Self-care, Remote Monitoring and Elearning for Children and Young People With Asthma

Asthma is a long-term condition in children, often managed in primary care but around 20% children with asthma require secondary or tertiary level treatment and care by experienced respiratory paediatricians and nurses. The positive effects of treatment with inhaler and anti-inflammatory medications for childhood asthma are well-documented however, less than 50% children take their medications regularly as prescribed. Asthma deaths in children are rare but the national review of asthma deaths in the UK between 2012 and 2013 concluded that two thirds of the asthma deaths were preventable and that poor adherence to therapy was found to be a preventable cause in 34%.

It is known that educational interventions and use of written action plans improve asthma control. However, two thirds of patients do not attend their asthma review. Lack of adherence to medications is a global problem with £300million worth of medications /yr wasted in primary care due to poor adherence and 50% patients not taking medication as prescribed. With the UK facing an increasingly unmanageable demand on healthcare services, this morbidity and cost needs to be addressed.

So, why do people with asthma omit their medications? Clinicians have developed a conceptual framework to enable clinicians to understand the barriers to medication adherence. Habit formation is underpinned by a complex interaction of feedback, problem solving, prompts and implementation plans. The interaction between motivation (reasons that people "won't" take medication, such as illness perceptions, medication beliefs and contrivance) and capability opportunity (reasons that people "can't" take medication, such as forgetting, being too busy, having trouble incorporating into the routine) needs to be understood and addressed in order to change and sustain habit formation.

Adherence monitoring methods have been studied at length in patients with asthma, ranging from non-judgemental questioning by a clinician, which is cheap and easy to do in clinic, but vastly overestimates adherence, to self-report questionnaires and diary cards to prescription refill data and drug assays. These methods are increasingly objective, but remain subject to inaccuracies due to susceptibility to dose "dumping" and impracticalities. The most objective method of adherence monitoring is the use of electronic monitoring devices (EMDs) which can provide continuous monitoring and "smart" features such as transmission of data to electronic devices. The "STAAR" (Study of Asthma Adherence Reminders) study used adherence monitoring with feedback to target both motivation and capability opportunity with an educational/behavioural intervention and a practical adherence facilitator with reminder alarms chosen from a range of alarms by the child. Although a significant improvement in adherence from 49% to 70% was noted in the intervention group, there was no significant improvement in ACQ, the primary outcome measure. There was, however, a significantly lower number of exacerbations in the intervention group, measured by number of hospital and GP visits, number of courses of oral steroids and number of days missed from school.

There is a growing number of digital solutions for asthma Self-Care, with many of these produced by pharmaceutical companies as companion products or research tools. In addition, an increasing number of HealthApps and remote monitoring self-management software platforms are appearing on the commercial market. There are challenges to overcome before these can be implemented in paediatric clinical practice as all are adult based, are of variable quality, and more research is needed to refine the technology and links to electronic health records. However, smart inhalers and HealthApps in a digitally evolving NHS have the potential to support self-management of long-term conditions such as asthma at scale, to support digital transformation of health services to risk stratify according to need and to provide a personalised approach to care, thereby reducing emergency admissions and improving patient safety and quality of life.