【Cochrane简语概要】帮助哮喘患者按处方服药的数字化技术
综述问题的背景
哮喘是全世界最常见的慢性疾病之一。有可治疗症状的有效药物，例如含类固醇吸入剂。但是，为达最佳效果，需要按处方服用维持药物。许多人并未服药，是由于日程繁忙以及坚信药物只是短期需要。此即所谓“不依从”，这可引出更多症状和发作。不依从是一个主要的健康问题；达到依从对预防发作和降低死亡风险非常重要。医疗保健领域越来越多在使用数字化干预，例如手机、文本消息和可反馈服药信息的“智能”吸入器。然而，有关这些技术是否改善哮喘药物服用或改善症状的证据有限。
本综述旨在了解数字化技术是否真起作用而改善哮喘药物的服用，以及这种依从性改善是否带来对哮喘症状和其他益处的改善。
（图片来自canadianinquirer.net）
研究特征
我们发现了40项研究，纳入15000多名患有哮喘的成人和儿童。研究时间范围为大约2周至24个月，因此我们并不能说，这些方法是否长期（多年）有效。我们检索了多个信息源以找到相关研究。本综述最新截至2020年6月。我们查看数据旨在了解数字化技术是否会帮助哮喘患者按处方服药，以及使用该技术者是否比不用该技术者对哮喘控制更好、哮喘发作更少。
主要结果
与未接受该技术者相比，接受了数字化技术以支持哮喘药物服用的哮喘者能更好地按处方服药；与未接受数字化技术者（平均服用其药物处方量的45%）相比，接受数字化技术者按规定服药者增加了15%（可能处在8%至22%之间）。重要的是，接受数字化技术者有更好的哮喘控制，并将哮喘发作的风险降低一半（可能处在32%至91%之间），这对降低哮喘相关死亡风险有直接的益处。我们看到生活质量和肺功能有改善，但对肺功能的影响小，其临床意义可能有限。计划外医疗保健就诊中未见任何改善。没有足够的信息告诉我们，数字化技术对下班或上学时间的影响或成本效益，也没有足够的信息来告诉我们，是否数字化技术有任何伤害。技术通常为患者所接受。特定类型的技术（如“智能”吸入器和文本消息）似乎比其它技术类型更能改善服药；而研究数量少意味着，我们并不确定这些技术肯定比其它技术更有作用。
证据质量
我们的结果存在些不确定，因为研究彼此间相当不同。这些差异意味着，我们不能完全确定真正的益处是什么，因为这些益处可能是由于其它与技术没有直接关系的因素（例如，参与一项研究改善服药）所致。有时是各研究未给予我们足够的信息，以使我们将它们与其它研究一起纳入而算出其有效性。我们对四分之一的研究有担忧，其中有人没有完成研究，而且我们并不确定这些研究是否报告其每项测量。
关键信息
我们发现的研究表明，与没有该技术者相比，数字化技术可能帮助哮喘者更好地服药、改善其哮喘控制，而且有潜力将哮喘发作风险减半。特定类型的数字化技术（如文本短信干预）可能比其它技术效果更好。但是，我们对有些研究报告的信息质量存在些不确定，加之不同技术类型的研究数量少，这意味着我们无法100%确定其益处。
作者结论:
总体而言，数字化干预可能会导致依从性大幅增加（低质量证据）。有中等质量证据显示，数字化依从性干预可对哮喘控制达到有重要临床意义的改善，并可能提高生活质量，但对肺功能则几乎没有改善。本综述发现有低质量证据显示，数字化干预可能减少哮喘发作。亚组分析显示，EMDs可能使依从性改善23%，SMS干预可能使依从性改善12%，而且，有面对面成分和依从性反馈的干预可能对哮喘控制和依从性各有更大益处。未来的研究应将依从性百分比作为常规结局测量，从而使各研究间能进行比较和进行meta分析，并使用验证过的问卷来评估依从性和各结局。
作者:Chan A, De Simoni A, Wileman V, Holliday L, Newby CJ, Chisari C, Ali S, Zhu N, Padakanti P, Pinprachanan V, Ting V, Griffiths CJ；译者：石丹，Cochrane Hong Kong，香港中文大学医学院那打素护理学院；审校：臧渝梨，Cochrane Hong Kong，香港中文大学医学院那打素护理学院；编辑排版：索于思，北京中医药大学循证医学中心
相关文章链接
【Cochrane Plain Language Summary】
Digital technologies to help people with asthma take their medication as prescribed
Background to the question
Asthma is one of the most common long-term conditions worldwide. There are effective medicines available to treat symptoms, such as inhalers containing steroids. However, for best effect, maintenance medication need to be taken as prescribed. Many people do not take their medication, due to busy schedules and the belief that medication is only needed short-term. This is known as 'non-adherence', which can lead to more symptoms and attacks. Non-adherence is a major health problem; achieving adherence is very important to prevent attacks and reduce the risk of death. In healthcare there is increasing use of digital interventions such as mobile phones, text messages, and 'smart' inhalers that can feed back information about medication-taking. However, there is limited evidence on whether these technologies work to improve asthma medication-taking or improve symptoms.
This review aimed to find out whether digital technologies really work to improve asthma medication-taking, and whether this improved adherence leads to improvements in asthma symptoms and other benefits.
Study characteristics
We found 40 studies including more than 15,000 adults and children with asthma. Studies ranged from about 2 weeks to 24 months' duration, so we cannot say whether these methods are effective in the long term (a long period of years). We searched multiple information sources to identify relevant studies. This review is current as of June 2020. Looking at the data, we aimed to find out whether digital technologies helped people with asthma to take their medication as prescribed, and whether people who used the technology had better asthma control, and fewer asthma attacks, than those who did not use the technology.
Key results
People with asthma who were given the digital technology to support asthma medication-taking were better at taking their medication as prescribed compared to people who did not get the technology; 15% more people (likely to be somewhere between 8% and 22%) took their medication as prescribed when they received the digital technology, compared to those who did not (who took their medication on average 45% of the amount prescribed). Importantly, people who got the digital technology had much better asthma control and half the risk of asthma attacks (likely somewhere between 32% and 91%), which has direct benefits for reducing the risk of asthma-related deaths. We saw improvements in quality of life and lung function, but the effect on lung function was small and may be of limited clinical relevance. No improvements were seen in unscheduled healthcare visits. There was not enough information to tell us about the effect of digital technologies on time off work or school or the cost-benefits, nor whether there are any harms. Technologies were generally acceptable to patients. Certain types of technologies such as 'smart' inhalers and text messages seemed to be better for improving medication-taking than other technology types, although the small number of studies means we cannot be certain that these technologies definitely work better than others.
Quality of the information
There is some uncertainty about our results because the studies were quite different from each other. These differences mean that we cannot be completely sure what the real benefit is, as the benefits may be due to other factors not directly related to the technology - for example, being involved in a study can improve medication-taking. Sometimes the studies did not give us enough information for us to include them with the other studies to work out their effectiveness. We had concerns about a quarter of the studies where people did not finish the study, and we were uncertain whether studies reported everything they measured.
Key message
The studies we found suggest that digital technologies may help people with asthma take their medication better, improve their asthma control, and potentially halve their risk of asthma attacks, compared with people who did not get the technology. Certain types of digital technologies, such as text-message interventions, may work better than others. However, we have some uncertainties about the quality of the information reported in some studies, and the small number of studies for the different technology types, which means we cannot be 100% certain of their benefits.
Authors' conclusions:
Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.
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