Patient-Centered Tablet Application for Improving Medication Adherence after a Drug-Eluting Stent

Adherence to dual antiplatelet therapy after coronary stenting: A study conducted at two Vietnamese hospitals

Introduction: Adherence to dual antiplatelet therapy (DAPT) is critical after drug-eluting stent(DES) placement. We aimed to assess patient’s knowledge, rates of DAPT adherence, trends in DAPT use over time, and patient‐level factors associated with nonadherence in the patient with acute coronary syndrome (ACS). Methods: ACS patients who received one or more DES between May and September 2018from two hospitals in Vietnam and used DAPT after stent placement were eligible for a direct interview to assess patient’s knowledge on disease and DAPT. Telephone interviews were conducted one, three, and six months following discharge. Nonadherence was defined as premature discontinuation of DAPT. Factors related to nonadherent patients were analyzed using the chi-square test. Results: Of the 200 patients identified, 154 (77%) participated. Of the ten questions related to knowledge, the mean score of correct answers was 8.2 ± 2.3, and 71.7% had good knowledge.Adherence to DAPT was high at one month (94.2%) but declined by three months (44.2%) and then by six months (46.8%). Aspirin adherence was 99.3%-100% throughout. Three factors associated with nonadherence of DAPT following DES placement by six months included: rural location, linactive occupation, and inadequate knowledge on disease and DAPT (p<0.05). Conclusion: DAPT adherence is high at one month but is suboptimal at three and six months.Factors associated with the nonadherence of DAPT will be helpful in the planning of patient education strategies.

Effects of the Interactive Web-Based Video "Mon Coeur, Mon BASIC" on Drug Adherence of Patients With Myocardial Infarction: Randomized Controlled Trial

BACKGROUND

Secondary prevention strategies after acute coronary syndrome (ACS) presentation with the use of drug combinations are essential to reduce the recurrence of cardiovascular events. However, lack of drug adherence is known to be common in this population and to be related to treatment failure. To improve drug adherence, we developed the "Mon Coeur, Mon BASIC" video. This online video has been specifically designed to inform patients about their disease and their current medications. Interactivity has been used to increase patient attention, and the video can also be viewed on smartphones and tablets.

OBJECTIVE

The objective of this study was to assess the long-term impact of an informative web-based video on drug adherence in patients admitted for an ACS.

METHODS

This randomized study was conducted with consecutive patients admitted to University Hospital of Lausanne for ACS. We randomized patients to an intervention group, which had access to the web-based video and a short interview with the pharmacist, and a control group receiving usual care. The primary outcome was the difference in drug adherence, assessed with the Adherence to Refills and Medication Scale (ARMS; 9 multiple-choice questions, scores ranging from 12 for perfect adherence to 48 for lack of adherence), between groups at 1, 3, and 6 months. We assessed the difference in ARMS score between both groups with the Wilcoxon rank sum test. Secondary outcomes were differences in knowledge, readmissions, and emergency room visits between groups and patients' satisfaction with the video.

RESULTS

Sixty patients were included at baseline. The median age of the participants was 59 years (IQR 49-69), and 85% (51/60) were male. At 1 month, 51 patients participated in the follow-up, 50 patients participated at 3 months, and 47 patients participated at 6 months. The mean ARMS scores at 1 and 6 months did not differ between the intervention and control groups (13.24 vs 13.15, 13.52 vs 13.68, respectively). At 3 months, this score was significantly lower in the intervention group than in the control group (12.54 vs 13.75; P=.03). We observed significant increases in knowledge from baseline to 1 and 3 months, but not to 6 months, in the intervention group. Readmissions and emergency room visits have been very rare, and the proportion was not different among groups. Patients in the intervention group were highly satisfied with the video.

CONCLUSIONS

Despite a lower sample size than we expected to reach, we observed that the "Mon Coeur, Mon BASIC" web-based interactive video improved patients' knowledge and seemed to have an impact on drug adherence. These results are encouraging, and the video will be offered to all patients admitted to our hospital with ACS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03949608; https://clinicaltrials.gov/ct2/show/NCT03949608.

Diabetes to Go-Inpatient: Pragmatic Lessons Learned from Implementation of Technology-Enabled Diabetes Survival Skills Education Within Nursing Unit Workflow in an Urban, Tertiary Care Hospital

BACKGROUND

Diabetes survival skills education (DSSE) focuses on core knowledge and skills necessary for safe, effective, short-term diabetes self-care. Inpatient DSSE delivery approaches are needed. Diabetes to Go (D2Go) is an evidence-based DSSE program originally designed for outpatients.

