Mobile direct observation of therapy (MDOT) - A rapid systematic review and pilot study in children with asthma

We describe, for the first time, the use of a mobile device platform for remote direct observation of inhaler use and technique. The research programme commenced with a rapid systematic review of mobile device (or videophone) use for direct observation of therapy (MDOT). Ten studies (mainly pilots) were identified involving patients with tuberculosis, sickle cell disease and Alzheimer's disease. New studies are ongoing (ClinicalTrials.gov website) in TB, stroke, sickle cell disease, HIV and opioid dependence. Having identified no prior use of MDOT in inhaler monitoring, we implemented a feasibility study in 12 healthy volunteer children (2-12 years; 8 females and 4 males) over a period of 14 days, with twice daily video upload of their 'dummy' inhaler use. Two children uploaded 100% of the requested videos, with only one child having an inhaler upload rate of <75%. The quality of uploaded videos was generally good (only 1.7% of unacceptable quality for evaluation). The final aspect of the research was a pilot study using MDOT (6 weeks) in 22 children with difficult to treat asthma. Healthcare professionals evaluated inhaler technique using uploaded videos and provided telephone instruction on improving inhaler use. The main outcomes were assessed at week 12 post initiation of MDOT. By week 5, all children still engaging in MDOT (n = 18) were judged to have effective inhaler technique. Spirometry values did not vary to a significantly significant degree between baseline and 12 weeks (P>0.05), however, mean fraction of exhaled nitric oxide (FeNO) values normalised (mean 38.7 to 19.3ppm) and mean Asthma Control Test values improved (13.1 to mean 17.8). Feedback from participants was positive. Overall the findings open up a new paradigm in device independent (can be used for any type of inhaler device) monitoring, providing a platform for evaluating / improving inhaler use at home.