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An interview with a Children's Hospital Colorado investigator on new remote-monitoring research into children's adherence trends.
Late-breaking data presented at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2021 Virtual Sessions showed an inconsistent—and even seasonally-influenced—pattern of pediatric patient adherence to controller therapy for severe asthma.
The research, presented by William Anderson, MD, of the Children’s Hospital Colorado and University of Colorado School of Medicine, showed a near 50% adherence to controller therapy among pediatric severe asthma patients who were remotely monitored for their care via a Propeller Health device.
In an interview with HCPLive® regarding the data, Anderson discussed the trial’s makeup and outcome, its contribution to currently understood patterns of pediatric asthma adherence, and the influence of factors including COVID-19 and the summer season on asthmatic care monitoring and adherence among children.
What is the known history of pediatric asthma patient adherence to controller therapy?
Anderson: We know that when it comes to approaching patients who either have difficult-to-control or severe asthma, the one of the very first steps is to check to make sure that patients are adhering to the controller therapy. Because it does provide us great guidance to know, 'Do we need to be stepping up for therapy if they're poorly controlled, or potentially do we need to be addressing barriers to why they're not taking their medication?' And that could be the reason why they're poorly controlled.
So historically, the way that we've been monitoring the adherence is either through medication refills, insurance claims, or using a dose count on the back of the medication. However, all of those have their own limitations associated with it. So for example, a patient might still have medication, but they never use it. You can think that they're taking it, but they're really not. So one thing that this technology and this kind of advancement allows us to do is get a real-time objective feedback of how they're doing and taking their medication.
Could you share bit more detail into this device?
Anderson: For our project, we use the Propeller Health device. These are monitors that are attached to patient rescue and controller medication. And they provide real-time objective data on when a patient takes their medication. So there ends up being a timestamp associated when patients use their medications, and both the patient as well as the care team have access to this information. So we can trend their adherence over time, and then also provide feedback to the patient, depending on what we're seeing with the stack.
How well-equipped is such a device in US asthma care right now?
Anderson: This is a relatively new device. It's been around for actually the last several years. But these technologies are still gaining incorporation to clinical practice. So. a lot of them initially started in the research setting and are now moving towards clinical practice. So we are, to my knowledge, one of the few pediatric severe asthma clinics in the country that are using this on a routine basis with our patient population.
The first thought that comes to mind is the utility of such a device at a time when in-person care is very minimal due to COVID-19. With a pediatric population, it's very pivotal that we assure they're gaining confidence and trust in the use of their controller medication for asthma, especially at-risk patients at a time when we're monitoring this respiratory-affecting virus.
Were there heightened stakes into this level of remote adherence and monitoring research?
Anderson: Certainly, one of the things that COVID-19 has done is it's really propelled forward the use of this kind of more remote monitoring or home-based technology, knowing that patients cannot always make it into the office. So having this data really helps benefit our patients and care for them beyond just that in-person or telehealth clinic encounter.
We can really follow up with them on more consistently outside of our standard clinic setting in this way. And I will say that this technology is obviously one aspect of that. You're also seeing this happen with home spirometry as another way that patients and providers are trying to monitor their asthma management.
Could you tell us more on the study's findings?
Anderson: This was a study that was conducted in our multi-disciplinary asthma clinic. So this is a clinic for patients with either difficult-to-control or severe asthma. Patients are typically referred to this clinic if they have had recurrent hospitalizations, or emergency room visits, or they still do not have good asthma control despite guidelines-based therapy. So at the start, we're working with definitely a higher-risk population. And this clinic is being staffed by allergy, pulmonology, nurse care coordinators, and social work, as well as speech therapy and nutrition as needed. So certainly, a comprehensive team environment. And what we wanted to do with this technology is just really understand what are the adherence patterns of our patients? Are they taking their medications or not?
We ended up enrolling about 20 patients. It was a small, more pilot study. But we enrolled 20 patients in this study, and we gave them that Propeller Health device—they volunteer to do this. And the patients were aware that they had access to the data, we had access to the data, and that we would provide them feedback on their adherence overall. And then we calculated their adherence as a seven-day rolling average. And then we also tried to break it down based on seasonal trends, as well to see if there's any difference with that.
So overall, for our patients, we found that their mean adherence was about 57%. So a little over 50% of the time, they ended up taking their medication. The total duration study was about 203 days as the median. And patients were using primarily combination ICS-LABA therapy, with one patient just being on ICS therapy alone.
We did find that patients usually started with a higher adherence, and then had a drop over time. And in general for our population, at about 160 days is where they kind of settled into their baseline where they then remained for the remainder of the study. Overall, in terms of the seasons, we found that the during the summer months, there was an increase in the frequency of patients who had very low adherence, 0-25%. So essentially, during the school year, there was really no significant differences in their adherence patterns but they did drop in their adherence over the summer—which could potentially be secondary to some of the loss of structure that comes with the school year.
Our conclusions for this study was that despite being a high-risk population, voluntarily signing up for this program and providing adherence feedback, their overall adherence was only about 57%. Now, I will say we had hoped that it would be higher than that. But actually, when you look at other studies that look at real-world adherence patterns in patients, this is actually a pretty good adherence. It's comparable to, if not higher than some other real-world studies.
So overall, what we're recognizing from this is that it's really important, obviously, to recognize what is the adherence patterns for your patient so that if they are not adherent to the medication, we need to see why that might be the case. Is that because they feel like the medications aren't working for them? Is it because they don't have? It doesn't work with their schedule? Are they having side effects for the medication? What could it potentially be?
And then on the flip side, for those patients who are very adherent to the medications, and they're still not well-controlled—those are the ones we really need to target, in terms of escalating their therapy, and especially for those most severe patients, they might be a good candidate for biologics. And, as you're probably aware, the biologics are a very expensive medication. So it's important to know that you're targeting the right patient population to use these medications.
The study, “Objective Controller Medication Adherence Patterns in Pediatric Patients with Asthma in a High-Risk Multidisciplinary Asthma Clinic,” was presented at AAAAI 2021.