METHODS

Implementation science principles were used to redesign D2Go for delivery by staff on medicine and surgery units in a tertiary care hospital to adults with type 2 diabetes (T2DM) using a tablet-based e-learning platform. Implementation efficacy was evaluated from staff and patient engagement perspectives. The Practical, Robust Implementation and Sustainability Model (PRISM) guided redesign. The team conducted qualitative evaluation (implementation barriers and facilitators); program redesign (via stakeholder feedback and education and human factors principles); implementation design for tablet delivery and patient engagement by unit staff; and a prospective implementation feasibility study.

RESULTS

Among 596 T2DM patients identified on three medical/surgical units, 415 (69.6%) were program eligible. Of those eligible, 59 (14.2%) received, accessed, and engaged with the platform; and among those, 43 (72.9%) completed the intervention, representing just 10.4% of those eligible. Multilevel implementation barriers were encountered: staff (receptivity, time, production pressures, culture); process (electronic health record [EHR] integration, patient identification, data tracking, bedside delivery); and patient (receptivity, acuity, availability, accessibility). Most completers required technology support.

CONCLUSION

Time constraints, limited EHR integration, and patient barriers markedly impeded implementation of the delivery of diabetes education at the bedside, despite stated staff interest. As a result, uptake and adoption of a tablet-based DSSE e-learning program in a high-acuity care setting was limited.

Development and Evaluation of a Tailored Mobile Health Intervention to Improve Medication Adherence in Black Patients With Uncontrolled Hypertension and Type 2 Diabetes: Pilot Randomized Feasibility Trial

BACKGROUND

Research has underscored the need to develop socioculturally tailored interventions to improve adherence behaviors in minority patients with hypertension (HTN) and type 2 diabetes (T2D). Novel mobile health (mHealth) approaches are potential methods for delivering tailored interventions to minority patients with increased cardiovascular risk.

OBJECTIVE

This study aims to develop and evaluate the acceptability and preliminary efficacy of a tailored mHealth adherence intervention versus attention control (AC) on medication adherence, systolic blood pressure (SBP), diastolic blood pressure (DBP), and hemoglobin A1c (HbA1c) at 3 months in 42 Black patients with uncontrolled HTN and/or T2D who were initially nonadherent to their medications.

METHODS

This was a two-phase pilot study consisting of a formative phase and a clinical efficacy phase. The formative phase consisted of qualitative interviews with 10 members of the target patient population (7/10, 70% female; mean age 65.8 years, SD 5.6) to tailor the intervention based on the Information-Motivation-Behavioral skills model of adherence. The clinical efficacy phase consisted of a 3-month pilot randomized controlled trial to evaluate the tailored mHealth intervention versus an AC. The tablet-delivered intervention included a tailoring survey, an individualized adherence profile, and a personalized list of interactive adherence-promoting modules, whereas AC included the tailoring survey and health education videos delivered on the tablet. Acceptability was assessed through semistructured exit interviews. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale, whereas blood pressure and HbA1c were assessed using automated devices.

RESULTS

In phase 1, thematic analysis of the semistructured interviews revealed the following 5 major barriers to adherence: disruptions in daily routine, forgetfulness, concerns about adverse effects, preference for natural remedies, and burdens of medication taking. Patients recommended the inclusion of modules that address improving patient-provider communication, peer vignettes, and stress reduction strategies to facilitate adherence. A total of 42 Black patients (23/42, 55% male; mean age 57.6 years, SD 11.1) participated in the clinical efficacy pilot trial. At 3 months, both groups showed significant improvements in adherence (mean 1.35, SD 1.60; P<.001) and SBP (-4.76 mm Hg; P=.04) with no between-group differences (P=.50 and P=.10). The decreases in DBP and HbA1c over time were nonsignificant (-1.97 mm Hg; P=.20; and -0.2%; P=.45, respectively). Patients reported high acceptability of the intervention for improving their adherence.

CONCLUSIONS

This pilot study demonstrated preliminary evidence on the acceptability of a tailored mHealth adherence intervention among a sample of Black patients with uncontrolled HTN and T2D who were initially nonadherent to their medications. Future research should explore whether repeated opportunities to use the mHealth intervention would result in improvements in behavioral and clinical outcomes over time. Modifications to the intervention as a result of the pilot study should guide future efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01643473; http://clinicaltrials.gov/ct2/show/ NCT01643473.

