Digital remote maintenance inhaler adherence interventions in COPD: a systematic review and meta-analysis

Abstract

Introduction: Sub-optimal inhaler adherence undermines the efficacy of pharmacotherapy in COPD. Digitalised care pathways are increasingly used to improve inhaler-use behaviour remotely. This review investigated the feasibility and impact of remote electronic inhaler adherence monitoring (EIM) and intervention platforms on clinical outcomes in COPD.

Methods: A literature search was conducted and studies investigating maintenance inhaler use among people with COPD using digital technology were selected. Pairwise and proportional meta-analyses were employed with heterogeneity assessed using I² statistics. When meta-analysis was not feasible, a narrative synthesis of outcomes was conducted.

Results: We included 10 studies including 1432 people with COPD whose maintenance inhaler usage was supported by digital inhalers and apps featuring audiovisual reminders and educational content with or without engagement with healthcare providers (HCPs). Inhaler adherence rate (AR) varied with calculation methods, but an overall suboptimal adherence was observed among people with COPD. HCP-led adherence interventions alongside EIM improved mean AR by 18% (95% CI 9-27) versus passive EIM only. Enhanced AR may reduce COPD-related healthcare utilisation with little impact on health-related quality of life and exacerbation rate. Despite encountering technical issues among 14% (95% CI 5-23%) of participants, 85% (95% CI 76-94%) found digital platforms convenient to use, while 91% (95% CI 79-100%) perceived inhaler reminders as helpful.

Conclusion: Digitalised interventions can enhance maintenance inhaler adherence in COPD but their overall effect on clinical outcomes remains uncertain. Further work is required to tailor interventions to individuals' adherence behaviour and investigate their longer-term impact.

FIGURE 1

PRISMA flow diagram for the literature search and study selection. MPR: medication possession ratio.

FIGURE 2

Maintenance inhaler adherence rate (AR) among people with COPD using electronic inhaler adherence monitoring (EIM) as per different calculation methods, as follows: mean (%) of prescribed inhaled doses taken during the study period, mean (%) of adherent days (i.e. days with correct sets of inhalations) and mean complete AR (%) of inhaled doses taken with proper timing, intervals and technique assessed by the area under curve metric.

FIGURE 3

Change in a) mean maintenance inhaler adherence rate (AR) and b) Clinical COPD Questionnaire (CCQ) scores between digitalised interventions delivered by healthcare providers with full features versus standalone passive electronic inhaler adherence monitoring (EIM) among people with COPD. c) Overall change in COPD Assessment Test (CAT) scores by digitalised interventions. The funnel plots are provided in figures B and C of the supplementary file.

FIGURE 4

a) Proportion of participants who experienced technical problems during study participation. b) Feedback on platform usage and its inhaler reminders provided by participants who completed digitalised interventions on maintenance inhaler use.

FIGURE 5

Key elements to consider for future study designs. BEC: blood eosinophil count; EIM: electronic inhaler adherence monitoring; F_ENO: fractional exhaled nitric oxide; HCP: healthcare practitioner; HRQoL: health-related quality of life.