Electronic Interventions Show Promise for Pediatric Asthma, But Challenges Loom Large

As one of the most common chronic diseases — affecting roughly 10% of children worldwide — adherence to asthma treatment and management strategies is paramount for positive patient outcomes.¹ Although healthcare providers are well-versed in providing education, information, and interventions for patients, medication and therapeutic adherence remains low in the pediatric population, with one estimate suggesting that adherence rates hover below 50%.²

According to Amelia Licari, MD, of the department of clinical-surgical, diagnostic, and pediatric sciences at the University of Pavia in Italy, and colleagues, poor adherence to treatments result in compromised treatment effectiveness, uncontrolled disease, life-threatening asthma attacks, and increased utilization of healthcare resources.¹

“Given the multidimensional complexity of nonadherence in asthma, different tools with variable accuracy have been proposed for implementation in clinical practice to objectively assess and monitor treatment adherence in children … Among these, electronic health (e-Health) solutions are potentially valuable assets for children and adolescents with asthma and for their families,” according to Dr. Licari and colleagues.¹

In a review published in the Journal of Allergy and Clinical Immunology: In Practice,¹ the investigators explored the most relevant issues affecting e-Health implementation in pediatric asthma, as well as the associated evidence gaps, research limitations, and perspectives for future research. Currently, there are a range of available e-Health tools and mobile applications, which patients can use to create an optimal and personalized asthma management system.¹ Mobile and tablet applications include options for symptom self-monitoring and tracking therapy adherence, while providing an avenue for the distribution of self-management action plans and educational materials.³ While many of these tools are targeted toward the pediatric demographic, there is a distinct lack of data, in terms of both randomized controlled trials and observational studies, to assess the effectiveness of these solutions.^3,4

Inhaler technique and adherence is a vital part of asthma management, noted the investigatorss.¹ While previous evidence examining the impact of e-Health on inhaler technique was inconclusive,⁵ adolescents have accepted the use of digital health platforms in their care plan. Specifically, adolescents have indicated that they are very or somewhat satisfied with inhaler sensor devices.⁶ One adult study, examining patients with asthma or chronic obstructive pulmonary disease, found that the Spacer Data Logger system could be helpful in improving inhaler adherence. However, this finding must be confirmed in clinical trials in a pediatric population.¹

A currently ongoing trial, the CONNected Electronic Inhalers Asthma Control Trial 1 (CONNECT1; ClinicalTrials.gov identifier NCT03890666), will ultimately provide updated findings on both the feasibility and effectiveness of a smart inhaler — specifically, an albuterol multidose dry powder inhaler with an integrated electronic module system — for patients with asthma aged 13 years and older.⁷ This 12-week, multicenter, open-label, randomized, parallel group comparison feasibility study will examine device effectiveness in patients with suboptimal asthma control compared with standard of care albuterol rescue inhalers.⁷

According to the 2019 Global Initiative for Asthma report on difficult-to-treat and severe asthma in adolescent and adult patients, electronic inhaler monitoring has been endorsed as an “objective tool for assessing adherence.”⁸ However, despite this endorsement, a small number of studies assessing the efficacy of this intervention in children with severe asthma has precluded physicians from “drawing definitive conclusions” and limiting the applicability of these devices in daily practice.¹

Data about the role of electronic reminders to improve medication adherence is lacking, according to researchers and the results of a recent Cochrane review.^1,9 The use of these reminders and inhaler trackers were both inconsistent and inconclusive across a wide range of clinical outcomes.¹

Another targeted review, published in the Annals of Allergy, Asthma, and Immunology,¹⁰ analyzed the results of 16 studies focused on the effectiveness of e-Health technologies. In 5 randomized controlled trials, investigators found that interactive websites had “some positive results.”^1,10 Comparatively, findings for electronic monitoring devices and mobile applications were mixed.¹⁰ Generally, better clinical outcomes, including, for example, asthma control and medication adherence, were improved with interventions that ranged from interactive website features to daily diary entries to asthma e-learning to earning points for redeemable gift cards.

Currently, an ongoing 1-year observational study is seeking to use mobile healthcare (mHealth) and home-monitoring sensors to predict episodes of uncontrolled asthma in 150 adults with asthma.¹¹ These outcomes, the researchers noted, can be used to develop both tailored predictive models and personalized self-management plans that can be integrated into patient mHealth systems.¹

Additional research focused on telehealth strategies, the Propeller Health Asthma Platform is being used to examine the real-world effectiveness of telemonitoring in reducing the use of short-acting ß-antagonists (SABA).¹² This study found that the Propeller Health digital platform significantly decreased SABA use, increased SABA-free days, and improved patient scores on an asthma control test. Just under 500 patients were enrolled in the parallel-arm study, with a “fair number” of patients aged younger than 18 who were included in both arms (30.6% and 29.6% of the routine care and intervention groups, respectively).^1,12

Quality patient education is one of the key components in asthma treatment adherence, especially in pediatric patients. So-called “serious games” (games that “do not have entertainment, enjoyment, or fun as their primary purpose”) have emerged as a new generation of video games aimed at providing patients with education and training. ¹ In France, researchers from Paris Descartes University conducted a systematic review evaluating the effect of serious games on pediatric asthma outcomes.¹³ Over the 12 articles that evaluated 10 computer or web-based serious games, investigators found that these games did improve pediatric patients’ asthma knowledge. However, this increased knowledge did no+t translate into “parallel behavior changes” in terms of medication adherence or improved asthma outcomes.¹

Mobile Adolescents’ Disease Empowerment and Persistency Technology is an electronic medication monitor that, through integration with a smart application, provides educational interventions to pediatric patients with asthma. A small proof of concept study¹⁴ has been conducted to explore the effectiveness of this intervention. Results indicated that there was an improvement in adherence to inhaled corticosteroids and asthma control.^1,14 Most recently, clinical evaluations of the MyTherapeutic Education Program failed to show significant differences in medication adherence in children with mild to moderate asthma who participated in the program vs in children who used an mHealth program alone.¹

Despite technological advances in the last few decades, researchers posited that overall, strategies aimed at implementing e-Health for better asthma management have failed in improving treatment adherence. Although e-Health strategies have generally favorable acceptability ratings, concerns exist, including data transmission failure and loss of devices. As such, physicians must consider the barriers to treatment adherence that can occur within the clinical setting. Specifically, age, socioeconomic status, cost-effectiveness, quality control processes, and information misunderstanding must be considered before suggesting e-Health strategies.¹

Although younger children generally have a higher rate of uncontrolled asthma, therapy adherence rates in this group are generally high, possibly a reflection of parental or caregiver involvement. Determinations of medication adherence, or adherence to e-Health strategies, may vary greatly across age groups and the adherence pathway.¹

Socioeconomic status is closely associated with both social challenges and lower health literacy.¹ Underserved minority children typically have the worst clinical outcomes and medication adherence rates with the least access to e-Health interventions.¹ Children who live in resource-limited settings or remote areas may benefit from telemedicine care, particularly in emergency situations.¹