32 Chapter 2 2 Background Despite the availability of effective inhaler medication, almost half of all asthma patients have poor asthma control (1,2). Poor adherence to maintenance inhalers is a major cause of inadequate asthma control and is associated with 2.5-fold increased risk of uncontrolled asthma. As such, non-adherence is associated with increased risk of severe asthma exacerbations, more asthma-related emergency department visits, hospitalization and decreased lung function and quality of life (3-5). Moreover, non-adherence has been shown to increase healthcare costs, as patients with uncontrolled asthma require more frequent medical visits, interventions and stepups in medication regimen (6,7). In addition, medication non-adherence is often accompanied by over-reliance on short-acting B2 agonists (SABA) for symptom relief (8-11). This is of particular concern as high SABA use is associated with increased exacerbations and 2.2 times higher asthma-related healthcare costs than low SABA use (12). Hence, it is important to address poor medication adherence and promote appropriate SABA usage. Numerous factors contribute to poor medication adherence, including forgetfulness, limited understanding of the importance of adherence (necessity), and concerns about medication side effects (13,14). Improving medication adherence may be especially challenging among people with mild asthma as they may have a lower feeling of necessity and underestimate the importance of adhering to the maintenance inhaler compared to people with severe asthma (15). Interventions, such as patient education, reminder systems, and simplified medication regimens, have been developed to target the problem of poor adherence (16). More recent technological developments targeting poor adherence include electronic monitoring devices (EMDs) to track and monitor inhaler usage, providing objective and accurate data on medication adherence. EMD data can be used by healthcare providers to identify patients who do not adhere to their medication regimens, intervene with appropriate education, and support or help in decisions on the step-up of treatment. EMDs that connect to patients’ smartphones (also known as smart inhalers) can, in addition, provide patient self- management support by providing medication reminders, personalized feedback and motivational messages. Overall, EMDs have shown promise in improving medication adherence, however their impact on asthma control and the long-term sustainability in improving adherence and asthma control still require further investigation (17-21). Studies on the effectiveness of smart inhalers have primarily focused on examining the overall effect on medication adherence, rather than identifying which patient groups benefit the most based on determinants of non-adherence. Nevertheless, it is generally believed that smart asthma inhalers, featuring electronic reminders, primarily benefit unintentional non-adherence due to forgetfulness (22). Furthermore, while people with severe or persistent asthma have shown interest in using an app to manage their condition (23). This interest may stem from their heightened necessity for effective asthma control (15,21-23). Moreover, it should be noted that self-management-based interventions are typically used by individuals who are
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