Elderly Medication Adherence Intervention Using the My Interventional Drug-Eluting Stent Educational App: Multisite Randomized Feasibility Trial

BACKGROUND

A lifesaving treatment for myocardial infarction is the placement of a stent in a closed or obstructed coronary artery. The largest modifiable risk factor after receiving a stent is medication adherence to Dual AntiPlatelet Therapy, a combination of P2Y12 inhibitors and aspirin.

OBJECTIVE

This study aimed to determine the acceptability of a protocol and an intervention using the My Interventional Drug-Eluting Stent Educational App (MyIDEA) and to evaluate medication adherence using the proportion of days covered (PDC) and platelet activation tests in a multisite randomized controlled trial.

METHODS

Potential participants who received a post percutaneous coronary intervention (PCI) procedure with a drug-eluting stent were approached. All patients older than 50 years and who spoke English were recruited. Participants were recruited, baseline demographics were collected, and the Hospital Anxiety and Depression Scale (HADS), Rapid Estimate of Adult Literacy in Medicine-Short Form, Burden-Benefit questionnaire, 36-Item Short Form Health Survey, and PCI knowledge questionnaire were administered. Block randomization was used to randomize participants to either usual care or MyIDEA supplementation. MyIDEA is a personalized educational intervention based on the Kolb experiential learning theory using patient narratives for education. During the visits, participants' blood was collected to measure platelet suppression from medication. During the second and third encounters, the Morisky medication adherence score and cardiology outcomes were measured. The study was conducted at the University of Illinois Hospital and John H Stroger Jr Cook County Hospital with appropriate ethical approvals. Platelet suppression was measured through aspirin reactive units and P2Y12 reactive units. Medication adherence was measured using the PDC. The analysis team was blinded to the participants' group membership. The primary outcome was a feasibility analysis of recruitment and retention.

RESULTS

The mean age of participants was 60.4 years (SD 7.1); the majority of patients were black and non-Hispanic. The majority of patients' reading levels were seventh grade or above, and they were not very familiar with other electronic devices for information and communication. The number of control subjects was 21, and the number of participants in the interventional arm was 24. The interventional group was able to use MyIDEA in both the hospital and outpatient setting. However, there was no significant difference in platelet suppression or medication adherence between groups. There were also differences between the groups in terms of depression and anxiety, initially, as measured by HADS. No documented adverse event associated with the intervention was found.

CONCLUSIONS

Elderly patients are willing to use tablet devices to be educated about health conditions. Additional studies are required to measure the effectiveness and determine the most suitable timing and location for patient education.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04439864; https://clinicaltrials.gov/ct2/show/NCT04439864.

Effectiveness of Mobile Applications on Medication Adherence in Adults with Chronic Diseases: A Systematic Review and Meta-Analysis

BACKGROUND

Medication adherence is frequently suboptimal in adults with chronic diseases, resulting in negative consequences. Traditional interventions to improve adherence are complex and not widely effective. Mobile applications may be a scalable means to support medication adherence.

OBJECTIVE

To investigate the effect of mobile apps on medication adherence in adults with chronic diseases.

METHODS

MEDLINE, EMBASE, CINAHL Plus, Cochrane Central Register of Controlled Trials, and Web of Science were searched for randomized controlled trials evaluating the effectiveness of any mobile application (app) intervention directed at patients with chronic disease to improve medication adherence in comparison with usual care. A random-effects model was used to pool the outcome data. Risk of bias and quality of study were assessed per Cochrane guidelines.

RESULTS

Fourteen studies were included in this systematic review involving 1,785 participants, 940 of whom were randomized to a mobile app intervention group and 845 to the usual care group. The meta-analysis showed that the use of mobile apps was associated with a significant improvement in patient adherence to medication (Cohen's d = 0.40, 95% CI = 0.27-0.52; P < 0.001), with a low quality of GRADE evidence. There was no evidence of publication bias (Egger's test; P = 0.81) or substantial heterogeneity (I2 = 29%). In the sensitivity analysis, our findings remained robust to change in inclusion criteria based on study quality (Cohen's d = 0.43, 95% CI = 0.33-0.54; P < 0.001). The included apps incorporated 9 features, sorted from high to low based on relative weights (RW): documentation (RW = 0.254), medication reminder (RW = 0.204), data sharing (RW = 0.148), feedback message (RW = 0.104), clinical decision support (RW = 0.097), education (RW = 0.081), customization (RW = 0.049), data statistics (RW = 0.041), and appointment reminder (RW = 0.041). In the subgroup analysis, the effect was not sensitive to study characteristics or app features (0.37 ≤ P ≤ 0.95). App acceptability was reported by participants in the intervention group in 8 studies: 144 of 156 participants (91.7%) were satisfied with all aspects of the apps.

