma, which is critical to effective asthma control.

OBJECTIVE

We conducted a fully remote randomized controlled trial (RCT) to assess the efficacy of juli, a commercially available smartphone self-management platform for asthma.

METHODS

We conducted a pragmatic single-blind, RCT of juli for asthma management. Our study included participants aged 18 years and older who self-identified as having asthma and had an Asthma Control Test (ACT) score of 19 or lower (indicating uncontrolled asthma) at the beginning of the trial. Participants were randomized (1:1 ratio) to receive juli for 8 weeks or a limited attention-placebo control version of the app. The primary outcome measure was the difference in ACT scores after 8 weeks. Secondary outcomes included remission (ACT score greater than 19), minimal clinically important difference (an improvement of 3 or more points on the ACT), worsening of asthma, and health-related quality of life. The primary analysis included participants using the app for 8 weeks (per-protocol analysis), and the secondary analysis used a modified intention-to-treat (ITT) analysis.

RESULTS

We randomized 411 participants between May 2021 and April 2023: a total of 152 (37%) participants engaged with the app for 8 weeks and were included in the per-protocol analysis, and 262 (63.7%) participants completed the week-2 outcome assessment and were included in the modified ITT analysis. Total attrition between baseline and week 8 was 259 (63%) individuals. In the per-protocol analysis, the intervention group had a higher mean ACT score (17.93, SD 4.72) than the control group (16.24, SD 5.78) by week 8 (baseline adjusted coefficient 1.91, 95% CI 0.31-3.51; P=.02). Participants using juli had greater odds of achieving or exceeding the minimal clinically important difference at 8 weeks (adjusted odds ratio 2.38, 95% CI 1.20-4.70; P=.01). There were no between group differences in the other secondary outcomes at 8 weeks. The results from the modified ITT analyses were similar.

CONCLUSIONS

Users of juli had improved asthma symptom control over 8 weeks compared with users of a version of the app with limited functionality. These findings suggest that juli is an effective digital self-management platform that could augment existing care pathways for asthma. The retention of patients in RCTs and real-world use of digital health care apps is a major challenge.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) registry ISRCTN87679686; https://www.isrctn.com/ISRCTN87679686.

Barriers to clinical remission in severe asthma

Severe asthma is associated with an increased risk for exacerbations, reduced lung function, fixed airflow obstruction, and substantial morbidity and mortality. The concept of remission in severe asthma as a new treatment goal has recently gained attention due to the growing use of monoclonal antibody therapies, which target specific pathologic pathways of inflammation. This review evaluates the current definitions of asthma remission and unveils some of the barriers for achieving this state in the severe asthma population. Although there is no unified definition, the concept of clinical remission in asthma should be based on a sustained period of symptom control, elimination of oral corticosteroid exposure and exacerbations, and stabilization of pulmonary function. The conjugation of these criteria seems a realistic treatment target in a minority of asthmatic patients. Some unmet needs in severe asthma may affect the achievement of clinical remission. Late intervention with targeted therapies in the severe asthma population may increase the risk of corticosteroid exposure and the development of irreversible structural airway changes. Moreover, airway infection is an important component in persistent exacerbations in patients on biologic therapies. Phenotyping exacerbations may be useful to guide therapy decisions and to avoid the liberal use of oral corticosteroids. Another challenge associated with the aim of clinical remission in severe asthma is the multifaceted interaction between the disease and its associated comorbidities. Behavioural factors should be evaluated in case of persistent symptoms despite optimised treatment, and assessing biomarkers and targeting treatable traits may allow for a more objective way of reaching remission. The concept of clinical remission will benefit from an international consensus to establish unifying criteria for its assessment, and it should be addressed in the future management guidelines.

Expert Insight Into the Use of eHealth Interventions to Aid Medication Adherence During COVID-19

Background and Aim

The COVID-19 pandemic has transformed the way healthcare is delivered by the increased utilisation of eHealth tools to deliver remote patient consultations. These eHealth tools served various functions during COVID-19 including monitoring and surveillance of patients. Therefore, assessment of digital health interventions for monitoring medication adherence is crucial to maximise the potential benefits of eHealth. The aim of this study is to understand the perspectives of experts in medication adherence around eHealth interventions used to aid adherence during COVID-19.

