A behavioral economics-based telehealth intervention to improve aspirin adherence following hospitalization for acute coronary syndrome

A systematic review of the impacts of remote patient monitoring (RPM) interventions on safety, adherence, quality-of-life and cost-related outcomes

Due to rapid technological advancements, remote patient monitoring (RPM) technology has gained traction in recent years. While the effects of specific RPM interventions are known, few published reviews examine RPM in the context of care transitions from an inpatient hospital setting to a home environment. In this systematic review, we addressed this gap by examining the impacts of RPM interventions on patient safety, adherence, clinical and quality of life outcomes and cost-related outcomes during care transition from inpatient care to a home setting. We searched five academic databases (PubMed, CINAHL, PsycINFO, Embase and SCOPUS), screened 2606 articles, and included 29 studies from 16 countries. These studies examined seven types of RPM interventions (communication tools, computer-based systems, smartphone applications, web portals, augmented clinical devices with monitoring capabilities, wearables and standard clinical tools for intermittent monitoring). RPM interventions demonstrated positive outcomes in patient safety and adherence. RPM interventions also improved patients' mobility and functional statuses, but the impact on other clinical and quality-of-life measures, such as physical and mental health symptoms, remains inconclusive. In terms of cost-related outcomes, there was a clear downward trend in the risks of hospital admission/readmission, length of stay, number of outpatient visits and non-hospitalisation costs. Future research should explore whether incorporating intervention components with a strong human element alongside the deployment of technology enhances the effectiveness of RPM. The review highlights the need for more economic evaluations and implementation studies that shed light on the facilitators and barriers to adopting RPM interventions in different care settings.

Assessing the Impact of Behavioral Sciences Interventions on Chronic Disease Prevention and Management: A Systematic Review of Randomized Controlled Trials

Studies have highlighted the importance of applying Behavioral Sciences interventions to develop equity in the prevention of chronic diseases in the public health domain. Our study aims to assess the evidence of this influence. We undertook a systematic review study using the electronic databases PubMed, Web of Science, Scopus and Cochrane, searching for work published between 2013 and 2023. The research analyzed the influence of Behavioral Sciences intervention studies on public health. This review was registered and published in PROSPERO, registration number CRD42023412377. The systematic search identified 2951 articles. The review analyzed 26 studies. The quality assessment of the articles showed an overall average of 74%, with the majority of studies being of high quality. The interventions with the best evidence for chronic diseases used framing messages, nudges and vouchers. Messages with incentives also showed satisfactory evidence. The most prevalent outcomes were related to screening tests and patient adherence to treatment. The current state of decision-making remains mainly at the patient level, with potential for further exploration of the roles of healthcare professionals and decision-makers in future research efforts. Limitations relate to the heterogeneity of the study sample, which hinders a more precise analysis of specific interventions and outcomes in chronic diseases.

Could nudges reduce health literacy disparities in CVD prevention? An experiment using alternative messages for CVD risk assessment screening

OBJECTIVE

To explore the effect of SMS nudge messages amongst people with varying health literacy on their intention to get a Heart Health Check.

METHODS

A 3 (Initial SMS: scarcity, regret, or control nudge) x 2 (Reminder SMS: social norm or control nudge) factorial design was used in a hypothetical online experiment. 705 participants eligible for Heart Health Checks were recruited. Outcomes included intention to attend a Heart Health Check and psychological responses.

RESULTS

In the control condition, people with lower health literacy had lower behavioural intentions compared to those with higher health literacy (p = .011). Scarcity and regret nudges closed this gap, resulting in similar intention levels for lower and higher health literacy. There was no interactive effect of the reminder nudge and health literacy (p = .724).

CONCLUSION

Scarcity and regret nudge messages closed the health literacy gap in behavioural intentions compared to a control message, while a reminder nudge had limited additional benefit. Health literacy should be considered in behavioural intervention evaluations to ensure health equity is addressed.

PRACTICE IMPLICATIONS

Results informed a national screening program using a universal precautions approach, where messages with higher engagement for lower health literacy groups were used in clinical practice.

Improving medication adherence in cardiovascular disease

Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.

Efficacy of eHealth Technologies on Medication Adherence in Patients With Acute Coronary Syndrome: Systematic Review and Meta-Analysis

BACKGROUND

Suboptimal adherence to cardiac pharmacotherapy, recommended by the guidelines after acute coronary syndrome (ACS) has been recognized and is associated with adverse outcomes. Several randomized controlled trials (RCTs) have shown that eHealth technologies are useful in reducing cardiovascular risk factors. However, little is known about the effect of eHealth interventions on medication adherence in patients following ACS.

OBJECTIVE

The aim of this study is to examine the efficacy of the eHealth interventions on medication adherence to selected 5 cardioprotective medication classes in patients with ACS.

