Mobile app guides users to improvements in asthma control
Click Here to Manage Email Alerts
Key takeaways:
- The juli app asks users to rate their asthma, track inhaler usage and more each day.
- Patients who used the full version had better asthma control than those who used a limited version at 8 weeks.
Patients with moderately or poorly controlled asthma experienced improvements in asthma control after using a mobile app for 8 weeks, according to a study published by medRxiv.
The app represents a low-risk and low-cost adjunct to care, Joseph F. Hayes, MD MSc, PhD, cofounder of juli health and professor of psychiatry at University College London, and colleagues wrote.
“Two key obstacles in asthma control are timely identification of asthma triggers and adherence to preventative medication,” Hayes told Healio. “These are identified as necessary interventions by health care providers. However, the onus for action is on the patient, and this can be very challenging.”
The app’s design
Gamification experts collaborated with patients, a psychiatrist and a pulmonologist to develop the juli app (juli health), which automatically prompts users to open it each day at a user-inputted time.
The app asks users to rate their asthma on a scale with five emoji faces. It also asks users about their emergency inhaler use that day, how frequently they have shortness of breath, and if they woke during the night because of shortness of breath.
Further, juli lets users track factors that may impact their symptoms, such as exposure to tobacco smoke. It connects to smart peak flow meters so users can manually enter this information as well.
“The juli app helps people identify triggers of asthma and respond to these appropriately,” Hayes said.
The app presents patients with hyper-localized weather, pollen and air pollution data and shows how these triggers are associated with acute asthma symptoms in each user, Hayes said.
“It also shows how other triggers such as exercise, mood and stress might affect symptoms and sleep quality,” he continued.
Additional functionality includes passively gathered smartphone and wearable sensor information, behavioral activation techniques, customizable medication reminders and positive affect journaling encouragement.
“The app is highly personalizable, so patients can track things that might be specific to their asthma such as pet dander or second-hand smoke exposure,” Hayes said.
Also, the app gamifies positive behavioural change to impact asthma symptoms, Hayes said.
“Medication reminders are central to juli, and showing how adherence relates to symptom control is a key part of patient education that is shown on the user’s dashboard — and can be communicated to the health care provider,” Hayes said.
Users can choose which evidence-based approaches they want to engage in for their asthma self-management when they use the app, which is designed to be highly accessible for patients with asthma and available in Android and Apple formats around the world, according to the researchers.
Study design, results
The study involved English-speaking patients aged 18 to 65 years with access to a smartphone. All of the patients had moderately or poorly controlled asthma based on an Asthma Control Test (ACT) score of 19 or lower at baseline.
Patients used the full version of juli or a limited version of the app that asked users to rate how they were feeling with the five-face emoji scale without any of the full app’s other functionality.
After the baseline assessment, patients participated in follow-up assessments via the ACT and the 12-Item Short Form Health Survey (SF-12) at 2, 4, 6 and 8 weeks remotely from within the app.
The per-protocol analysis group included 67 patients (mean age, 35.73 years; 77.61% women) in the intervention arm with the full version of the app and 85 patients (mean age, 36.62 years; 82.35% women) in the active control arm with the limited version of the app who completed the 8-week assessment.
Overall, 75.66% of the patients had been diagnosed with asthma by a physician more than 5 years before the study. They also had been in ongoing contact with a doctor for their asthma and had a mean baseline ACT score of 12.84 (standard deviation [SD], 4).
“Patients randomised to juli had a significant improvement in symptoms, compared to those randomised to a very basic form of the app, after 8 weeks,” Hayes said.
“Those in the juli arm of the trial were more than twice as likely to experience a minimal important difference in their symptoms, ie, an improvement in asthma control that patients would notice,” he continued.
At 8 weeks, mean ACT scores included 17.93 (SD, 4.72) for the intervention group and 16.24 (SD, 5.78) for the group using the limited version. Adjustment for baseline ACT scores indicated greater improvements among the intervention group (adjusted beta coefficient, 1.91; 95% CI, 0.31-3.51).
