Systematic Review of Electronic Monitoring to Increase Medication Adherence in Children with Asthma

Abstract

Introduction.

While asthma can be well-controlled with the use of inhaled corticosteroids (ICS), most children do not adhere to treatment, leading to exacerbations, emergency department (ED) visits, hospitalizations, and deaths. Electronic monitoring devices (EMDs) have been shown to increase ICS adherence and improve asthma outcomes, but have not been well-studied in young people. The aim of this systematic review is to determine the feasibility and efficacy of EMDs in children with asthma.

Methods.

This review was conducted according to PRISMA guidelines. PubMed and CINAHL were searched using keywords such as asthma, wearable electronic devices, and medication adherence. Search results were screened and appraised using Covidence software. Articles were included if they were in English, peer-reviewed, published since 2000, used EMDs for inhaled corticosteroid (ICS) treatment adherence, and included participants with asthma under age 21.

Results.

Fourteen studies met inclusion criteria, with durations ranging from 2 to 12 months. Recruitment rates varied from 28% to 100%, and retention rates ranged from 51% to 100%. Participants found EMDs acceptable in four of six and feasible in five of six studies, highlighting ease of use and perceived benefits. Six of the 12 studies measuring ICS adherence reported improvements using EMDs with feedback compared to monitoring alone. Seven out of nine studies found improvements in asthma control, and four out of seven found reduced ED visits and hospitalizations. These findings highlight the overall efficacy of EMDs.

Conclusion.

EMDs can improve ICS adherence in children with asthma, especially with sustained feedback. However, inconsistent results highlight the need for comprehensive approaches addressing behavioral and systemic factors.

Introduction

Asthma is the most common chronic disease in childhood, affecting more than 5.1 million children under 18, or about 7% of the U.S. population.^1,2 Effective asthma management aims to control symptoms and reduce exacerbations.^3,4 Treatment adherence is essential for managing asthma in pediatric patients, yet measuring it accurately remains challenging.^4–6 Subjective measures have not been validated in children, and objective measures, such as prescription refill rates, often overestimate adherence, limiting effective and timely interventions.^7,8 Although most children can achieve good asthma control with inhaled corticosteroids (ICS), adherence remains low, with 50% to 80% of children not consistently following their treatment.^9–12 Contributing factors include parents’ mistrust of ICS and concerns about side effects,¹³ forgetfulness and difficulty incorporating medication into daily routines,¹⁴ complexity of medication regimens,¹⁵ and the gradual transition of responsibility for medication use as children grow older.¹⁶

Poor adherence increases the risk of uncontrolled asthma, leading to emergency department (ED) visits, hospitalizations, and deaths.^7,17,18 Childhood asthma is responsible for nearly 75,000 hospitalizations and 770,000 ED visits annually,¹ with U.S. asthma-related costs totaling around $82 billion each year.¹⁹ Notably, 20% of asthma patients with uncontrolled moderate to severe disease account for more than 80% of asthma-related healthcare costs.²⁰ Emerging technologies, however, offer new opportunities for patients, caregivers, and clinicians to monitor asthma symptoms and medication use, enabling timely and impactful interventions.

Electronic monitoring devices (EMDs) present an innovative approach to asthma care, using remote sensors to track medication usage. Bluetooth-enabled sensors attach to standard asthma inhalers, recording the date and time of each inhalation. Data are transmitted to a mobile application (app) on the patient’s (or caregiver’s) smartphone and can be shared with the clinician via cloud-based technology. Automated reminders notify the patient (or caregiver) if a dose is missed, helping prevent unintentional non-adherence. EMDs also allow clinicians to monitor medication use, enabling early intervention. These data can support open discussions about asthma self-management, promoting a collaborative, patient-centered approach. Feedback may be used to identify adherence barriers and develop strategies to address them.

Although EMDs have shown efficacy in improving treatment adherence and health outcomes in patients with asthma, few studies have focused on children and adolescents.^20–23 Fewer studies have included individuals from racial and ethnic minority groups, representing a gap in research that may contribute to asthma-related health disparities.²⁴ Failure to address this gap perpetuates inequality in asthma control and outcomes for minority children.²⁵ Further research is needed to explore the potential of EMDs to improve treatment adherence and asthma outcomes among underserved and minority pediatric populations.^26–28

This systematic review examines the outcomes, feasibility, and effective features of EMDs for children and adolescents with asthma, providing insights for integrating these technologies into clinical care while addressing implementation barriers and cost minimization. This review addressed the following research question: What are the feasibility and efficacy of EMDs to improve medication adherence and health outcomes in children and adolescents with asthma? We considered multiple aspects of feasibility including recruitment rate, retention rate, reasons for declining participation, reasons for attrition, acceptability, and implementation issues such as lost devices and syncing difficulties. For efficacy, we examined medication adherence and a range of asthma-related health outcomes including asthma control test (ACT) scores, oral corticosteroid (OCS) use, ED visits, and hospitalizations.

Methods

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.²⁹ The protocol is registered in the PROSPERO database (ID# CRD42024505311). No changes were made to the published protocol during the review.

Study Search

Two electronic literature databases were searched, PubMed and CINAHL, using a combination of MeSH terms and keywords such as asthma, wearable electronic devices, digital technology, medical electronics, and medication adherence (detailed in the Appendix). A field-specific librarian was consulted to validate and refine the search strategy. Gray literature was considered through a review of references from relevant papers. The initial search was conducted in early 2024 and updated in December 2024 to ensure the inclusion of the most recent publications. The review process was facilitated with a systematic review management software (Covidence, Melbourne, Australia). Search eligibility was restricted to peer-reviewed articles published in English since 2000, focused on children and adolescents with asthma. No additional filters beyond the search terms and date range (January 2000 onward) were applied at this stage to ensure a broad capture of potentially relevant records.

Eligibility Criteria

The final inclusion criteria were as follows: (1) peer-reviewed original research articles, (2) use of EMDs for asthma treatment adherence, (3) participants younger than 21 years, (4) published in English, and (5) published since January 2000. Due to the emerging nature of EMDs for pediatric asthma and the limited availability of data for meaningful comparisons with control groups, a range of study designs were included, such as RCTs, non-randomized controlled trials, quasi-experiments, single-arm, feasibility, and pilot studies. Studies that utilized EMDs solely for medication measurement and tracking, without a behavioral component such as feedback or reminders, were excluded. Eligibility criteria were applied consistently across all stages of the review, including search, screening, data extraction, and analysis, to ensure a transparent and reproducible review process.

Study Selection

Two reviewers (MH and JB) independently applied eligibility criteria during the initial screening phase. Disagreements were resolved through discussion. In the full-text screening phase, MH and JB independently reviewed selected articles to confirm eligibility for data extraction and quality assessment. Discrepancies were resolved by consensus or by consulting a third reviewer (SY) (Figure 1). Studies were eligible for data extraction and quality assessment if they reported at least one feasibility measure (e.g., recruitment, retention, acceptability, implementation issues such as lost devices or syncing problems) and/or at least one efficacy outcome (e.g., adherence rates, ACT scores, OCS use, ED visits, or hospitalizations).

Figure 1.