Methods

The study was exploratory and utilized a mixed-method approach. Data was gathered from a survey distributed by the International society for Medication Adherence, and from arranging subsequent structured interviews. Purposive sampling was used to collect data from individuals who were rich in knowledge about the field of medication adherence. Template analysis was used to analyse the collected data.

Results

Twenty-one participants responded to the survey and 6 completed the interviews. Results showed that eHealth tools reduced barriers to medication adherence by improving health literacy of patients. The main strengths of eHealth technology used in COVID-19 highlighted by participants were convenience and user empowerment. Moreover, weaknesses and barriers included lack of cooperation between technology providers, lack of awareness of doctors about eHealth and patient's digital health literacy.

Conclusion and Future Directions

The increased utility of eHealth tools during COVID-19 highlighted their vital role in aiding medication adherence of patients. These technologies have both decreased and increased barriers to medication adherence through numerous ways. Future directions should focus on gaining the perspectives of patients on the use of eHealth interventions and its role in aiding medication adherence.

Machine Learning Approaches to Predict Asthma Exacerbations: A Narrative Review

The implementation of artificial intelligence (AI) and machine learning (ML) techniques in healthcare has garnered significant attention in recent years, especially as a result of their potential to revolutionize personalized medicine. Despite advances in the treatment and management of asthma, a significant proportion of patients continue to suffer acute exacerbations, irrespective of disease severity and therapeutic regimen. The situation is further complicated by the constellation of factors that influence disease activity in a patient with asthma, such as medical history, biomarker phenotype, pulmonary function, level of healthcare access, treatment compliance, comorbidities, personal habits, and environmental conditions. A growing body of work has demonstrated the potential for AI and ML to accurately predict asthma exacerbations while also capturing the entirety of the patient experience. However, application in the clinical setting remains mostly unexplored, and important questions on the strengths and limitations of this technology remain. This review presents an overview of the rapidly evolving landscape of AI and ML integration into asthma management by providing a snapshot of the existing scientific evidence and proposing potential avenues for future applications.

Expert Consensus on SABA Use for Asthma Clinical Decision-Making: A Delphi Approach

PURPOSE OF REVIEW

A modified Delphi process was undertaken to provide a US expert-led consensus to guide clinical action on short-acting beta2-agonist (SABA) use. This comprised an online survey (Phase 1), forum discussion and statement development (Phase 2), and statement adjudication (Phase 3).

RECENT FINDINGS

In Phase 1 (n = 100 clinicians), 12% routinely provided patients with ≥4 SABA prescriptions/year, 73% solicited SABA use frequency at every patient visit, and 21% did not consult asthma guidelines/expert reports. Phase 3 experts (n = 8) reached consensus (median Likert score, interquartile range) that use of ≥3 SABA canisters/year is associated with increased risk of exacerbation and asthma-related death (5, 4.75-5); SABA use history should be solicited at every patient visit (5, 4.75-5); usage patterns over time, not absolute thresholds, should guide response to SABA overuse (5, 4.5-5). Future asthma guidelines should include clear recommendations regarding SABA usage, using expert-led thresholds for action.

The Design of a Persuasive Game to Motivate People with Asthma in Adherence to Their Maintenance Medication

Objective

This study aimed to design a persuasive game, using objective adherence data, to motivate people with asthma to adhere to their medication regimen.

Methods

A participatory user-centered design approach was employed, involving end-users and other stakeholders throughout the study. The approach consisted of four phases. Semi-structured interviews and a survey were conducted to understand user needs and reasons for poor adherence (Phase 1: define). Key themes were identified, leading to the formulation of behavior change strategies and design and game requirements. Several design directions were ideated, resulting in a concept for a serious game (Phase 2: ideate). Two rounds of user-tests were performed to evaluate a prototype of the serious game in terms of usability, perceived impact on medication adherence and motivation (Phase 3: prototype and Phase 4: evaluate).

