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Xu H, Jiang X, Zeng Q, Li R. Application of e-Health tools in the assessment of inhalation therapy adherence in patients with chronic obstructive pulmonary disease: Scoping review coupled with bibliometric analysis. Respir Med 2024; 236:107898. [PMID: 39638011 DOI: 10.1016/j.rmed.2024.107898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Revised: 11/25/2024] [Accepted: 11/28/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder, and the assessment of inhalation therapy adherence is an important component of management in COPD patients. The emergence of e-Health tools provides new prospects for the assessment of inhalation therapy adherence. However, there is no comprehensive summary of the application of e-Health tools in assessing inhalation therapy adherence in COPD patients. OBJECTIVES This review aims to clarify the current state, effects, benefits, and limitations of using e-Health tools in assessing inhalation therapy adherence in COPD patients and provide future directions and recommendations for development in this field. METHODS This scoping review follows the 5-step framework developed by Arksey and O'Malley. Literature on the practical application of e-Health tools was systematically searched from PubMed, Embase, Web of Science, CINAHL, and Cochrane Library, spanning from inception to April 2024. Additionally, VOSviewer (version 1.6.20) was used to construct visualization maps of countries, institutions, authors, and keywords to investigate the internal relations of included literature and to explore research hotspots. RESULTS A total of 26 studies were included. The e-Health tools mainly include electronic monitoring devices (EMDs), smartphone app, electronic prescription, and web-based tool. e-Health tools can assess inhalation therapy adherence in COPD patients in real-time and objectively, and improve inhalation therapy adherence and clinical outcomes. Bibliometric analysis indicates that there is no network of co-authorship between countries or academic organizations. Two collaborative networks have been formed centered on Greene G. EMDs and disease exacerbations are the popular research directions. CONCLUSIONS e-Health tools have a wide range of applications and promising prospects in the assessment of inhalation therapy adherence in COPD patients. In the future, it is necessary to strengthen the cooperation between countries or research institutions, explore the cost-effectiveness of e-Health tools, and improve their accessibility and usability while adopting integrated design and combining artificial intelligence to improve the effectiveness of e-Health tools in the management of COPD.
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Affiliation(s)
- Haibo Xu
- School of Nursing, Guangzhou Medical University, Guangzhou, 510182, China
| | - Xiaoke Jiang
- School of Nursing, Guangzhou Medical University, Guangzhou, 510182, China
| | - Qiuxuan Zeng
- National Clinical Research Center for Respiratory Diseases, State Key Laboratory of Respiratory Diseases, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Ronghua Li
- School of Nursing, Guangzhou Medical University, Guangzhou, 510182, China.
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2
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Widjanarko ND, Subagya JC, Maksi JI, Suryatenggara FG, Sihole SCE. Utilization of apitherapy in allergic asthma: A systematic review of clinical and preclinical studies. Tzu Chi Med J 2024; 36:440-451. [PMID: 39421494 PMCID: PMC11483089 DOI: 10.4103/tcmj.tcmj_233_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/11/2023] [Accepted: 11/21/2023] [Indexed: 10/19/2024] Open
Abstract
Objectives This systematic review aimed to summarize the benefit of apitherapy in human and animal models of asthma. Materials and Methods The procedures in this review were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 protocol, where MEDLINE, ProQuest, and EBSCOhost databases were used to obtain eligible studies dating to 2023. Furthermore, the risk of bias was assessed using Risk of Bias Tool 2.0 (RoB-2) for randomized-control trials and Systematic Review Centre for Laboratory Animal Experimentation's RoB for animal studies. Results A total of 12 studies were included in the review based on the predetermined eligibility criteria, consisting of 4 human and 8 animal model reports. Among the four human studies, two had a low risk, while the other two had some concerns of bias. In the case of eight animal model of asthma, a total of three domains had a high risk of bias. Moreover, the anti-inflammatory properties of apitherapy were demonstrated by its capacity to inhibit NF-κB, nuclear factor of activated T cells, and IgE antibodies, leading to decreased production of tumor necrosis factor-α, interleukin-2 (IL-2), IL-6, and IL-8, and an increase in IL-10 levels. These beneficial effects were reported to be associated with improvements in clinical manifestations and lung function parameters in human subjects. The use of apitherapy was also related to the restoration of airway structure, and reduction of inflammatory cell infiltration, epithelial thickness, and mucus secretion in lung tissue of animal model of asthma. Conclusion Based on the results, apitherapy was effective in improving asthma symptoms and reducing inflammation in human and animal models of asthma.
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Affiliation(s)
- Nicolas Daniel Widjanarko
- Department of General Medicine, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Jonathan Christianto Subagya
- Department of General Medicine, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Josephine Immanuel Maksi
- Department of General Medicine, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
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Koyuncu A, Ari A. Filling the gaps in the evaluation and selection of mobile health technologies in respiratory medicine. Expert Rev Respir Med 2024; 18:159-174. [PMID: 38795074 DOI: 10.1080/17476348.2024.2361048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/24/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising digital technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs. AREAS COVERED While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine. EXPERT OPINION Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.
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Affiliation(s)
- Ayfer Koyuncu
- Graduate School of Science and Engineering, Bioengineering Department, Hacettepe University, Ankara, Turkey
| | - Arzu Ari
- College of Health Professions Department of Respiratory Care, Regent's Professor and Associate Dean for Research, Texas State University, Round Rock, TX, USA
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Case MA, Eakin MN. Up-to-date guidance towards improving medication adherence in patients with chronic obstructive pulmonary disease. Expert Rev Respir Med 2023; 17:539-546. [PMID: 37494126 PMCID: PMC10529685 DOI: 10.1080/17476348.2023.2239708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Despite efficacious treatment for chronic obstructive pulmonary disease (COPD), medication adherence remains quite poor, with most estimates based on electronic monitoring devices ranging from 20-30%. This degree of nonadherence represents a significant missed opportunity to realize the benefits of treatment of this disease. AREAS COVERED In this article, we review research on the prevalence of nonadherence among patients with COPD, the association of nonadherence with health outcomes, barriers to adherence in this patient population, and potential interventions. EXPERT OPINION Integrating research into practice involves assessing patients' adherence, identifying modifiable barriers to adherence, open discussion of these barriers with patients, and tailored interventions to address them. These interventions may include treatment of previously unrecognized comorbid disease, providing educational or behavioral interventions, optimizing prescribing strategies, use of adherence aids, or addressing cost and other access barriers. Electronic inhaler monitors are promising interventions for both monitoring and improving adherence. However, remaining concerns about integration into patient care, data management, cost, acceptability, and ethical and privacy issues must be overcome prior to their implementation in clinical practice.
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Affiliation(s)
- Meredith A. Case
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine
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Hesso I, Nabhani-Gebara S, Kayyali R. Objective Assessment of Adherence and Inhaler Technique among Asthma and COPD Patients in London: A Study in Community Pharmacies Using an Electronic Monitoring Device. PHARMACY 2023; 11:94. [PMID: 37368420 DOI: 10.3390/pharmacy11030094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The INhaler Compliance Assessment (INCATM) device is an electronic monitoring device (EMD) that assesses both patient's adherence and inhaler technique (IT). This study aimed, first, to assess the value of using the INCATM device as an objective measure during medicine use review (MUR) consultations provided by community pharmacists (CPs) on patients' adherence and IT. Second, we aimed to explore patients' perceptions about the INCATM device. METHODS A mixed methods approach was used, involving two phases. Phase one was a service evaluation in independent community pharmacies in London with a before-and-after study design. The service included provision of an MUR consultation to asthma and COPD patients using objective feedback about adherence and IT generated with the INCATM device. Descriptive and inferential statistics were performed using SPSS. Phase two involved semi-structured interviews with respiratory patients. Thematic analysis was performed to generate key findings. MAIN FINDINGS Eighteen patients participated in the study (12 COPD and 6 asthma). The results showed significant improvement in the INCATM actual adherence from 30% to 68% (p = 0.001) and significant reduction in IT error rate from 51% to 12% (p = 0.002) after conducting the service. Analysis of the interviews revealed patients' positive attitudes in terms of the perceived benefits of the technology and a desire for future use and recommendation for others. Patients had also positive attitudes towards the consultations provided. CONCLUSION Embedding an objective measure about adherence and IT during CPs' consultations showed a significant improvement in patients' adherence and IT and was accepted by patients as well.
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Affiliation(s)
- Iman Hesso
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Penrhyn Road, Kingston upon Thames, London KT1 2EE, UK
| | - Shereen Nabhani-Gebara
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Penrhyn Road, Kingston upon Thames, London KT1 2EE, UK
| | - Reem Kayyali
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Penrhyn Road, Kingston upon Thames, London KT1 2EE, UK
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Pleasants RA, Chan AH, Mosnaim G, Costello RW, Dhand R, Schworer SA, Merchant R, Tilley SL. Integrating digital inhalers into clinical care of patients with asthma and chronic obstructive pulmonary disease. Respir Med 2022; 205:107038. [PMID: 36446239 DOI: 10.1016/j.rmed.2022.107038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
Modernizing inhaled medications through digital technology can help address persistent problems of non-adherence and poor inhaler technique in patients with obstructive lung diseases. With a growing body of supportive clinical studies, advances in digital inhaler sensors and platforms, greater support from payers and healthcare organizations, significant growth with these technologies is expected. While all digital (smart) inhalers record adherence, these are distinguished by their compatibility with commercial inhalers, capabilities to guide inhaler technique, use of patient-reported outcomes, and user-friendliness for both the healthcare professional (HCP) and patient. Due to the complexity and novelty of employing digital inhalers, collaboration with multiple entities within health systems is necessary and a well-planned integration is needed. For HCPs and patients, cybersecurity and privacy are critical, it will require review by each healthcare organization. In the US, some payers reimburse for remote monitoring using digital inhalers, but reimbursement is currently unavailable in other countries. There are several models for remote patient care, as employing an active, ongoing digital interface between the HCP and patient or they may choose to only review data at clinical encounters. Personalization of therapies and feedback are key to success. While digital inhaler malfunction uncommonly occurs, patient attrition over a year is significant. Some patients will be challenged to use digital platforms or have the necessary technology. Additional research is needed to address cost-effectiveness, in vivo accuracy of inspiratory measurement capable devices, ability to teach inhaler technique, their application for monitoring lung function, and lastly real-world adoption and implementation in routine clinical practice.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Amy Hy Chan
- Faculty of Medical and Health Sciences, University of Auckland, USA.
| | - Giselle Mosnaim
- NorthShore University Health System, Clinical Associate Professor at the University of Chicago Pritzker School of Medicine, USA.
| | - Richard W Costello
- Royal College of Surgeons Ireland, 123 St Stephen's Green, Dublin 2, D02 YN77, Ireland.
