Medication adherence: emerging use of technology

Lower opportunity ZIP code is associated with worse outcomes after listing in pediatric heart transplantation

BACKGROUND

The Child Opportunity Index (COI) comprehensively measures children's social determinants of health. We describe association between COI and outcomes after listing for heart transplantation.

METHODS

We conducted a retrospective review of the United Network for Organ Sharing (UNOS) database for U.S. children listed for heart transplant between 2012 and 2020. ZIP codes were utilized to assign COI. Primary outcome was survival from time of listing. Secondary outcomes included waitlist survival, 1-year post-transplant survival, and conditional 1-year post-transplant survival. Cox regression was performed adjusting for payor, age, race, diagnosis, and support at listing for all outcomes except waitlist survival, for which Fine-Gray competing risk analysis was performed.

RESULTS

Of 5,723 children listed, 109 were excluded due to missing ZIP codes. Race/ethnicity and payor were associated with COI (p < 0.001). Patients living in very low COI ZIP codes compared to all others had increased mortality from time of listing (HR 1.16, CI 1.03-1.32, p = 0.02) with 1-, 5-, and 9-year survival of 79.3% vs 82.2%, 66.5% vs 73.0%, and 53.6% vs 64.7% respectively, were more likely to be removed from the waitlist due to death or being too sick (subdistribution HR 1.26, 95% CI 1.10-1.42), and had increased mortality conditional on one-year post-transplant survival (HR 1.38, 1.09-1.74, p = 0.008) with 1-, 3-, and 5- year survival of 94.7% vs 97.3%, 87.0% vs 93.1%, and 78.6% vs 86.9%.

CONCLUSIONS

Children living in lower opportunity ZIP codes had poorer survival from time of listing, poorer waitlist survival, and poorer conditional one-year post-transplant survival.

Health Information Technology Supporting Adherence Memory Disorder Patients: A Systematic Literature Review

BACKGROUND

People with memory disorders have difficulty adhering to treatments. With technological advances, it remains important to investigate the potential of health information technology (HIT) in supporting medication adherence among them.

OBJECTIVES

This review investigates the role of HIT in supporting adherence to medication and therapies among patients with memory issues. It also captures the factors that impact technology adherence interventions.

METHODS

We searched the literature for relevant publications published until March 15, 2023, using technology to support adherence among patients with memory issues (dementia, Alzheimer's, amnesia, mild cognitive impairment, memory loss, etc.). The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We conducted a quality assessment of the papers following the Mixed Methods Appraisal Tool.

RESULTS

Fifteen studies were included after carefully reviewing the 3,773 articles in the search. Methodological quality, as appraised, ranged from 80 to 100% with eight studies rated 100%. The studies overall did not have a high risk of bias. Thus, all of the 15 studies were included. Technologies investigated were classified into four groups based on their impact: therapeutic patient education, simplifying treatment regimens, early follow-up visits and short-term treatment goals, and reminder programs. Different technologies were used (automatic drug dispensers or boxes, mobile health-based interventions, game-based interventions, e-health-based interventions, patient portals, and virtual reality). The factors impacting patients' adherence to technology-based treatment and medication were clustered into human-computer interaction and integration challenges.

CONCLUSION

This study contributes to the literature by classifying the technologies that supported medication adherence among patients with memory issues in four groups. It also explores and presents the possible limitations of existing solutions to drive future research in supporting care for people with memory disorders.

NPS MedicineWise application in supporting medication adherence in chronic heart failure: an acceptability and feasibility pilot study

Introduction

Heart failure (HF) is an increasing global concern. Despite evidence-based pharmacotherapy, associated morbidity and mortality remain high. This study aimed to assess the acceptability, feasibility, and value of the NPS MedicineWise dose reminder app in a tiered, pharmacist-led intervention to address medication non-adherence in patients with HF.

Methods

This prospective, single-blinded, randomised controlled trial recruited 55 patients with HF between September 2019 and October 2020. Participants were randomly assigned to either the intervention or control arms. Intervention participants used the app which prompted medication administration at each dosing interval. Control participants received standard care and remained blinded to the app throughout the study. Treatment non-adherence prompted a tiered, pharmacist-led intervention. Comparison of the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) at baseline and 6-months measured the app's value in supporting medication adherence. Secondary outcome measures included self-reported medication knowledge, health-related quality of life, psychological wellbeing, and signs and symptoms of HF. Data were analysed using standard statistical tests with significance set at α 0.05.

Results

Approximately half of respondents reported managing HF and medications better by using the MedicineWise app (Tier 1). Most respondents expressed satisfaction with the in-app messages (Tier 2) and pharmacists' phone calls (Tier 3). The intervention participants demonstrated a significant improvement in the SEAMS between baseline and 6-months follow-up.

Discussion

It is feasible and potentially of value to use the MedicineWise app with a tiered, pharmacist-led intervention to support medication adherence in patients with HF. Our findings provide clinicians with "real-world" information on the practicality and potential value of using mobile health to support treatment adherence in patients with HF.

Trial registration number

Australian New Zealand Clinical Trials Registry Clinical trial registration number: ACTRN12619000289112p (http://www.ANZCTR.org.au/ACTRN12619000289112p.aspx).

Patient randomised controlled trial of technology enabled strategies to promote treatment adherence in liver transplantation: rationale and design of the TEST trial

BACKGROUND AND AIMS

Liver transplantation is a life-saving procedure for end-stage liver disease. However, post-transplant medication regimens are complex and non-adherence is common. Post-transplant medication non-adherence is associated with graft rejection, which can have long-term adverse consequences. Transplant centres are equipped with clinical staff that monitor patients post-transplant; however, digital health tools and proactive immunosuppression adherence monitoring has potential to improve outcomes.

METHODS AND ANALYSIS

This is a patient-randomised prospective clinical trial at three transplant centres in the Northeast, Midwest and South to investigate the effects of a remotely administered adherence programme compared with usual care. The programme monitors potential non-adherence largely levering text message prompts and phenotypes the nature of the non-adhere as cognitive, psychological, medical, social or economic. Additional reminders for medications, clinical appointments and routine self-management support are incorporated to promote adherence to the entire medical regimen. The primary study outcome is medication adherence via 24-hour recall; secondary outcomes include additional medication adherence (ASK-12 self-reported scale, regimen knowledge scales, tacrolimus values), quality of life, functional health status and clinical outcomes (eg, days hospitalised). Study implementation, acceptability, feasibility, costs and potential cost-effectiveness will also be evaluated.

ETHICS AND DISSEMINATION

The University of Pennsylvania Review Board has approved the study as the single IRB of record (protocol # 849575, V.1.4). Results will be published in peer-reviewed journals and summaries will be provided to study funders.

TRIAL REGISTRATION NUMBER

NCT05260268.

The Synergistic Effect of Nurse Proactive Phone Calls With an mHealth App Program on Sustaining App Usage: 3-Arm Randomized Controlled Trial

BACKGROUND

Although mobile health application (mHealth app) programs have effectively promoted disease self-management behaviors in the last decade, usage rates have tended to fall over time.

OBJECTIVE

We used a case management approach led by a nurse and supported by a health-social partnership team with the aim of sustaining app usage among community-dwelling older adults and evaluated the outcome differences (i.e, self-efficacy, levels of depression, and total health service usages) between those who continued to use the app.

METHODS

This was a 3-arm randomized controlled trial. A total of 221 older adults with hypertension, diabetes, or chronic pain were randomized into 3 groups: mHealth (n=71), mHealth with interactivity (mHealth+I; n=74), and the control (n=76). The mHealth application was given to the mHealth and mHealth+I groups. The mHealth+I group also received 8 proactive calls in 3 months from a nurse to encourage use of the app. The control group received no interventions. Data were collected at preintervention (T1), postintervention (T2), and at 3 months' postintervention (T3) to ascertain the sustained effect.