PRISMA Flow Diagram - Electronic Monitoring Devices for Pediatric Asthma

Risk of Bias

Given the diversity of included studies, the Cochrane Risk of Bias Tool 2 was used to evaluate the risk of bias in RCTs.³⁰ We focused on primary outcomes of each study to evaluate potential bias in line with our research question. MH and JB independently assessed each RCT, with disagreements resolved by consensus or by consulting SY as needed.

Data Extraction and Analysis

Data extraction was conducted collaboratively by MH and JB and compiled into an Excel spreadsheet (Table 1 summarizes the key findings). Due to heterogeneity, Meta-analysis was not feasible. Only studies that met all eligibility criteria were extracted for key elements relevant to our review question. Findings are presented as follows: an overview of study designs, participant characteristics, and study settings; a description of interventions and strategies (e.g., feedback, incentives); a summary of key outcomes, including feasibility, acceptability, medication adherence, and healthcare utilization; and finally, risk of bias and certainty of evidence assessment for the primary outcome variables of the RCTs.

Table 1.

Overview of Studies on Remote Patient Monitoring Interventions on Medication Adherence in Children with Asthma

First Author Year	Design Setting	Sample	Intervention	Outcomes Measures	Results	Limitations Notes
Burgess 2010	RCT 2 arms: 1. Intervention ( EMD + feedback) 2. Control (EMD only) Pediatric asthma clinic within an outer metropolitan general hospital in Australia	N=26 Children aged 6–14 years with unstable asthma despite ICS Tx (reported hx of asthma symptoms including wheeze or activity limitation >2x per week requiring rescue inhaler use and/or reduced lung function [FEV1 <80% predicted]) (n=14) intervention group (n=12) control group	Smartinhaler EMD for ICS Patient/family/clinician feedback 4-month intervention including monthly clinic appointments with adherence review Data were downloaded at clinic visits	ICS adherence (EMD) Asthma control (symptom questionnaire including exacerbations and SABA use ≥3x/week) Pulmonary function (FEV1 [% predicted])	100% retention rate Mean ICS adherence across 4 months = 79% in intervention group vs. 58% in control group (p<.01) Monthly ICS adherence increased in the intervention group and decreased in the control group over 4 months (p≤.05) At baseline, 15/26 participants (58%) reported using their rescue inhaler ≥3x per week in the previous month vs. 2/26 participants (8%) post-intervention (4 months) (p=.02) in both groups The mean FEV1 (% predicted) increased from 75% at baseline to 85.2% at 4 months (p<.01) in both groups The change in FEV1 (% predicted) was greater in the intervention group (13.8%) vs. controls (9.8%) but lung function was lower in the intervention group at baseline and the difference between groups was not significant No difference in asthma control (exacerbations, rescue inhaler use) between groups	Adherence may have increased because participants knew their physician would be monitoring ICS use Unclear which symptom questionnaire was used Both groups were provided with preventive medication Recruitment rate not reported Race and ethnicity not reported
Chan 2015	RCT 2 arms: 1. Intervention (EMD + reminders) 2. Control (EMD only) Regional ED in Auckland, NZ	N=220 Children aged 6–15 years with ED visit for asthma exacerbation (dix of acute asthma with twice-daily ICS Rx) (n=110) intervention group (n=110) control group Mean age 8.5 (sd=2.5) 38% European (83/220) 8% Maori (17/220) 21% Pacific peoples (46/220) 18% Asian (39/220) (n=8) Middle Eastern, Latin American, or African (4%) (n=27) other race (13%) Children with other significant chronic health conditions were excluded	SmartTrack and SmartInhaler Tracker EMD for ICS and SABA Patient reminders (device ringtones) and feedback (visual display) 6-month intervention with follow-up clinic visits q2 months Data were downloaded during clinic visits	ICS adherence (EMD) School absence Asthma control (ACT, asthma morbidity score) Lung function (FEV1) SABA use ED visits Asthma exacerbations Work absence Safety (adverse events)	69% recruitment rate (220/318) 97% retention rate (213/220) 6% of devices were lost (81/1391) Median ICS adherence was 84% in the intervention group vs. 30% in the control group (p<.0001) No difference in school absences between groups Asthma morbidity score improved in the intervention group vs. controls from baseline to 6 months (p=.008) ACT score was greater in intervention vs. control group at all time points (p<.0001) but there was no interaction between treatment group and time Median daily SABA use was 10% in the intervention group vs. 17% in the control group (p=.002) Change in lung function did not differ between groups Exacerbations decreased in the intervention group vs. controls (p=.02) No difference in ED visits No difference in parental work absence No adverse events	MDI were provided to patients and quality control checks were done in clinic, including adherence monitoring and audiovisual reminder functions Adherence data were downloaded during clinic visits, but it’s unclear if these data were reviewed by the patient/family/provider and used to guide practice, or if simply used for data collection
Cushing 2016	Feasibility study Mixed methods Interviews and focus groups 2 outpatient pediatric clinics in NYC	N=7 Adolescents aged 11–19 with asthma on controller medication Aged 11–18 (m=14.1) 14% White (1/7) 14% African American (1/7) 14% more than 1 race (1/7) 57% Hispanic (4/7) Exclusion criteria: pregnant, foster care, emancipated minor; non English-speaking; no access to an iPhone	Asthma Hero EMD for ICS Bluetooth-enabled sensor and mobile app with feedback, reminders, incentives, and an avatar 12-week intervention 7 patients received an EMD and 4 patients also received a mobile app Theory-based: Fogg’s Motivation/Trigger/Incentive Participants received up to $50 in gift card incentives for ICS adherence	Feasibility (successful data download) Acceptability (interviews and focus groups) Hospitalizations ED visits	71% retention rate (2/7 lost to follow-up, 1 in each group) 86% had successful data download (1/7 didn’t sync) All 3 mobile app users were interested in continuing use, would recommend it to others, and felt it improved their asthma control 40% worried about long-term effects of and dependency on medication at baseline vs. 14% at posttest >60% agreed or strongly agreed with necessity of taking asthma medication at baseline vs. 30% at posttest Several B-IPQ domains improved from pre to post 0 patients had an ED visit and 2 had asthma-related hospitalizations in the 12 months pre-intervention vs. 0 ED visits and 0 hospitalizations during the 12-week intervention	Patients/parents needed an iOS device to participate (Android users were excluded) Small sample precluded statistical analysis Recruitment rate not reported
De Keyser 2023	RCT 2 arms: 1. Intervention (EMD + Incentive ) 2. Control (EMD Only) Pulmonary Clinic, Allergy Clinic, Child Health and Adolescent Medicine Clinics, emergency department and inpatient department at Children’s Hospital Colorado	N = 48 (n=24) intervention group (n=24) control group Adolescents aged 12–17 years with physician-diagnosed asthma, at least one inhaled controller medication, English or Spanish-speaking, and owning a smartphone Median age 14 Baseline ACT scores were similar (Intervention: 21 vs. Control: 20.5) Adolescents with severe chronic lung disease, tracheostomy/ventilator dependence, cystic fibrosis, interstitial lung disease, significant developmental delay were excluded.	Propeller Health EMD Bluetooth enabled sensor, mobile app for real-time medication use tracking and adherence reminders, and a clinician portal EMD for ICS and SABA Synced via Bluetooth to the participant’s smartphone (reminder to re-sync if disconnected); parents could also request data syncing to their phone. Adherence results could be shared with providers at the participant’s discretion; not shared routinely. No additional medication reminders or counseling provided. Devices returned at study end for a final sync to capture any missed data. The intervention group received $1/day for 100% adherence (i.e., no partial rewards if participants took only 1 out of 2 doses for a day) for 3 months (max $84), credited weekly to a debit card. Followed by 1 month of EMD only. The control group received EMD only for 4 months.	Pediatric Inhaler Adherence Questionnaire (assessing baseline differences in medication attitudes that may influence behavior) Medication beliefs Weekly adherence rate over 16 weeks Rescue medication use Missed school days Exacerbations Asthma Control Test scores	Incentives did not significantly improve adherence beyond EMD monitoring/reminders. Mean adherence declined in both groups over 16 weeks, with no significant change in the rate of decline in the incentives group after payment discontinuation. Control: 80% → 64% Intervention: 90% → 58% No baseline demographic differences. No significant differences in rescue medication use, missed school days, exacerbations, or Asthma Control Test scores. No significant difference between groups in changes in adherence rates (p = 0.76). Across both groups, baseline medication beliefs (e.g., perceptions of missing medications) influenced adherence; participants who believed missing doses were important showed higher adherence.	Small sample size from a single site. The financial incentive ($1/day) may have been insufficient; socioeconomic data were not collected at baseline, limiting interpretation. Smartphone requirements may have excluded lower-income families. Although EMDs were donated by Propeller Health, the study stated it was free of commercial bias. The intervention did not include habit formation or behavioral change components. Adolescents may experience stigma and hold medication beliefs differently, potentially influencing adherence but not accounted for in this study. No data were provided on parental or provider involvement, though voluntary, which may have affected adolescents’ practices. It remains unclear how incentives affected different subgroups (e.g., male vs. female, younger vs. older participants, or those with vs. without parent/provider involvement).