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | - Stephen A Schworer
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | - Rajan Merchant
- Woodland Clinic Medical Group, Dignity Health Medical Foundation, CommonSpirit Health Research Institute, CommonSpirit Health Dignity Health, Woodland Clinic, 632 W Gibson Rd, Woodland, CA, USA.
| | - Stephen L Tilley
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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7
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Proposed Strategies to Improve Adult Asthma Management in Egypt: Expert Review and Recommendations. Ann Glob Health 2022; 88:103. [DOI: 10.5334/aogh.3782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/31/2022] [Indexed: 11/18/2022] Open
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Martin-Grace J, Costello RW, Sherlock M. Corticosteroid Suppression in Patients Receiving Inhaled Glucocorticoids: Time to Reassess Risk? J Clin Endocrinol Metab 2022; 107:e4256-e4258. [PMID: 35908292 DOI: 10.1210/clinem/dgac431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Indexed: 11/19/2022]
Affiliation(s)
| | - Richard W Costello
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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Dhruve H, Jackson DJ. Assessing adherence to inhaled therapies in asthma and the emergence of electronic monitoring devices. Eur Respir Rev 2022; 31:31/164/210271. [PMID: 35613744 DOI: 10.1183/16000617.0271-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/12/2022] [Indexed: 02/07/2023] Open
Abstract
Infrequent use of inhaled corticosteroids (ICS) and/or over-reliance of short-acting β-agonists (SABA) are recognised as key contributors to increased morbidity and mortality in asthma. The most frequent measures of ICS adherence and SABA use rely on patient-reported questionnaires or prescription refill records, neither of which are considered sufficiently reliable. Technological advancements in the development of electronic monitoring of inhaler devices allow for monitoring of use, as well as recording of and feedback on inhaler technique for some devices. Most electronic monitoring devices (EMDs) are paired with a smartphone application, allowing patients to set reminders and display both preventer and reliever use over time. This allows identification of intentional and unintentional ICS non-adherence as well as frequency of SABA use. This information assists clinicians in distinguishing difficult-to-control from severe asthma. Although additional evidence is required to assess the impact of EMDs on clinical outcome measures such as exacerbation rate, the introduction of EMDs into the asthma armoury is a significant step forward in asthma care with the potential to improve asthma-related outcomes.
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Affiliation(s)
- Hetal Dhruve
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, UK.,School of Immunology and Microbial Sciences, King's College London, London, UK
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, UK .,School of Immunology and Microbial Sciences, King's College London, London, UK
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W H Kocks J, Wouters H, Bosnic-Anticevich S, van Cooten J, Correia de Sousa J, Cvetkovski B, Dekhuijzen R, Dijk L, Dvortsin E, Garcia Pardo M, Gardev A, Gawlik R, van Geer-Postmus I, van der Ham I, Harbers M, de la Hoz A, Janse Y, Kerkhof M, Lavorini F, Maricoto T, Meijer J, Metz B, Price D, Roman-Rodriguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani O, Leving MT. Factors associated with health status and exacerbations in COPD maintenance therapy with dry powder inhalers. NPJ Prim Care Respir Med 2022; 32:18. [PMID: 35618739 PMCID: PMC9135702 DOI: 10.1038/s41533-022-00282-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/10/2022] [Indexed: 01/25/2023] Open
Abstract
The study aimed to determine the associations of Peak Inspiratory Flow (PIF), inhalation technique and adherence with health status and exacerbations in participants with COPD using DPI maintenance therapy. This cross-sectional multi-country observational real-world study included COPD participants aged ≥40 years using a DPI for maintenance therapy. PIF was measured three times with the In-Check DIAL G16: (1) typical PIF at resistance of participant’s inhaler, (2) maximal PIF at resistance of participant’s inhaler, (3) maximal PIF at low resistance. Suboptimal PIF (sPIF) was defined as PIF lower than required for the device. Participants completed questionnaires on health status (Clinical COPD Questionnaire (CCQ)), adherence (Test of Adherence to Inhalers (TAI)) and exacerbations. Inhalation technique was assessed by standardised evaluation of video recordings. Complete data were available from 1434 participants (50.1% female, mean age 69.2 years). GOLD stage was available for 801 participants: GOLD stage I (23.6%), II (54.9%), III (17.4%) and IV (4.1%)). Of all participants, 29% had a sPIF, and 16% were shown able to generate an optimal PIF but failed to do so. sPIF was significantly associated with worse health status (0.226 (95% CI 0.107–0.346), worse units on CCQ; p = 0.001). The errors ‘teeth and lips sealed around mouthpiece’, ‘breathe in’, and ‘breathe out calmly after inhalation’ were related to health status. Adherence was not associated with health status. After correcting for multiple testing, no significant association was found with moderate or severe exacerbations in the last 12 months. To conclude, sPIF is associated with poorer health status. This study demonstrates the importance of PIF assessment in DPI inhalation therapy. Healthcare professionals should consider selecting appropriate inhalers in cases of sPIF.
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Affiliation(s)
- Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands. .,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands. .,Observational and Pragmatic Research Institute, Singapore, Singapore. .,Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Hans Wouters
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Lars Dijk
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Evgeni Dvortsin
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marina Garcia Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Radosław Gawlik
- Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | | | - Iris van der Ham
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marten Harbers
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Ymke Janse
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marjan Kerkhof
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Federico Lavorini
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Groningen, The Netherlands
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Miguel Roman-Rodriguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Kirsten Schuttel
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar Usmani
- Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, UK
| | - Marika T Leving
- General Practitioners Research Institute, Groningen, The Netherlands
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11
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Tay TR, van Boven JFM, Chan A, Hew M. Electronic Inhaler Monitoring for Chronic Airway Disease: Development and Application of a Multidimensional Efficacy Framework. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1189-1201.e1. [PMID: 34915225 DOI: 10.1016/j.jaip.2021.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 06/14/2023]
Abstract
Inhaled therapy is the cornerstone of chronic airway disease therapy, but poor adherence to controller inhalers worsens clinical outcomes and increases cost. Monitoring of controller use is needed to improve adherence, and monitoring of reliever use can predict impending exacerbations. Both can be accurately achieved by electronic inhaler monitoring (EIM). However, evidence for EIM use in clinical practice is limited and varied, and knowledge gaps remain across different outcomes and health settings. We aimed to develop a framework to assess EIM systematically across all aspects of efficacy, apply this framework to the current literature, and identify gaps in efficacy to inform future development in the field. We adapted an existing framework for diagnostic tests, consisting of six levels of efficacy with ascending clinical relevance: technical, diagnostic accuracy, diagnostic thinking, therapeutic, patient outcome, and societal efficacy. Tailoring this framework to EIM, we incorporated expert feedback and applied it to the EIM efficacy literature. We found that EIM has good diagnostic accuracy, diagnostic thinking, and therapeutic efficacies, but evidence is lacking for specific aspects of technical, patient outcome, and societal efficacies. Further development of EIM requires improved reliability, usability, and data security for patients, and optimal integration with electronic medical records and overall patient care. Defining appropriate target patient groups and pairing EIM data with effective interventions, in conjunction with reducing costs through technological innovation and economies of scale, will enhance patient and societal outcome efficacies.
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Affiliation(s)
- Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, the Netherlands; Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia; Medication Adherence Expertise Center of the Northern Netherlands, Groningen, the Netherlands
| | - Amy Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mark Hew
- Allergy, Asthma, and Clinical Immunology, Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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12
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O’Toole J, Krishnan M, Riekert K, Eakin MN. Understanding barriers to and strategies for medication adherence in COPD: a qualitative study. BMC Pulm Med 2022; 22:98. [PMID: 35305609 PMCID: PMC8934480 DOI: 10.1186/s12890-022-01892-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Medication adherence in chronic obstructive pulmonary disease (COPD) is low, though not enough is known about the factors that affect adherence in COPD. This study uses qualitative methods to understand the patient perspective on facilitators and barriers to medication adherence in COPD as well as patient-reported strategies for self-management of disease. Methods Semi-structured interviews were conducted with 30 individuals (n = 30). Transcripts were analyzed using iterative qualitative coding by 2 independent coders, and codes were categorized using thematic analysis. Results Challenges with adherence reported were gaps in understanding, forgetfulness of the patient, physician availability, cost navigation, and overcoming substance use. Most commonly, the financial burden of COPD medications caused patients to source other countries to obtain medications, rely on sample medications collected during doctors’ visits, and to alter medication dosage and frequency to extend the length of a prescription. Tools and resources reported by patients to support self-management of COPD included pharmacist assistance, physician office information, and community resources. Individuals further reported that the use of logs or diaries to track medication usage, visual or temporal cues to take medications, and support from family members were helpful in promoting adherence to their COPD medication regimen. Conclusions Medication adherence in individuals with COPD is affected by challenges with self-management of disease and financial burden of medications. However, patients reported multiple tools and resources to support adherence. Physician recognition of these factors impacting self-management, as well as awareness of strategies to promote adherence and manage disease, may improve patient outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01892-5.
