Specialist commentator comments
Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.
Three out of 5 specialist commentators were familiar with this type of technology, with 1 out of 5 using a similar device regularly. None of the specialist commentators had used Smartinhalers.
Three commentators said that Smartinhaler device was a novel concept, 2 felt that there was a limited level of innovation. It was noted that there are other similar devices, and that some emerging technologies can monitor the quality of inhaler usage, although these are not yet widely available and have less communication functionality. Several noted that the Smartinhaler is not compatible with all inhaler devices.
Commentators agreed that improving adherence in appropriate groups of patients was likely to lead to better control and reduced symptoms, and could potentially reduce the number of hospital visits and need for escalation of treatment. They also agreed that the existing evidence on Smartinahler user was not sufficient to show these outcomes at this point in time. One commentator felt the technology was not sufficiently advanced to result in fewer hospital visits or less invasive treatments.
Several commentators noted groups who may benefit in particular including adolescents, people who have repeated emergency attendance, people with poorly controlled asthma and people with very busy lifestyles. Other groups mentioned were people under consideration for advanced therapies, people with high fractional exhaled nitric oxide levels, and people with cognitive defects or mental health disorders. Commentators noted that there was currently no evidence for benefit in any of these groups.
One commentator noted that some patients may find this 'supervision' of treatment invasive especially if this is then used to frame further adherence discussions, but another said that Smartinhalers may reinforce good adherence behaviour and self-management as well as supporting a move to managing people according to their need.
Limitations on impact are that non-adherence is only one of the factors to be considered when a patient's asthma is poorly controlled. The technology does not address other reasons for non-adherence, such as such as inhalers running out or prescription costs. It also does not address inhaler technique which can be a very important factor.
The system would require some level of training for patients and staff, and patients would need to understand what data was collected and who would access it.
Some commentators noted that there would be a significant resource implication to using this technology, and that currently there was no evidence to show that there would be a reduction in the number of clinic visits needed.
It was noted that resource implications include purchasing the devices, accessing software, having IT systems in place, and clinician time to set up devices and review data. There is likely to be an additional cost to replace lost or broken devices.
One commentator noted that the cost to access the data may be particularly significant for GPs with low numbers of patients using the system.
One commentator felt that Smartinhaler might be used only for brief periods with patients to look at adherence prior to a medication review, because of device costs, and that this would diminish the potential benefits.
One commentator felt there may be an increase in reviews for patients in the short term, but that improved control would lead to fewer emergency visits and admissions to hospital over time.
Current care pathways rely on subjective measures of adherence and can be time consuming and inaccurate. Early identification of non-adherence may prevent unnecessary treatment escalation and allow discussion of barriers to adherence. One commentator noted that the trials had much higher frequency of review than normal clinical practice, which will also influence adherence.
Some patients have multiple inhalers stored in different locations.