De Simoni 2021	Single-arm feasibility study Mixed methods Interviews and questionnaires U.K. tertiary care clinic	N=10 Adolescents aged 12–16 years with poor asthma control and adherence Mean age = 14.2 (sd=1.3) 20% Black (2/10) 10% Black Caribbean (1/10) 30% Caucasian (3/10) 20% Asian (2/10) 20% more than 1 race (2/10)	Hailie EMD for ICS Mobile app, feedback, reminders, and incentives for adherence 24-week intervention with 3 clinic visits q8 weeks Theory: Perceptions and Practicalities framework	Feasibility (recruitment and retention) Acceptability (patient and family) ICS adherence Asthma control (ACT) Lung function (FEV1, FeNO) Beliefs about illness (B-IPQ) Beliefs about medication (BMQ)	83% recruitment rate (10/12) 80% retention rate (1/10 lost to follow-up, 1/10 withdrew) 3/10 participants paired app up to visit 4 Overall ICS adherence did not change (53% at baseline vs. 51% at visit 4) In 3/10 participants who paired the app, ICS adherence increased from 51% at baseline to 86% throughout the study No analysis was performed on ACT, BMQ, B-IPQ, FeNO, or spirometry due to small sample Increased self-monitoring and motivation Users experienced technical difficulties (difficulty pairing, reminders not working, too much time to pair)	Audio reminders could be programmed by the patient to be delivered via mobile app or sensor It’s not clear if the healthcare team had access to adherence data Because clinic visits were converted to remote appointments during the COVID-19 pandemic, 5 patients did not provide outcome data at visit 4 Missed appointments and scheduling issues increased the length of the intervention from 24 to 40 weeks in some participants If patients were unable to pair their app, data were downloaded in clinic via USB
Gupta 2021	RCT 5 Chicago medical clinics (3 primary care, 1 allergy, 1 pulmonary)	N=252 Caregiver and child dyads including children aged 4–17 years with moderate to severe and not well-controlled asthma (n=125) intervention group (n=127) control group Mean age = 9.2 (sd=3.4) 24% non-Hispanic White 28% non-Hispanic Black 34% Hispanic 8% other 6% not reported Non-English speakers and children with severe chronic health conditions were excluded	Propeller Health EMD for ICS and SABA Bluetooth enabled sensor, mobile app, and clinician portal with feedback and reminders 12-month intervention with follow-up at 1, 3, 6, 9 and 12 months Providers were alerted for low ICS adherence or high SABA use; telephone calls were initiated for alerts	Asthma control (ACT) Healthcare utilization (OCS, ED visits, hospitalizations) Caregiver quality of life (PACQLQ) ICS adherence (EMD) Caregiver reported exacerbations, school absences, asthma-related sick clinic visits	61% recruitment rate (252/411) 100% retention rate ACT scores improved in the intervention group vs. controls (p<.01) ED visits and hospitalizations increased in the intervention group vs. controls (p<.01) Caregiver quality of life improved at 1 month (p=.04), effect was attenuated at months 3, 6, and 9, and reemerged at 12 months (p=.01) Mean daily ICS adherence increased from 45% at 3 months to 53% at 12 months in the intervention group (not monitored in the control group) No difference between groups in caregiver-reported exacerbation frequency, in-office visits for asthma attacks, missed school days, or OCS Rx in the ED or hospital setting Caregiver-reported exacerbations requiring OCS Rx by a medical office were greater in the intervention group (73%) vs. controls (35%) (p<.01) 102 patients had transmitting sensors at baseline vs. 56 patients at 12 months 13% of inhalers were incompatible with the sensor, requiring manual data entry	Unclear what the control condition was (usual care?) Only intervention group received sensors, precluding comparison between groups
Hoch 2019	Pilot feasibility study Entry and exit surveys patient/families and providers (if interested)	N=25 Children aged 6–17 years with asthma, ≥1 hospitalization or ≥2 ED visits in the prior year Mean age 10 48% male (12/25) 60% Hispanic (15/25) 20% Black (5/25) 72% Medicaid (18/25) 8 out of 25 providers participated 6/25 prescribed fluticasone/salmeterol 7/25 prescribed mometasone/formoterol 12/25 prescribed fluticasone	Propeller Health EMD Bluetooth enabled sensor, mobile app, and clinician portal Patients’ real-time medication use tracking, educational modules, and adherence reminders Reminders if medications were not taken within 15 minutes of the designated time 3-month intervention with follow-up at 3 month Parents and providers alerted for decreased ICS adherence (missed medications ≥7 days) and increased rescue medication use No instructions to parents on frequency of app interaction No instructions to providers on actions to take Participants without a compatible smartphone were provided a Bluetooth-enabled hub, with access to a web dashboard and email	ICS adherence (EMD) Feasibility Usability (ease of use, ease of interpreting collected data, intention to continue use)	80% retention rate (20/25 completed exit survey) Mean ICS adherence across 3 months = 56% (declined over time) 96% owned a smartphone (24/25) 96% very comfortable using the app 90% reported device was easy to use (18/20) 100% found data received from app easy to understand (20/20) 85% found it helpful to learn about their child’s asthma (17/20) 25% discussed the data with providers (5/20) 62.5% of providers (5/8) reported changes in some aspects of care (e.g., patient/provider communication, visit frequency, allergy assessments, adherence, awareness of asthma trends/triggers/symptoms) 90% would recommend device to others (18/20) 95% would continue to use (esp. with provider recommendation) (19/20)	No control group No comparison of outcomes between smartphone and hub users Limited or no provider-patient interactions reports One author is a consultant for Propeller Health (conflict of interest disclosed) SABA use not reported Unclear if participants received compensation Recruitment setting not reported
Kenyon 2016	Pilot feasibility study Academic primary care clinic affiliated with the Children’s Hospital of Philadelphia	N=14 Children aged 3–16 years with moderate to severe persistent asthma, high healthcare utilization, and Medicaid plan enrollment (mean ACT=15.9) Median age=3.5 years (range 3–9) Mean=7.8 ED visits and hospitalizations in previous year (range 5–15) Mean ACT score =15.9 (range 9–24) 100% non-Hispanic Black (14/14) Mean number of combined ED visits/hospitalizations in previous year = 7.8 (range 5–15) Children with other severe chronic health conditions excluded	SmartTouch EMD for ICS and SABA Data uploaded to website; clinical team monitored website and called/texted caregivers with reminders for ICS under/overuse and alerts for SABA overuse Motivational interviewing Led by a community health worker Participants received mobile phones with unlimited talk and text 3-month intervention	Feasibility Acceptability (modified technology acceptance model questionnaire) Asthma control (ACT) ICS Adherence (EMD)	Feasibility issues included recruitment, data transmission failure, and lost devices 28% recruitment rate (14/50) 64% retention rate (9/14) Target enrollment was 15–20 participants, but only 14 enrolled 43% of devices were lost (12/28); of those that were returned, 63% (10/16) were not charged or no longer able to charge ICS adherence over the first 30 days: 29% of patients had sustained use (4/14), 36% (5/14) had periodic use, and 36% (5/14) lapsed within 2 weeks 9/14 caregivers completed the study and found the intervention acceptable; 100% noted ease of use, saw benefit, and would recommend to others; 56% felt it improved asthma control Families noted competition for electrical outlets and concerns about increased bills; 50% unplugged the modem or lost the sensor ACT scores improved by a mean of 2.7 points over the 2 month study (p=0.05)	SABA use was monitored by not reported Study staff provided inhalers and affixed sensors Families received a modem to transmit sensor data to website
Kenyon 2019	Pilot study Mixed methods Caregiver surveys and interviews Large academic pediatric health system in Philadelphia (CHOP)	N=20 Children aged 5–11 years with multiple yearly asthma-related hospitalizations (mean ACT at baseline = 15.3) Mean age=7.8 95% Black Non-English speakers and children with other significant chronic health conditions were excluded	CoHero Health EMD for ICS Bluetooth-enabled mobile app with feedback, reminders, and incentives (up to $1/day x 30 days for the child [month 1] plus $20 for parents at each visit, followed by monitoring only [month 2]) 2-month intervention	Feasibility (recruitment rate, technology issues) Acceptability (survey) Preferences ICS adherence (EMD) ED visits Hospitalizations	69% recruitment rate (20/29) 80% ICS adherence in month 1 vs. 33% in month 2 (p<0.001) 94% of caregivers found daily reminders and feedback helpful; 88% would have liked reminders to continue 75% liked receiving incentives in month 1; 94% liked the idea of receiving incentives in month 2 (despite none being given) The app was opened 54 times/month during intervention and 24 times/month during observation 47% of caregivers reported their child asked to check medication progress ≥2 times/week during month 1 vs. 44% in month 2 1 ED visit, 0 hospitalizations during the 2-month period (vs. 3 ED visits and 1 hospitalization in the 12 months pre-intervention) Themes from interviews: competing priorities as barriers, incentives helped adherence, visualization of adherence data was helpful 20% of families had technological issues (4/20) No devices were lost	Retention rate not reported ACT scores were reported at baseline but no follow-up values are available for comparison Change in behavior may be limited to the intervention period and may not promote sustained change Financial incentives may “crowd out” the intrinsic motivation of children to engage in health behavior Participants were recruited during or after an asthma-related hospitalization and may have been more acutely aware of the importance of ICS adherence