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Chan AHY, Pleasants RA, Dhand R, Tilley SL, Schworer SA, Costello RW, Merchant R. Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: A Scientific Perspective. Pulm Ther 2021; 7:345-376. [PMID: 34379316 PMCID: PMC8589868 DOI: 10.1007/s41030-021-00167-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022] Open
Abstract
Impressive advances in inhalation therapy for patients with asthma and chronic obstructive pulmonary disease (COPD) have occurred in recent years. However, important gaps in care remain, particularly relating to poor adherence to inhaled therapies. Digital inhaler health platforms which incorporate digital inhalers to monitor time and date of dosing are an effective disease and medication management tool, promoting collaborative care between clinicians and patients, and providing more in-depth understanding of actual inhaler use. With advances in technology, nearly all inhalers can be digitalized with add-on or embedded sensors to record and transmit data quantitating inhaler actuations, and some have additional capabilities to evaluate inhaler technique. In addition to providing an objective and readily available measure of adherence, they allow patients to interact with the device directly or through their self-management smartphone application such as via alerts and recording of health status. Clinicians can access these data remotely and during patient encounters, to better inform them about disease status and medication adherence and inhaler technique. The ability for remote patient monitoring is accelerating interest in and the use of these devices in clinical practice and research settings. More than 20 clinical studies of digital inhalers in asthma or COPD collectively show improvement in medication adherence, exacerbation risk, and patient outcomes with digital inhalers. These studies support previous findings about patient inhaler use and behaviors, but with greater granularity, and reveal some new findings about patient medication-taking behaviors. Digital devices that record inspiratory flows with inhaler use can guide proper inhaler technique and may prove to be a clinically useful lung function measure. Adoption of digital inhalers into practice is still early, and additional research is needed to determine patient and clinician acceptability, the appropriate place of these devices in the therapeutic regimen, and their cost effectiveness. Video: Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: A Scientific Perspective (MP4 74535 kb)
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Affiliation(s)
- Amy H. Y. Chan
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1023 New Zealand
| | - Roy A. Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN USA
| | - Stephen L. Tilley
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Stephen A. Schworer
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Richard W. Costello
- Royal College of Surgeons Ireland, 123 St Stephen’s Green, Dublin 2, D02 YN77 Ireland
| | - Rajan Merchant
- Dignity Health Woodland Clinic, 632 W Gibson Rd, Woodland, CA USA
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14
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Brennan V, Mulvey C, Costello RW. The clinical impact of adherence to therapy in airways disease. Breathe (Sheff) 2021; 17:210039. [PMID: 34295431 PMCID: PMC8291957 DOI: 10.1183/20734735.0039-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
For a physician, the final step of a consultation consists of developing a treatment plan and prescription. For the patient, this is the start of a process. First, their role in the treatment plan must be clarified, then they may have to obtain an alternative prescription from their general practitioner. Next, they must have the prescription filled and dispensed from the pharmacy and, finally, they must take the treatment on time and for the required duration. For people with chronic conditions, this requires repeatedly returning to the pharmacy for the prescription to be renewed and dispensed. Given that many patients are on multiple treatment regimens and may have poor health literacy, this becomes a complex process and it is not surprising that this can, and frequently does, go wrong. Research shows that when a patient does not adhere to standard asthma or COPD treatment, they report poor control and overuse of rescue β-agonists, experience frequent exacerbations and are often prescribed add-on treatments such as biological agents. In short, poor treatment adherence can manifest in the same way as a refractory condition. These clinical features should prompt a clinician to investigate poor adherence as they might investigate a new blood or radiological finding. Examining a patient's prescription refill records or a digitally enabled inhaler can demonstrate a number of patterns of inhaler use. A small minority regularly use their treatment as prescribed but many appear to be “cluster users”: a group of patients who use their treatment correctly when they are unwell, but once some level of personal control is attained, they cease or reduce their use. Others may cease using their treatment because they are not perceiving a benefit or because an alternative condition accounts for their symptoms. In other words, clinicians can consider that treatment adherence is like a clinical sign: something to be investigated so that they may understand the patient's condition better. Suspected poor treatment adherence should be treated as a clinical sign. It should be suspected among patients with asthma and COPD who have excessive reliever use or recurrent exacerbations. It can be detected using pharmacy data or electronic devices.https://bit.ly/3oqwS5L
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Affiliation(s)
- Vincent Brennan
- Beaumont Hospital, Dublin, Ireland.,INCA Group, Dept of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher Mulvey
- INCA Group, Dept of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard W Costello
- Beaumont Hospital, Dublin, Ireland.,INCA Group, Dept of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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15
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Moore A, Preece A, Sharma R, Heaney LG, Costello RW, Wise RA, Ludwig-Sengpiel A, Mosnaim G, Rees J, Tomlinson R, Tal-Singer R, Stempel DA, Barnes N. A randomised controlled trial of the effect of a connected inhaler system on medication adherence in uncontrolled asthmatic patients. Eur Respir J 2021; 57:13993003.03103-2020. [PMID: 33334936 PMCID: PMC8176348 DOI: 10.1183/13993003.03103-2020] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/19/2020] [Indexed: 11/18/2022]
Abstract
Suboptimal adherence to maintenance therapy contributes to poor asthma control and exacerbations. This study evaluated the effect of different elements of a connected inhaler system (CIS), comprising clip-on inhaler sensors, a patient-facing app and a healthcare professional (HCP) dashboard, on adherence to asthma maintenance therapy. This was an open-label, parallel-group, 6-month, randomised controlled trial in adults with uncontrolled asthma (asthma control test (ACT) score less than 20) on fixed-dose inhaled corticosteroids/long-acting β-agonist maintenance therapy (n=437). All subjects received fluticasone furoate/vilanterol ELLIPTA dry-powder inhalers for maintenance and salbutamol/albuterol metered-dose inhalers for rescue, with a sensor attached to each inhaler. Participants were randomised to one of five CIS study arms (allocation ratio 1:1:1:1:1) reflecting the recipient of the data feedback from the sensors, as follows: 1) maintenance use to participants and HCPs (n=87); 2) maintenance use to participants (n=88); 3) maintenance and rescue use to participants and HCPs (n=88); 4) maintenance and rescue use to participants (n=88); and 5) no feedback (control) (n=86). For the primary endpoint, observed mean±sd adherence to maintenance therapy over months 4–6 was 82.2±16.58% (n=83) in the “maintenance to participants and HCPs” arm and 70.8±27.30% (n=85) in the control arm. The adjusted least squares mean±se was 80.9±3.19% and 69.0±3.19%, respectively (study arm difference: 12.0%, 95% CI 5.2–18.8%; p<0.001). Adherence was also significantly greater in the other CIS arms versus the control arm. The mean percentage of rescue medication free days (months 4–6) was significantly greater in participants receiving data on their rescue use compared with controls. ACT scores improved in all study arms with no significant differences between groups. A CIS can improve adherence to maintenance medication and reduce rescue medication use in patients with uncontrolled asthma. In individuals with uncontrolled asthma, data feedback on maintenance therapy use from a connected inhaler system led to increased maintenance adherence and feedback on rescue medication usage led to more rescue-free days but did not improve asthma controlhttps://bit.ly/39kmVBA
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Affiliation(s)
| | | | | | - Liam G Heaney
- Queen's University Belfast, Belfast, UK.,United Kingdom Medical Research Council Refractory Asthma Stratification Programme
| | - Richard W Costello
- United Kingdom Medical Research Council Refractory Asthma Stratification Programme.,Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | | | | | | | | | | | | | - Neil Barnes
- GlaxoSmithKline R&D, Brentford, UK.,St Bartholomew's Hospital, London, UK
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16
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Usmani OS, Hickey AJ, Guranlioglu D, Rawson K, Stjepanovic N, Siddiqui S, Dhand R. The Impact of Inhaler Device Regimen in Patients with Asthma or COPD. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3033-3040.e1. [PMID: 33901714 DOI: 10.1016/j.jaip.2021.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
Many inhaler devices with varying handling requirements for optimal use are available for the treatment of asthma and chronic obstructive pulmonary disease (COPD). Patients may be prescribed different device types for reliever and maintenance medications, which may lead to confusion and suboptimal device use. We aimed to understand whether simplifying inhaler regimens by employing a single device type in patients who use multiple devices or prescribing a device with which a patient was already experienced could improve clinical and economic outcomes in asthma and COPD management. A targeted literature search was performed and additional articles were identified through hand searching citations within screened publications. A total of 114 articles were included in the final review. Findings suggest that simplifying inhaler regimens by applying the same type of inhaler for concomitant inhaled medications over time minimizes device misuse, leading to improved clinical outcomes and reduced health care use in patients with asthma or COPD. Physicians should consider a patient's suitability for a device and training needs when prescribing an inhaled medication and before changing the medication type or dose, especially when suboptimal treatment outcomes are observed. Further research is required to determine whether consistent use of the same device type is associated with better treatment adherence and persistence in patients with asthma or COPD. Nevertheless, this literature review identified clinical benefits and reduced health care use with simplified inhaler regimens.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, United Kingdom.