Results

Findings from semi-structured interviews (n = 6) and the online survey (n = 20) revealed that people's non-adherence was often attributed to the perception of asthma as an episodic condition, the delayed experienced effect of maintenance inhalers, and lack of knowledge regarding difference of effect between maintenance and reliever inhalers. The study used behavior change strategies to translate these insights into design requirements for the development of the narrative-based persuasive game Ademgenoot. This six-week challenge-based game combines various behavior change strategies, including personal goal setting and continuous visual feedback, as well as persuasive game design elements, such as a narrative and rewards, with the aim of enhancing motivation to adhere to their medication regimen. User-testing (n = 8; round 1 and 2) showed that Ademgenoot is feasible in clinical practice and has the potential to support people with mild asthma in adherence to their maintenance medication.

Discussion

Future efforts should be directed towards a larger evaluation to assess the impact on motivation and inhaler use behaviour.

Effect of monitoring adherence to regular inhaled corticosteroid (ICS) alone or in combination with a long-acting β2-agonist (LABA) using electronic methods on asthma outcomes: a narrative systematic review

OBJECTIVES

To evaluate through a systematic review the effectiveness of electronic methods in monitoring adherence to regular inhaled corticosteroids (ICS) alone or in combination with long-acting β2-agonists (LABAs) and their effect on clinical outcomes.

DESIGN

A narrative systematic review.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Web of Science were searched through up to 10 July 2022.

ELIGIBILITY CRITERIA

We included peer-reviewed studies of qualitative and quantitative outcomes that compared the effect of electronic methods to routine non-electronic monitoring intervention or placebo among children and adults with asthma on medication adherence rates to regular ICS alone or in combination with LABA, asthma control and asthma exacerbations.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed according to a predetermined sheet specific to the review objectives. The risk of bias was assessed using the Cochrane Risk of Bias Tool for randomised controlled trials and the Risk of Bias in Systematic Reviews tool for systematic reviews. Meta-analysis was not possible based on the findings of the scoping search; however, a narrative review was performed to allow for the grouping of results based on asthma inhaler adherence rates, asthma control and exacerbations.

RESULTS

Six articles comprising 98 studies published from 1998 to 2022 in the USA, Canada and the UK were included. Compared with the control, electronic monitoring devices (EMDs) showed a 23% adherence improvement, mean difference (MD) of 23%, 95% CI 10.84 to 34.16, p=0.0002. Asthmatic children were 1.5 times more likely to be adherent using EMDs compared with non-EMD users (RR=1.5, 95% CI 1.19 to 1.9) (p<0.001). Mobile devices and text message reminders (MHealth) showed a 12% adherence improvement (MD 12%, 95% CI 6.22 to 18.03) (p<0.0001), alongside a small to medium improvement in asthma control (standardised mean difference (SMD) 0.31, 95% CI 0.17 to 0.44), small improvement in asthma-related quality of life (SMD 0.26) (p=0.007) and variable risk reduction in asthma exacerbations for digital health (risk ratio 0.53, 95% CI 0.32 to 0.91) (p=0.02) compared with EMDs, which showed insignificant differences (risk ratio 0.89, 95% CI 0.45 to 1.75) (p=0.72). Technologies combined yielded variable adherence effects, with an SMD for eHealth of 0.41, 95% CI 0.02 to 0.79, and MD for digital health was 14.66% higher than the control, 95% CI 7.74 to 21.57. Heterogeneity between studies was significant (eHealth I2=98%, digital I2=94%).

CONCLUSION

Electronic methods improved adherence to inhaled medications in asthma. EMDs appear to be the most effective technology, followed by mHealth. The adherence improvement was associated with a small clinical improvement. There was inconsistent overlapping of terminology describing electronic methods that require standardisation. Data on the cost-effectiveness of electronic devices and their utilisation in severe asthma are lacking and require further research.