METHODS

A systematic literature search of PubMed, Embase, Scopus, and Web of Science was conducted between May and October 2022, with an update in October 2023 to identify RCTs that evaluated the effectiveness of eHealth technologies, including texting, smartphone apps, or web-based apps, to improve medication adherence in patients after ACS. The risk of bias was evaluated using the modified Cochrane risk-of-bias tool for RCTs. A pooled meta-analysis was performed using a fixed-effect Mantel-Haenszel model and assessed the medication adherence to the medications of statins, aspirin, P2Y12 inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and β-blockers.

RESULTS

We identified 5 RCTs, applicable to 4100 participants (2093 intervention vs 2007 control), for inclusion in the meta-analysis. In patients who recently had an ACS, compared to the control group, the use of eHealth intervention was not associated with improved adherence to statins at different time points (risk difference [RD] -0.01, 95% CI -0.03 to 0.03 at 6 months and RD -0.02, 95% CI -0.05 to 0.02 at 12 months), P2Y12 inhibitors (RD -0.01, 95% CI -0.04 to 0.02 and RD -0.01, 95% CI -0.03 to 0.02), aspirin (RD 0.00, 95% CI -0.06 to 0.07 and RD -0.00, 95% CI -0.07 to 0.06), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (RD -0.01, 95% CI -0.04 to 0.02 and RD 0.01, 95% CI -0.04 to 0.05), and β-blockers (RD 0.00, 95% CI -0.03 to 0.03 and RD -0.01, 95% CI -0.05 to 0.03). The intervention was also not associated with improved adherence irrespective of the adherence assessment method used (self-report or objective).

CONCLUSIONS

This review identified limited evidence on the effectiveness of eHealth interventions on adherence to guideline-recommended medications after ACS. While the pooled analyses suggested a lack of effectiveness of such interventions on adherence improvement, further studies are warranted to better understand the role of different eHealth approaches in the post-ACS context.

Optimising the implementation of digital-supported interventions for the secondary prevention of heart disease: a systematic review using the RE-AIM planning and evaluation framework

BACKGROUND

mHealth technologies are now widely utilised to support the delivery of secondary prevention programs in heart disease. Interventions with mHealth included have shown a similar efficacy and safety to conventional programs with improvements in access and adherence. However, questions remain regarding the successful wider implementation of digital-supported programs. By applying the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework to a systematic review and meta-analysis, this review aims to evaluate the extent to which these programs report on RE-AIM dimensions and associated indicators.

METHODS

This review extends our previous systematic review and meta-analysis that investigated the effectiveness of digital-supported programs for patients with coronary artery disease. Citation searches were performed on the 27 studies of the systematic review to identify linked publications that reported data for RE-AIM dimensions. All included studies and, where relevant, any additional publications, were coded using an adapted RE-AIM extraction tool. Discrepant codes were discussed amongst reviewers to gain consensus. Data were analysed to assess reporting on indicators related to each of the RE-AIM dimensions, and average overall reporting rates for each dimension were calculated.

RESULTS

Searches found an additional nine publications. Across 36 publications that were linked to the 27 studies, 24 (89%) of the studies were interventions solely delivered at home. The average reporting rates for RE-AIM dimensions were highest for effectiveness (75%) and reach (67%), followed by adoption (54%), implementation (36%) and maintenance (11%). Eleven (46%) studies did not describe relevant characteristics of their participants or of staff involved in the intervention; most studies did not describe unanticipated consequences of the intervention; the ongoing cost of intervention implementation and maintenance; information on intervention fidelity; long-term follow-up outcomes, or program adaptation in other settings.

CONCLUSIONS

Through the application of the RE-AIM framework to a systematic review we found most studies failed to report on key indicators. Failing to report these indicators inhibits the ability to address the enablers and barriers required to achieve optimal intervention implementation in wider settings and populations. Future studies should consider alternative hybrid trial designs to enable reporting of implementation indicators to improve the translation of research evidence into routine practice, with special consideration given to the long-term sustainability of program effects as well as corresponding ongoing costs.

REGISTRATION

PROSPERO-CRD42022343030.

Digital Health Programs to Reduce Readmissions in Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

The use of mobile health (mHealth, wireless communication devices, and/or software technologies) in health care delivery has increased rapidly in recent years. Their integration into disease management programs (DMPs) has tremendous potential to improve outcomes for patients with coronary artery disease (CAD), yet a more robust evaluation of the evidence is required.

Objectives

The purpose of this study was to undertake a systematic review and meta-analysis of mHealth-enabled DMPs to determine their effectiveness in reducing readmissions and mortality in patients with CAD.

