119 ACCEPTANCE protocol 5 Route C (recruitment via pharmacies) Pharmacies are identified via a database search of all pharmacies in the Netherlands. Pharmacies are invited to participate via email and are followed-up via telephone or email. Pharmacies are also recruited via word of mouth. Potentially eligible patients are identified via pharmacy records. Pharmacies are asked to select and invite these patients following the steps outlined in route A. Patients who express their interest are screened on eligibility. Since pharmacies cannot identify patients by asthma diagnosis, the inclusion criterion ‘doctor-diagnosed asthma’ is checked by the general practice. The general practice is not asked to participate as a cluster, as we want to alleviate the burden that general practitioners face due to the COVID-19 pandemic (i.e., an increase in absenteeism due to illness and a postponement of care due to several lockdowns). For the same reason, the inclusion criterion doctor-diagnosed asthma will be checked at 12 months of follow-up instead of at inclusion. Inclusion and exclusion criteria On expression of interest, all potentially eligible patients are screened by a research assistant telephonically for further eligibility. Patients aged 18 years and older, who have uncontrolled asthma (defined as an Asthma Control Questionnaire (ACQ)-5 score of ≥0.75), use budesonide/formoterol Symbicort Turbuhaler as maintenance therapy for at least 8 weeks before entering the run-in period, have a doctor diagnosed asthma and are in the possession of a Turbu+ Insights application compatible smartphone (i.e., Android or iOS as mobile operating system) are eligible for inclusion. Patients can receive asthma treatment in primary care or (temporarily) in secondary care, and must provide digital (i.e., via DocuSign) or written informed consent. Furthermore, patients should be classified as ‘non-adherent’, as observed during the run-in period, during which inhalation actuations are electronically monitored. Non-adherent is defined as an adherence rate of below 80% over the third and fourth weeks of the 6-week run-in period. The adherence rate is defined as the number of adherent days as a proportion of the total number of days. An adherent day is considered a day on which the patient takes at least the number of inhalations prescribed (less inhalations than prescribed means a non-adherent day). Validity of inhalation data can be compromised by change in adherence behaviour due to the knowledge on participating in a trial. To minimise impact, inhalation actuations from the first, second, fifth and sixth weeks of the run-in period are disregarded. Patients who meet one or more of the exclusion criteria are excluded. Exclusion criteria are (1) use of Symbicort as Symbicort Maintenance and Reliever Therapy (SMART) (to be able to draw valid conclusions on the effect on the primary outcome medication adherence); (2) change in inhaled corticosteroids (ICSs) dose in the 4 weeks prior to the run-in period; (3) use of systemic corticosteroids in the 4 weeks prior to the run-in period, including maintenance therapy (i.e., to exclude patients recovering from an exacerbation at study start); (4) current use of biologics, including anti-interleuking (IL)-5, anti-IL-4Rα or anti-IgE; (5) diagnosis of chronic obstructive pulmonary disease, interstitial lung diseases, bronchiectasis or other significant respiratory conditions; (6) malignancy with life expectancy of < 1 year; (7) pregnancy;
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