RESULTS

A total of 37.8% of mHealth+I and 18.3% of mHealth group participants continued using the mHealth app at least twice per week until the end of the sixth month. The difference in app usage across the 2 groups between T2 and T3 was significant (χ²₁=6.81, P=.009). Improvements in self-efficacy (β=4.30, 95% CI 0.25-8.35, P=.04) and depression levels (β=-1.98, 95% CI -3.78 to -0.19, P=.03) from T1 to T3 were observed in the mHealth group participants who continued using the app. Although self-efficacy and depression scores improved from T1 to T2 in the mHealth+I group, the mean values decreased at T3. Health service usage decreased for all groups from T1 to T2 (β=-1.38, 95% CI -1.98 to -0.78, P<.001), with a marginal increase at T3.

CONCLUSIONS

The relatively low rates of mHealth app usage at follow-up are comparable to those reported in the literature. More work is needed to merge the technology-driven and in-person aspects of mHealth.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03878212; https://clinicaltrials.gov/ct2/show/NCT03878212.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1159/000509129.

Impact of COVID-19 Pandemic on Adherence to Chronic Therapies: A Systematic Review

The spread of the coronavirus disease 2019 (COVID-19) pandemic caused a sudden and significant disruption in healthcare services, especially for patients suffering from chronic diseases. We aimed at evaluating the impact of the pandemic on adherence to chronic therapies through a systematic review of available studies. PubMed, EMBASE, and Web of Science were searched since inception to June 2022. Inclusion criteria were: (1) observational studies or surveys; (2) studies on patients with chronic diseases; (3) reporting the effects of COVID-19 pandemic on adherence to chronic pharmacological treatment, as a comparison of adherence during the pandemic period vs. pre-pandemic period (primary outcome) or as rate of treatment discontinuation/delay specifically due to factors linked to COVID-19 (secondary outcome). Findings from 12 (primary outcome) and 24 (secondary outcome) studies showed that many chronic treatments were interrupted or affected by a reduced adherence in the pandemic period, and that fear of infection, difficulty in reaching physicians or healthcare facilities, and unavailability of medication were often reported as reasons for discontinuation or modification of chronic therapies. For other therapies where the patient was not required to attend the clinic, continuity of treatment was sometimes ensured through the use of telemedicine, and the adherence was guaranteed with drug stockpiling. While the effects of the possible worsening of chronic disease management need to be monitored over time, positive strategies should be acknowledged, such as the implementation of e-health tools and the expanded role of community pharmacists, and may play an important role in preserving continuity of care for people with chronic diseases.

SPUR: A Patient-Reported Medication Adherence Model as a Predictor of Admission and Early Readmission in Patients Living with Type 2 Diabetes

PURPOSE

Poor medication adherence (MA) is linked to an increased likelihood of hospital admission. Early interventions to address MA may reduce this risk and associated health-care costs. This study aimed to evaluate a holistic Patient Reported Outcome Measure (PROM) of MA, known as SPUR, as a predictor of general admission and early readmission in patients living with Type 2 Diabetes.

PATIENTS AND METHODS

An observational study design was used to assess data collected over a 12-month period including 6-month retrospective and 6-month prospective monitoring of the number of admissions and early readmissions (admissions occurring within 30 days of discharge) across the cohort. Patients (n = 200) were recruited from a large South London NHS Trust. Covariates of interest included: age, ethnicity, gender, level of education, income, the number of medicines and medical conditions, and a Covid-19 diagnosis. A Poisson or negative binomial model was employed for count outcomes, with the exponentiated coefficient indicating incident ratios (IR) [95% CI]. For binary outcomes (Coefficient, [95% CI]), a logistic regression model was developed.

RESULTS

Higher SPUR scores (increased adherence) were significantly associated with a lower number of admissions (IR = 0.98, [0.96, 1.00]). The number of medical conditions (IR = 1.07, [1.01, 1.13]), age ≥80 years (IR = 5.18, [1.01, 26.55]), a positive Covid-19 diagnosis during follow-up (IR = 1.83, [1.11, 3.02]) and GCSE education (IR = 2.11, [1.15,3.87]) were factors associated with a greater risk of admission. When modelled as a binary variable, only the SPUR score (-0.051, [-0.094, -0.007]) was significantly predictive of an early readmission, with patients reporting higher SPUR scores being less likely to experience an early readmission.

CONCLUSION

Higher levels of MA, as determined by SPUR, were significantly associated with a lower risk of general admissions and early readmissions among patients living with Type 2 Diabetes.

Impact of the COVID-19 Pandemic on the Therapeutic Continuity among Outpatients with Chronic Cardiovascular Therapies

The COVID-19 pandemic poses major challenges to healthcare systems. We aimed to investigate the impact of the pandemic on prescription and adherence patterns of chronic cardiovascular therapies (lipid-lowering [LL], oral antidiabetic drugs [AD], and antihypertensives [AH]) using administrative pharmaceutical databases. For each treatment, two cohorts of prevalent cases in 2019 and 2020 were compared. We evaluated the percentage change in dispensed packages and treatment adherence as a proportion of days covered (PDC). For all therapies, an increase was observed during March-April 2020 (LL: +4.52%; AD: +2.72%; AH: +1.09%), with a sharp decrease in May-June 2020 (LL: -8.40%; AD: -12.09%; AH: -10.54%) compared to 2019. The impact of the COVID-19 pandemic on chronic cardiovascular treatments appears negligible on adherence: 533,414 patients showed high adherence to LL (PDC ≥ 80%) in January-February 2020, and 2.29% became poorly adherent (PDC < 20%) in the following four-month period (vs. 1.98% in 2019). A similar increase was also observed for AH (1.25% with poor adherence in 2020 vs. 0.93% in 2019). For AD, the increase was restrained (1.55% with poor adherence in 2020 vs. 1.37% in 2019). The rush to supply drugs at the beginning of lockdown preserved the continuity of chronic cardiovascular therapies.

Influencing medication taking behaviors using automated two-way digital communication: A narrative synthesis systematic review informed by the Behavior Change Wheel

PURPOSE

Around half of prescribed medications for long-term conditions are not taken as directed. Automated two-way digital communication, such as text messaging and interactive voice response technology, could deliver interventions to improve medication adherence, and subsequently health. However, exploration of how such interventions may improve medication adherence is limited. This review aimed to explore how automated two-way digital communication can improve medication taking with or without using non-digital intervention components, such as phone calls with healthcare professionals.

METHODS

A theory-informed narrative synthesis systematic review. Several databases were searched including CINAHL, Embase, Medline, and Web of Science using key words relating to 'medication adherence' and digital communication technologies. The Behavior Change Technique (BCT) coding using the BCT Taxonomy V1 and the Behavior Change Wheel were used to identify BCTs delivered within the included interventions.

RESULTS

A total of 3,018 records were screened with 43 study reports included in the review. Four medication-taking behaviors: taking medication, obtaining medication, self-testing, and asking for support were identified as targets for behavior change within the included interventions. Most BCTs within the digital communication component aimed to increase motivation for medication adherence, with non-digital intervention components included to address other medication taking barriers, such as physical and psychological capability.

CONCLUSION

Automated two-way digital communication can detect barriers to medication adherence by monitoring performance of the taking medication behavior. Monitoring outcomes from taking medication may increase reflective motivation to take medicines. Addressing physical opportunity to taking medication by facilitating the behavior obtaining medication may also increase adherence.

Evaluation of Telephone-Based Cardiac Rehabilitation Services Delivered to Adults 65 and Older During the Early Months of the COVID-19 Pandemic

This study was performed to evaluate the effectiveness of a hybrid, telephone-based cardiac rehabilitation (TBCR) program implemented early in the COVID-19 pandemic compared with in-person, center-based programming offered prior to the pandemic. The focus was on older adults’ engagement and outcomes. Matched groups of hybrid and in-person cardiac rehabilitation (CR) participants were created from existing data and compared using t-tests and repeated measures ANOVAs. Qualitative interviews were conducted with participating CR staff then transcribed, coded, and analyzed for key themes. There were significant differences in body mass index and weight from pre-to post-CR within both hybrid and in-person groups. Despite this, CR staff believed exercise adherence was reduced in the hybrid group when compared to those in the in-person program. In the future, TBCR should be considered as an adjunct to in-person CR. Reluctance to prescribe exercise needs to be addressed through CR staff training.

