Background: Adherence to chronic disease management is critical to achieving improved health outcomes, quality of life, and cost-effective health care. As the burden of chronic diseases continues to grow globally, so does the impact of non-adherence. Mobile technologies are increasingly being used in health care and public health practice (mHealth) for patient communication, monitoring, and education, and to facilitate adherence to chronic diseases management. Objective: We conducted a systematic review of the literature to evaluate the effectiveness of mHealth in supporting the adherence of patients to chronic diseases management (“mAdherence”), and the usability, feasibility, and acceptability of mAdherence tools and platforms in chronic disease management among patients and health care providers. Methods: We searched PubMed, Embase, and EBSCO databases for studies that assessed the role of mAdherence in chronic disease management of diabetes mellitus, cardiovascular disease, and chronic lung diseases from 1980 through May 2014. Outcomes of interest included effect of mHealth on patient adherence to chronic diseases management, disease-specific clinical outcomes after intervention, and the usability, feasibility, and acceptability of mAdherence tools and platforms in chronic disease management among target end-users. Results: In all, 107 articles met all inclusion criteria. Short message service was the most commonly used mAdherence tool in 40.2% (43/107) of studies. Usability, feasibility, and acceptability or patient preferences for mAdherence interventions were assessed in 57.9% (62/107) of studies and found to be generally high. A total of 27 studies employed randomized controlled trial (RCT) methods to assess impact on adherence behaviors, and significant improvements were observed in 15 of those studies (56%). Of the 41 RCTs that measured effects on disease-specific clinical outcomes, significant improvements between groups were reported in 16 studies (39%). Conclusions: There is potential for mHealth tools to better facilitate adherence to chronic disease management, but the evidence supporting its current effectiveness is mixed. Further research should focus on understanding and improving how mHealth tools can overcome specific barriers to adherence. [J Med Internet Res 2015;17(2):e52]

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Impact of mHealth Chronic Disease Management on Treatment Adherence and Patient Outcomes: A Systematic Review

Importance Adherence to long-term therapies in chronic disease is poor. Traditional interventions to improve adherence are complex and not widely effective. Mobile telephone text messaging may be a scalable means to support medication adherence. Objectives To conduct a meta-analysis of randomized clinical trials to assess the effect of mobile telephone text messaging on medication adherence in chronic disease. Data Sources MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL (from database inception to January 15, 2015), as well as reference lists of the articles identified. The data were analyzed in March 2015. Study Selection Randomized clinical trials evaluating a mobile telephone text message intervention to promote medication adherence in adults with chronic disease. Data Extraction Two authors independently extracted information on study characteristics, text message characteristics, and outcome measures as per the predefined protocol. Main Outcomes and Measures Odds ratios and pooled data were calculated using random-effects models. Risk of bias and study quality were assessed as per Cochrane guidelines. Disagreement was resolved by consensus. Results Sixteen randomized clinical trials were included, with 5 of 16 using personalization, 8 of 16 using 2-way communication, and 8 of 16 using a daily text message frequency. The median intervention duration was 12 weeks, and self-report was the most commonly used method to assess medication adherence. In the pooled analysis of 2742 patients (median age, 39 years and 50.3% [1380 of 2742] female), text messaging significantly improved medication adherence (odds ratio, 2.11; 95% CI, 1.52-2.93; P P  = .002). There was moderate heterogeneity ( I 2  = 62%) across clinical trials. After adjustment for publication bias, the point estimate was reduced but remained positive for an intervention effect (odds ratio, 1.68; 95% CI, 1.18-2.39). Conclusions and Relevance Mobile phone text messaging approximately doubles the odds of medication adherence. This increase translates into adherence rates improving from 50% (assuming this baseline rate in patients with chronic disease) to 67.8%, or an absolute increase of 17.8%. While promising, these results should be interpreted with caution given the short duration of trials and reliance on self-reported medication adherence measures. Future studies need to determine the features of text message interventions that improve success, as well as appropriate patient populations, sustained effects, and influences on clinical outcomes.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/2484905/ioi150104.pdf

Mobile Telephone Text Messaging for Medication Adherence in Chronic Disease: A Meta-analysis

Objectives To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps. Practice description Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful. Practice innovation Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior. Main outcome measures Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. RESULTS 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality. Conclusion Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.

https://www.japha.org/article/S1544-3191(15)30311-3/pdf

Smartphone medication adherence apps: Potential benefits to patients and providers

Nonadherence with medication occurs in all chronic medical disorders It is a particular challenge in schizophrenia due to the illness's association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence There is no gold standard approach to the measurement of adherence as all methods have pros and cons Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence

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Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies

Background: Nonadherence with medication is a complex and multidimensional health care problem. The causes may be related to the patient, treatment, and/or health care provider. As a consequence, substantial numbers of patients do not benefit optimally from pharmacotherapy, resulting in increased morbidity and mortality as well as increased societal costs. Several interventions may contribute to improved adherence. However, most interventions have only a modest effect. Thus, despite the many efforts made, there has been little progress made as yet in tackling the problem of nonadherence. Methods: This paper summarizes the definitions and taxonomy of adherence with medication, as well as types and causes of nonadherence. In addition, interventions aimed at improvement of adherence are discussed. Conclusion: There is not just one solution for the nonadherence problem that fits all patients. Most interventions to improve adherence are aimed at all patients regardless of whether they are adherent or not. Recently, a number of tailored interventions have been described in the literature. Modern techniques are useful. Electronic pill boxes combined with Short Message Service reminders are specifically designed to improve unintentional adherence and have resulted in an increase in refill adherence in diabetic patients with suboptimal adherence. Tailored Internet interventions are a possibility for influencing patient drug-taking behavior and show promising results. Tailored counseling interventions targeted at the underlying causes of nonadherence seem an attractive method for supporting patients with their use of drugs. However, despite the plausible theoretical framework, data on long-term health effects of the various interventions are not available. To improve adherence effectively, there is a need for a tailored approach based on the type and cause of nonadherence and the specific needs of the patient. © 2013 Hugtenburg et al, publisher and licensee Dove Medical Press Ltd.