| | - Anthony J Hickey
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | - Rajiv Dhand
- Graduate School of Medicine, University of Tennessee, Knoxville, TN
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17
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van der Kolk A, Lammers N, Brusse-Keizer M, van der Palen J, Faber J, Spenkelink-Visser R, Thio BJ. Comparison of inhalation technique with the Diskus and Autohaler in asthmatic children at home. ERJ Open Res 2021; 7:00215-2019. [PMID: 33898617 PMCID: PMC8053909 DOI: 10.1183/23120541.00215-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/04/2021] [Indexed: 11/22/2022] Open
Abstract
Objective Asthma is the most common chronic disease in childhood and anti-inflammatory medication is the cornerstone of treatment. Inhalers are frequently used incorrectly when demonstrated in the hospital, suggesting poor technique at home. We aimed to 1) compare daily inhalation technique with the Diskus and Autohaler in asthmatic children by filming inhalations at home and 2) compare daily inhalation technique with technique demonstrated in the hospital. Methods We performed a randomised study in asthmatic children (aged 6–18 years) from the outpatient clinic of Medisch Spectrum Twente hospital (Enschede, The Netherlands) from July 2014 to April 2016. Children received inhalation instructions for the Diskus and Autohaler and were randomised to use one device in the morning and the other in the evening. During the 28-day study period, inhalations were filmed at home and subsequently demonstrated in the hospital. All inhalations were checked for seven critical errors per device. Results 636 videos with the Diskus and 663 with the Autohaler were provided by 27 children. The most common critical error in daily life was an incorrect device position during preparation of the Diskus (n=271) and an insufficiently deep inhalation (n=39) using the Autohaler. Percentage of correct days using the Diskus was 44%, compared to 96% with the Autohaler (p<0.001). The two most common errors with the Diskus were made at least twice as often at home than in the hospital. Conclusion Inhalation technique at home was markedly better with the Autohaler than with the Diskus. Paediatricians should be aware that hospital-based demonstrations can overestimate daily inhalation technique with the Diskus. Inhalation technique at home is markedly better with the Autohaler than with the Diskus. Paediatricians should be aware that hospital-based demonstrations can overestimate daily inhalation technique with the Diskus.https://bit.ly/3cYK4eq
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Affiliation(s)
| | - Natasja Lammers
- Dept of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands.,Dept of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands
| | - Joyce Faber
- Dept of Pediatrics, Deventer Ziekenhuis, Deventer, The Netherlands
| | | | - Bernard J Thio
- Dept of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands.,Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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18
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Sulaiman I, Costello RW. Adherence to Asthma Treatments: An Audit of a Warehouse of Data. Chest 2021; 159:891-892. [PMID: 33678266 DOI: 10.1016/j.chest.2020.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Imran Sulaiman
- Clinical Research Centre, Royal College of Surgeons in Ireland, RCSI Education & Research Centre, Beaumont Hospital, Dublin, Ireland
| | - Richard W Costello
- Clinical Research Centre, Royal College of Surgeons in Ireland, RCSI Education & Research Centre, Beaumont Hospital, Dublin, Ireland.
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19
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Mosnaim G, Safioti G, Brown R, DePietro M, Szefler SJ, Lang DM, Portnoy JM, Bukstein DA, Bacharier LB, Merchant RK. Digital Health Technology in Asthma: A Comprehensive Scoping Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2377-2398. [PMID: 33652136 DOI: 10.1016/j.jaip.2021.02.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements. OBJECTIVE To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma. METHODS We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient. RESULTS Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use. CONCLUSIONS Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.
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Affiliation(s)
- Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, North Shore University Health System, Evanston, Ill
| | | | - Randall Brown
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa
| | - Michael DePietro
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa.
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jay M Portnoy
- Pediatric Allergy and Immunology, Children's Mercy Hospital, Kansas City School of Medicine, Kansas City, Mo
| | - Don A Bukstein
- Allergy, Asthma and Sinus Center, Milwaukee, Greenfield, Wis
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn
| | - Rajan K Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, Calif
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20
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Bakker JP. Piecing Together the Puzzle of Adherence in Sleep Medicine. Sleep Med Clin 2021; 16:xiii-xiv. [PMID: 33485535 DOI: 10.1016/j.jsmc.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Jessie P Bakker
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA.
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21
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Himes BE, Leszinsky L, Walsh R, Hepner H, Wu AC. Mobile Health and Inhaler-Based Monitoring Devices for Asthma Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:2535-2543. [PMID: 31706485 DOI: 10.1016/j.jaip.2019.08.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/16/2022]
Abstract
Mobile health and web applications (apps), wearables, and other personal monitoring devices have tremendous potential to improve the management of asthma. More than 500 asthma-related apps, whether standalone or paired with sensors on inhalers, are currently available for health education, symptom recording, tracking of inhaler use, displaying environmental alerts, and providing medication reminders. Benefits of these tools include the ability to longitudinally collect symptom, trigger, and inhaler usage data, allowing the detection of significant changes over time to help patients and their caregivers determine whether symptoms are worsening. In addition, data from external information sources, including weather, allergen, and air quality reports, can be integrated with user-specific data to enhance predictions on when patients may experience symptoms and/or need to avoid triggers. Barriers to adoption of asthma-related apps and inhaler-based devices include uncertain efficacy and effectiveness, potential high cost, sustained user engagement, and concerns about privacy. Moreover, ensuring the acceptability and utility of asthma management apps for individuals of all races/ethnicities, socioeconomic groups, ages, genders, and literacy levels is necessary. Based on studies thus far, mobile health apps and inhaler-based devices have great potential to serve as useful tools in the patient-doctor relationship and revolutionize asthma care.
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Affiliation(s)
- Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Lena Leszinsky
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Ryan Walsh
- Center for Healthcare Research in Pediatrics (CHeRP) and PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Hannah Hepner
- Center for Healthcare Research in Pediatrics (CHeRP) and PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Ann Chen Wu
- Center for Healthcare Research in Pediatrics (CHeRP) and PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
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22
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Vestbo J, Janson C, Nuevo J, Price D. Observational studies assessing the pharmacological treatment of obstructive lung disease: strengths, challenges and considerations for study design. ERJ Open Res 2020; 6:00044-2020. [PMID: 33083435 PMCID: PMC7553106 DOI: 10.1183/23120541.00044-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/01/2020] [Indexed: 11/05/2022] Open
Abstract
Randomised controlled trials (RCTs) are the gold standard for evaluating treatment efficacy in patients with obstructive lung disease. However, due to strict inclusion criteria and the conditions required for ascertaining statistical significance, the patients included typically represent as little as 5% of the general obstructive lung disease population. Thus, studies in broader patient populations are becoming increasingly important. These can be randomised effectiveness trials or observational studies providing data on real-world treatment effectiveness and safety data that complement efficacy RCTs. In this review we describe the features associated with the diagnosis of asthma and chronic obstructive pulmonary disease (COPD) in the real-world clinical practice setting. We also discuss how RCTs and observational studies have reported opposing outcomes with several treatments and inhaler devices due to differences in study design and the variations in patients recruited by different study types. Whilst observational studies are not without weaknesses, we outline recently developed tools for defining markers of quality of observational studies. We also examine how observational studies are capable of providing valuable insights into disease mechanisms and management and how they are a vital component of research into obstructive lung disease. As we move into an era of personalised medicine, recent observational studies, such as the NOVEL observational longiTudinal studY (NOVELTY), have the capacity to provide a greater understanding of the value of a personalised healthcare approach in patients in clinical practice by focussing on standardised outcome measures of patient-reported outcomes, physician assessments, airway physiology, and blood and airway biomarkers across both primary and specialist care.
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Affiliation(s)
- Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Christer Janson
- Dept of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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23
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Inhaler devices in asthma and COPD patients - a prospective cross-sectional study on inhaler preferences and error rates. BMC Pulm Med 2020; 20:222. [PMID: 32819337 PMCID: PMC7439539 DOI: 10.1186/s12890-020-01246-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background Inhalation therapy is the backbone of asthma and COPD control. However, inhaler adherence and device mishandling continue to be a problem in real life. Some studies have shown that using a patient-preferred inhaler may reduce device handling errors and improve adherence to prescribed chronic inhaler drug therapy. The aim of this study was to compare the preferences for commonly used inhaler devices in Germany in patients with chronic obstructive respiratory disease. We also pursued the question which properties of an inhaler device are particularly important to the user and what effects age, gender and type of disease (asthma or COPD) may have on device preference and handling errors. Methods Prospective, open-label cross-sectional study in which 105 patients with asthma (58%) or COPD (42%) participated. Validated checklists were used to objectively assess inhaler technique and errors with 10 different placebo devices. For each device, patients were asked to test the handling, to assess the device properties and to name the device that they would most or least prefer. Results Across the 10 placebo inhaler devices tested, patients needed an average of 1.22 attempts to error-free use. The device with the lowest mean number of attempts was the Turbohaler® (1.02), followed by the Nexthaler® (1.04), the Diskus® (1.07) and the Spiromax® (1.10). Patients over 60 years vs. younger age (p = 0.002) and COPD vs. asthma patients (p = 0.016) required more attempts to ensure correct use. 41% of the study participants chose one of the devices they already used as the most preferred inhaler. Overall, 20% opted for the Spiromax®, 15% for the Nexthaler® and 14% for the Turbohaler® or a pMDI. The least preferred device was the Elpenhaler® (0%). From a selection of 7 predefined inhaler attributes, patients stated easy handling as the most important for them. This was followed by short inhalation time and low inhalation resistance. Conclusions Patient preference may vary between inhaler devices. The lowest number of attempts to error-free use was reported for the Turbohaler® and the Nexthaler®. The Spiromax® and the Nexthaler® achieved the best overall ratings and were the devices most preferred by patients.
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24
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Movia D, Prina-Mello A. Preclinical Development of Orally Inhaled Drugs (OIDs)-Are Animal Models Predictive or Shall We Move Towards In Vitro Non-Animal Models? Animals (Basel) 2020; 10:E1259. [PMID: 32722259 PMCID: PMC7460012 DOI: 10.3390/ani10081259] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/18/2022] Open
Abstract
Respiratory diseases constitute a huge burden in our society, and the global respiratory drug market currently grows at an annual rate between 4% and 6%. Inhalation is the preferred administration method for treating respiratory diseases, as it: (i) delivers the drug directly at the site of action, resulting in a rapid onset; (ii) is painless, thus improving patients' compliance; and (iii) avoids first-pass metabolism reducing systemic side effects. Inhalation occurs through the mouth, with the drug generally exerting its therapeutic action in the lungs. In the most recent years, orally inhaled drugs (OIDs) have found application also in the treatment of systemic diseases. OIDs development, however, currently suffers of an overall attrition rate of around 70%, meaning that seven out of 10 new drug candidates fail to reach the clinic. Our commentary focuses on the reasons behind the poor OIDs translation into clinical products for the treatment of respiratory and systemic diseases, with particular emphasis on the parameters affecting the predictive value of animal preclinical tests. We then review the current advances in overcoming the limitation of animal animal-based studies through the development and adoption of in vitro, cell-based new approach methodologies (NAMs).