Lin 2019	Single-arm feasibility and efficacy study 3 economically disadvantaged schools in urban Ohio (Cincinnati)	N=21 Children aged 10–17 years with uncontrolled asthma (physician-dx and screened with ACT) Mean age=13.7 (sd=2.5) 67% Black/African American (14/21) 19% Caucasian (4/21) 10% unknown (2/20) 5% other race (1/20) 86% Medicaid-insured	Propeller Health EMD for ICS and SABA Bluetooth sensor, mobile app, and clinician portal 6-month multicomponent intervention including school-based telehealth appointments with 7 monthly medical visits and 5 self-management visits every 2 weeks x 10 weeks, followed by an 8-week observational period Participants received smartphones with prepaid data plans Intervention delivered by an asthma specialist (pediatric pulmonologist or allergist) and an adherence psychologist	Feasibility Asthma control (ACT, modified CASI) ICS adherence SABA use School absences Healthcare utilization (OCS Rx, ED visits, hospitalizations)	38% recruitment rate (21/55) 100% retention rate 100% of self-management visits were completed 92% of medical visits were completed 14% required a replacement Smartphone 57% required ≥1 replacement sensor (mean=3 sensors/patient) 86% of patients had complete adherence data Adherence improved from 40% at baseline to 49% during the intervention (self-management visits x 10 weeks) (p=.03) but not from baseline to follow-up (39% at 8 weeks post-intervention) SABA use did not change during the intervention, but was reduced from .22 puffs per day at baseline to .10 puffs during follow-up (p=.03) While CASI did not change, specific domains improved: daytime symptoms (p=.02), nighttime symptoms (p=.002), exacerbations (p=.0001), and controller treatment (p<.0001) Children with severe asthma (baseline CASI ≥4) had a sharp decrease in CASI from a mean score of 8 at visit 1 to a score of 5 at visit 2 (p<.0001), a change that was not observed in children with less severe asthma (CASI <4) OCS, ED visits, and hospitalizations decreased (p<.0001) ACT score improved from 18 to 20 (p=.0001) School absences decreased from 2 to 0 per month (p=.0003) 100% of children and parents were satisfied with the telehealth visits and rated their study experience as good or excellent; 100% of parents and 95% of children found telehealth visits as helpful as office visits; 100% of parents and 92% of children would recommend the study to others	During self-management visits, the adherence psychologist reviewed adherence data with the participant, identified barriers, discussed link between adherence and asthma control, problem solved, and sent supportive text messages and reminders Study coordinators assisted the children with syncing data to an internet hub at school
Makhecha 2020	RCT Mixed methods Interviews and focus groups 4 arms: 1. Hailie EMD 2. Rafi-Tone app 3. INCA 4. R-DOT Pediatric asthma clinic at the Royal Brompton Hospital in London, UK	N=35 Children aged 6–16 years with asthma dx, prescribed ICS, and attending a pediatric asthma clinic Median age=12	Hailie EMD for ICS Mobile app, reminders, and feedback (4 different types of EMD compared) 12-week intervention	Usability Acceptability ICS adherence (EMD) Asthma control (ACT) Quality of life (mini PAQLQ) Lung function (FeNO, FEV1, FVC) and bronchodilator reversibility (BDR)	67% recruitment rate (35/52) 51% retention rate (18/35) 20% lost to follow-up (7/35) Median adherence: Hailie 65%, R-DOT 72%, Rafi-tone 87% 11% device failure (4/35) 11% lost device (4/35) 7% withdrew (2/35) Monitoring duration varied by device (median number of days, range): Hailie: 89, 6–120; Rafi-tone: 26, 25–26; R-DOT 54, 8–145; Not enough data from INCA Hailie’s notifications, reminders, and visual data display were positively received by children and healthcare professionals Concerns about privacy (“Big Brother” effect) and device costs ACT scores, PAQLQ scores, and lung function improved in the Hailie and other groups but no inferential statistics were analyzed	31% of participants received the Hailie EMD (11/35); 27% were lost to follow-up (3/11) and 18% lost their device (2/11) Hailie is the only EMD that provided feedback on inhaler technique
Morton 2017	RCT 2 arms: 1. EMD + reminders + feedback 2. EMD only 2 hospital clinics in London, UK	N=90 Children aged 6–16 years with poorly controlled asthma (ACQ ≥1.5) taking ICS Intervention group (n=47) Control group (n=43) Mean age 10.3 years (sd=2.9) (n=54) 60% White British (54/90) 10% Black African (9/90) 24% British Pakistani (22/90) 1% British Indian (1/90) 1% Asian other (1/90) 2% Black Caribbean (2/90) Non-English speakers and children with other significant chronic health conditions were excluded	SmartTurbo and SmartTrack EMD for ICS 12-month intervention with daily reminders and feedback in clinic during routine visits q3 months Data downloaded during clinic visits	Asthma control (ACQ) ICS adherence OCS courses Unplanned clinic visits (parent report) ED visits (parent report) Hospitalizations Missed school days Quality of life (mini PAQLQ) SABA use Pulmonary function (FEV1%) BTS level Parental beliefs about ICS (BMQ) Parental perceptions about asthma (IPQ)	97% recruitment rate (90/93) 86% retention rate (77/90) (39/47 intervention, 38/42 control) No difference between groups in change in ACQ, unplanned clinic visits, ED visits, missed school days, SABA use, BTS level, quality of life, parental beliefs, or parental perceptions Mean ICS adherence=70% in the intervention group vs. 49% in the control group (p≤.001) Intervention group required fewer OCS courses (p=.008) and hospitalizations (p≤.001) vs. controls FEV1% improved in both groups with no difference between groups from baseline to 12 months 1% inhaler not compatible (1/90) 8% lost devices (7/90) 21% broken devices (19/90) 4% lost to follow-up (did not attend clinic visits, not contactable) (4/90) 3% withdrawn due to changes in health status (improved ACQ, triamcinolone injections, adrenal insufficiency) (3/90) 3% withdrew consent (3/90)	Unknown how and when SABA use was assessed; no data reported in Table 2 31% of participants forgot to bring device to clinic for data download 28/90 20% of clinic appointments were no-shows (71/360) Control participants were aware they were being monitored, which may have increased their adherence at 3 months
Spaulding 2011	Single-arm study Medical clinic in West Virginia	N=5 Children aged 8–17 years with asthma and low ICS adherence Aged 11–14 (m=12.4) 100% Caucasian (5/5)	MDI Log II EMD for ICS Approximately 2- to 3-month intervention including feedback from medical staff (range 27–50 days), followed by monitoring alone (no feedback) x 30 days Home visits were done by clinical staff for data download, then patients were counseled in clinic	ICS adherence (EMD) Inhaler technique Lung function (FEV1%, FEF25–75%) Asthma functional severity (AFSS) SABA use	100% recruitment rate (5/5) 100% retention rate (5/5) 80% of participants increased adherence from baseline to the feedback condition (4/5) (range 52–89%); when feedback was withdrawn, adherence varied (range 37–93%) 100% improved inhaler technique (5/5) 100% improved lung function (5/5) 100% improved functional severity (5/5) 60% reduced SABA use (5/5)	This report seemed more like a case series Small sample size with limited power for statistical analysis and low generalizability Limitations included device cost, software and hardware cost, technical expertise required, frequent patient contact to change medication canisters, coordination of data collection between home and clinic, and the medication-specific nature of the device
Teufel 2018	Pilot feasibility study Mixed methods Surveys and interviews 2 university-affiliated children’s hospitals and ambulatory clinics in South Carolina	N=14 Children aged 8–16 years with high-risk asthma (ED visit or hospitalization past 12 months) 93% African American (13/14) 0% White (0/14) 7% other race (1/14) 100% non-Hispanic (14/14) 79% Medicaid plan enrollees (11/14) English speakers and Android phone users only	Smartphone Asthma Monitoring System (SAMS) EMD 2-month intervention with Bluetooth enabled mobile app and clinician portal including ecological momentary assessment of asthma symptoms (coughing, wheezing) and contextual factors (boredom, stress); no feedback or reminders Parents received $50 gift card at enrollment and $150 at study completion	Acceptability, usability, and comfort (technology acceptability model survey) ICS adherence Symptom-free days (EMA) Asthma exacerbations ED visits Hospitalizations Data collection on inhaler use, asthma symptoms Contextual factors including mood and symptoms (EMA via app)	70% recruitment rate (14/20) Youth and caregivers reported overall acceptability ICS adherence=30% but increased when asthma symptoms or boredom were reported 38% reported coughing, 7% wheezing, 8% chest tightness, 52% boredom 10 acute asthma exacerbations reported over 2 months 1 ED visit during the study vs. 5 acute care visits 6 months before the study and 3 acute care visits 6 months after All youth and parents agreed or strongly agreed with usability and comfort Data were received on 89% (606/681) of study days	Participants manually entered medication use when their device didn’t function, and in some cases this approach was preferred by families This was the only study to use ecological momentary assessment which can increase understanding of the contextual reasons for behavior to maximize adherence in future interventions Some phones were lost or damaged, but no specific figures were reported

