Beyond the reminder: The next steps in pharmacist-driven, mHealth patient engagement

The Use of eHealth for Pharmacotherapy Management With Patients With Respiratory Disease, Cardiovascular Disease, or Diabetes: Scoping Review

BACKGROUND

eHealth is increasingly considered an important tool for supporting pharmacotherapy management.

OBJECTIVE

We aimed to assess the (1) use of eHealth in pharmacotherapy management with patients with asthma or chronic obstructive pulmonary disease (COPD), diabetes, or cardiovascular disease (CVD); (2) effectiveness of these interventions on pharmacotherapy management and clinical outcomes; and (3) key factors contributing to the success of eHealth interventions for pharmacotherapy management.

METHODS

We conducted a scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review) statement. Databases searched included Embase, MEDLINE (PubMed), and Cochrane Library. Screening was conducted by 2 independent researchers. Eligible articles were randomized controlled trials and cohort studies assessing the effect of an eHealth intervention for pharmacotherapy management compared with usual care on pharmacotherapy management or clinical outcomes in patients with asthma or COPD, CVD, or diabetes. The interventions were categorized by the type of device, pharmacotherapy management, mode of delivery, features, and domains described in the conceptual model for eHealth by Shaw at al (Health in our Hands, Interacting for Health, Data Enabling Health). The effectiveness on pharmacotherapy management outcomes and patient- and clinician-reported clinical outcomes was analyzed per type of intervention categorized by number of domains and features to identify trends.

RESULTS

Of 63 studies, 16 (25%), 31 (49%), 13 (21%), and 3 (5%) included patients with asthma or COPD, CVD, diabetes, or CVD and diabetes, respectively. Most (38/63, 60%) interventions targeted improving medication adherence, often combined for treatment plan optimization. Of the 16 asthma or COPD interventions, 6 aimed to improve inhaled medication use. The majority (48/63, 76%) of the studies provided an option for patient feedback. Most (20/63, 32%) eHealth interventions combined all 3 domains by Shaw et al, while 25% (16/63) combined Interacting for Health with Data Enabling Health. Two-thirds (42/63, 67%) of the studies showed a positive overall effect. Respectively, 48% (23/48), 57% (28/49), and 39% (12/31) reported a positive effect on pharmacotherapy management and clinician- and patient-reported clinical outcomes. Pharmacotherapy management and patient-reported clinical outcomes, but not clinician-reported clinical outcomes, were more often positive in interventions with ≥3 features. There was a trend toward more studies reporting a positive effect on all 3 outcomes with more domains by Shaw et al. Of the studies with interventions providing patient feedback, more showed a positive clinical outcome, compared with studies with interventions without feedback. This effect was not seen for pharmacotherapy management outcomes.

CONCLUSIONS

There is a wide variety of eHealth interventions combining various domains and features to target pharmacotherapy management in asthma or COPD, CVD, and diabetes. Results suggest feedback is key for a positive effect on clinician-reported clinical outcomes. eHealth interventions become more impactful when combining domains.

Mobile Health Applications and Medication Adherence of Patients With Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Current evidence has revealed the beneficial effects of mobile health applications on systolic and diastolic blood pressure. However, there is still no solid evidence of the underlying factors for these outcomes, and hypertension treatment is performed mainly by medication intake. This study aims to analyze the impacts of health applications on medication adherence of patients with hypertension and understand the underlying factors.

METHODS

A systematic review and meta-analysis were conducted considering controlled clinical trials published, without year filter, through July 2020. The searches were performed in the electronic databases of Scopus, MEDLINE, and BVSalud. Study characteristics were extracted for qualitative synthesis. The meta-analysis examined medication-taking behavior outcomes using the generic inverse-variance method to combine multiple variables.

