PMC:7275133 / 19887-30323 JSONTXT

{"target":"http://pubannotation.org/docs/sourcedb/PMC/sourceid/7275133","sourcedb":"PMC","sourceid":"7275133","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7275133","text":"Use of Electronic Monitoring Devices in Asthma\nElectronic monitoring devices (EMDs) in asthma are increasingly more common since they provide objective data and are not biased by patient self-report. The majority of the currently available EMDs focus on addressing medication adherence, with a limited few focusing on sleep monitoring and identifying asthma triggers. The devices measuring adherence use a variety of approaches from recording audio during inhaler use, using time and date to detect medication use and capturing spirometry measures. These devices are paired with mobile applications (Apps) on smartphones which can provide the patient with audiovisual reminders for taking medications, correlate medication use with environmental exposures (i.e., weather, ozone, pollution) using smartphone GPS coordinates and feedback on proper inhaler use. A summary of some of the current and emerging technologies in the asthma space is provided in Table 2.\nTable 2 Current and emerging technologies in asthma\nTechnology Measures Outcomes in asthma studies Comments\nWearable technology\n− Fitbit™\n− Apple™ Watch Fitbit: heart rate (available on most but not all models), steps/day, physical activity (light, moderate and vigorous), sedentary time, sleep efficiency, wake counts\nApple Watch: heart rate, EKG, steps/day, physical activity (light, moderate and vigorous), sedentary time − Fitbit overestimated sleep efficiency and underestimated wake counts compared with actigraphy.18\n− Fitbit-derived sleep quality correlated with PROMIS pediatric asthma impact score.21 Corresponding Apps: Apple Watch App on iPhone, Fitbit App on iPhone and Android\nPros: portable; commercially available; may be useful when used with other measures such as air quality, lung function and asthma symptoms to digitally phenotype asthma patients\nCons: No sleep data available on Apple Watch without 3rd party App\nData sharing: Data does not sync to EMR directly but patient can access file and send to provider via mail, secure email, or patient portal.\nElectronic monitoring devices (e.g., inhaler sensors ± digital health platform) Digihaler™:\n− Inhaler time of inhaler use, peak inspiratory flow rate (PIFR), time to PIFR, inhalation volume and duration.\nPropeller Health System:\n− Inhaler sensor: date, time and number of doses taken\n− Asthma Health Platform App: Location of inhaler use using phone GPS, current weather/pollen counts/air pollution and self-report asthma symptoms/triggers\nHailie™ solution:\n− Inhaler sensor: date, time, number of inhaler actuations and missed doses\n− Hailie™ App: medication adherence, daily medication reminders\nInhaler compliance assessment device:\nTime of dose, inhaler technique errors − Greater asthma control31,38–39 and symptom-free days33\n− Reduction in daily symptoms31, rescue medication use29,32–33, and exacerbations34,38–39\n− Improved medication adherence36–40\n− High patient acceptability of device and digital health platform36–37. Corresponding Apps: Digihaler™, Propeller Health, Hailie™. Web-based platform also available for Propeller Health, Hailie™ solution.\nPros: portable, high acceptability among patients, improvements in asthma control in those with a digital health platform (e.g., Propeller Health, Hailie™ solution).\nCons: Additional efficacy studies of the devices are needed, cost of devices are not always covered by insurance reimbursement\nData sharing: Provider platform available to share results (e.g. Digihaler™, Propeller Health, Hailie™ solution), patients may share data from Digihaler™ also via file share.\nMobile-based applications Self-monitoring of:\n− Asthma symptoms\n− Triggers\n− Medication use -Improvements in asthma control though low-quality evidence45\n-Improvements in asthma control in five studies, lung function in two studies and quality of life in three studies46 Pros: Acceptable and feasible to use\nCons: Vary in quality; data are self-reported, most apps have not been validated; risk of loss of privacy of health information\nData sharing: Vary in ability to share with provider, most are up to user to share with provider\nTeva’s Digihaler™ has been FDA approved for use with ProAir® (albuterol sulfate 117 mcg), AirDuo® (fluticasone propionate and salmeterol), and ArmonAir® (fluticasone propionate) inhalers. The Digihaler™ contains built-in sensors that records inhalation data with timestamps. The inhalation data includes parameters that are important for assessing inhaler technique including peak inspiratory flow rate and inhalation duration [27]. The device is connected via Bluetooth® technology to a companion App that provides information on inhaler use to the patient. While to date, the efficacy of Digihalers has not been evaluated; one pilot study has shown its ability to predict exacerbations [28]. Adults with exacerbation-prone asthma (n = 360) used the ProAir® Digihaler™ for 12 weeks. The Digihaler™ was able to predict asthma exacerbations (defined as need for oral corticosteroids) with an area under the receiver operating characteristic curve of 0.75. The most predictive factor was the average number of albuterol inhalations per day during a period of 5 days before an exacerbation. Further developments of the model in larger populations are needed to determine the efficacy of the Digihaler™ to predict exacerbations.