Note. ACQ = Asthma Control Questionnaire; AFSS = Asthma Functional Severity Scale; B-IPQ = Brief Illness Perception Questionnaire; BMQ = Beliefs about Medicines Questionnaire; BTS = British Thoracic Society; ED = emergency department; EMA = ecological momentary assessment; EMD = electronic monitoring device; FEF_25–75%; FeNO = fractional exhaled nitric oxide; FEV₁ = Forced Expiratory Volume in 1 second; ICS = inhaled corticosteroid(s); INCA = INhaler Compliance Assessment Device; IPQ = Illness Perceptions Questionnaire; LABA = long-acting beta agonist; OCS = oral corticosteroid(s); PACQLQ = Pediatric Asthma Caregiver Quality of Life Questionnaire; PAQLQ = Pediatric Asthma Quality of Life Questionnaire; RCT = randomized controlled trial; SABA = short-acting beta agonist; R-DOT=remote Directly Observed Therapy

Results

Overview of Study Characteristics

Study Design and Duration

Fourteen studies were reviewed, including six RCTs,^31–35,43 one non-randomized trial,³⁶ and seven single-arm studies.^37–42,44 Eight were pilot or feasibility studies^36–42,44 and six studies used mixed methods.^{34,36,37,39,41,42} Study duration ranged from 2 months^39–41 to 12 months.^33,35

