Feedback-enhanced electronic monitoring for asthma inhaler adherence: A systematic review and meta-analysis of...

Asthma affects an estimated 260 million people worldwide. Adherence to inhaled corticosteroids ranges from 22% to 63% and accounts for about 24% of exacerbations. Feedback-enhanced electronic monitoring couples electronic recording of inhaler use with active feedback, unlike passive monitoring. Randomized trial evidence for this approach has not been synthesized.

To evaluate the effect of feedback-enhanced electronic monitoring on medication adherence, exacerbations, disease control, health-related quality of life, safety and acceptability in people with asthma.

Systematic review and meta-analysis of randomized controlled trials.

PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, Web of Science and Scopus were searched from inception to October 2025 without language restriction, supplemented by reference lists and trial registries.

Trials comparing electronic monitoring combined with at least one feedback modality against standard care were eligible. Two reviewers independently screened records, extracted data and appraised risk of bias with the Cochrane risk of bias tool for randomized trials, version 2. Random-effects meta-analyses were performed and certainty of evidence was rated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Twenty-eight trials with 4410 participants were included. Feedback-enhanced electronic monitoring improved adherence relative to standard care (mean difference 18.43%, 95% confidence interval 13.02 to 23.84; 21 trials, 2567 participants; moderate certainty), with consistent benefit in children (22.21%), adults (14.23%) and mixed populations (23.18%). Exacerbation rates fell (mean difference -2.65, 95% confidence interval -4.39 to -0.91; 10 trials, 1569 participants; low certainty) and the proportion with well-controlled asthma rose (mean difference 6.67%, 95% confidence interval 4.47 to 8.86; 5 trials, 1709 participants; low certainty). Quality of life improved (Mini Asthma Quality of Life Questionnaire mean difference 0.26, 95% confidence interval 0.13 to 0.40; 5 trials, 787 participants; moderate certainty), whereas the change in Asthma Control Test score did not reach statistical significance (mean difference 0.53, 95% confidence interval -0.24 to 1.31; 9 trials). Adverse events were comparable and acceptability was high (System Usability Scale 69.4 to 80.1).

Feedback-enhanced electronic monitoring improves inhaler adherence in asthma across age groups, and this is accompanied by fewer exacerbations, a higher proportion of patients reaching disease control and better quality of life. The benefit appears to arise from converting passive monitoring into active behavior change. Device durability, user training, integration with health services and digital equity require attention at implementation.

Adding feedback to electronic inhaler monitoring raises asthma medication adherence by 18% and improves control and quality of life.