This difference further increased with adjustments for additional imbalanced baseline characteristics, such as physician contact, to 2.01 points on the ACT (95% CI, 0.48-3.53).
There was no difference in the chance for remission at week 8 between the groups after accounting for baseline asthma severity, but the patients in the intervention group were more likely to experience a minimally clinically important difference (MCID; adjusted OR = 2.38; 95% CI, 1.2-4.7).
The researchers called this effect consistent at all four follow-up assessments. Also, both arms had similar odds for worsening symptoms (aOR = 0.55; 95% CI, 0.23-1.32), with no differences between the groups in the mental or physical component scores of the SF-12 either.
The researchers additionally conducted an intention-to-treat analysis of 133 patients using the full app and 129 using the limited version who completed the assessment at 2 weeks, which also showed greater improvements in ACT scores for patients who used the full app (adjusted beta coefficient, 1.56; 95% CI, 0.32-2.79).
The intervention group also was more likely to experience a MCID (aOR = 2.17; 95% CI, 1.25-3.78), but both groups had similar odds for remission, worsening symptoms and SF-12 scores.
Overall, mean improvements in asthma control included 5.33 for the intervention group and 3.2 for the control group, with the intervention group experiencing more than twice the odds for improvements in ACT scores of three points or greater.
The researchers could not identify which functions in the full version of the app led to these improvements, but they believed that the app’s ability to let users choose which functions suit them best is a strength of its design.
Conclusions
Hayes called these findings significant.
“Very few early-stage start-ups have tested themselves in such a rigorous manner,” Hayes said. “Effective self-management of asthma is important for individual patient well-being and empowerment.”
Further, Hayes noted that poorly controlled asthma will cost approximately $300 billion over the next 20 years in the United States, with the prevalence of asthma increasing year-on-year.
“Remote self-management is the solution to the problem of increasing health care expenditure on asthma,” Hayes said. “Whilst juli is very patient-focused, we also provide integration into the electronic health record, so these data can be available to physicians and other health care providers.”
Although these findings indicate the app’s efficacy in managing asthma, the researchers said, further research is needed to understand the most cost-effective support procedures for improving adherence to digital self-management tools and how they can be best integrated into clinical practice.
Additionally, Hayes said that he and his colleagues also have completed a randomized controlled trial indicating reduced symptoms of depression with 8 weeks of juli use, adding that the company believes it is important to prove the app’s efficacy in two very different conditions.
“We are interested in how comorbidities interact in individuals, and we are adding new conditions all the time,” Hayes explained, including COPD, migraine, headache, chronic pain, anxiety, depression, bipolar disorder and hypertension.
“We have estimated the potential reductions in asthma health care expenditure through use of juli, but we would like to see it implemented in a way where we can measure true cost savings,” he said.
For more information:
Joseph F. Hayes, MSc, PhD, can be reached at jh@juli.co.
Perspective
Back to Top
The recent results from the Kandola study are quite exciting, as they demonstrate positive findings that can inform the future of respiratory care management using digital health tools including smartphone apps. Not only does this study show statistically significant improvement in asthma control, but it also shows clinically meaningful improvement in just 8 short weeks, which is impactful and useful information for health care professionals, patients and even policymakers who may be considering using digital health technologies to manage chronic disease.
These findings add to the growing body of literature on the impact of digital health tools in asthma and uniquely provide information on randomized controlled trial approaches to understanding the impact of health apps in asthma self-management. Access to this type of data can help health care professionals continue to support a patient’s self-management of their asthma and is imperative for groups like our nonprofit, Digital Health for Equitable Health Alliance, that seek clinical evidence of improvement of care with digital health tools to support our advocacy of policies to provide access to these technologies to patients. But although the results of this study are promising, more research on these types of technologies in underserved populations is warranted.
Collapse
Read more about
Click Here to Manage Email Alerts