Personalized biofeedback on inhaler adherence and technique by community pharmacists: a cluster randomized clinical trial

Susan O'Dwyer, Garrett Greene, Elaine MacHale, Breda Cushen, Imran Sulaiman, Fiona Boland, Sinthia Bosnic-Anticevich, Matshediso C. Mokoka, Richard B. Reilly, Terence Taylor, Sheila A. Ryder, Richard W. Costello

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40 Citations (Scopus)


Background: Guidelines recommend that patients treated with inhalers receive adherence counseling and device training. Digital technologies that assess both inhaler adherence and technique have been developed. Using these technologies community pharmacists, who have regular contact with patients, are well placed to deliver personalized inhaler education. Objective: To determine the impact of a pharmacist intervention, informed by digital technology, on inhaler technique and adherence of patients with asthma in the community. Methods: A cluster randomized, parallel-group, multisite pharmacy study was conducted over 6 months. All study groups had an electronic device (inhaler compliance assessment device) attached to their maintenance inhaler. A biofeedback group received personalized inhaler training informed by data recorded by the device. The demonstration group received inhaler training, by physical demonstration with a placebo inhaler. The control group received usual care. The primary outcome was inhaler adherence, which was classified as “actual adherence” and expressed as the proportion of expected drug accumulation if adherence and technique had been perfect. Secondary outcomes were quality-of-life scores as measured by the St George's Respiratory Questionnaire, symptoms, and exacerbations. Results: A total of 152 participants (n = 74 biofeedback, n = 56 demonstration, and n = 22 control) were recruited. Asthma was the predominant condition among participants (n = 83), with chronic obstructive pulmonary disease (n = 55) and asthma/chronic obstructive pulmonary disease overlap also reported (n = 8). In intention-to-treat analysis, adherence in the biofeedback group during month 2 was 62%, 18% higher (95% CI, 6 to 30) than that in the demonstration group (P =. 004) and 24% higher (95% CI, 9 to 40) than that in the control group (P =. 003). During month 6, adherence was 14% higher (95% CI, −1 to 30; P =. 07) in the biofeedback group than in the demonstration group and 31% higher (95% CI, 13 to 48; P =. 001) than in the control group. At the end of the study, the biofeedback group had a sustained fall in St George's Respiratory Questionnaire from baseline, −6.1 (95% CI, −9 to −0.4; P =. 04) and had significantly improved daily respiratory symptoms. Conclusions: Community pharmacist–delivered inhaler training informed by a digital technology improved adherence and health status.

Original languageEnglish
Pages (from-to)635-644
Number of pages10
JournalJournal of Allergy and Clinical Immunology: In Practice
Issue number2
Publication statusPublished - Feb 2020
Externally publishedYes


  • Adherence
  • Asthma
  • Clinical outcomes
  • Community pharmacy
  • COPD
  • Inhaler
  • Randomized clinical trial


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