Methods

We systematically searched English language studies from January 1, 2007, to August 3, 2021, in multiple databases. Studies comparing mHealth-enabled DMPs with standard DMPs without mHealth were included if they had a minimum 30-day follow-up for at least one of all-cause or cardiovascular-related mortality, readmissions, or major adverse cardiovascular events.

Results

Of the 3,411 references from our search, 155 full-text studies were assessed for eligibility, and data were extracted from 18 publications. Pooled findings for all-cause readmissions (10 studies, n = 1,514) and cardiac-related readmissions (9 studies, n = 1,009) indicated that mHealth-enabled DMPs reduced all-cause (RR: 0.68; 95% CI: 0.50-0.91) and cardiac-related hospitalizations (RR: 0.55; 95% CI: 0.44-0.68) and emergency department visits (RR: 0.37; 95% CI: 0.26-0.54) compared to DMPs without mHealth. There was no significant reduction for mortality outcomes (RR: 1.72; 95% CI: 0.64-4.64) or major adverse cardiovascular events (RR: 0.68; 95% CI: 0.40-1.15).

Conclusions

DMPs integrated with mHealth should be considered an effective intervention for better outcomes in patients with CAD.

Nursing care and management of adverse events for patients with BRAFV600E-mutant metastatic colorectal cancer receiving encorafenib in combination with cetuximab: a review

Encorafenib is a B-Raf proto-oncogene serine/threonine-protein kinase (BRAF) inhibitor, approved in the EU and USA, in combination with the epidermal growth factor receptor (EGFR) inhibitor cetuximab, for the treatment of patients with BRAF^V600E-mutant metastatic colorectal cancer (mCRC). In the pivotal BEACON CRC trial, patients achieved longer survival with encorafenib in combination with cetuximab vs. conventional chemotherapy. This targeted therapy regimen is also generally better tolerated than cytotoxic treatments. However, patients may present with adverse events unique to the regimen and characteristic of BRAF and EGFR inhibitors, which produce their own set of challenges. Nurses play an essential role in navigating the care of patients with BRAF^V600E-mutant mCRC and managing adverse events that patients may experience. This includes early and efficient identification of treatment-related adverse events, subsequent management of adverse events and education of patients and their caregivers around key adverse events. This manuscript aims to provide support to nurses managing patients with BRAF^V600E-mutant mCRC receiving encorafenib in combination with cetuximab, by summarising potential adverse events and providing guidance on how to manage them. Special attention will be paid to the presentation of key adverse events, dose modifications that may be required, practical recommendations and supportive care measures.

Applications of Behavioral Economics to Pharmaceutical Policymaking: A Scoping Review with Implications for Best-Value Biological Medicines

BACKGROUND AND OBJECTIVE

Pharmaceutical policies are generally based on the assumption that involved stakeholders make rational decisions. However, behavioral economics has taught us that this is not always the case as people deviate from rational behavior in rather predictable patterns. This scoping review examined to what extent behavioral concepts have already been applied in the pharmaceutical domain and what evidence exists about their effectiveness, with the aim of formulating future applications and research hypotheses on policymaking for best-value biologicals.

METHODS

A scoping literature review was conducted on the evidence of behavioral applications to pharmaceuticals. Scientific databases (Embase, MEDLINE, APA PsycArticles, and Scopus) were searched up to 20 October, 2021.

RESULTS

Forty-four full-text scientific articles were identified and narratively described in this article. Pharmaceutical domains where behavioral concepts have been investigated relate to influencing prescribing behavior, improving medication adherence, and increasing vaccination uptake. Multiple behavioral concepts were examined in the identified studies, such as social norms, defaults, framing, loss aversion, availability, and present bias. The effectiveness of the applied interventions was generally positive, but depended on the context. Some of the examined interventions can easily be translated into effective policy interventions for best-value biological medicines. However, some applications require further investigation in a research context.

CONCLUSIONS

Applications of behavioral economics to pharmaceutical policymaking are promising. However, further research is required to investigate the effect of behavioral applications on policy interventions for a more sustainable market environment for best-value biological medicines.

Use of Mobile Applications to Increase Therapeutic Adherence in Adults: A Systematic Review

Failure to comply with therapeutic treatments implies negative repercussions for the patient's quality of life, their social environment, and health system. The use of information and communication technologies, especially mobile applications, has favored the increase in global therapeutic adherence figures. The objective of this study is to characterize the use of mobile applications as a strategy to increase therapeutic adherence in adults. A systematic literature review in Web of Science and Scopus was performed following the Preferred Information elements for Systematic Reviews and Meta-analysis. Information such as: the year of publication, the study population, the medical conditions of the participants, the main characteristics or functionalities of the mobile applications, and the methods or tools used to measure treatment adherence were extracted from each included article. The risk of bias was assessed. Twelve randomized controlled trials (RCTs), published in English from 1996 to May 2021, were included. Chronic diseases have been mostly addressed through interventions with mobile applications. The most reported functions of mobile applications were reminders, educational modules, two-way communication, and games. Tools such as: "Morisky Medication Adherence Scale of eight items"; "Medication adherence questionnaire"; "Self-reported adherence"; among others, were used to evaluate and report the treatment adherence. In conclusion, including treatment interventions using mobile applications in clinical practice has proven to be beneficial to improve therapeutic adherence. However, it is necessary to develop high-quality clinical trials (size and duration) to generalize results and justify their use in conventional health services.