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Affiliation(s)
- Dania Movia
- Laboratory for Biological Characterisation of Advanced Materials (LBCAM), Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College, The University of Dublin, Dublin D8, Ireland;
| | - Adriele Prina-Mello
- Laboratory for Biological Characterisation of Advanced Materials (LBCAM), Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College, The University of Dublin, Dublin D8, Ireland;
- AMBER Centre, CRANN Institute, Trinity College, The University of Dublin, Dublin D2, Ireland
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25
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Perumal R, Leite M, van Zyl-Smit RN. The Relationship Between Clinical Trial Participation and Inhaler Technique Errors in Asthma and COPD Patients. Int J Chron Obstruct Pulmon Dis 2020; 15:1217-1224. [PMID: 32581528 PMCID: PMC7277230 DOI: 10.2147/copd.s249620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Incorrect inhaler use is associated with poorer health outcomes, reduced quality of life, and higher healthcare utilisation in patients with asthma and COPD. Methods We performed an observational study of pressurized metered-dose inhaler technique in patients with asthma or COPD. Patients were assessed using a six-point inhaler checklist to identify common critical inhaler technique errors. An inadequate inhaler technique was defined as the presence of one or more critical errors. A multivariate logistic regression model was used to determine the odds of an inadequate inhaler technique. Results During the 14-month study period, 357 patients were enrolled. At least one critical error was executed by 66.7% of participants, and 24.9% made four or more critical errors. The most common errors were failure to exhale completely prior to pMDI activation and inhalation (49.6%), failure to perform a slow, deep inhalation following device activation (48.7%), and failure to perform a breath-hold at the end of inspiration (47.3%). The risk of a critical error was higher in COPD patients (aOR 2.25, 95% CI 1.13-4.47). Prior training reduced error risk specifically when trained by a doctor (aOR 0.08, 95% CI 0.1-0.57) or a pharmacist (aOR 0.02, 95% CI 0.01-0.26) compared to those with no training. Previous clinical trial participation significantly reduced error risk and rate: <3 trials (aOR 0.35, 95% CI 0.19-0.66) and ≥3 trials (aOR 0.17, 95% CI 0.07-0.42). The rate of critical errors was not significantly associated with age, sex, or prior pMDI experience. Conclusion This study found a high rate of critical inhaler technique errors in a mixed population of asthma and COPD patients; however, prior training and, in particular, multiple previous clinical trial participation significantly reduced the risk of errors.
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Affiliation(s)
- Rubeshan Perumal
- Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa
| | - Marcia Leite
- UCT Lung Institute, University of Cape Town, Western Cape, South Africa
| | - Richard Nellis van Zyl-Smit
- Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa
- UCT Lung Institute, University of Cape Town, Western Cape, South Africa
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Costello RW, Cushen B. Looking back to go forward: adherence to inhaled therapy before biologic therapy in severe asthma. Eur Respir J 2020; 55:55/5/2000954. [PMID: 32381635 DOI: 10.1183/13993003.00954-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/05/2022]
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Bloom CI, Douglas I, Usmani OS, Quint JK. Inhaled Corticosteroid Treatment Regimens and Health Outcomes in a UK COPD Population Study. Int J Chron Obstruct Pulmon Dis 2020; 15:701-710. [PMID: 32308379 PMCID: PMC7136662 DOI: 10.2147/copd.s241568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/10/2020] [Indexed: 01/23/2023] Open
Abstract
Background Inhaled corticosteroids (ICS) are a prevailing treatment option for COPD patients but recent guidelines have relegated their use predominantly to patients with frequent exacerbations. Yet large numbers of patients worldwide are currently treated with ICS-containing regimens. We wished to determine in routine clinical practice how common ICS withdrawal is and the differences in health outcomes between patients managed on ICS-containing and non-ICS containing regimens. Patients and Methods COPD patients were identified from the UK primary care electronic healthcare records, between 2014 and 2018. Patients were grouped into three treatment regimens: long-acting beta-agonist (LABA) and inhaled corticosteroids (ICS), LABA and long-acting muscarinic antagonist (LAMA), and triple therapy (LABA, LAMA and ICS). Annual incidence of ICS withdrawal was measured. Multivariable logistic regression was used to identify patient factors associated with withdrawal. Multivariable Poisson regression was used to assess the association of exacerbations and hospitalised pneumonia between the ICS-containing regimens (LABA-ICS and triple therapy) and patients prescribed LABA-LAMA. Results Of 117,046 patients, around three-quarters were prescribed ICS-containing inhalers but ICS withdrawal occurred annually in only approximately 2–3% of patients. Exacerbations in the past year, but not a past history of pneumonia, were associated with ICS withdrawal. A total of 31,034 patients using three treatment regimens (LABA-ICS, LABA-LAMA or triple therapy) were assessed for their relative risk of exacerbations and pneumonia; the exacerbation risk was slightly lower in LABA-ICS users but the same in triple therapy users, as compared to LABA-LAMA users (LABA-ICS adjusted IRR=0.82 (95% CI 0.73–0.93), triple adjusted IRR=0.99 (95% CI 0.88–1.11)). There was no difference in the pneumonia risk (LABA-ICS adjusted IRR=0.96 (95% CI 0.71–1.31), triple adjusted IRR=1.16 (95% CI 0.87–1.57)). Conclusion Use of ICS-containing inhaled medication is prevalent across the UK while ICS withdrawal from established treatment was relatively uncommon. Exacerbations and pneumonia risk was similar between the ICS-containing and non-ICS containing treatment regimens.
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Affiliation(s)
- Chloe I Bloom
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| | - Ian Douglas
- London School of Hygiene and Tropical Medicine, London, UK
| | - Omar S Usmani
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| | - Jennifer K Quint
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
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Hesso I, Nabhani Gebara S, Greene G, Co Stello RW, Kayyali R. A quantitative evaluation of adherence and inhalation technique among respiratory patients: An observational study using an electronic inhaler assessment device. Int J Clin Pract 2020; 74:e13437. [PMID: 31621983 DOI: 10.1111/ijcp.13437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/09/2019] [Accepted: 10/13/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Problems related to poor adherence and inhaler technique (IT) are historically reported in the literature. Most common methods used for adherence and IT assessment are reported to be either inaccurate or subjective. Few electronic monitoring devices (EMDs) that provide an objective measure of both adherence and IT while patients use inhalers at home now exist. Therefore, this study aimed to examine adherence level and IT among respiratory patients in community care using such an EMD for the first time in England. METHODS A prospective, multicentre, observational cohort study was conducted. Patients with chronic obstructive pulmonary disease (COPD) or asthma were recruited from independent community pharmacies within West and South London. Patients were provided with a dry-powder inhaler (DPI) mounted with an EMD to use for 1 month. Adherence was also assessed using pharmacy dispensing data, inhaler dose counter and self-reporting. RESULTS Data were available for 48 patients. Only eight patients used their inhaler in the correct manner at the correct interval as identified by the chosen EMD. The median actual adherence rate, as measured by the EMD, was 42.7%. This was significantly different from the median dose counter adherence (100%), medication refill adherence (MRA) (100%), proportions of days covered (PDC) (97.8%) and self-reported adherence (P < .001, each). Within a 1-month period, there were 2188 files showing attempted use of the DPI, of which 840 had IT errors. The median technique error rate (TER) was 30.1%. Most common errors recorded were as follows: multiple inhalations, drug priming without inhalation and failure to prime the device correctly. CONCLUSION The current study demonstrates that measures such as dose counter, prescription refill and self-reporting showed a high level of adherence among the observed patients. However, the objective data provided by the EMD showed a significantly lower actual adherence rate, reflecting how adherence remains variable and problematic among patients in the community.
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Affiliation(s)
- Iman Hesso
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston upon Thames, United Kingdom
| | - Shereen Nabhani Gebara
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston upon Thames, United Kingdom
| | - Garrett Greene
- Clinical Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - R W Co Stello
- Clinical Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Reem Kayyali
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston upon Thames, United Kingdom
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Attaway AH, Alshabani K, Bender B, Hatipoğlu US. The Utility of Electronic Inhaler Monitoring in COPD Management: Promises and Challenges. Chest 2020; 157:1466-1477. [PMID: 31981565 DOI: 10.1016/j.chest.2019.12.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 12/19/2019] [Accepted: 12/28/2019] [Indexed: 12/15/2022] Open
Abstract
COPD is a common respiratory disorder that poses a major health-care burden with societal and financial ramifications. Although effective inhaled therapies are available, nonadherence is common among patients with COPD and potentially contributes to the burden of this disease. Electronic inhaler monitoring (EIM) is a novel modality that enables real-time assessment of adherence to inhaled therapy and informs the assessment of treatment effectiveness. EIM can be combined with physician feedback, automated audiovisual reminders, and text messaging to bolster adherence. Clinical studies have suggested that EIM can diagnose nonadherence, improve adherence, and predict exacerbations. Using an EIM-guided protocol has the potential to avoid treatment escalation in the nonadherent. Coupling EIM to behavioral intervention is an area of ongoing research with mixed results, with some studies showing benefit and others showing minimal or no significant change in clinical outcomes. Further investigation is necessary to understand the incremental benefits of EIM features, delineate optimal program implementation, and target patient populations that would benefit the most from monitoring.
