Summary of findings 1. Digital adherence interventions compared to usual care for asthma.
| Digital adherence interventions compared to usual care for asthma | ||||||
| Patient or population: asthma Setting: primary or secondary care Intervention: digital adherence interventions Comparison: usual care | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | № of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Risk with usual care | Risk with digital adherence interventions | |||||
| Adherence (percentage of people adhering to their prescribed medication) Follow‐up (weighted mean): 8.0 months (range: 1 to 24 months) |
Weighted mean (44.8%); range (‐4.4% to 82.7%) | MD 14.66 higher (7.74 higher to 21.57 higher) | — | 8885 (16 RCTs) | ⊕⊕⊝⊝ LOW 1 | Digital adherence interventions may increase adherence. |
| Asthma control ‐ change from baseline (various scales; higher scores = better asthma control ‐ standardised for different scales, scale reversed if in opposite direction) Follow‐up (weighted mean): 5.7 months (range 1 to 12 months) |
The mean change from baseline in asthma control in the intervention group compared to the control group was an increase: 0.31 SD higher (0.17 SD higher to 0.44 SD higher) | — | 1638 (15 RCTs) | ⊕⊕⊕⊝ MODERATE 2 | Digital adherence interventions likely increase asthma control when compared to baseline. The SMD describes the difference between the digital intervention and usual care groups adjusted for the different measurement scales used and measurement imprecision (Faraone 2008). The SMD is a Cohen's effect size and can be interpreted as small (< 0.4 = small, 0.4 to 0.7 = moderate, > 0.70 = large) (Undela 2021). For asthma control, the MCID depends on the questionnaire used and the population. An SMD of 0.3 to 0.5 has been used for an MCID when different questionnaires and settings are used (Angst 2017). Here, the SMD suggests that the increase in asthma control with digital adherence interventions is clinically significant. |
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| Asthma exacerbations ‐ Number of people with one or more exacerbations Follow‐up (weighted mean): 7.5 months (range 3 to 12 months) |
198 per 1000 | 105 per 1000 (63 to 180) | RR 0.53 (0.32 to 0.91) | 678 (6 RCTs) | ⊕⊕⊝⊝ LOW 3 | Digital adherence interventions may result in a reduction in asthma exacerbations. Overall, the number of people with one or more asthma exacerbations halved when receiving digital interventions compared to usual care. |
| Unscheduled healthcare utilisation ‐ number of hospital or GP/ED visits Follow‐up (weighted mean): 10.0 months (range 3 to 12 months) |
199 per 1000 | 147 per 1000 (102 to 211) | RR 0.74 (0.51 to 1.06) | 446 (4 RCTs) | ⊕⊕⊝⊝ LOW 4 | Digital adherence interventions may result in a slight change in unscheduled healthcare utilisation. Overall, the risk of people with unscheduled healthcare visits may be reduced by 25% in those receiving digital interventions compared to usual care, though the interventions may also increase unscheduled healthcare utilisation. |
| Lung function ‐ FEV1 % predicted (change from baseline) Follow‐up (weighted mean): 8.1 months (range 3 to 12 months) |
Weighted mean change from baseline was 1.7%; range (‐4.4% to 7.7%) | The mean change from baseline in FEV1 was 3.58% predicted higher (1% to 6.17% higher) | — | 1052 (7 RCTs) | ⊕⊕⊕⊝ MODERATE 5 | Digital adherence interventions may result in little to no difference in lung function compared to baseline. An increase in FEV1 of 12% after bronchodilator use is considered meaningful (Kaminsky 2019); in children a lower increase of 8% to 9% is considered relevant (Hopp 2016). |
| Quality of life ‐ change from baseline (various scales; higher scores indicate better quality of life) Follow‐up (weighted mean): 6.4 months (range 1 to 12 months) |
The mean change from baseline in quality of life score was an increase: 0.26 SD higher (0.07 SD higher to 0.45 SD higher) | — | 848 (10 RCTs) | ⊕⊕⊕⊝ MODERATE 6 | Digital adherence interventions likely increase quality of life compared to baseline. An SMD of 0.3 to 0.5 would be considered a MCID (Angst 2017). |
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| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). Note follow‐up time for each outcome differs depending on the study duration. CI: confidence interval; FEV1: forced expiratory volume in 1 second; MCID: minimum clinically important difference; MD: mean difference; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation; SMD: standardised mean difference | ||||||
| GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect | ||||||
1Downgraded twice due to risk of bias related to allocation concealment in the highly weighted studies (unclear in half of the studies, and of the 16 studies included, we judged nine to be at high risk of bias in at least one domain unrelated to performance bias), and imprecision (heterogeneity is high with I2 = 94%).
2Downgraded once due to high performance and detection bias in studies that have high weighting in this outcome.
3Downgraded twice due to high risk of bias (detection and performance bias) in the studies with high weighting, and the low number of studies included.
4Downgraded twice due to high risk of performance and detection bias, attrition bias, and imprecision of the results with a low number of included studies.
5Downgraded once as most of the studies with high weighting towards this outcome have high risk of bias (detection and performance bias).
6Downgraded once due to high risk of performance and detection bias.