RESULTS

A total of 1,199 records were identified, of which 10 studies met the inclusion criteria for qualitative synthesis, and 9 met the criteria for meta-analysis with 1,495 participants. The analysis of mean changes revealed significant improvements in medication adherence (standardized mean difference=0.41, 95% CI=0.02, 0.79, I²=82%, p=0.04) as well as the analysis of the values measured after follow-up (standardized mean difference=0.60, 95% CI=0.30, 0.90, I²=77%, p<0.0001). Ancillary improvements were also identified, such as patients' perceived confidence, treatment self-efficacy and self-monitoring, acceptance of technology, and knowledge about the condition and how to deal with health issues.

DISCUSSION

There is evidence that mobile health applications can improve medication adherence in patients with hypertension, with broad heterogeneity between studies on the topic. The use of mobile health applications conceivably leads to ancillary improvements inherent to better medication adherence.

Digital transformation of the mobile connected pharmacy: a first step toward community pharmacy 5.0

Community pharmacies have made significant advances in digital technology; however, mobile systems are only emerging in this sector and mostly focusing patient-centric connections. This study reveals a case of digital transformation in a mobile connected pharmacy, balancing efficient pharmaceutical services and digital innovation. A mobile connected pharmacy solution (mPharmaCare) is developed for a community of near 100.000. The first stage includes a bibliometric analysis and a structured literature review of the mobile connected pharmacy. In the second stage, action research was conducted to evaluate mPharmaCare adoption. A dual organizational structure was tested to cope with innovation and efficient exploration of pharmacy services. Community Pharmacy 5.0 is an inspiring vision that will take advantage of mobility. However, there are tensions between the core pharmacy business and the new technology layers of community connections. Community pharmacies require both client-centric and community-centric approaches to achieve individualization of patient care and horizontal and end-to-end digital integration of pharmacy data. Digital transformation can remove silos in the community pharmacy. Creating an - internal or outsourced - innovation division may be suitable for medium and large community pharmacies. Moreover, pharmacies must consider shifting to a product-service system offer, deploying synchronization mechanisms with different stakeholders.

Using an Electronic App to Promote Home-Based Self-Care in Older Patients With Heart Failure: Qualitative Study on Patient and Informal Caregiver Challenges

Background

Heart failure (HF) affects many older individuals in North America, with recurrent hospitalizations despite postdischarge strategies to prevent readmission. Proper HF self-care can potentially lead to better clinical outcomes, yet many older patients find self-care challenging. Mobile health (mHealth) apps can provide support to patients with respect to HF self-care. However, many mHealth apps are not designed to consider potential patient barriers, such as literacy, numeracy, and cognitive impairment, leading to challenges for older patients. We previously demonstrated that a paper-based standardized diuretic decision support tool (SDDST) with daily weights and adjustment of diuretic dose led to improved self-care.

Objective

The aim of this study is to better understand the self-care challenges that older patients with HF and their informal care providers (CPs) face on a daily basis, leading to the conversion of the SDDST into a user-centered mHealth app.

Methods

We recruited 14 patients (male: 8/14, 57%) with a confirmed diagnosis of HF, aged ≥60 years, and 7 CPs from the HF clinic and the cardiology ward at the Hamilton General Hospital. Patients were categorized into 3 groups based on the self-care heart failure index: patients with adequate self-care, patients with inadequate self-care without a CP, or patients with inadequate self-care with a CP. We conducted semistructured interviews with patients and their CPs using persona-scenarios. Interviews were transcribed verbatim and analyzed for emerging themes using an inductive approach.

Results

Six themes were identified: usability of technology, communication, app customization, complexity of self-care, usefulness of HF-related information, and long-term use and cost. Many of the challenges patients and CPs reported involved their unfamiliarity with technology and the lack of incentive for its use. However, participants were supportive and more likely to actively use the HF app when informed of the intervention’s inclusion of volunteer and nurse assistance.

Conclusions

Patients with varying self-care adequacy levels were willing to use an mHealth app if it was simple in its functionality and user interface. To promote the adoption and usability of these tools, patients confirmed the need for researchers to engage with end users before developing an app. Findings from this study can be used to help inform the design of an mHealth app to ensure that it is adapted for the needs of older individuals with HF.

Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review

BACKGROUND AND OBJECTIVE

Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings.

METHODS

We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer.

RESULTS

Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed.

CONCLUSIONS

Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.