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Affiliation(s)
- Amy H Attaway
- Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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Real-life inhaler adherence and technique: Time to get smarter! Respir Med 2019; 158:24-32. [DOI: 10.1016/j.rmed.2019.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/30/2022]
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Personalized Biofeedback on Inhaler Adherence and Technique by Community Pharmacists: A Cluster Randomized Clinical Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:635-644. [PMID: 31568927 DOI: 10.1016/j.jaip.2019.09.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 08/15/2019] [Accepted: 09/02/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Guidelines recommend that patients treated with inhalers receive adherence counseling and device training. Digital technologies that assess both inhaler adherence and technique have been developed. Using these technologies community pharmacists, who have regular contact with patients, are well placed to deliver personalized inhaler education. OBJECTIVE To determine the impact of a pharmacist intervention, informed by digital technology, on inhaler technique and adherence of patients with asthma in the community. METHODS A cluster randomized, parallel-group, multisite pharmacy study was conducted over 6 months. All study groups had an electronic device (inhaler compliance assessment device) attached to their maintenance inhaler. A biofeedback group received personalized inhaler training informed by data recorded by the device. The demonstration group received inhaler training, by physical demonstration with a placebo inhaler. The control group received usual care. The primary outcome was inhaler adherence, which was classified as "actual adherence" and expressed as the proportion of expected drug accumulation if adherence and technique had been perfect. Secondary outcomes were quality-of-life scores as measured by the St George's Respiratory Questionnaire, symptoms, and exacerbations. RESULTS A total of 152 participants (n = 74 biofeedback, n = 56 demonstration, and n = 22 control) were recruited. Asthma was the predominant condition among participants (n = 83), with chronic obstructive pulmonary disease (n = 55) and asthma/chronic obstructive pulmonary disease overlap also reported (n = 8). In intention-to-treat analysis, adherence in the biofeedback group during month 2 was 62%, 18% higher (95% CI, 6 to 30) than that in the demonstration group (P = .004) and 24% higher (95% CI, 9 to 40) than that in the control group (P = .003). During month 6, adherence was 14% higher (95% CI, -1 to 30; P = .07) in the biofeedback group than in the demonstration group and 31% higher (95% CI, 13 to 48; P = .001) than in the control group. At the end of the study, the biofeedback group had a sustained fall in St George's Respiratory Questionnaire from baseline, -6.1 (95% CI, -9 to -0.4; P = .04) and had significantly improved daily respiratory symptoms. CONCLUSIONS Community pharmacist-delivered inhaler training informed by a digital technology improved adherence and health status.
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Basheti IA, Salhi YB, Basheti MM, Hamadi SA, Al-Qerem W. Role of the pharmacist in improving inhaler technique and asthma management in rural areas in Jordan. Clin Pharmacol 2019; 11:103-116. [PMID: 31413644 PMCID: PMC6662524 DOI: 10.2147/cpaa.s213271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/22/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Pharmacists can have a valuable role in educating patients on correct inhaler technique leading to improved asthma management. Rural areas can benefit from the role of the pharmacist considering the barriers found in attending primary health-care facilities. Objectives This study aimed to assess the impact of inhaler technique education delivered by pharmacists on patients’ inhaler technique, Asthma Control Test (ACT) score, forced expiratory volume in the first 1 second (FEV1%), and reliever use (puffs/day). Methods A pre–post interventional study was conducted over 6 months from February 2017 to July 2017 in rural areas in Jordan. Asthma patients visiting respiratory clinics and using metered dose inhaler (MDI) or turbuhaler (TH) controlled medication were randomly recruited. Inhaler technique was assessed via published checklists. The ACT, FEV1%, and reliever use (puffs/day) were assessed. Patients were educated on inhaler technique via demonstration with return demonstration education. All assessments were repeated 3 months post education. Results A total of 103 (TH, n=44; MDI, n=59) patients were recruited (mean age=46.5±13.5), 74% females. Patients reported an overuse of their reliever (5.1±4.2 puffs/day). Only 2 patients (1.9%) had well-controlled asthma, while the rest had either moderately (19.4%) or poorly (78.6%) controlled asthma. Patients using the MDI achieved 3.03±4.30 ACT score improvement (p<0.001), which is a clinically significant improvement in control. Patients using the TH achieved a statistically significant improvement of 2.07±4.72 (p=0.031). FEV1% improved significantly for MDI users (p=0.005) but not for TH users (p=0.097). Reliever use decreased significantly for MDI and TH users. Conclusion Asthmatic patients living in rural areas in Jordan reported poor inhaler technique, ACT scores, and FEV1% scores and high use of reliever medications. Pharmacist-led educational intervention resulted in improved inhaler technique scores, ACT scores, and FEV1% scores and lowered reliever use over time.
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Affiliation(s)
- Iman A Basheti
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Yara B Salhi
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Mariam M Basheti
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Salim A Hamadi
- Department of Pharmacology & Biomedical Sciences, Faculty of Pharmacy and Medical Sciences, Petra University, Amman, Jordan
| | - Walid Al-Qerem
- Department of Pharmacy, Al-Zaytoonah University of Jordan, College of Pharmacy, Amman, Jordan
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Bosnic-Anticevich S. Inhaler device use: Should we just forgo the detail and go for the 'big picture' approach? Respirology 2019; 24:924-925. [PMID: 31294528 DOI: 10.1111/resp.13645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Sydney, NSW, Australia
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Residual fluticasone in the oral cavity after inhalation with different tongue positions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1668-1670. [PMID: 30529063 DOI: 10.1016/j.jaip.2018.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 11/22/2022]
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Baiardini I, Novakova S, Mihaicuta S, Oguzulgen IK, Canonica GW. Adherence to treatment in allergic respiratory diseases. Expert Rev Respir Med 2018; 13:53-62. [PMID: 30518277 DOI: 10.1080/17476348.2019.1554438] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.
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Affiliation(s)
- Ilaria Baiardini
- a Department of Biomedical Sciences , Humanitas University , Milano , Italy
| | - Silviya Novakova
- b Allergy Unit of Internal Consulting Department , University Hospital "St. George" , Plovdiv , Bulgaria
| | - Stefan Mihaicuta
- c Pulmonology Department, CardioPrevent Foundation , University of Medicine and Pharmacy "Dr Victor Babes" , Timisoara , Romania
| | | | - Giorgio Walter Canonica
- a Department of Biomedical Sciences , Humanitas University , Milano , Italy.,e Personalized Medicine, Asthma and Allergy Clinic , Humanitas Research Hospital, Milano, Italy
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Bender BG. Nonadherence to Asthma Treatment: Getting Unstuck. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 4:849-51. [PMID: 27587318 DOI: 10.1016/j.jaip.2016.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Bruce G Bender
- Division of Pediatric Behavioral Health, Department of Pediatrics, National Jewish Health, Denver, Colo.
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Gillissen A, Gessner C, Hechenbichler K, Herth FJF, Juenemann R, Kanniess F, Kardos P, Lommatzsch M, Schneidereit R, Windisch W. Patient Satisfaction and Clinical Outcomes with Budesonide plus Formoterol Spiromax for Asthma and Chronic Obstructive Pulmonary Disease: A Real-World, Observational Trial. Respiration 2018; 97:292-301. [PMID: 30391944 DOI: 10.1159/000493860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The fixed-dose combination of budesonide/formoterol (B/F) has been available in the Spiromax® dry powder inhaler since 2014. OBJECTIVES To assess patient satisfaction, inhaler use errors, and disease control in patients with asthma or chronic obstructive pulmonary disease (COPD) treated with B/F Spiromax. METHODS This non-interventional, prospective, 12-week study enrolled consecutive asthma or COPD patients who had recently begun treatment with B/F Spiromax or were switched from another inhaled corticosteroid/long-acting β2-agonist combination to B/F Spiromax in routine clinical practice. Patients recruited from 243 specialist respiratory clinics or general practices in Germany were assessed for patient satisfaction (Satisfaction with Inhalers and Preference questionnaire), inhaler application errors (modified Easy Low Instruction over Time checklist), disease control, and safety. RESULTS The population included 3,943 patients: asthma n = 2,707 (68.7%); COPD n = 1,236 (31.3%). At baseline, 60.1% of patients were "satisfied" or "very satisfied" with their previous inhaler, and this increased to 88.8% at week 12 of B/F Spiromax use. Overall, 62.1% of pre-treated patients preferred B/F Spiromax to their old inhaler. The frequency of any handling error observed with B/F Spiromax at week 12 was lower than at baseline (11.9 vs. 25.5% of patients, respectively). After 12 weeks, 77.4% were assessed as having improved (minimally, much, or very much) overall health status versus baseline. Guideline-defined disease severity (as rated by physicians) and patient-reported symptom severity improved during the study in both asthma and COPD patients. B/F Spiromax was well tolerated. CONCLUSION B/F Spiromax was associated with high patient satisfaction, low device handling error rate, and improvements in clinical outcomes in real-world clinical practice.
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Affiliation(s)
- Adrian Gillissen
- Kreiskliniken Reutlingen/Ermstalklinik, Reutlingen-Bad Urach, Germany,
| | | | | | - Felix J F Herth
- Thoraxklink, University of Heidelberg and Translational Lung Research Center (TLRC), Heidelberg, Germany
| | | | | | | | | | | | - Wolfram Windisch
- Cologne Merheim Hospital, Witten/Herdecke University, Cologne, Germany
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Blakey JD, Bender BG, Dima AL, Weinman J, Safioti G, Costello RW. Digital technologies and adherence in respiratory diseases: the road ahead. Eur Respir J 2018; 52:1801147. [PMID: 30409819 PMCID: PMC6364097 DOI: 10.1183/13993003.01147-2018] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/25/2018] [Indexed: 01/09/2023]
Abstract
Outcomes for patients with chronic respiratory diseases remain poor despite the development of novel therapies. In part, this reflects the fact that adherence to therapy is low and clinicians lack accurate methods to assess this issue. Digital technologies hold promise to overcome these barriers to care. For example, algorithmic analysis of large amounts of information collected on health status and treatment use, along with other disease relevant information such as environmental data, can be used to help guide personalised interventions that may have a positive health impact, such as establishing habitual and correct inhaler use. Novel approaches to data analysis also offer the possibility of statistical algorithms that are better able to predict exacerbations, thereby creating opportunities for preventive interventions that may adapt therapy as disease activity changes. To realise these possibilities, digital approaches to disease management should be supported by strong evidence, have a solid infrastructure, be designed collaboratively as clinically effective and cost-effective systems, and reflect the needs of patients and healthcare providers. Regulatory standards for digital interventions and strategies to handle the large amounts of data generated are also needed. This review highlights the opportunities provided by digital technologies for managing patients with respiratory diseases.