Analyzing the effects of barriers to and facilitators of medication adherence among patients with cardiometabolic diseases: a structural equation modeling approach

Background

Based on the theoretical model of medication adherence (WHO, 2003), the aims of the study were (1) to develop and test a theory-based multidimensional model for the predictive power of barriers to and facilitators of medication adherence and (2) to identify the mediating effects of barriers to medication adherence on drug-related patient outcomes (barrier “MedAd- “: forget; facilitator “MedAd + ”: regular intake).

Methods

Within a cross-sectional study entitled “Increasing medication adherence to improve patient safety in cardiological rehabilitation (PaSiMed)”, the model was evaluated in structural analytical terms based on data collected online of N = 225 patients with cardiometabolic diseases. The revised “Freiburg questionnaire on medication adherence (FF-MedAd-R)" was used to measure the latent constructs (e.g., facilitator: communication; barrier: reservations).”

Results

The structural equation model proved to exhibit an appropriate data fit (RMSEA: .05; CFI: .92). For all first-order facilitators of medication adherence, a high proportion of variance (62–94%) could be explained by the second-order factor “Physician–patient relationship (PPR)”. All paths from “PPR” to the constructs depicting barriers to medication adherence showed significant negative effects. Facilitators (“MedAd + ”) and barriers (“MedAd-”) accounted for 20% and 12% of the variance, respectively, in global items of medication adherence. Whereas “Carelessness” showed a full mediation for “MedAd-”, ‘‘Reservations’’ showed a partial mediation for “MedAd + ”.

Conclusions

“PPR” is an important predictor of patient medication adherence. The results underline the importance of a trustful physician–patient relationship in reducing barriers and enhancing medication adherence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07987-3.

Acceptability and feasibility of the NPS MedicineWise mobile phone application in supporting medication adherence in patients with chronic heart failure: Protocol for a pilot study

INTRODUCTION

Heart failure (HF) is an increasing global concern. Despite evidence-based pharmacotherapy, morbidity and mortality remain high in HF. Medication non-adherence is a crucial factor in optimising clinical outcomes. A growing number of smartphone applications (apps) assist management. While evidence support their use to promote treatment adherence, apps alone may not be the solution. The objective of this pilot study is to assess the acceptability and feasibility of a tiered intervention added to the NPS MedicineWise dose reminder app (MedicineWise app) in supporting medication adherence in HF.

METHODS AND ANALYSIS

This prospective, single-blinded, randomised controlled trial will recruit 55 Australian patients with HF to be randomly assigned to either intervention (MedicineWise app + usual care) or control (usual care alone) arm. Control participants will remain unaware of the intervention throughout the study. At baseline, intervention participants will be instructed in the MedicineWise app. A reminder will then prompt medication administration at each dosing interval. If non-adherence is suggested from 24 hourly reports (critical medications) or 72 hours (non-critical medications), the individual/s will be escalated through a tiered, pharmacist-led intervention. The primary outcome will be the acceptability and feasibility of this approach in supporting adherence. Between-group comparison of the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) at baseline, 3 and 6 months will be used to measure the app's value in supporting adherence. Secondary outcome measures include self-reported medication adherence and knowledge, health-related quality of life, psychological wellbeing, signs and symptoms of HF, and medication and HF knowledge.

ETHICS AND DISSEMINATION

The protocol received ethics approval from Central Adelaide Clinical Human Research Ethics Committee (Protocol number R20190302) and University of South Australia Human Research Ethics Committee (Protocol number 202450). Findings will be disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry Clinical trial number: ACTRN12619000289112p (http://www.ANZCTR.org.au/ACTRN12619000289112p.aspx).

Investigating the Usability, Efficacy and Accuracy of a Medication Entering Software System for a Healthcare Robot

Purpose: This research aimed to evaluate medication software for a healthcare robot. Study I compared two software versions (RoboGen and RoboGen2) for system usability, speed and accuracy of medication entry; Study II evaluated system usability and community pharmacists' views of RoboGen2. Methods: Study I had a within-subjects experimental design and recruited 40 Health Sciences students to enter different, comparable sets of prescriptions into the two systems, in randomized order, within a limit of 15 min. Screen activity was recorded to observe prescription errors. Study II had a cross-sectional observational design and recruited 20 community pharmacists using convenience sampling. Pharmacists entered three prescriptions using RoboGen2. Participants in both studies completed the System Usability Scale (SUS) following each task. Study I participants completed a questionnaire on system preference, and Study II participants a semi-structured interview. Results: Study I participants preferred Robogen2 (p < 0.001) due to its sleek and modern layout, good flow, ease of use, and intuitive design. SUS scores [t (40) = -3.40, p = 0.002] and speed of medication entry favored Robogen2 (t = 3.65, p < 0.001). No significance was found in accuracy (t = 1.12, p = 0.27). In study 2, pharmacists rated the usability of RoboGen2 below average. Themes from interviews were navigation and streamlining the system, ease of use, and integration with pharmacy software systems. Conclusion: Adding safety features and better aesthetics can improve the usability and safety of a medication prescription system. Streamlining workflow and pre-populating data can increase speed of prescription entry without compromising patient safety. However, a better approach is integration with pre-existing pharmacy systems to reduce workload while incorporating safety features built into existing dispensing systems.

Integration of a smart multidose blister package for medication intake: A mixed method ethnographic informed study of older adults with chronic diseases

Smart adherence products are marketed to assist with medication management. However, little is known about their in-home integration by older adults. It is necessary to investigate the facilitators and barriers older adults face when integrating these products into their medication taking routines before effectiveness can be examined. The aim of this study was to (a) examine the integration of a smart multidose blister package and (b) understand medication intake behaviour of adults with chronic diseases using an integrated theoretical model comprised of the Technology Acceptance Model (TAM), Theory of Planned Behaviour (TPB) and Capacity, Opportunity, Motivation and Behaviour (COM-B) Model. An ethnographic-informed study was conducted with older adults using the smart multidose blister package to manage their medications for eight weeks. Data was collected quantitatively and qualitatively using in-home observations, photo-elicitation, field notes, semi-structured interviews, system usability scale (SUS) and net promoter scale (NPS). The interview guide was developed with constructs from the TAM, TPB and COM-B Model. Data were analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL) framework to generate themes and sub-themes which were mapped back to TAM, TBP and COM-B Model. Ten older adults with an average age of 76 years, of which 80% were female, participated in the study. On average, participants reported five medical conditions, while the average number of medications was 11.1. The mean SUS was 75.50 and overall NPS score was 0. Qualitative analysis identified three themes; (1) factors influencing medication intake behaviour (2) facilitators to the product use and, (3) barriers to the product use. The smart blister package was found to be easy to use and acceptable by older adults. Clinicians should assess an older adult’s medication intake behavior as well as barriers and facilitators to product use prior to recommending an adherence product for managing medications.

Technology-based interventions to improve adherence to antihypertensive medications - An evidence-based review

Background

Poor adherence to anti-hypertensive medications leads to poorly controlled blood pressure which is associated with worse cardiovascular outcomes. Emerging technologies may be utilised advantageously in interventions to improve adherence and reduce morbidity and mortality from poorly controlled hypertension.

Objective

To determine the efficacy of technology-based interventions in improving adherence to antihypertensive medications.

Methods

PubMed and EMBASE databases were searched using keywords and MeSH terms. Included studies met the following criteria: randomized controlled trial (RCT); adults ≥ 18 years old taking anti-hypertensives; intervention delivered by or accessed using a technological device or process; intervention designed to improve adherence.