PROSPERO REGISTRATION NUMBER

CRD42022303069.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Personalised management and supporting individuals to live with their asthma in a primary care setting

INTRODUCTION

Complementing recognition of biomedical phenotypes, a primary care approach to asthma care recognizes diversity of disease, health beliefs, and lifestyle at a population and individual level.

AREAS COVERED

We review six aspects of personalized care particularly pertinent to primary care management of asthma: personalizing support for individuals living with asthma; targeting asthma care within populations; managing phenotypes of wheezy pre-school children; personalizing management to the individual; meeting individual preferences for provision of asthma care; optimizing digital approaches to enhance personalized care.

EXPERT OPINION

In a primary care setting, personalized management and supporting individuals to live with asthma extend beyond the contemporary concepts of biological phenotypes and pharmacological 'treatable traits' to encompass evidence-based tailored support for self-management, and delivery of patient-centered care including motivational interviewing. It extends to how we organize clinical practiceand the choices provided in mode of consultation. Diagnostic uncertainty due to recognition of phenotypes of pre-school wheeze remains a challenge for primary care. Digital health can support personalized management, but there are concerns about increasing inequities. This broad approach reflects the traditionally holistic ethos of primary care ('knowing their patients and understanding their communities'), but the core concepts resonate with all healthcare.

Retrospective assessment of a collaborative digital asthma program for Medicaid-enrolled children in southwest Detroit: reductions in short-acting beta-agonist (SABA) medication use

BACKGROUND

Real-world evidence for digitally-supported asthma programs among Medicaid-enrolled children remains limited. Using data from a collaborative quality improvement program, we evaluated the impact of a digital intervention on asthma inhaler use among children in southwest Detroit.

METHODS

Children (6-13 years) enrolled with Kids Health Connection (KHC), a program involving home visits with an asthma educator, were invited to participate in a digital self-management asthma program (Propeller Health). Patients were provided with a sensor to capture short-acting beta-agonist (SABA) medication use, and given access to a paired mobile app to track usage. Patients' healthcare providers and caregivers ("followers") were invited to view data as well. Retrospective paired t-tests assessed change in mean SABA use and SABA-free days (SFD) over time, and regressions explored the relationship between followers and medication use.

RESULTS

Fifty-one patients were assessed. Mean program participation was nine months, and patients had on average 3 followers. From the first to last participation month, mean SABA use decreased from 0.68 to 0.25 puffs/day (p < 0.001), and mean SFD increased from 25.2 to 28.1 days/month (p < 0.001). 76% of patients had an increase in the number of SFD. There was a positive, but non-significant, relationship between the number of followers and reductions in SABA inhaler use.

CONCLUSIONS

We observed a significant reduction in SABA inhaler use and an increase in the number of SABA-free days among Medicaid-enrolled children enrolled in a multi-modal digital asthma program.

Current and Optimal Practices in Childhood Asthma Monitoring Among Multiple International Stakeholders

Importance

Childhood asthma control largely depends on rigorous and regular monitoring. Although various clinical parameters, biomarkers, and patient-reported outcomes are helpful for monitoring purposes, there is no consensus on the minimum and/or optimal set of parameters and their relative priority.

Objective

To assess actual and perceived optimal childhood asthma monitoring practices used globally.

Design, Setting, and Participants

This international, multistakeholder survey study surveyed health care professionals and clinical academics with a professional interest in and exposure to childhood asthma between April 12 and September 3, 2021, to test for differences between the frequency that different techniques are actually used in practice vs optimal practice, between-group differences, and differences across medical settings and country economies.

Main Outcomes and Measures

Outcomes were frequency of duration of asthma monitoring visits as well as actual and perceived optimal use and importance of monitoring tools and domains.