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Affiliation(s)
- John D Blakey
- Respiratory Medicine, Royal Liverpool Hospital and Health Services Research, University of Liverpool, Liverpool, UK
| | - Bruce G Bender
- Dept of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Alexandra L Dima
- Health Services and Performance Research, Université Claude Bernard Lyon 1, Lyon, France
| | - John Weinman
- Institute of Pharmaceutical Science and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Richard W Costello
- RCSI Education and Research Centre, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
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Yoshida T, Kondo R, Horiguchi T. A comparison of posterior pharyngeal wall areas between different tongue positions during inhalation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:743-745.e1. [PMID: 30075338 DOI: 10.1016/j.jaip.2018.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/22/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Takazumi Yoshida
- Department of Respiratory Medicine II, Fujita Health University School of Medicine, Otobashi, Nakagawa-ku, Nagoya, Japan.
| | - Rieko Kondo
- Department of Respiratory Medicine II, Fujita Health University School of Medicine, Otobashi, Nakagawa-ku, Nagoya, Japan
| | - Takahiko Horiguchi
- Department of Respiratory Medicine II, Fujita Health University School of Medicine, Otobashi, Nakagawa-ku, Nagoya, Japan
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Bosnic-Anticevich SZ, Cvetkovski B, Azzi EA, Srour P, Tan R, Kritikos V. Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management. Pulm Ther 2018; 4:1-12. [PMID: 32026244 PMCID: PMC6966926 DOI: 10.1007/s41030-018-0051-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 12/24/2022] Open
Abstract
Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.
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Affiliation(s)
- Sinthia Z Bosnic-Anticevich
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia.
- Woolcock Emphysema Centre, University of Sydney, Sydney, Australia.
- Sydney Local Health District, Sydney, Australia.
| | - Biljana Cvetkovski
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Elizabeth A Azzi
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Pamela Srour
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachel Tan
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
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Greene G, Costello RW, Cushen B, Sulaiman I, Mac Hale E, Conroy RM, Doyle F. A novel statistical method for assessing effective adherence to medication and calculating optimal drug dosages. PLoS One 2018; 13:e0195663. [PMID: 29677197 PMCID: PMC5909911 DOI: 10.1371/journal.pone.0195663] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/27/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE We derive a novel model-based metric for effective adherence to medication, and validate it using data from the INhaler Compliance Assessment device (INCATM). This technique employs dose timing data to estimate the threshold drug concentration needed to maintain optimal health. METHODS The parameters of the model are optimised against patient outcome data using maximum likelihood methods. The model is fitted and validated by secondary analysis of two independent datasets from two remote-monitoring studies of adherence, conducted through clinical research centres of 5 Irish hospitals. Training data came from a cohort of asthma patients (~ 47,000 samples from 218 patients). Validation data is from a cohort of 204 patients with COPD recorded between 2014 and 2016. RESULTS The time above threshold measure is strongly predictive of adverse events (exacerbations) in COPD patients (Odds Ratio of exacerbation = 0.52 per SD increase in adherence, 95% Confidence Interval [0.34-0.79]). This compares well with the best known previous method, the Area Under the dose-time Curve (AUC) (Odds Ratio = 0.69, 95% Confidence Interval [0.48-0.99]). In addition, the fitted value of the dose threshold (0.56 of prescribed dosage) suggests that prescribed doses may be unnecessarily high given good adherence. CONCLUSIONS The resulting metric accounts for missed doses, dose-timing errors, and errors in inhaler technique, and provides enhanced predictive validity in comparison to previously used measures. In addition, the method allows us to estimate the correct dosage required to achieve the effect of the medication using the patients' own adherence data and outcomes. The adherence score does depend not on sex or other demographic factors suggesting that effective adherence is driven by individual behavioural factors.
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Affiliation(s)
- Garrett Greene
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
| | - Richard W. Costello
- Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Breda Cushen
- Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Imran Sulaiman
- Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elaine Mac Hale
- Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronan M. Conroy
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Doyle
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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43
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Horiguchi T, Kondo R. Determination of the preferred tongue position for optimal inhaler use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1039-1041.e3. [PMID: 29410307 DOI: 10.1016/j.jaip.2018.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 01/09/2018] [Accepted: 01/13/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Takahiko Horiguchi
- Department of Respiratory Medicine II, Fujita Health University School of Medicine, Nakagawa-ku, Nagoya, Japan.
| | - Rieko Kondo
- Department of Respiratory Medicine II, Fujita Health University School of Medicine, Nakagawa-ku, Nagoya, Japan
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44
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Taylor TE, Zigel Y, Egan C, Hughes F, Costello RW, Reilly RB. Objective Assessment of Patient Inhaler User Technique Using an Audio-Based Classification Approach. Sci Rep 2018; 8:2164. [PMID: 29391489 PMCID: PMC5794789 DOI: 10.1038/s41598-018-20523-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/16/2018] [Indexed: 12/29/2022] Open
Abstract
Many patients make critical user technique errors when using pressurised metered dose inhalers (pMDIs) which reduce the clinical efficacy of respiratory medication. Such critical errors include poor actuation coordination (poor timing of medication release during inhalation) and inhaling too fast (peak inspiratory flow rate over 90 L/min). Here, we present a novel audio-based method that objectively assesses patient pMDI user technique. The Inhaler Compliance Assessment device was employed to record inhaler audio signals from 62 respiratory patients as they used a pMDI with an In-Check Flo-Tone device attached to the inhaler mouthpiece. Using a quadratic discriminant analysis approach, the audio-based method generated a total frame-by-frame accuracy of 88.2% in classifying sound events (actuation, inhalation and exhalation). The audio-based method estimated the peak inspiratory flow rate and volume of inhalations with an accuracy of 88.2% and 83.94% respectively. It was detected that 89% of patients made at least one critical user technique error even after tuition from an expert clinical reviewer. This method provides a more clinically accurate assessment of patient inhaler user technique than standard checklist methods.
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Affiliation(s)
- Terence E Taylor
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland. .,School of Engineering, Trinity College, The University of Dublin, Dublin, Ireland.
| | - Yaniv Zigel
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland.,Department of Biomedical Engineering, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Clarice Egan
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fintan Hughes
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard B Reilly
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland.,School of Engineering, Trinity College, The University of Dublin, Dublin, Ireland.,School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
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45
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Taylor TE, Lacalle Muls H, Costello RW, Reilly RB. Estimation of inhalation flow profile using audio-based methods to assess inhaler medication adherence. PLoS One 2018; 13:e0191330. [PMID: 29346430 PMCID: PMC5773205 DOI: 10.1371/journal.pone.0191330] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 01/03/2018] [Indexed: 01/18/2023] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) patients are required to inhale forcefully and deeply to receive medication when using a dry powder inhaler (DPI). There is a clinical need to objectively monitor the inhalation flow profile of DPIs in order to remotely monitor patient inhalation technique. Audio-based methods have been previously employed to accurately estimate flow parameters such as the peak inspiratory flow rate of inhalations, however, these methods required multiple calibration inhalation audio recordings. In this study, an audio-based method is presented that accurately estimates inhalation flow profile using only one calibration inhalation audio recording. Twenty healthy participants were asked to perform 15 inhalations through a placebo Ellipta™ DPI at a range of inspiratory flow rates. Inhalation flow signals were recorded using a pneumotachograph spirometer while inhalation audio signals were recorded simultaneously using the Inhaler Compliance Assessment device attached to the inhaler. The acoustic (amplitude) envelope was estimated from each inhalation audio signal. Using only one recording, linear and power law regression models were employed to determine which model best described the relationship between the inhalation acoustic envelope and flow signal. Each model was then employed to estimate the flow signals of the remaining 14 inhalation audio recordings. This process repeated until each of the 15 recordings were employed to calibrate single models while testing on the remaining 14 recordings. It was observed that power law models generated the highest average flow estimation accuracy across all participants (90.89±0.9% for power law models and 76.63±2.38% for linear models). The method also generated sufficient accuracy in estimating inhalation parameters such as peak inspiratory flow rate and inspiratory capacity within the presence of noise. Estimating inhaler inhalation flow profiles using audio based methods may be clinically beneficial for inhaler technique training and the remote monitoring of patient adherence.
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Affiliation(s)
- Terence E. Taylor
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- * E-mail:
| | - Helena Lacalle Muls
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Richard W. Costello
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard B. Reilly
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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46
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Sulaiman I, Greene G, MacHale E, Seheult J, Mokoka M, D'Arcy S, Taylor T, Murphy DM, Hunt E, Lane SJ, Diette GB, FitzGerald JM, Boland F, Sartini Bhreathnach A, Cushen B, Reilly RB, Doyle F, Costello RW. A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma. Eur Respir J 2018; 51:51/1/1701126. [PMID: 29301919 DOI: 10.1183/13993003.01126-2017] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/29/2017] [Indexed: 11/05/2022]
Abstract
In severe asthma, poor control could reflect issues of medication adherence or inhaler technique, or that the condition is refractory. This study aimed to determine if an intervention with (bio)feedback on the features of inhaler use would identify refractory asthma and enhance inhaler technique and adherence.Patients with severe uncontrolled asthma were subjected to a stratified-by-site random block design. The intensive education group received repeated training in inhaler use, adherence and disease management. The intervention group received the same intervention, enhanced by (bio)feedback-guided training. The primary outcome was rate of actual inhaler adherence. Secondary outcomes included a pre-defined assessment of clinical outcome. Outcome assessors were blinded to group allocation. Data were analysed on an intention-to-treat and per-protocol basis.The mean rate of adherence during the third month in the (bio)feedback group (n=111) was higher than that in the enhanced education group (intention-to-treat, n=107; 73% versus 63%; 95% CI 2.8%-17.6%; p=0.02). By the end of the study, asthma was either stable or improved in 54 patients (38%); uncontrolled, but poorly adherent in 52 (35%); and uncontrolled, but adherent in 40 (27%).Repeated feedback significantly improved inhaler adherence. After a programme of adherence and inhaler technique assessment, only 40 patients (27%) were refractory and adherent, and might therefore need add-on therapy.