Results

12 papers met inclusion criteria for the current review: 5 studies significantly improved adherence when compared to usual care; of these 5 studies, 2 had corresponding significant improvement in blood pressure. Successful interventions were: electronic medication bottle cap with audio-visual reminder; short message service (SMS) containing educational information (2 studies); reporting of self-measured blood pressure to a telephone-linked computer system; sending a video of every drug ingestion to obtain monetary rewards.

Conclusion

RCTs on technological interventions to improve adherence and those showing significant effect are rare. Some of the interventions show potential to be applied to other populations, especially if targeted at patients with poor adherence at baseline.

Voice Assistant Reminders and the Latency of Scheduled Medication Use in Older Adults With Pain: Descriptive Feasibility Study

Background

Pain is difficult to manage in older adults. It has been recommended that pain management in older adults should include both nonpharmacologic and pharmacologic strategies. Unfortunately, nonadherence to pain medication is more prevalent than nonadherence to any other chronic disease treatment. Technology-based reminders have some benefit for medication adherence, but adherence behavior outcomes have mostly been verified by self-reports.

Objective

We aimed to describe objective medication adherence and the latency of medication use after a voice assistant reminder prompted participants to take pain medications for chronic pain.

Methods

A total of 15 older adults created a voice assistant reminder for taking scheduled pain medications. A subsample of 5 participants were randomly selected to participate in a feasibility study, in which a medication event monitoring system for pain medications was used to validate medication adherence as a health outcome. Data on the subsample’s self-assessed pain intensity, pain interference, concerns and necessity beliefs about pain medications, self-confidence in managing pain, and medication implementation adherence were analyzed.

Results

In the 5 participants who used the medication event monitoring system, the overall latency between voice assistant reminder deployment and the medication event (ie, medication bottle cap opening) was 55 minutes. The absolute latency (before or after the reminder) varied among the participants. The shortest average time taken to open the cap after the reminder was 17 minutes, and the longest was 4.5 hours. Of the 168 voice assistant reminders for scheduled pain medications, 25 (14.6%) resulted in the opening of MEMS caps within 5 minutes of the reminder, and 107 (63.7%) resulted in the opening of MEMS caps within 30 minutes of the reminder.

Conclusions

Voice assistant reminders may help cue patients to take scheduled medications, but the timing of medication use may vary. The timing of medication use may influence treatment effectiveness. Tracking the absolute latency time of medication use may be a helpful method for assessing medication adherence. Medication event monitoring may provide additional insight into medication implementation adherence during the implementation of mobile health interventions.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

A review of features and characteristics of smart medication adherence products

Background

Smart medication adherence products (smart MAPs) capture and transmit real-time medication intake by using various means of connectivity, allowing for remote monitoring. Numerous such products with different features are available to address medication nonadherence. A comparison of the features of these products is needed for clinical decision-making. Therefore, the objective of this review was to compare smart MAPs available for in-home use.

Methods

We searched grey and published literature and videos to identify smart MAPs. To be considered smart, products required 2 features: connectivity (the ability for collected data to exist outside the physical device) and automaticity (the ability for data to be analyzed or processed automatically). Products were excluded if product descriptions were not available in English, not for in-home use and unable to dispense medications.

Results

Of the 51 products identified, 38 commercially available and 13 prototypes met the definition. Of these, 75% (n = 38) contained alarms, 24% (n = 12) were unit-dose, 63% (n = 32) were multidose, 43% (n = 22) had locking features, 41% (n = 21) were portable and 88% (n = 45) sent notifications to patients. The cost of marketed products, excluding subscriptions, ranged from $10 to $1500 USD. Some products required a monthly (n = 16) or yearly (n = 1) subscription ranging from $10 to $100 USD.

Discussion

There is a growing market of smart MAPs for in-home patient use with variable features. Clinicians can use these features to identify and recommend products according to the specific needs of their patients to address medication adherence. Can Pharm J (Ott) 2021;154:xx-xx.

Blood Pressure Control, Accessibility, and Adherence to Antihypertensive Medications: Patients Seeking Care in Two Hospitals in the Ashanti Region of Ghana

Hypertension is the second leading cause of death in Ghana, partly accounting for two-thirds of all medical admissions and more than 50% of deaths. This study aimed to comparatively evaluate adherence and accessibility to antihypertensive medications at two different levels of healthcare facilities in Kumasi, Ghana, and determine factors associated with medicine accessibility and adherence. A cross-sectional study involving outpatient department (OPD) hypertensive patients, 143 at KNUST Hospital (UHS) and 342 at Komfo Anokye Teaching Hospital (KATH), was conducted using a semistructured questionnaire. Correlations were drawn to evaluate the effect of accessibility and adherence on blood pressure control. A face-to-face interview was also conducted with relevant stakeholders involved in procurement of medicines. Blood pressure was uncontrolled in 50.4% (n = 72) of participants at UHS and 52.9% (n = 181) at KATH. With respect to medicine accessibility, 98.8% (n = 338) and 42.9% (n = 61) received at least one medication from the hospital pharmacy of KATH and UHS, respectively. Using MARS-10, 49.2% (n = 70) and 52.9% (n = 181) were nonadherent in UHS and KATH, respectively. There was a significant association between adherence and BP control at both UHS (p=0.038) and KATH (p=0.043). At UHS, there was a significant association between accessibility to medicines at the hospital and BP control (p=0.031), whilst at KATH, no significant association was observed (p=0.198). Supply chain practices and delays in payment by the NHIA affected accessibility to antihypertensive medications. Blood pressure control was inadequate among participants in both facilities. Accessibility to medicines was better at the tertiary facility compared to the secondary facility. Increased accessibility and adherence to antihypertensives were related to blood pressure control in both facilities. Good supply chain practices and prompt payment by the National Health Insurance Authority would enhance accessibility to antihypertensive medications.

Treatment Adherence in Chronic Conditions during Ageing: Uses, Functionalities, and Cultural Adaptation of the Assistant on Care and Health Offline (ACHO) in Rural Areas

The increasingly common scenario of an ageing population is related to a rise in the prevalence of problems associated with chronic conditions and comorbidities. Polypharmacy is frequent among this population, and it is a situation that can create medication management and adherence issues. This article introduces the features and functionalities of a voice assistant (Assistant on Health and Care Offline, ACHO) that aims to facilitate treatment adherence among elderly adults. Specifically adapted for its use in rural contexts, it does not require an Internet connection. Its development consisted of two stages: a first stage of problem diagnosis, in which the classic tools of ethnographic fieldwork were used, and a second stage of design implementing methodologies developed by Ambient Assisted Living (AAL) programmes. The main design characteristic of this new digital care system is that it is adapted to the needs of its end-users. It includes features such as voice customisation and the personal identification of medication, it can be connected to other digital devices, and information is introduced and supervised by healthcare professionals. These custom features introduce a safer medication administration procedure, improve supervision strategies, and increase patients' trust in the prescription process.

Prevalence of Drug-Related Problems and Complementary and Alternative Medicine Use in Malaysia: A Systematic Review and Meta-Analysis of 37,249 Older Adults

Drug-related problems (DRPs) in the elderly include polypharmacy, potentially inappropriate medications, nonadherence, and drug-related falls. In this systematic review and meta-analysis, the prevalence of DRPs and complementary and alternative medicine (CAM) use among the Malaysian elderly was estimated. PubMed, Scopus, Web of Science, and Google Scholar databases were searched to identify studies published since their inception up to 24 August 2020. A random-effects model was used to generate the pooled prevalence of DRPs along with its corresponding 95% confidence interval (CI). The heterogeneity of the results was estimated using the I² statistics, and Cochran’s Q test and sensitivity analyses were performed to confirm the robustness of the results. We identified 526 studies, 23 of which were included in the meta-analysis. (n = 29,342). The pooled prevalence of DRPs among Malaysian elderly was as follows: (1) polypharmacy: 49.5% [95% CI: 20.5–78.6], (2) potentially inappropriate medications: 28.9% [95% CI: 25.4–32.3], (3) nonadherence to medications: 60.6% [95% CI: 50.2–70.9], and (4) medication-related falls 39.3% [95% CI: 0.0–80.8]. Approximately one in two Malaysian elderly used CAM. The prevalence of polypharmacy and potentially inappropriate medications among the Malaysian elderly population was high, calling for measures and evidence-based guidelines to ensure the safe medication use.