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Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions

SMS reminders improve adherence to oral medication in type 2 diabetes patients who are real time electronically monitored.

Aims: To investigate short- and long-term effects of real-time monitoring medication use combined with short message service (SMS) reminders for missed doses on refill adherence to oral anti-diabetic medication. Methods: A randomized controlled trial with two intervention groups and one control group involving 161 participants with Type 2 diabetes with suboptimal adherence. For 6 months, participants in the SMS group (n = 56) were monitored and received SMS reminders if they missed their medication. Participants in the non-SMS group (n = 48) were only monitored. The control group (n = 57) was not exposed to any intervention. Primary outcome measure was refill adherence to oral anti-diabetic medication. Multi-level regression analyses were performed to examine intervention effects on adherence between and within groups after 1 and 2 years of follow-up. Results: At baseline, mean refill adherence was comparable between the groups. After 1 year, adherence in the SMS group was significantly higher than in the control group (79.5% vs. 64.5%; P < 0.001) and showed a significant improvement from baseline (+16.3%; P < 0.001). Mean adherence in the non-SMS group reached 73.1% (+7.3%; P < 0.05), but did not differ from the control group (P = 0.06). After 2 years, the improved adherence in the SMS group persisted and remained significantly higher than in the control group (80.4% vs. 68.4%; P < .01), contrary to the non-SMS group whose adherence approached baseline level again (65.5%). Conclusions: This study shows the long-term effectiveness of real-time medication monitoring combined with SMS reminders in improving refill adherence. This new reminder system can strengthen the self-management of people with diabetes. (aut.ref.)

Short- and long-term effects of real-time medication monitoring with short message service (SMS) reminders for missed doses on the refill adherence of people with Type 2 diabetes : evidence from a randomized controlled trial

Een oplettend medicijndoosje vergroot de therapietrouw van patienten. Patienten die een herinnerings-sms’je krijgen als ze hun medicijnen vergeten, nemen 16% meer van hun medicijnen dan patienten uit de controlegroep. 

Niet iedere patient slikt trouw de pillen die de arts hem voorschrijft. Gemiddeld ligt de therapietrouw van patienten tussen de 40 en 70%, zo is bekend uit eerder onderzoek van het NIVEL (Nederlands Instituut voor onderzoek van de gezondheidszorg). Terwijl beter medicijngebruik leidt tot minder complicaties bij patienten, minder ziekenhuisopnames en lagere zorgkosten. Ondanks talrijke pogingen de therapietrouw van patienten te verbeteren, is dit de afgelopen decennia niet gelukt. 

Oplettend medicijndoosje
Het NIVEL onderzocht of een oplettend medicijndoosje de therapietrouw verbetert. Voor het onderzoek werden diabetespatienten gevraagd die hun medicijnen niet consequent hadden opgehaald bij de apotheek. “Lastig bereikbare patienten dus”, verklaart NIVEL-onderzoeker Marcia Vervloet. “Wij wilden kijken of wij juist bij deze groep met het slimme medicijndoosje een verbetering konden bereiken.” 

Samenwerking
Het project is een initiatief van Zilveren Kruis Achmea, Mediq Apotheken, Evalan en het NIVEL. Het onderzoek is uitgevoerd bij 40 Mediq Apotheken in de regio’s: Rotterdam Rijnmond, de kop van Noord-Holland, Drenthe, Helmond, Zutphen en Heerlen. “In Nederland gebruiken circa 3,2 miljoen mensen chronisch geneesmiddelen. Na twee eerdere pilots met het slimme medicijndoosje, wilden we de daadwerkelijke verbeteringen serieus laten onderzoeken”, aldus Melanie Schultz van Haegen, directeur Zorginkoop bij Zilveren Kruis Achmea. 

Sms-herinnering op maat
De patienten werden in drie groepen van ongeveer vijftig patienten verdeeld. Twee groepen kregen het medicijndoosje dat registreert wanneer het opengaat. Ging het doosje niet binnen de afgesproken tijd open, dan volgde in een groep een sms met een herinnering. De andere groep kreeg geen sms-herinneringen. De derde groep – zonder medicijndoosje – beantwoordde alleen twee vragenlijsten over hun therapietrouw. 

Regelmatig
Van de sms-groep nam gemiddeld 16% meer medicijnen dan de controlegroep. “Sommige mensen wilden zelfs de sms voor zijn”, vertelt Marcia Vervloet. “Bij de sms-groep is het innamepatroon ook veel regelmatiger. Ze namen hun medicijnen vaker op dezelfde tijd. Dat is bij bepaalde geneesmiddelen heel belangrijk.” 

Toekomst
“Patienten waarderen de apotheekbegeleiding met deze innovatie en verbeteren hun medicijngebruik. Daarom is het onze ambitie deze innovatie met partners bij alle 230 Mediq Apotheken beschikbaar te maken, want er zijn vele patienten die hier baat bij kunnen hebben”, stelt Peter van Wingerden, Manager Zorg van Mediq Apotheken.

B. van Vlijmen

Papers

SMS reminders improve adherence to oral medication in type 2 diabetes patients who are real time electronically monitored.

Short- and long-term effects of real-time medication monitoring with short message service (SMS) reminders for missed doses on the refill adherence of people with Type 2 diabetes : evidence from a randomized controlled trial

Een oplettend medicijndoosje voor diabetes type 2 patiënten: een onderzoek naar de effecten van Real-Time Medication Monitoring.