Adherence to daily inhaled corticosteroids and short-acting β-agonist medications is an important yet complicated component of asthma management. Despite the importance of daily preventive medication, up to 70% of pediatric patients with asthma are nonadherent to their prescribed medical treatments,1–14 which often leads to increased illness exacerbations, health care use, and missed days of school.15,16 With recent advancements in technology such as Bluetooth sensors, sensor-based monitoring of these medications has become increasingly accessible and popular. Most often, these monitors are paired with a mobile health app that provides some combination of self-monitoring; feedback; education about health, asthma, medications and triggers; encouragement; and the potential to data share with the medical team.
In this issue of Pediatrics, Gupta et al17 conducted a randomized controlled trial (RCT) evaluating Propeller Health’s sensor-based electronic monitoring system (Propeller Health, Madison, WI). Findings suggest that sensor-based inhaler monitoring with clinical feedback may improve asthma symptom control and caregiver quality of life within diverse populations. It should be noted, however, that although a statistically significant improvement in asthma symptom control was demonstrated, this change did not meet the threshold for a clinically meaningful difference.18 One interesting finding of this study is the increase in health care use in the intervention group to nearly twice as many emergency department (ED) visits and 3 times as many hospitalizations as the control group over 12 months. Although it is plausible that, as the authors suggest, greater asthma knowledge and monitoring may have led to increased vigilance of asthma symptoms, it seems that this would have only led to an increase in ED visits but not hospitalizations. For example, because participants were more closely monitoring symptoms and medication use on a digital platform, perhaps they noticed or were directed to the ED by providers at an increased rate. However, it does not seem likely that they would have been admitted to the hospital at an increased rate.
An important strength of this study is that the authors conducted a multicenter RCT with a racially and socioeconomically diverse sample of children with asthma. Although studies have revealed preliminary effectiveness of sensor-based monitoring systems in adults,19,20 this study provides a critical next step by evaluating this sensor-based system in an RCT with children with asthma. This study also included children with severe asthma (at least 1 exacerbation or steroid use) and a wide age range, each of which aids in the generalizability of the findings. Additionally, Propeller Health’s US Food and Drug Administration–approved portal provided alerts for providers to contact participants if they (1) missed doses of an inhaled corticosteroid for 4 consecutive days and/or (2) used >4 doses of a short-acting inhaled β-agonist per day, which extended the sensor-based system beyond a digital platform.
The study has a number of limitations, as acknowledged by the authors. Some of the participants’ inhalers were incompatible with the sensor, requiring manual data entry of doses taken. Self-reported adherence is fraught with limitations, including potential bias, and it can be complicated to understand data that include both objective electronic monitoring and subjective self-report.21 In addition, despite the primary goal of sensor-based monitoring being self-monitoring, along with feedback regarding adherence, adherence was not assessed in the control group nor in a baseline period for the intervention group. Thus, analyses to determine if adherence to asthma medications was improved because of the sensor-monitoring–based intervention within a group or compared with a control group were not possible. One option would be to disable the intervention component and use the sensor as an adherence measurement tool during a baseline period or in a control group to determine if adherence is the mechanism for improved asthma control.
In addition to the sensor-based electronic monitoring and feedback intervention, providers in this study were also triggered by the sensor-informed portal to initiate participant–provider phone calls to help guide asthma management. Given that, in our recent review of digital interventions for pediatric asthma management, we concluded that interventions combining digital technology with support from a health care team member often results in improved adherence and asthma outcomes,22 it is commendable that, in this study, researchers delivered, as needed, an individually tailored telephone call with a medical professional to further improve outcomes. It seems, however, that these participant–provider phone calls were neither standardized nor tracked, and variability in the subject matter and delivery of this intervention is possible. This could have a varying impact on adherence and asthma management, making understanding the effect of the sensor-based electronic monitoring and the replicability of this complete intervention difficult.
The authors should be commended for their multisite RCT examining the use of sensor-based electronic monitoring in a diverse sample of children with varying asthma severities. This study provides support for the use of sensor-based electronic monitoring in children with asthma with regard to improved symptom control and caregiver quality of life. Future studies should include an examination of the replicability of these findings as well as chart reviews to discover possible reasoning for increased health care use. Additional studies might include the examination of sensor-based electronic monitoring in addition to a more systematic behavioral intervention at pertinent time points (eg, use of daily inhaled corticosteroids decreases, use of short-acting β agonist increases). Overall, this article underscores the feasibility and importance of sensor-based electronic monitoring of adherence in pediatric asthma and encourages future research in this area.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: Supported by Dr Ramsey’s career development award (K23HL139992) from the National Institutes of Health. Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-1330.
POTENTIAL CONFLICT OF INTEREST: Dr Guilbert reports personal fees from the American Board of Pediatrics Pediatric Pulmonary Subboard, personal fees from GlaxoSmithKline, personal fees from Teva Pharmaceuticals, personal fees from Novartis, grants from the National Institutes of Health, grants and personal fees from Sanofi and Regeneron, grants and personal fees from AstraZeneca, and royalties from UpToDate; and Dr Ramsey has indicated she has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.