\nPropeller Health has developed a system which includes a sensor that can attach to both rescue and controller inhalers and an Asthma Health Platform [29]. The inhaler sensor collects date and time of inhaler use and number of puffs taken. This data is transferred via Bluetooth® technology to the Asthma Health Platform on a mobile device and can be matched with GPS coordinates obtained from the mobile device. The Asthma Health Platform can also be used to record asthma symptoms and triggers which integrates with other data streams such as weather, pollen counts, and pollution. The Propeller Health System is one of the most studied to date. A 4-month pilot study conducted in 30 individuals showed when the device and app were used along with weekly feedback, participants had an improvement in asthma control and a decline in day-to-day asthma symptoms [30]. The effectiveness of Propeller Health System on rescue inhaler has also been examined [31••]. In a study of 495 patients, all patients received the Propeller Health System but only 250 received sensor-based feedback. The authors found a decrease in mean daily rescue medication use in those receiving sensor-based feedback (0.19 vs. 0.25 in control arm) which was more pronounced in patients with uncontrolled asthma at baseline. These findings were confirmed in another study of 120 participants with a decrease in rescue medication use by 39% and an increase in symptom-free days by 12% [32]. Propeller Health has also developed a provider-facing web interface (portal) that allows providers and their staff to view patient medication use and asthma control status. This is available to providers that enroll their patients with the Propeller Health System but can be integrated into existing EMR systems to allow for data sharing among providers. Merchant et al. evaluated this enhanced Propeller Health System and found a decrease in asthma-related emergency department visits and hospitalizations [33].\nThe Hailie™ solution (previously known as SmartInhaler™ platform) is a system of medication sensors (e.g., SmartTrack™, SmartTouch™, SmartTouch AV™, SmartTurbo™; http://www.smartinhaler.com/devices/) that wrap around existing inhalers and automatically sends usage data to a patient’s smartphone [34]. The sensors record the date and time of actuations, the total number of actuations used, and missed doses. The device pairs with the Hailie™ App and enables the patient and healthcare professionals to track medication adherence, set daily reminders, and discover insights into their medication usage. The SmartInhaler™ sensors have been studied extensively and have demonstrated high user acceptability as well as efficacy in increasing medication adherence [35, 36]. Five randomized controlled trials using the SmartInhaler™ have been conducted in the UK, Australia, and New Zealand, including a total of 589 adults and children with asthma in a community setting [35–39]. The authors of these studies conclude that SmartInhaler™ devices were more effective than standard care in improving adherence to asthma medication. Two of the studies showed significant improvement in clinical outcomes (e.g., asthma exacerbations, asthma control, and healthcare utilization) [37, 38].\nThe Inhaler Compliance Assessment (INCA) device uses time-stamped audio recordings of inhaler use to assess not only inhaler adherence but also inhaler technique (http://www.tueohealth.com/). Specifically, it can assess proper inhaler technique by measuring a failure to prime the inhaler, inadequate inspiratory flow, and dose dumping. This information can be used to determine if medication was not properly delivered due to inhaler technique errors (attempted adherence) or missed/late medication doses. In one study of 184 people with chronic obstructive pulmonary disease, the INCA device was used to assess controller inhaler adherence [40]. The mean rate of attempted adherence was 58.7%, whereas actual adherence (proper timing and technique) was only 23%. Only 7% of participants had actual adherence above 80%, underscoring the importance of addressing proper inhaler technique. Currently, there is no mobile app for the INCA tool and the data must be downloaded onto a computer for analysis. Additional studies are currently being conducted using an INCA App to assess its ability to improve asthma outcomes.\nTueo Health, which was acquired by Apple in 2019, developed a passive EMD to help parents monitor nighttime asthma symptoms in children. Using commercial breathing sensors placed under the mattress, the device can passively measure key physiologic parameters during sleep (http://www.tueohealth.com/). An asthma control score is then calculated from the physiologic data and available for the patient to view through a mobile app. The score gives direct indication of their asthma control status based on their provider-issued asthma action plan and recommends evidence-based steps to manage asthma. Such steps include reminders to avoid known triggers, refill a prescription, or make an appointment to see their healthcare 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