Mapping the role of digital health technologies in the case detection, management, and treatment outcomes of neglected tropical diseases: a scoping review

BACKGROUND

Neglected tropical diseases (NTDs) are a diverse group of communicable diseases that principally impact the world's poorest people. The use of digital health technologies is an emerging and promising way to improve disease prevention, diagnosis, case detection, treatment delivery, and patient follow-up and facilitating health facility appointments thereby improving health outcomes. While the growing implementation of digital health technologies is evident, there is a lack of comprehensive evidence on the impact of digital health technologies in the control of NTDs. The main objective of this review was to map different pieces of evidence on the use of digital health technologies for case detection, management, and treatment outcome of the neglected tropical diseases.

METHODS

We conducted a scoping review guided by the Joanna Briggs Institute guidelines. The studies were searched using electronic databases like MEDLINE (PubMed), Science Direct, Cochrane Library, and manual searching engines. Two authors extracted the data and compared the results. Discrepancies were resolved by discussion or the third reviewer made the decision. We produced the distribution of geographical locations, residents (setting), types of publications, and digital health technologies used on neglected tropical diseases using tables and graphs.

FINDINGS

A total of 996 potentially relevant studies were generated from the initial search, and six studies were found to satisfy all the inclusion criteria and included in the final review. The review found that telehealth, eHealth, mHealth, telemedicine, and electronic health record were used digital health technologies to assess their impact on case detection, disease management, and treatment outcome of neglected tropical diseases. Mobile health was a feasible digital health technology for lymphatic filariasis patient identification and mHealth, eHealth, and electronic health records found to improve the service access, outcomes, and monitoring of visceral leishmaniasis at the community health system.

CONCLUSION

The scoping review identified that there were limited studies to see the impact of digital health technologies on case detection, management, and treatment outcomes for neglected tropical diseases. We also found that digital health technologies like ehealth, electronic medical linkage, telemed, and telehealth were practicable for patient identification, for treatment and diagnosis through contact with health professionals and teleconsultation, and support in improving health service delivery at the community-health system for managing the disease in both rural and urban settings.

Perceptions of community pharmacists to implementing technologies in the workplace: an exploratory study

Background The proliferation of different technologies in pharmacies has begun to change the role and work of pharmacists; however, while workplace integration of technologies has been shown to be beneficial, there are still barriers to their implementation. Few studies have investigated pharmacists' perceptions of these technologies. Objective To investigate the views of community pharmacists on the implementation of technologies in pharmacy practice. Setting Community pharmacies in Auckland, New Zealand. Methods Semi-structured interviews were conducted June-September 2018 with a convenience sample of 20 pharmacists. Interviews explored current medication management and technologies used to support this service, experiences with technologies, confidence in learning new technologies, and whether the introduction of technologies could solve any needs in pharmacy practice. Data were analysed using inductive thematic analysis. Main outcome measure Community pharmacists views on pharmacy technologies. Results Four key themes were identified: attitudes to existing medication management technologies, adapting to new technologies, acceptance of technology, and barriers to implementing technology in pharmacies. Pharmacists were accepting of technology to help with medication management and allowing them to provide more patient-centered care. Most pharmacists expressed confidence in using new technologies and viewed technology as a tool to address current limitations in their practice. Barriers to technology were cost, consequences of medication error, fear that technology may replace people, and an over-reliance on technology. Conclusion Community pharmacists made use of several types of technologies to promote medication management, including robotics. While mostly accepting of new technologies to streamline tasks and reduce error, pharmacists highlighted the importance of addressing barriers to technology implementation prior to workplace implementation.

Medication adherence support of an in-home electronic medication dispensing system for individuals living with chronic conditions: a pilot randomized controlled trial

BACKGROUND

Medication adherence is challenging for older adults due to factors such as the number of medications, dosing schedule, and the duration of drug therapy. The objective of this study was to examine the effectiveness of an in-home electronic medication dispensing system (MDS) on improving medication adherence and health perception in older adults with chronic conditions.

METHODS

A pilot Randomized Controlled Trial (RCT) was conducted using a two-arm parallel assignment model. The intervention group used an MDS as their medication management method. The control group continued to use their current methods of medication management. Block randomization was used to assign participants into the intervention or control group. The inclusion criteria included 1) English speaking 2) age 50 and over 3) diagnosed with one or more chronic condition(s) 4) currently taking five or more oral medications 5) City of Calgary resident. Participants were recruited from a primary care clinic in Alberta, Canada. The study was open-label where knowledge about group assigned to participants after randomization was not withheld. Medication adherence was captured over a continuous, six-month period and analyzed using Intention-to-Treat (ITT) analysis.

RESULTS

A total of 91 participants were assessed for eligibility and 50 were randomized into the two groups. The number of participants analyzed for ITT was 23 and 25 in the intervention and control group, respectively. Most of the demographic characteristics were comparable in the two groups except the mean age of the intervention group, which was higher compared to the control group (63.96 ± 7.86 versus 59.52 ± 5.93, p-value = 0.03). The average recorded adherence over 26 weeks was significantly higher in the intervention group than the control group (98.35% ± 2.15% versus 91.17% ± 9.76%, p < 0.01). The self-rated medication adherence in the intervention group also showed a significant increase from baseline to 6-month (Z=-2.65, p < 0.01). The control group showed a non-significant increase (Z=-1.79, p = 0.07).

CONCLUSION

The MDS can be an effective, long-term solution to medication non-adherence in older adults experiencing chronic conditions and taking multiple medications. The technology induces better consistency and improvement in medication taking behaviour than simple, non-technological intervention.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov on April 09, 2020 with identifier NCT04339296 .

Effectiveness of IT-based interventions on self-management in adult kidney transplant recipients: a systematic review

Background

Kidney transplant outcomes are broadly associated with transplant recipients’ capacity in following a complex and continuous self-management regimen. Health information technology has the potential to empower patients. This systematic review aimed to determine the impacts of IT-based interventions for self-management in kidney transplant recipients.

Methods

A comprehensive investigation was performed in MEDLINE (via PubMed) and EMBASE (via Scopus) in April 2019. Eligible studies were the randomized controlled trials which aimed to design an automated IT-based intervention. All English papers including adult kidney transplant recipients were included. To assess the clinical trial’s quality, Cochrane Collaboration’s assessment tool was employed. The articles were integrated based on category of outcomes, characteristics of interventions, and their impact. The interventions were classified based on the used IT-based tools, including smart phones, coverage tools, computer systems, and a combination of several tools. The impact of interventions was defined as: (1) positive effect (i.e. statistically significant), and (2) no effect (i.e. not statistically significant).

Results

A total of 2392 articles were retrieved and eight publications were included for full-text analysis. Interventions include those involving the use of computerized systems (3 studies), smart phone application (3 studies), and multiple components (2 studies). The studies evaluated 30 outcomes in total, including 24 care process and 6 clinical outcomes. In 18 (80%) out of 30 outcomes, interventions had a statistically significant positive effect, 66% in process and 33% in clinical outcomes.

Conclusions

IT-based interventions (e.g. mobile health applications, wearable devices, and computer systems) can improve self-management in kidney transplant recipients (including clinical and care process outcomes). However, further evaluation studies are required to quantify the impact of IT-based self-management interventions on short- and long-term clinical outcomes as well as health care costs and patients' quality of life.