Participant Demographics and Characteristics

A total of 787 children and adolescents are represented across 14 studies, with sample sizes ranging from 5⁴⁰ to 252 participants.³³ Participant ages ranged from 4 years³³ to 19 years.³⁶ Seven studies targeted children,^{31,32,34,35,38,42,44} three were aimed at adolescents,^36,37,43 and four recruited caregiver and child dyads.^33,39–41 Four studies included predominantly Black or African American populations,^38,39,41,44 two included mostly White or Caucasian participants,^35,40 and two included largely Hispanic or Latino samples.^36,42 Many studies recruited participants from under-resourced backgrounds, including children who were publicly insured,^{33,36,38,39,41–44} from low-income households,^36,39 and/or living in socioeconomically deprived communities.³²

Study Settings and Geographic Distribution

Ten studies were implemented in the outpatient clinic setting,^{31,33–37,40–43} three recruited asthma registry patients,^32,38,39 one included adolescents treated in the ED or hospital,⁴³ and one was delivered through telehealth appointments at school.⁴⁴ Two studies were conducted in Australia,^31,32 three in the U.K.,^34,35,37 and nine in the U.S.^{33,36,38–44} Most took place in urban settings such as New York,³⁶ Chicago,³³ and Philadelphia.^38,39

Intervention Strategies

Feedback and Reminders

Feedback and reminders were provided in various ways, including mobile apps, clinic-based feedback, and home and school-based programs. Nine studies used mobile apps to provide patients and caregivers with real-time feedback and reminders.^{33,34,36–38,41–44} Six studies used clinician dashboards, which enabled providers to monitor medication usage and intervene as necessary.^{33,34,38,41–42,44} Kenyon et al.³⁸ had asthma navigators use motivational interviewing when adherence was low, and Lin et al.⁴⁴ included a behavioral psychologist who discussed barriers to adherence and offered support through texts and reminders. Spaulding et al.⁴⁰ conducted home visits for data downloads, with follow-up counseling at clinic visits. Overall, feedback ranged from real-time notifications and in-clinic reviews to community-based support, each tailored to improve adherence through patient and caregiver engagement and targeted approaches by healthcare providers.

Incentives

Three studies distributed inhalers to participants^31,32,38 and two provided smartphones with prepaid data plans.^38,44 Four studies employed strategies to encourage ICS adherence, including financial incentives^36,37,39,43 ranging from $30 to $147 in gift cards. Two of these studies were guided by theoretical frameworks, such as Fogg’s Motivational Behavioral Theory³⁶ and Horne’s Perceptions and Practicalities Approach.³⁷

Outcomes

Feasibility

Recruitment rates ranged from 28%³⁸ to 100%⁴⁰ and retention rates ranged from 51%³⁴ to 100%.^{31,33,39,40,44} However, feasibility challenges included lost devices,^34,35,38 data transmission failures,^38,43 incompatible metered dose inhalers,³⁵ withdrawal of consent,^32,34,35,37 and loss to follow-up.^{32,35–38,43} Despite these barriers, studies demonstrate that EMDs and digital interventions are generally feasible for asthma management.^{36,37,39,41–42,44} Successful real-time data uploads from EMDs support at-home monitoring,³⁶ and interventions integrating EMDs with electronic reminders, incentives, or smartphone monitoring have shown promise.^37,39,41 Additionally, a school-based intervention combining EMDs with medical support improved asthma outcomes among minority children from low-income families^,44 further highlighting the feasibility of these approaches.

Acceptability

Seven studies evaluated intervention acceptability with surveys, interviews, or focus groups. Overall, patients and caregivers found EMDs acceptable,^34,38,41 easy to use,^38,42 perceived a benefit,^36,38,39 would recommend it to others,^36,38 and were interested in continuing its use.^36,39,42 Many found the visual data displays, notifications, and reminders particularly helpful.^34,39 They shared that EMDs helped them self-monitor their medication use and provided a source of motivation for using their inhalers.³⁷ In one study, participants were particularly motivated by the financial incentive of up to one U.S dollar per day for ICS adherence.³⁹ In another study, parents found it helped them learn about their children’s asthma and facilitate discussion with their healthcare providers.⁴² Similarly, providers indicated that EMDs improved communication with patients and families and guided several aspects of their care.⁴²

ICS Adherence

Six of the 12 studies that measured ICS adherence reported improvements among children who received EMDs with feedback compared to monitoring alone.^{31–33,39,40,44} In one RCT with 220 children, the median ICS adherence rate was 84% in the intervention group compared to 30% in the control group over 6 months.³² Another RCT with 26 children found a mean ICS adherence rate of 79% in the intervention group versus 58% in the control group over 4 months.³¹ Finally, an RCT of 252 children showed that ICS adherence increased from 45% at 3 months to 53% at 12 months in the intervention group, although this outcome was not reported for the control group.³³

De Keyser et al.⁴³ randomly assigned 48 adolescents to two groups, EMDs with financial incentives (up to $1 per day for a maximum of $84) or EMDs without financial incentives. ICS adherence rates declined from 90% to 58% in the incentive group and from 80% to 64% in the control group over 12 weeks, with no significant difference between groups.

Single-arm trials have demonstrated favorable trends in ICS adherence with the use of EMDs plus feedback. One study with 20 children found that the mean adherence rate was 80% during the first month with feedback, dropping to 33% in the second month when feedback was withdrawn.³⁹ Another study with 21 children saw a modest improvement in adherence rate from 40% at baseline to 49% during a 10-week intervention, though it dropped to 39% at 8 weeks post-intervention.⁴⁴ Finally, in a smaller study with 5 children, the mean ICS adherence rate increased from 54% at baseline to 75% during a 10-week feedback period, but decreased to 67% with monitoring alone.⁴⁰ By contrast, one study with 25 children who received EMDs reported a mean ICS adherence rate of 56% over 12 weeks, with adherence declining gradually over time.⁴²

Asthma Control

Ten out of 14 studies assessed change in asthma control, including 6 RCTs and 4 single-arm trials. Three of the six RCTs found improvements in asthma control from baseline to intervention with the use of EMDs. One RCT found mean ACT scores improved from 19.1 at baseline to 21.8 at 12 months in children who received EMDs compared those who received usual care.³³ Another found that ACT scores were consistently higher in children who received an EMD, although no interaction was observed between the treatment groups by time over six months.³² However, the asthma morbidity score improved in the intervention group compared to controls. In another trial, Makhecha et al.³⁴ found that mean ACT scores improved from 17.0 at baseline to 18.7 at 12 weeks in children who received an EMD, though no inferential analysis was conducted, nor were comparisons made between groups. By contrast, two RCTs did not find any differences between groups regarding changes in asthma control.^31,35

All four single-arm studies reported improvements in asthma control with the use of EMDs. In one study, the mean ACT score improved by 2.7 points over 2 months.³⁸ In another study, the mean ACT score increased from 17.8 to 20.5 over 6 months.⁴⁴ While the Composite Asthma Score Index (CASI) did not change, specific domains improved, including daytime symptoms, nighttime symptoms, exacerbations, and controller use.⁴⁴ Children with severe asthma (baseline CASI ≥4) had a sharp decrease in the CASI from a mean score of 8 at visit 1 to a score of 5 at visit 2. In a smaller study, the mean ACT score increased from 18.5 at baseline to 20.8 at 16 weeks, but fell to 19.5 at 32 weeks; no statistical analysis was conducted.³⁷ Similarly, Spaulding et al.⁴⁰ found that all five children in their study noted improvement in their Asthma Functional Severity Scale scores after receiving EMDs, but the sample was too small for inferential data analysis.

