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].