Medication management and adherence during the COVID-19 pandemic: Perspectives and experiences from low-and middle-income countries

The current coronavirus disease 2019 (COVID-19) pandemic is placing a huge strain on health systems worldwide. Suggested solutions like social distancing and lockdowns in some areas to help contain the spread of the virus may affect special patient populations like those with chronic illnesses who are unable to access healthcare facilities for their routine care and medicines management. Retail pharmacy outlets are the likely facilities for easy access by these patients. The contribution of community pharmacists in these facilities to manage chronic conditions and promote medication adherence during this COVID-19 pandemic will be essential in easing the burden on already strained health systems. This paper highlights the pharmaceutical care practices of community pharmacists for patients with chronic diseases during this pandemic. This would provide support for the call by the WHO to maintain essential services during the pandemic, in order to prevent non-COVID disease burden on healthcare systems particularly in low-and middle-income countries.

Smartphone-based application to improve medication adherence in patients after surgical coronary revascularization

BACKGROUND

Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG.

METHODS

The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle.

RESULTS

A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months).

CONCLUSIONS

A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes.

Medication adherence for atrial fibrillation patients: triangulating measures from a smart pill bottle, e-prescribing software, and patient communication through the electronic health record

OBJECTIVE

Our primary objectives were to examine adherence rates across two technologies (e-prescribing software and smart pill bottle) with cross-validation from alert-triggered messaging within the patient electronic health record (EHR) portal and to explore the benefits and challenges faced by atrial fibrillation (AF) patients in using a smart pill bottle.

MATERIALS AND METHODS

We triangulated the rate of oral anticoagulant medication adherence among 160 AF patients over 6 months using an EHR in combination with data from the AdhereTech© Wireless Smart Pill Bottle and Surescripts©. In addition, we collected qualitative feedback on patients' Smart Pill Bottle usage through structured interviews with 153 participants.

RESULTS

Patients maintained an average adherence rate of 90.0% according to the smart pill bottle; however, when dose misses were calibrated based on patient or provider feedback, the adjusted adherence was 93.6%. Surescripts adherence rates for refills were 92.2%. Participants generally found the bottle easy to operate but suggested that its size and functionality did not fit seamlessly into their existing routine, as many used weekly pill organizers to manage multiple medications.

DISCUSSION

Though each method of tracking adherence has positive and negative attributes, combining them and seeking patient feedback may help capture a more accurate adherence rate than any single technological intervention. Technologies may have different design considerations for research and consumer use.

CONCLUSION

Overall, these technologies provide useful but imperfect adherence data for research purposes, and smart pill bottles could be improved with patient-centered design.

LAY SUMMARY

Medication adherence is very important for those with chronic health issues. For those with heart disease, medication adherence not only offers opportunities for improving quality of life, but it also can be life-saving. Nonetheless, many patients with heart disease, including those with atrial fibrillation (the target group for this study) do not take their medications regularly. As technologies advance, there is unprecedented opportunity to track patients' medication adherence through various methods, which might provide motivation and information to patients as they make daily choices about medication use. In this study, we cross-referenced the results of two of these measures over 6 months-a smart pill bottle, which we used to track pill bottle openings, and e-prescribing software, which we used to track medication refills. We also supplemented these measures with nurse-patient communication via the EHR messaging portal to record exceptions (eg, travel and medication changes) and interviewed patients about their medication use during the 6-month trial. Overall, the tracking technologies worked relatively well to track patient (n = 160) medication behavior; however, they did not capture exceptions. Hence, triangulating data from different sources, with a patient feedback loop, appears critical for gathering accurate data on medication adherence.

How Behavior Change Strategies are Used to Design Digital Interventions to Improve Medication Adherence and Blood Pressure Among Patients With Hypertension: Systematic Review

BACKGROUND

Information on how behavior change strategies have been used to design digital interventions (DIs) to improve blood pressure (BP) control or medication adherence (MA) for patients with hypertension is currently limited.

OBJECTIVE

Hypertension is a major modifiable risk factor for cardiovascular diseases and can be controlled with appropriate medication. Many interventions that target MA to improve BP are increasingly using modern digital technologies. This systematic review was conducted to discover how DIs have been designed to improve MA and BP control among patients with hypertension in the recent 10 years. Results were mapped into a matrix of change objectives using the Intervention Mapping framework to guide future development of technologies to improve MA and BP control.

METHODS

We included all the studies regarding DI development to improve MA or BP control for patients with hypertension published in PubMed from 2008 to 2018. All the DI components were mapped into a matrix of change objectives using the Intervention Mapping technique by eliciting the key determinant factors (from patient and health care team and system levels) and targeted patient behaviors.

RESULTS

The analysis included 54 eligible studies. The determinants were considered at two levels: patient and health care team and system. The most commonly described determinants at the patient level were lack of education, lack of self-awareness, lack of self-efficacy, and forgetfulness. Clinical inertia and an inadequate health workforce were the most commonly targeted determinants at the health care team and system level. Taking medication, interactive patient-provider communication, self-measurement, and lifestyle management were the most cited patient behaviors at both levels. Most of the DIs did not include support from peers or family members, despite its reported effectiveness and the rate of social media penetration.

CONCLUSIONS

This review highlights the need to design a multifaceted DI that can be personalized according to patient behavior(s) that need to be changed to overcome the key determinant(s) of low adherence to medication or uncontrolled BP among patients with hypertension, considering different levels including patient and healthcare team and system involvement.

Perspectives of older adults, caregivers, and healthcare providers on frailty screening: a qualitative study

BACKGROUND

Screening is an important component of understanding and managing frailty. This study examined older adults', caregivers' and healthcare providers' perspectives on frailty and frailty screening.

METHODS

Fourteen older adults and caregivers and 14 healthcare providers completed individual or focus group interviews. Interviews were audio recorded, transcribed verbatim, and analyzed using line-by-line emergent coding techniques and inductive thematic analysis.

RESULTS

The interviews yielded several themes with associated subthemes: definitions and conceptualizations of frailty, perceptions of "frail", factors contributing to frailty (physical,, cognitive, social, pharmaceutical, nutritional), and frailty screening (current practices, tools in use, limitations, recommendations).

CONCLUSION

Older adults, caregivers and healthcare providers have similar perspectives regarding frailty; both identified frailty as multi-dimensional and dynamic. Healthcare providers need clear "next steps" to provide meaning to frailty screening practices, which may improve use of frailty-screening tools.

Users' Perceptions of an in-Home Electronic Medication Dispensing System: A Qualitative Study

Background

Managing and taking multiple medications as prescribed can be a difficult task for older adults. In-home medication dispensing technologies could help enhance care. The objective of the study was to determine users’ perspectives on a medication dispensing system (MDS) in supporting medication adherence of individuals living at home with chronic conditions.

Methods

This analysis is a part of a randomized controlled trial on an MDS in a Western Canadian province. We interviewed participants who were recruited into the intervention group and started using an MDS. A maximum variation purposive sampling was used to select interview participants based on age, number of medications, and health conditions.

Results

Thirteen participants were interviewed; most participants were females (n=11) and the average age was 63.7 (SD=8.2) years with an average of 8.9 (SD=3.6) prescribed medications. The most common health conditions were hypertension, diabetes, arthritis, and anxiety and depression. Four main themes emerged from thematic analysis: MDS acceptability, MDS patient support, need for the MDS, and areas of technology improvement. Most of the participants found the MDS to be acceptable and convenient, although privacy and security was an issue for some older adults. Audio and visual reminders and pre-organized medication supported participants’ medication adherence and independence in daily routines. The perceived necessity of the MDS was split among participants with cost being one of the main concerns. Areas of technology improvement included the hard-to-open plastic medication packets and the sometimes inexact recording of medication adherence by the MDS if medications were dispensed on behalf of the patients.

Conclusion

The MDS is an acceptable tool for improving medication management and adherence in older adults. Increased medication adherence may lead to patient and system-level benefits.