Healthcare Utilization

Of the three studies that assessed the need for OCS therapy, two observed a reduction with the use of EMDs. One RCT reported that children receiving feedback and reminders required fewer OCS courses compared to those who were monitored only.³⁵ Conversely, another RCT found that exacerbations requiring OCS were more frequent among children using an EMD (73%) compared to usual care (35%).³³ However, one single-arm study reported a decrease in OCS prescriptions among children participating in a school-based telehealth program that included EMDs.⁴⁴

Seven studies examined asthma-related ED visits and hospitalizations, with differing outcomes. Two out of three RCTs found no difference between intervention and control groups in ED visits^32,35 or hospitalizations.³⁵ However, one RCT observed an unexpected increase in ED visits and hospitalizations among children using EMDs compared to usual care.³³

Three out of four single-arm studies reported fewer ED visits and hospitalizations with EMDs. In one study, the proportion of participants who had ED visits or hospitalizations decreased from 38% at baseline to 0% during the intervention period (p<.0001).⁴⁴ In another study, the frequency of ED visits dropped from three during the baseline period to one during the intervention period.³⁹ Similarly, Teufel et al.⁴¹ observed one ED visit during a 2-month intervention period, compared to five acute care visits in the six months before the study, and three acute care visits in the six months after. Only one study with seven children found no change in ED visits from baseline to post-intervention.³⁶ By contrast, two single-arm studies observed a modest reduction in hospitalizations, from one or two during the baseline period to zero during the intervention period.^36,39

Lung Function

Six studies evaluated pulmonary function, including four RCTs and two single-arm studies. None of the RCTs found a difference in lung function changes between intervention and control groups.^31,32,34,35 One RCT reported that the mean percentage of predicted forced expiratory volume in one second (FEV₁%) increased from 75% at baseline to 85% at 4 months in both groups.³¹ Although the intervention group showed a larger improvement (14% vs. 10%), baseline lung function was lower in the intervention group, and the between-group difference was not significant. Another RCT found that FEV₁% improved from 78% at baseline to 85% at 12 weeks in children using EMDs, but the change was not significant, and no comparison was made between groups.³⁴ Of the two single-arm studies, one reported an improvement in forced mid-expiratory flow (FEF_25–75%) in five children using an EMD.⁴⁰ The other did not analyze lung function outcomes due to a small sample size.³⁷

Psychosocial Outcomes

Two RCTs evaluated patient quality of life using the Mini Pediatric Asthma Quality of Life Questionnaire (PAQLQ). One study reported an improvement in mean PAQLQ scores from 5.1 to 5.4 over 12 weeks, but did not perform a statistical analysis.³⁴ The other study found no difference between groups in PAQLQ score changes.³⁵ One RCT assessed caregiver quality of life with the Pediatric Asthma Caregiver Quality of Life Questionnaire.³³ While caregiver quality of life improved from baseline to 1 month in the intervention group vs. controls (p=.04), the effect diminished at 3, 6, and 9 months before reemerging at 12 months.

Two studies investigated parental beliefs and perceptions about asthma and medication using the Beliefs About Medicines Questionnaire and the Illness Perception Questionnaire.^35,37 The RCT found no difference between groups in changes to these variables,³⁵ while the single-group study did not analyze these outcomes due to a small sample size.³⁷

Of the four studies that evaluated school absences, three RCTs found no differences in the change over time between groups.^32,33,35 One single-arm study observed a decrease in school absences from 2 per month at baseline to 0 at 6 months.⁴⁴ The only RCT that assessed change in caregiver work absences found no difference between groups.³²

Implementation

Several studies reported technology issues, including incompatible and non-functioning sensors, phones, and apps. One study found that the number of participants with transmitting sensors decreased from 102 at baseline to 56 at 12 months (a 50% decrease).³³ In another study with 14 participants, 5 (36%) had no data transmission after a mean of 45 days.³⁸ In contrast, Chan et al.³² noted that complete data were available from >1300 EMDs that were returned to the clinic, and Lin et al.⁴⁴ found that 86% of participants (18/21) had complete adherence data.

Multiple studies that featured mobile apps reported issues with syncing,^36,37,39,43 and in one study some participants found that the sensors would not stay in place on their inhalers.³⁶ Other studies found that ICS usage data were entered manually by 13%³³ to 20% of participants.³⁹

Morton et al.³⁵ reported that 20% of clinic appointments were canceled or unattended and 31% of participants forgot to bring their devices to the clinic. As a result, only 41% of participants received provider feedback on ICS adherence at all three time points (3, 6, and 9 months).

The proportion of participants who lost their devices varied across studies, from 0%³⁹ to 57%.⁴⁴ Lin et al.⁴⁴ replaced an average of 3 sensors per participant and found that 14% of participants required a replacement Smartphone. Kenyon et al.³⁸ noted that 43% of devices were lost, and of those that were returned, 63% were not charged or no longer able to charge.

Risk of Bias

Of the six RCTs, one had a low overall risk of bias judgment,³² four raised some concerns,^31,33,33,43 and one was judged at high risk of bias,³⁴ primarily due to lack of reporting about allocation concealment and blinding during the randomization process (Table 2). Across studies, the domain most frequently associated with risk of bias was potential deviation from the intervention due to participant, caregiver, and clinician awareness of group assignment. All studies used EMDs to collect objective data on ICS adherence, which greatly reduced the risk of bias in measuring this primary outcome. However, the obvious nature of EMDs made it challenging to mask the intervention from children, families, and healthcare team members. This may have introduced bias that favors the active treatment group over usual care recipients. While the RCT design promotes a high degree of certainty in the evidence, we downgraded our assessment rating to moderate due to risk of bias across several domains.

Table 2.