Results

A total of 1319 participants with expertise in childhood asthma from 88 countries completed the survey. Participants included 1228 health care professionals with a balanced distribution across different care settings (305 [22.7%] primary care, 401 [29.9%] secondary, and 522 [38.9%] tertiary care) and 91 researchers. Children with mild to moderate asthma attended regular monitoring visits at a median (IQR) of 5.0 (2.5-8.0) months, with visits lasting a median (IQR) of 25 (15-25) minutes, whereas severe asthma required more frequent visits (median [IQR], 2.5 [1.0-2.5] months; median [IQR] duration, 25 [25-35] minutes). Monitoring of symptoms and control, adherence, comorbidities, lung function, medication adverse effects, and allergy were considered to be very high or high priority by more than 75% of the respondents. Different patterns emerged when assessing differences between actual and perceived optimal use of monitoring tools. For some tools, current and optimal practices did not differ much (eg, spirometry), whereas in others, there was considerable space for improvement (eg, standardized control and adherence tests). The largest gap was observed for between-visit monitoring with electronic trackers, apps, and smart devices. Differences across country economies, care settings, and medical specialties were modest.

Conclusions and Relevance

These survey results suggest that pediatric asthma monitoring is performed generally homogeneously worldwide, in most cases following evidence-based standards. Wider use of standardized instruments and the intensification of continuous between-visit monitoring, supported by electronic devices, is needed for further improvement of disease outcomes. The results of this survey, in conjunction with the available evidence base, can inform recommendations toward further optimization.

Epidemiology of patients with asthma in Korea: Analysis of the NHISS database 2006-2015

Background

There has been a concerning increase in the prevalence and socioeconomic burden of asthma in Korea. Korea's National Health Insurance System (NHIS) covers insurance payment and claims management for all Koreans. Using National Health Insurance Sharing Service (NHISS) claims data. This study aimed to investigate patterns of healthcare utilization and direct cost in patients with asthma over a 10-year period.

Methods

In this retrospective population-based study, we examined NHISS claims records between July 2005 and June 2016 and investigated healthcare utilization among patients with asthma based on age group and severity of disease (non-severe asthma [NSA] and severe asthma [SA]).

Results

From 2006 to 2015, the total number of patients with asthma in Korea steadily increased from 743 968 to 2 286 309, with a corresponding increase in prevalence from 1.62% to 4.74%. The proportion of patients with SA decreased from 3.16% in 2006 to 1.56% in 2015; the proportion was consistently higher in men than in women. In addition, patients with SA had a higher cost per outpatient visit than patients with NSA, and the number of outpatient visits per year increased. The inhaled corticosteroid (ICS) prescription rate among patients with asthma decreased from 22.9% in 2006 to 15.7% in 2015. Furthermore, for a period of 10 years, more than 40% of patients with SA have been prescribed short-acting β-2 agonists (SABAs).

Conclusions

Although patients with SA comprised a small proportion of patients with asthma, they incurred greater medical costs per person. The pharmaceutical prescription pattern indicated a lack of ICS-based prescriptions and frequent SABA prescriptions.

Advancing Digital Solutions to Overcome Longstanding Barriers in Asthma and COPD Management

Maintenance therapy delivered via inhaler is central to asthma and chronic obstructive pulmonary disease (COPD) management. Poor adherence to inhaled medication and errors in inhalation technique have long represented major barriers to the optimal management of these chronic conditions. Technological innovations may provide a means of overcoming these barriers. This narrative review examines ongoing advances in digital technologies relevant to asthma and COPD with the potential to inform clinical decision-making and improve patient care. Digital inhaler devices linked to mobile apps can help bring about changes in patients' behaviors and attitudes towards disease management, particularly when they build in elements of interactivity and gamification. They can also support ongoing technique education, empowering patients and helping providers maximize the value of consultations and develop effective action plans informed by insights into the patient's inhaler use patterns and their respiratory health. When combined with innovative techniques such as machine learning, digital devices have the potential to predict exacerbations and prompt pre-emptive intervention. Finally, digital devices may support an advanced precision medicine approach to respiratory disease management and help support shared decision-making. Further work is needed to increase uptake of digital devices and integrate their use into care pathways before their full potential in personalized asthma and COPD management can be realized.