Patient Adherence to Therapy After Myocardial Infarction: A Scoping Review

Background

Patients with myocardial infarction have low adherence to secondary prevention. Patients with acute coronary syndromes usually decide not to take cardiac drugs for 7 days after discharge for various reasons and adherence rates are usually very low. The aim of this scoping review was to identify factors influencing treatment adherence after myocardial infarction and the role of interventions to improve treatment adherence.

Methods

Two electronic databases (PubMed and Web of Science) were systematically searched for relevant published reviews of interventions for adherence after myocardial infarction. Inclusion criteria were study design: randomized control trial, systematic reviews; published in English; sample age ≥18 years. The methodological framework proposed by Arksey & O'Malley was used to guide the review process of the study.

Results

Thirteen articles met the inclusion/exclusion criteria. Four of the thirteen studies assessed factors influencing patient adherence to therapy after myocardial infarction, the remaining studies examined various interventions increasing adherence to treatment after myocardial infarction.

Conclusion

There is a need to improve adherence of patients to treatment after myocardial infarction. Studies show that the use of modern technologies and communication with the patients by phone improve adherence to treatment.

Behavioral Economics and Tobacco Control: Current Practices and Future Opportunities

Despite considerable progress, smoking remains the leading preventable cause of death in the United States. To address the considerable health and economic burden of tobacco use, the development of improved tobacco control and treatment interventions is critical. By combining elements of economics and psychology, behavioral economics provides a framework for novel solutions to treat smokers who have failed to quit with traditional smoking cessation interventions. The full range of behavioral economic principles, however, have not been widely utilized in the realm of tobacco control and treatment. Given the need for improved tobacco control and treatment, the limited use of other behavioral economic principles represents a substantial missed opportunity. For this reason, we sought to describe the principles of behavioral economics as they relate to tobacco control, highlight potential gaps in the behavioral economics tobacco research literature, and provide examples of potential interventions that use each principle.

The Role of Behavioral Economics in Improving Cardiovascular Health Behaviors and Outcomes

PURPOSE OF REVIEW

Behavioral economics represents a promising set of principles to inform the design of health-promoting interventions. Techniques from the field have the potential to increase quality of cardiovascular care given suboptimal rates of guideline-directed care delivery and patient adherence to optimal health behaviors across the spectrum of cardiovascular care delivery.

RECENT FINDINGS

Cardiovascular health-promoting interventions have demonstrated success in using a wide array of principles from behavioral economics, including loss framing, social norms, and gamification. Such approaches are becoming increasingly sophisticated and focused on clinical cardiovascular outcomes in addition to health behaviors as a primary endpoint. Many approaches can be used to improve patient decisions remotely, which is particularly useful given the shift to virtual care in the context of the COVID-19 pandemic. Numerous applications for behavioral economics exist in the cardiovascular care delivery space, though more work is needed before we will have a full understanding of ways to best leverage such applications in each clinical context.

Comparing medication adherence using a smartphone application and electronic monitoring among patients with acute coronary syndrome

AIM

The purpose of this study was to determine the extent of agreement between adherence measures obtained using two technological interventions, electronic monitoring (EM) and a smartphone application (App).

BACKGROUND

Clinicians, patients, and researchers depend on valid measurements of medication adherence to inform the delivery of preemptive care when needed. Technology is routinely used for monitoring medication adherence in both clinical practice and research, yet there is a dearth of research comparing novel App based approaches to traditional approaches used for assessing medication adherence.

METHODS

Adherence rates were captured on both the EM and the App for 3697 daily observations from 44 participants with acute coronary syndrome over 90 days immediately following discharge from acute care. For EM, adherence was measured using EM equipped pill bottles. For the App, adherence was measured by having participants upload daily photos to the App prior to taking their daily aspirin. Agreement was assessed using a Bland-Altman analysis.

RESULTS

The mean adherence rate was higher on the App, 92%, than the EM, 78% (p < 0.001). The mean difference in adherence rates between these methods was 14% (95% Confidence Interval: -23%, -5%).

CONCLUSIONS

These findings illustrate a lack of agreement between technological interventions used for measuring adherence in cardiovascular patient populations, with higher adherence rates observed with the App compared to EM. These findings are salient given the increased reliance on telehealth due to the ongoing COVID-19 pandemic.