Control
In accordance to the WHO proposal for chronic allergic diseases and in parallel to the GINA guidelines for asthma, the concept of control was introduced in AR, as a more feasible measure of both severity and response to treatment [57, 58]. Most recent AR management algorithms propose a stepwise approach based on the level of control achieved by a therapeutic intervention [23, 59]. A series of criteria to evaluate control were proposed in the PRACTAL report, including assessing symptom severity, quality of life (QoL) by means of disease burden at school, leisure and sleep, and upper respiratory function by objective measurements such as nasal flow and/or patency. Information regarding rescue medication use and (uncontrolled) comorbidities such as sinusitis and/or asthma are also considered relevant [23].
Patient reported outcome measures (PROMs) are currently acknowledged as valuable tools for assessing disease morbidity in a standard clinical setting. In respect to AR patients the Allergic Rhinitis Control Test (ARCT) [60] and the Pediatric Control of Allergic Rhinitis and Asthma test (CARATkids) [61, 62] have been validated for children and adolescents while the Rhinitis Control Assessment Test (RCAT) is currently validated only for adolescents [63]. The Visual Analogue Scale (VAS) is validated for control assessment only in adults with AR, however it can be used in all ages including preschool children by proxy [64, 65]. Thus, the ARIA algorithm has implemented VAS measurements for daily monitoring in a mobile app for patients over 12 years of age [66]. Nevertheless, it is well known that PROMs can be influenced by poor adherence to treatment, patient’s perceptions regarding disease’ severity and the individual’s psychosocial background [58].
eHealth and mHealth
eHealth refers to the application of information and communication technologies (ICT) in healthcare services. The WHO acknowledges digital technology potential and encourages health systems to endorse, improve and prioritize its implementation to benefit in terms of accessibility, quality, and affordability of health care [67]. The term “mobile health” (mHealth) refers to the use of mobile, wireless technologies to health practice and research in this respect [68].
Smartphones are most promising in promoting and supporting public health, as they are widely available, equipped with sophisticated microprocessors and a range of sensors which can communicate with other mobile devices, and provide access to the internet even in remote locations. As of mid-2020, 3.5 billion smartphones are in use, by approximately 41% of the world’s population [69]. In the USA, 95% of teens have access to a smartphone and 83% use it for learning purposes [70].
AR is often regarded as trivial by both patients and physicians and thus not always managed properly. mHealth applications (apps) aim at implementing personalized medicine strategies to patients and caregivers by monitoring symptoms, visualizing the burden of the disease, thus improving health literacy, and ultimately engaging in self-management and shared decision making [71]. Moreover, eHealth services can override access barriers to healthcare and reduce costs while providing healthcare professionals with real-life data on several aspects of the disease and its impact that otherwise would be difficult to identify.
Adherence to treatment is a common problem in chronic respiratory diseases, such as AR, moreover in adolescents [72]. In the MASK study, where a mobile app was used to assess real-world data from adolescents and adults with AR, non-adherence was observed in 69% of participants. The effect of e-health services on adherence to nasal steroids was studied in a randomized trial including children 5-18 years old with moderate-severe seasonal AR [73]. Patients that used an internet-based telemonitoring system instead of hard copy diaries, were significantly more adherent to treatment and better educated on their disease, although symptom scores and QoL were not affected. In addition, services such as updates on local pollen counts, online medical access and SMS reminders in case of missed entries can be provided.
mHealth apps are a booming market and caution should be taken on their credibility. Up to day, only a few apps on AR have been validated, while safety and efficacy data are scarce [74]. A recent study showed that the majority of mobile apps providing grass pollen forecasts are inaccurate and potentially harmful [75]. mHealth apps are now acknowledged as medical devices by both the EU and FDA [76], although FDA reserves the concern of potentially applying regulations in case of identifying risk on patient’s safety [77]. In Europe, the General Data Protection Regulation is also applied to manufacturers for ensuring consumers’ data privacy [78]. A stricter framework of regulations should be expected soon.
Currently, only a few mobile apps that monitor symptoms of both AR and asthma are available [74, 79]. Mask-air and Allergy Monitor allow patients to assess the time course of symptoms relative to treatment and the effect of AR on sleep, productivity, QoL, etc. by sharing information digitally [80]. Additionally, notifications prompt answering clinical questionnaires and treatment adherence daily [81]. In case of symptom worsening, patients are alerted to step up treatment or contact their doctor for consultation. These are key features for encouraging self-awareness and self-empowerment, especially in chronic diseases like AR, where patients or their caregivers are responsible for treatment administration [82]. Mask-air, a validated tool for assessing AR control in adolescents and adults, may also be integrated into a Clinical Decision Support System that guides clinicians into pertinent interventions depending on their patient’s status [83]. Evolving algorithms are currently exploring the possibility of data input automation, to improve uptake [84].