Adherence to lifestyle changes after coronary artery bypass graft: Outcome of preoperative peer education

OBJECTIVE

This study was done to investigate the effect of preoperative peer education on patients' adherence to medication and lifestyle changes after Coronary Artery Bypass Graft (CABG).

METHODS

In this randomized clinical trial, the peers of CABG patients conducted preoperative educational sessions at the ward in groups of 4-5 (n = 36) while the control group (n = 34) received routine education by a nurse. Adherence of both groups to medication and recommendations for lifestyle modification including physical activity, smoking, and diet was measured one and two months after discharge.

RESULTS

A multivariate analysis of co-variance showed the significant effect of peer education on adherence (F = 32.586, p < 0.001; η² = 0.671). Univariate ANCOVA revealed a significant difference in adherence to diet between the two groups (F = 62.316, p = 0 0.0001; η² = 0.482). Based on the repeated measures ANOVA, peer education significantly improved the CABG patients' adherence to diet (F = 55.373, p = 0.0001) and their total adherence (F = 9.911, p = 0.002) compared to the control group.

CONCLUSION

Preoperative peer education had a significant effect on improving CABG patients' adherence to lifestyle changes after hospital discharge.

PRACTICE IMPLICATION

Peer education can be used as an effective method to improve the CABG patients ' adherence to lifestyle changes.

A pilot study of the S-MAP (Solutions for Medications Adherence Problems) intervention for older adults prescribed polypharmacy in primary care: study protocol

Background

Adhering to multiple medications as prescribed is challenging for older patients (aged ≥ 65 years) and a difficult behaviour to improve. Previous interventions designed to address this have been largely complex in nature but have shown limited effectiveness and have rarely used theory in their design. It has been recognised that theory (‘a systematic way of understanding events or situations’) can guide intervention development and help researchers better understand how complex adherence interventions work. This pilot study aims to test a novel community pharmacy-based intervention that has been systematically developed using the Theoretical Domains Framework (12-domain version) of behaviour change.

Methods

As part of a non-randomised pilot study, pharmacists in 12 community pharmacies across Northern Ireland (n = 6) and London, England (n = 6), will be trained to deliver the intervention to older patients who are prescribed ≥ 4 regular medicines and are non-adherent (self-reported). Ten patients will be recruited per pharmacy (n = 120) and offered up to four tailored one-to-one sessions, in the pharmacy or via telephone depending on their adherence, over a 3–4-month period. Guided by an electronic application (app) on iPads, the intervention content will be tailored to each patient’s underlying reasons for non-adherence and mapped to the most appropriate solutions using established behaviour change techniques. This study will assess the feasibility of collecting data on the primary outcome of medication adherence (self-report and dispensing data) and secondary outcomes (health-related quality of life and unplanned hospitalisations). An embedded process evaluation will assess training fidelity for pharmacy staff, intervention fidelity, acceptability to patients and pharmacists and the intervention’s mechanism of action. Process evaluation data will include audio-recordings of training workshops, intervention sessions, feedback interviews and patient surveys. Analysis will be largely descriptive.

Discussion

Using pre-defined progression criteria, the findings from this pilot study will guide the decision whether to proceed to a cluster randomised controlled trial to test the effectiveness of the S-MAP intervention in comparison to usual care in community pharmacies. The study will also explore how the intervention components may work to bring about change in older patients’ adherence behaviour and guide further refinement of the intervention and study procedures.

Trial registration

This study is registered at ISRCTN: 10.1186/ISRCTN73831533

Electronic Health Record-Based Strategy to Promote Medication Adherence Among Patients With Diabetes: Longitudinal Observational Study

Background

Poor medication adherence is common; however, few mechanisms exist in clinical practice to monitor how patients take medications in outpatient settings.

Objective

This study aimed to pilot test the Electronic Medication Complete Communication (EMC²) strategy, a low-cost, sustainable approach that uses functionalities within the electronic health record to promote outpatient medication adherence and safety.

Methods

The EMC² strategy was implemented in 2 academic practices for 14 higher-risk diabetes medications. The strategy included: (1) clinical decision support alerts to prompt provider counseling on medication risks, (2) low-literacy medication summaries for patients, (3) a portal-based questionnaire to monitor outpatient medication use, and (4) clinical outreach for identified concerns. We recruited adult patients with diabetes who were prescribed a higher-risk diabetes medication. Participants completed baseline and 2-week interviews to assess receipt of, and satisfaction with, intervention components.

Results

A total of 100 patients were enrolled; 90 completed the 2-week interview. Patients were racially diverse, 30.0% (30/100) had a high school education or less, and 40.0% (40/100) had limited literacy skills. About a quarter (28/100) did not have a portal account; socioeconomic disparities were noted in account ownership by income and education. Among patients with a portal account, 58% (42/72) completed the questionnaire; 21 of the 42 patients reported concerns warranting clinical follow-up. Of these, 17 were contacted by the clinic or had their issue resolved within 24 hours. Most patients (33/38, 89%) who completed the portal questionnaire and follow-up interview reported high levels of satisfaction (score of 8 or greater on a scale of 1-10).

Conclusions

Findings suggest that the EMC² strategy can be reliably implemented and delivered to patients, with high levels of satisfaction. Disparities in portal use may restrict intervention reach. Although the EMC² strategy can be implemented with minimal impact on clinic workflow, future trials are needed to evaluate its effectiveness to promote adherence and safety.

Descriptive study of homeless patients' perceptions that affect medication adherence

PURPOSE

Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported.

METHODS

A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes.

RESULTS

Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects.

CONCLUSION

In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.

A Pilot Study of the Effect of an Educational Web Application on Asthma Control and Medication Adherence

BACKGROUND

An Asthma Adherence Pathway (AAP) application, which is an Internet application that combines patient and clinician education strategies to promote adherence to asthma therapy, has been developed.

OBJECTIVE

The primary objective of this pilot study was to evaluate the effectiveness of the AAP application with electronic adherence monitors on asthma control. Secondary objectives evaluated the effect of AAP and monitors on medication adherence, asthma symptoms, quality of life, psychosocial factors, and barriers to treatment.

METHODS

Adult patients with asthma were randomly assigned either to intervention (n = 19) or control (n = 20) groups in this 3-month prospective study, and they completed the Asthma Control Questionnaire (ACQ). Intervention patients completed the AAP software and were given barrier-specific motivational interviewing adherence strategies and a SmartTrack device to monitor mometasone furoate/formoterol (MF/F) use. Clinicians in the interventional group received adherence management training. Interventional patients were given feedback regarding adherence findings at each visit. Treatment adherence was determined by the mean of 4 measures of doses taken over 3 months. Control patients were not monitored for MF/F adherence.

RESULTS

The mean MF/F adherence in the intervention group was 81%. The intervention and control groups did not differ on the mean baseline ACQ. Thirteen intervention patients achieved the minimal important difference (defined as an improvement ≥0.5 units on the ACQ) compared with 6 control patients (P = .016). The intervention group showed greater improvement in the ACQ (0.75) than the control group (0.19) representing a moderate-to-large effect size of d = 0.638.

CONCLUSIONS

The AAP was effective in promoting adherence and helped to improve asthma control. These findings provide preliminary validation of the AAP model.

Effectiveness of a reminder card system versus a mobile application to improve medication adherence among asthma patients in a tertiary care hospital

OBJECTIVES

Asthma is a major public health problem affecting a large number of individuals worldwide. The effectiveness of medications depends on adherence to the instructions of the prescriber. This study aimed to assess and compare the effectiveness of a reminder card system versus a mobile application to improve the medication adherence of asthma patients in a tertiary care hospital.

METHODS

This prospective interventional study was conducted at a tertiary care hospital. The scores were obtained from the Morisky medication adherence scale.