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Affiliation(s)
- Imran Sulaiman
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Garrett Greene
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Elaine MacHale
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Jansen Seheult
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Matshediso Mokoka
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Shona D'Arcy
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland
| | - Terence Taylor
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland
| | - Desmond M Murphy
- Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,HRB Clinical Research Facility-Cork, University College Cork, Cork, Ireland
| | - Eoin Hunt
- Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,HRB Clinical Research Facility-Cork, University College Cork, Cork, Ireland
| | | | - Gregory B Diette
- Dept of Medicine, Johns Hopkins University Hospital, Baltimore, USA
| | - J Mark FitzGerald
- UBC Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, Canada
| | - Fiona Boland
- Population Health Sciences (Psychology), RCSI, Dublin, Ireland
| | | | - Breda Cushen
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Richard B Reilly
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland.,School of Engineering, Trinity College, The University of Dublin, Dublin, Ireland.,School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - Frank Doyle
- Population Health Sciences (Psychology), RCSI, Dublin, Ireland
| | - Richard W Costello
- Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland .,Dept of Respiratory Medicine, RCSI, Dublin, Ireland
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47
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Kim CH, Dilokthornsakul P, Campbell JD, van Boven JFM. Asthma Cost-Effectiveness Analyses: Are We Using the Recommended Outcomes in Estimating Value? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:619-632. [PMID: 28967548 DOI: 10.1016/j.jaip.2017.07.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/15/2017] [Accepted: 07/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Asthma medication cost-effectiveness analyses (CEAs) lack the qualitative assessment regarding whether they capture the National Institutes for Health (NIH) 2012 recommended outcomes necessary to allow robust cross-study comparisons. OBJECTIVE We aimed to assess the current asthma outcomes used in CEAs and recommend a direction for improvement. METHODS We performed a systematic search using electronic databases including PubMed, EMBASE, Tufts CEA registry, Cochrane, and NHSEED from January 2010 through December 2015. Key words included (1) cost-effectiveness, cost-utility, economic evaluation, health economics, or cost-benefit AND (2) asthma. All CEA studies evaluating 1 or more asthma medication were included. Authors assessed each CEA study with respect to asthma-specific NIH outcome recommendations including core (hospitalizations, emergency department visits, outpatient visits, medication, interventions costs), supplemental (visit categories and work/school absence), and emerging (academic/job-related) asthma outcomes. Besides outcomes of each CEA, issues that could prevent robust cross-study comparison were identified and thematically summarized. RESULTS A total of 12 pre-NIH and 14 post-NIH recommendation CEAs were included. Eleven (91.7%) and 14 (100%) of the pre-/post-NIH studies included at least 1 core outcome, respectively. Of the 26 total studies, 7 (26.9%) included asthma-specific outpatient visit categories, 6 (23.1%) included asthma school or work absences, 5 (19.2%) included respiratory health care use, and none of the studies included emerging outcomes. Other issues that hamper cross-study comparison include lack of standardized cost data, time frames, quality-of-life measures, and incorporation of adherence. CONCLUSIONS Although the use of NIH-recommended asthma core outcomes has improved, there is still room for improvement in using supplemental and emerging outcomes. To allow robust cross-study comparisons, future work should focus on further standardizing of data sources and methods.
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Affiliation(s)
- Chong H Kim
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colo
| | - Piyameth Dilokthornsakul
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colo; Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Jonathan D Campbell
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colo
| | - Job F M van Boven
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colo; Department of General Practice, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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48
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Taylor TE, Zigel Y, De Looze C, Sulaiman I, Costello RW, Reilly RB. Advances in Audio-Based Systems to Monitor Patient Adherence and Inhaler Drug Delivery. Chest 2017; 153:710-722. [PMID: 28887061 DOI: 10.1016/j.chest.2017.08.1162] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/11/2017] [Accepted: 08/28/2017] [Indexed: 11/28/2022] Open
Abstract
Hundreds of millions of people worldwide have asthma and COPD. Current medications to control these chronic respiratory diseases can be administered using inhaler devices, such as the pressurized metered dose inhaler and the dry powder inhaler. Provided that they are used as prescribed, inhalers can improve patient clinical outcomes and quality of life. Poor patient inhaler adherence (both time of use and user technique) is, however, a major clinical concern and is associated with poor disease control, increased hospital admissions, and increased mortality rates, particularly in low- and middle-income countries. There are currently limited methods available to health-care professionals to objectively and remotely monitor patient inhaler adherence. This review describes recent sensor-based technologies that use audio-based approaches that show promising opportunities for monitoring inhaler adherence in clinical practice. This review discusses how one form of sensor-based technology, audio-based monitoring systems, can provide clinically pertinent information regarding patient inhaler use over the course of treatment. Audio-based monitoring can provide health-care professionals with quantitative measurements of the drug delivery of inhalers, signifying a clear clinical advantage over other methods of assessment. Furthermore, objective audio-based adherence measures can improve the predictability of patient outcomes to treatment compared with current standard methods of adherence assessment used in clinical practice. Objective feedback on patient inhaler adherence can be used to personalize treatment to the patient, which may enhance precision medicine in the treatment of chronic respiratory diseases.
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Affiliation(s)
- Terence E Taylor
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland; School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland.
| | - Yaniv Zigel
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland; Department of Biomedical Engineering, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Céline De Looze
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland; School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Imran Sulaiman
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard B Reilly
- Trinity Centre for Bioengineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland; School of Engineering, Trinity College Dublin, The University of Dublin, Dublin, Ireland; School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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49
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Sulaiman I, Cushen B, Greene G, Seheult J, Seow D, Rawat F, MacHale E, Mokoka M, Moran CN, Sartini Bhreathnach A, MacHale P, Tappuni S, Deering B, Jackson M, McCarthy H, Mellon L, Doyle F, Boland F, Reilly RB, Costello RW. Objective Assessment of Adherence to Inhalers by Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2017; 195:1333-1343. [PMID: 27409253 DOI: 10.1164/rccm.201604-0733oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
RATIONALE Objective adherence to inhaled therapy by patients with chronic obstructive pulmonary disease (COPD) has not been reported. OBJECTIVES To objectively quantify adherence to preventer Diskus inhaler therapy by patients with COPD with an electronic audio recording device (INCA). METHODS This was a prospective observational study. On discharge from hospital patients were given a salmeterol/fluticasone inhaler with an INCA device attached. Analysis of this audio quantified the frequency and proficiency of inhaler use. MEASUREMENTS AND MAIN RESULTS Patients with COPD (n = 244) were recruited. The mean age was 71 years, mean FEV1 was 1.3 L, and 59% had evidence of mild/moderate cognitive impairment. By combining time of use, interval between doses, and critical technique errors, thus incorporating both intentional and unintentional nonadherence, a measure "actual adherence" was calculated. Mean actual adherence was 22.6% of that expected if the doses were taken correctly and on time. Six percent had an actual adherence greater than 80%. Hierarchical clustering found three equally sized well-separated clusters corresponding to distinct patterns. Cluster 1 (34%) had low inhaler use and high error rates. Cluster 2 (25%) had high inhaler use and high error rates. Cluster 3 (36%) had overall good adherence. Poor lung function and comorbidities were predictive of poor technique, whereas age and cognition with poor lung function distinguished those with poor adherence and frequent errors in technique. CONCLUSIONS These data may inform clinicians in understanding why a prescribed inhaler is not effective and to devise strategies to promote adherence in COPD.
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Affiliation(s)
| | | | | | | | - Dexter Seow
- 1 Clinical Research Centre, Beaumont Hospital
| | - Fiona Rawat
- 1 Clinical Research Centre, Beaumont Hospital
| | | | | | | | | | | | | | - Brenda Deering
- 3 COPD Outreach, Beaumont Hospital, Dublin, Ireland; and
| | | | | | | | | | | | - Richard B Reilly
- 5 Trinity Centre of Bioengineering.,6 School of Engineering, and.,7 School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - Richard W Costello
- 1 Clinical Research Centre, Beaumont Hospital.,8 Department of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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50
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Anderson WC, Apter AJ, Dutmer CM, Searing DA, Szefler SJ. Advances in asthma in 2016: Designing individualized approaches to management. J Allergy Clin Immunol 2017; 140:671-680. [PMID: 28709967 DOI: 10.1016/j.jaci.2017.06.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 12/12/2022]
Abstract
In this year's Advances in Asthma review, we discuss viral infections in asthmatic patients and potential therapeutic agents, the microbiome, novel genetic associations with asthma, air quality and climate effects on asthma, exposures during development and long-term sequelae of childhood asthma, patient-centered outcomes research, and precision medicine. In addition, we discuss application of biomarkers to precision medicine and new information on asthma medications. New evidence indicates that rhinovirus-triggered asthma exacerbations become more severe as the degree of sensitization to dust mite and mouse increase. The 2 biggest drivers of asthma severity are an allergy pathway starting with allergic sensitization and an environmental tobacco smoke pathway. In addition, allergic sensitization and blood eosinophils can be used to select medications for management of early asthma in young children. These current findings, among others covered in this review, represent significant steps toward addressing rapidly advancing areas of knowledge that have implications for asthma management.
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Affiliation(s)
- William C Anderson
- Allergy & Immunology Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Andrea J Apter
- Section of Allergy & Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Cullen M Dutmer
- Allergy & Immunology Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Daniel A Searing
- Allergy & Immunology Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Stanley J Szefler
- Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo.
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