Risk of Bias Assessment for Randomized Controlled Trials on Remote Patient Monitoring Interventions on Medication Adherence in Children with Asthma

	First Author and Year of Publication
	Burgess 201031	Chan 201532	De Keyser 202343	Gupta 202133	Makhecha 201734	Morton 201735
Domain 1: Randomization process
Random sequence generation	Y	Y	Y	Y	Y	Y
Allocation concealment	Y	Y	Y	Y	NI	Y
Baseline differences between groups	N	N	PY	N	NI	NI
Risk of bias judgement	Low	Low	Concerns	Low	Concerns	Low
Domain 2: Deviations from intended intervention
Participants aware of group assignment	Y	N	N	PY	Y	Y
Carers and interventionists aware of group assignment	Y	NI	NI	Y	Y	Y
Deviations due to trial context	NI	PN	NA	NI	NA	NI
Non-protocol interventions balanced between groups	NA	NA	NI	NA	NI	NA
Implementation failures affecting outcome	NA	NA	PN	NA	Y	NA
Non-adherence to intervention affecting outcome	NA	NA	PN	NA	Y	NA
Appropriate analysis	Y	Y	Y	Y	Y	Y
Risk of bias judgement	Concerns	Low	Low	Concerns	High	High
Domain 3: Missing outcome data
Data available for nearly all participants	NI	Y	PY	PY	N	PN
Evidence that result not biased by missing data	NI	NA	NA	NA	N	PY
Could missingness in outcome depend on its true value	NA	NA	NA	NA	PY	NA
Risk of bias judgement	Concerns	Low	Low	Low	High	Concerns
Domain 4: Measurement of outcome
Inappropriate outcome measure	N	N	N	N	N	N
Difference in measurement between groups	N	N	N	N	Y	N
Outcome assessors aware of group assignment	NI	NI	NI	NI	Y	NI
Could outcome assessment be influenced by knowledge	N	NA	NI	NI	PN	PN
Risk of bias assessment	Low	Low	Concerns	Concerns	Concerns	Low
Domain 5: Selection of reported result
Pre-specified data analysis plan	NI	NI	NI	Y	Y	NI
Result selected from multiple eligible outcomes	PY	PY	PY	PY	PY	PY
Result selected from multiple eligible analyses	N	N	N	N	N	NI
Risk of bias assessment	Concerns	Low	Concerns	Low	Concerns	Concerns
Overall risk of bias judgement	Concerns	Low	Concerns	Concerns	High	Concerns

Note. EMDs= electronic monitoring devices; ICS = inhaled corticosteroids; N= no; NA = not applicable; NI = no information; PN = probably no; PY = probably yes; Y = yes; red text indicates high risk while green text indicates low risk

Discussion

These results demonstrate that EMDs can improve ICS adherence among children with asthma, highlighting feedback as a key factor. ICS adherence more than doubled in one study³² and increased substantially in two others.^31,39 when feedback was part of the intervention. Adherence tended to decline when feedback was removed. Kenyon et al.³⁹ observed a significant drop when feedback was withdrawn, and Lin et al.⁴⁴ saw adherence fall post-intervention, suggesting that sustained feedback may be needed for long-term adherence.

Some studies reported little to no improvement or a mixed pattern in adherence. This variability might indicate that EMDs are less effective when not paired with regular feedback or may not work across all groups of children. While EMDs appear beneficial for improving adherence, their effectiveness likely depends on consistent use, active feedback, and individual-level factors, such as motivation and family support. Some children might respond well, while others may struggle to maintain adherence even with monitoring. Overall, these findings support the integration of EMDs with feedback into treatment plans for children with asthma, along with continuous, tailored feedback to sustain high adherence.

While many studies observed improvements in asthma control, results were inconsistent. Enhanced asthma control may require multifaceted approaches in addition to adherence, including addressing environmental factors. Given that the minimally significant change in the ACT score is three points, future research should aim beyond ICS adherence and consider integrating additional strategies to improve asthma control. Mixed findings on ED visits and hospitalizations suggest that EMDs may not uniformly reduce healthcare utilization. This highlights the importance of tailoring interventions to individual and community needs.

Motivational incentives for ICS adherence in children remain less understood. De Keyser et al. observed that incentives offered no added benefit beyond EMD monitoring with reminders for adherence.⁴³ While the financial incentive did not have much impact, and the novelty of EMDs appeared to diminish over time, both intervention and control groups received reminders and feedback, and their ICS adherence rates remained higher than what has been reported in the literature. Integrating a clinician dashboard with provider engagement would likely contribute to improved ICS adherence. Adding gamification and rewards to the app interface could provide another source of motivation for young people to take their medication.

Hoch (2025)⁴⁵ emphasized that while EMDs hold promise for improving asthma care, their uptake in clinical practice has been limited due to barriers at multiple levels. These include systemic challenges (e.g., reimbursement, formulary changes), provider-level issues (e.g., time, training, lack of implementation knowledge), and patient-level barriers (e.g., trust, digital divide, confidentiality concerns). Technical challenges such as network reliability and device syncing further hinder adoption. They noted that digital health navigators may help bridge the gap between providers and patients, and that understanding medication use patterns and patient behavior is essential for tailoring treatment plans.

Chan (2025)⁴⁶ extended this discussion by introducing the concepts of adherence phenotypes (patterns of medication-taking) and adherence endotypes (the underlying reasons for those patterns). This approach to precision medicine can distinguish between intentional and unintentional non-adherence, linking behavior with treatment responsiveness. EMDs can help identify phenotypes and endotypes by tracking medication use, timing, and technique, offering insights that enable more personalized interventions.The authors recommend three key steps: (1) characterizing medication use patterns, (2) identifying adherence drivers, and (3) personalizing interventions accordingly. This approach may improve the accuracy of asthma management and increase the likelihood of patients achieving remission.

The studies evaluated in this review included racially, ethnically, and socioeconomically diverse populations, providing evidence that digital health interventions can be implemented in underserved communities. However, the variability in outcomes highlights the need to address systemic barriers such as digital literacy and healthcare access. Designing culturally sensitive and accessible programs for underserved populations can help bridge asthma disparities. Additionally, conducting RCTs with larger, more diverse populations will improve the generalizability of findings.

Future studies should evaluate the long-term effects of digital interventions on adherence, asthma control, and healthcare utilization. Understanding the economic impact of these interventions is critical for healthcare policymakers. By addressing the gaps and building on the strengths identified in these studies, digital asthma management interventions can advance personalized care and improve outcomes for children and adolescents.

Limitations

This review has several limitations. First, inclusion was restricted to studies published in English, which may have excluded relevant studies in other languages. Second, only two databases (PubMed and CINAHL) were searched, and although gray literature was considered through reference lists, unpublished data may have been missed. Third, heterogeneity in study designs and outcomes limited the ability to synthesize findings quantitatively or conduct subgroup analyses. Missing data and study attrition due to device loss and other logistical issues highlights practical barriers.

This review also had several strengths. Including several RCTs enhances the reliability of findings related to intervention efficacy, while the mixed-methods and pilot studies offer detailed insights into feasibility and acceptability.

Conclusion

The use of EMDs for pediatric asthma management showed mixed results across studies. While some studies found improvements in ICS adherence, OCS use, ED visits, and hospitalizations, others found no significant differences or even unexpected increases in healthcare utilization. Overall, the effectiveness of EMDs appears context-dependent, with benefits seen in specific interventions or settings, but further research is needed to clarify their impact.

Key Message:

This systematic review evaluates the feasibility and efficacy of electronic monitoring devices (EMDs) in improving medication adherence among children with asthma. The findings suggest that EMDs, especially when paired with feedback, can enhance adherence to inhaled corticosteroid (ICS) therapy, which is crucial for preventing asthma exacerbations and reducing emergency department visits. While improvements in asthma control were observed in several studies, the impact on healthcare utilization was less consistent, indicating that EMDs may need to be part of a broader, multifaceted approach. The results may be of interest to clinicians, researchers, and policymakers focused on innovative asthma management strategies, particularly in underserved communities to help reduce disparities. However, further research is needed to evaluate long-term outcomes and its impacts.

Data Availability Statement:

All data generated or analyzed during this study are included in this published article and its supplementary information files.