RESULTS

In the card group, comparison of the baseline and follow-up scores for medication adherence showed a mean difference of 3.44, p = 0.001. The application group showed a mean difference of 4.02, p = 0.001, which reflects a highly significant association. Comparison of the effectiveness of reminder cards and the mobile application showed a mean difference of 0.72, p = 0.088 (>0.05) at baseline, showing no significant difference in adherence status before intervention. After intervention there was a mean difference of 0.86 (p = 0.001 < 0.05), indicating a significant difference in adherence status.

CONCLUSION

Provision of proper interventional tools can improve asthma medication adherence. In this study, the mobile application was found to be more effective than medication reminder cards.

The interaction of dyslipidaemia with glycaemia in an adult population study

Purpose

Individuals with dysglycaemic are prone to dyslipidaemia. Understanding the dyslipidaemic status of dysglycaemic individuals is essential for monitoring and early prevention. The aim was to assess the control of lipidaemia by glycaemic status in a representative adult population.

Methods

A retrospective health examination survey was performed on a sample of adults (n = 3947) in Malta in 2014-6. Sociodemographic data, biochemistry blood tests and anthropometric measurements were gathered. Statistical analysis was performed to evaluate the lipidaemic status and its control across the glycaemic spectrum (normoglycemic, impaired fasting glucose individuals, new diabetics and known diabetics).

Results

The prevalence of uncontrolled dyslipidaemia was 7.75% (CI 95%: 6.69-8.63), among whom 6.97% (CI 95%: 6.21-7.81) were naïve dyslipidaemic. A progressive elevation in both LDL-C and total cholesterol but not triglycerides was present among uncontrolled dyslipidaemia individuals across the glycaemic spectrum. Global dyslipidaemia was present in 19.26% (CI 95%: 18.05-20.52) of the total general population and in 46.59% (CI 95%: 40.49-52.69%) of known diabetics. Most individuals irrespective of lipid status were normoglycaemic.

Conclusions

Dyslipidaemia occurs in the presence of insulin resistance. Dyslipidaemia predominated in the normoglycaemic state irrespective of statins use, indicating the need to manage dyslipidaemia prior to dysglycaemia.

A survey of mobile technology usage and desires by caregivers of children with cancer

BACKGROUND

The use of mobile health (mHealth) has grown exponentially, even by caregivers of vulnerable populations. The study objective was to understand mobile technology usage, barriers, and desires by caregivers of children with cancer.

PROCEDURE

Paper surveys were mailed to caregivers of children diagnosed with cancer at Riley Hospital for Children between June 2015 and June 2017. The survey contained 13 questions, both fixed and open-ended, and was sent in both English and Spanish up to three times.

RESULTS

Respondents (n = 121) were primarily parents (93.2%), median age was 40.7 years (range 23-63), and most were white, non-Hispanic (74.4%). The majority made under $100,000 annual household income (72.9%) and had an education of at least some college or greater (74.5%). Nearly all owned a smart phone (99.2%) and most (61.2%) owned a tablet. Among operating systems, the majority used iOS (62.8%), while 49.6% used Android. About a third (37.1%) reported no barriers to mobile technology use, but 22.4% experienced "data limitations." Overall, 86.2% wanted at least one medical management website/app: medical knowledge (61.2%), symptom tracking/management (49.1%), and medication reminders (44.8%). Further, 62.1% wanted access to child's medical record and 58.6% wanted communication with medical providers. Lower education was significantly associated with experiencing phone/plan barriers (P = 0.008).

CONCLUSION

The majority of caregivers of children with cancer use mobile technology with minimal barriers; future research should focus on designing an mHealth tool to address the medical management needs by caregivers of children with cancer.

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

The Digital Drag and Drop Pillbox: Design and Feasibility of a Skill-based Education Model to Improve Medication Management

Objective:

We present the design and feasibility testing for the “Digital Drag and Drop Pillbox” (D-3 Pillbox), a skill-based educational approach that engages patients and providers, measures performance, and generates reports of medication management skills.

Methods:

A single-cohort convenience sample of patients hospitalized with heart failure was taught pill management skills using a tablet-based D-3 Pillbox. Medication reconciliation was conducted, and aptitude, performance (% completed), accuracy (% correct), and feasibility were measured.

Results:

The mean age of the sample (n = 25) was 59 (36–89) years, 50% were women, 62% were black, 46% were uninsured, 46% had seventh-grade education or lower, and 31% scored very low for health literacy. However, most reported that the D-3 Pillbox was easy to read (78%), easy to repeat-demonstrate (78%), and comfortable to use (tablet weight) (75%). Accurate medication recognition was achieved by discharge in 98%, but only 25% reported having a “good understanding of my responsibilities.”

Conclusions:

The D-3 Pillbox is a feasible approach for teaching medication management skills and can be used across clinical settings to reinforce skills and medication list accuracy.

Nonadherence to statins: individualized intervention strategies outside the pill box

Poor adherence to statin therapy is linked to significantly increased risk of cardiovascular events and death. Unfortunately, adherence to statins is far from optimal. This is an alarming concern for patients prescribed potentially life-saving cholesterol-lowering medication, especially for those at high risk of cardiovascular events. Research on statin adherence has only recently garnered broader attention; hence, major reasons unique to adherence to statin therapy need to be identified as well as suggestions for countermeasures. An integrated approach to minimizing barriers and enhancing facilitation at the levels of the patient, provider, and health system can help address adherence issues. Health care professionals including physicians, pharmacists, and nurses have an obligation to improve patient adherence, as routine care. In order to achieve sustained results, a multifaceted approach is indispensable.

Hospital Variation in Adherence Rates to Secondary Prevention Medications and the Implications on Quality

BACKGROUND

Medication adherence is important to improve the long-term outcomes after acute myocardial infarction (MI). We hypothesized that there is significant variation among US hospitals in terms of medication adherence after MI, and that patients treated at hospitals with higher medication adherence after MI will have better long-term cardiovascular outcomes.

METHODS

We identified 19 704 Medicare patients discharged after acute MI from 347 US hospitals participating in the ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines) from January 2, 2007, to October 1, 2010. Using linked Medicare Part D prescription filling data, medication adherence was defined as proportion of days covered >80% within 90 days after discharge. Cox proportional hazards modeling was used to compare 2-year major adverse cardiovascular events among hospitals with high, moderate, and low 90-day medication adherence.

RESULTS

By 90 days after MI, overall rates of adherence to medications prescribed at discharge were 68% for β-blockers, 63% for statins, 64% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 72% for thienopyridines. Adherence to these medications up to 90 days varied significantly among hospitals: β-blockers (proportion of days covered >80%; 59% to 75%), statins (55% to 69%), thienopyridines (64% to 77%), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (57% to 69%). Compared with hospitals in the lowest quartile of 90-day composite medication adherence, hospitals with the highest adherence had lower unadjusted and adjusted 2-year major adverse cardiovascular event risk (27.5% versus 35.3%; adjusted hazard ratio, 0.88; 95% confidence interval, 0.80-0.96). High-adherence hospitals also had lower adjusted rates of death or readmission (hazard ratio, 0.90; 95% confidence interval, 0.85-0.96), whereas there was no difference in mortality after adjustment.

CONCLUSIONS

Use of secondary prevention medications after discharge varies significantly among US hospitals and is inversely associated with 2-year outcomes. Hospitals may improve medication adherence after discharge and patient outcomes through better coordination of care between inpatient and outpatient settings.

Older adults and technology: in telehealth, they may not be who you think they are

When we established an emergency department-based telemedicine program, we assumed that many older patients would be skeptical of the new technology and choose not to participate. Our assumption was incorrect. Of the 1052 patients we evaluated in the first several months, 355 (33%) were 60, 2 were 99. Satisfaction and quality assessment scores among older patients were similar to those for younger patients. Many of these older patients demonstrated flexibility and interest in the novel use of technology. Our emergency department-based telemedicine program resulted in safe and satisfactory care and was readily accepted by our older patients.