Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study

JMIR mhealth and uhealth, vol. 10, pp. e25879

Abstract

BACKGROUND: Reliance on short-acting β-2 agonists and nonadherence to maintenance medication are associated with poor clinical outcomes in asthma. Digital health solutions could support optimal medication use and therefore disease control in patients with asthma; however, their use in community settings has not been determined. OBJECTIVE: The primary objective of this study is to investigate community implementation of the Turbu+ program designed to support asthma self-management, including adherence to budesonide and formoterol (Symbicort) Turbuhaler, a combination inhaler for both maintenance therapy or maintenance and reliever therapy. The secondary objective is to provide health care professionals with insights into how patients were using their medication in real life. METHODS: Patients with physician-diagnosed asthma were prescribed budesonide and formoterol as maintenance therapy, at a dose of either 1 inhalation twice daily (1-BID) or 2 inhalations twice daily (2-BID), or as maintenance and reliever therapy (1-BID and reliever or 2-BID and reliever in a single inhaler), and they received training on Turbu+ in secondary care centers across Italy. An electronic device attached to the patients' inhaler for ≥90 days (data cutoff) securely uploaded medication use data to a smartphone app and provided reminders, visualized medication use, and motivational nudge messages. Average medication adherence was defined as the proportion of daily maintenance inhalations taken as prescribed (number of recorded maintenance actuations per day or maintenance inhalations prescribed per day) averaged over the monitoring period. The proportion of adherent days was defined as the proportion of days when all prescribed maintenance inhalations were taken on a given day. The Wilcoxon test was used to compare the proportion of adherent days between patients in the maintenance regimen and patients in the maintenance and reliever regimen of a given dose. RESULTS: In 661 patients, the mean (SD) number of days monitored was 217.2 (SD 109.0) days. The average medication adherence (maintenance doses taken/doses prescribed) was 70.2% (108,040/153,820) overall and was similar across the groups (1-BID: 6332/9520, 66.5%; 1‑BID and reliever: 43,578/61,360, 71.0%; 2-BID: 10,088/14,960, 67.4%; 2-BID and reliever: 48,042/67,980, 70.7%). The proportion of adherent days (prescribed maintenance doses/doses taken in a given day) was 56.6% (31,812/56,175) overall and was higher with maintenance and reliever therapy (1-BID and reliever vs 1-BID: 18,413/30,680, 60.0% vs 2510/4760, 52.7%; P<.001; 2-BID and reliever vs 2-BID: 8995/16,995, 52.9% vs 1894/3740, 50.6%; P=.02). Rates of discontinuation from the Turbu+ program were significantly lower with maintenance and reliever therapy compared with maintenance therapy alone (P=.01). CONCLUSIONS: Overall, the high medication adherence observed during the study might be attributed to the electronic monitoring and feedback mechanism provided by the Turbu+ program.

Authors 10

1. Gabriele Rumi corresponding

   Università Cattolica del Sacro Cuore · Agostino Gemelli University Polyclinic · Istituti di Ricovero e Cura a Carattere Scientifico

   Affiliation as printed

   Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore - Medicina Interna, Rome, Italy

   Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore – Medicina Interna, Rome, Italy

2. Giorgio Walter Canonica

   Humanitas University

   Affiliation as printed

   Personalized Medicine Asthma & Allergy Clinic-Humanitas University & Research Hospital, IRCCS, Milan, Italy

3. Juliet Michelle Foster

   The University of Sydney · Woolcock Institute of Medical Research

   Affiliation as printed

   Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia

4. Niels Henrik Chavannes Aachen Department of Public Health and Primary Care

   Leiden University Medical Center

   Affiliation as printed

   Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands

5. Giuseppe Valenti

   University of Palermo

   Affiliation as printed

   PTA Biondo ASP Palermo, Palermo, Italy

6. Rosario Contiguglia
   Affiliation as printed

   Personalized Medicine Clinic of Respiratory Diseases, Messina, Italy

7. Eleni Rapsomaniki

   AstraZeneca (United Kingdom)

   Affiliation as printed

   BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom

8. Janwillem W.H. Kocks

   General Practitioners Research Institute

   Affiliation as printed

   General Practitioners Research Institute, Groningen, Netherlands

9. Dario De Brasi
   Affiliation as printed

   ASL Napoli 2 Nord, Naples, Italy

10. Fulvio Braido

    University of Genoa

    Affiliation as printed

    Department of Internal Medicine, University of Genova, Genova, Italy