CONCLUSIONS

Compared with conventional care, mobile apps are effective interventions to help improve medication adherence in adults with chronic diseases. Although promising, these results should be interpreted with caution given the low level of evidence and short intervention duration. Future research will not only need to identify ideal app features and the costs to providers but also need to improve the apps to make them user friendly, secure, and effective based on patient-centered theory.

DISCLOSURES

Funding for this study was provided by Chongqing Science and Technology Bureau (No. cstc2017shmsA130115). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors have no conflicts of interest to disclose.

Do mobile device apps designed to support medication adherence demonstrate efficacy? A systematic review of randomised controlled trials, with meta-analysis

OBJECTIVES

To estimate the efficacy of app-based interventions designed to support medication adherence and investigate which behaviour change techniques (BCTs) used by the apps are associated with efficacy.

DESIGN

Systematic review of randomised controlled trials (RCTs), with meta-analysis.

SETTING

Medline/PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase and Web of Science were searched from 1990 to November 2018 for RCTs conducted in any healthcare setting.

PARTICIPANTS

Studies of participants of any age taking prescribed medication for any health condition and for any duration.

INTERVENTION

An app-based intervention delivered through a smartphone, tablet computer or personal digital assistant to help, support or advise about medication adherence.

COMPARATOR

One of (1) usual care, (2) a control app which did not use any BCTs to improve medication adherence or (3) a non-app-based comparator.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the pooled effect size of changes in medication adherence. The secondary outcome was the association between BCTs used by the apps and the effect size.

RESULTS

The initial search identified 13 259 citations. After title and abstract screening, full-text articles of 83 studies were screened for eligibility. Nine RCTs with 1159 recruited participants were included. The mean age of participants was >50 years in all but one study. Health conditions of target populations included cardiovascular disease, depression, Parkinson's disease, psoriasis and multimorbidity. The meta-analysis indicated that patients who use mobile apps to support them in taking medications are more likely to self-report adherence to medications (OR 2.120, 95% CI 1.635 to 2.747, n=988) than those in the comparator groups. Meta-regression of the BCTs did not reveal any significant associations with effect size.

CONCLUSIONS

App-based medication adherence interventions may have a positive effect on patient adherence. Larger scale studies are required to further evaluate this effect, including long-term sustainability, and intervention and participant characteristics that are associated with efficacy and app usage.

PROSPERO REGISTRATION NUMBER

PROSPERO Protocol Registration Number: CRD42017080150.

Digital Competencies and Attitudes Toward Digital Adherence Solutions Among Elderly Patients Treated With Novel Anticoagulants: Qualitative Study

Background

Nonadherence to medication is a driver of morbidity and mortality, and complex medication regimens in patients with chronic diseases foster the problem. Digital technology might help, but despite numerous solutions being developed, none are currently widely used, and acceptance rates remain low, especially among the elderly.

Objective

This study aimed to better understand and operationalize how new digital solutions can be evaluated. Particularly, the goal was to identify factors that help digital approaches targeting adherence to become more widely accepted.

Methods

A qualitative study using a conceptual grounded theory approach was conducted. We included patients aged 65 years and older who routinely took new oral anticoagulants. To generate theses about the digital competencies of the target group with daily medication intake, face-to-face interviews were conducted, recorded, and anonymized. After coding the interviews, categories were generated, discussed, and combined with several theses until saturation of the statements was reached.

Results

The methodological approach led to the finding that after interviews in 20 of 77 potentially available patients, a saturation of statements was reached. The average patient’s age was 75 years, and 50% (10/20) of the subjects were female. The data identified five main coding categories—Diseases and medicine, Technology, Autonomy, Patient narrative, and Attitude toward technologies—each including positive and negative subcategories. Main categories and subcategories were summarized as Adherence Radar, which can be considered as a framework to assess the potential of adherence solutions in the process of prototyping and can be applied to all adherence tools in a holistic manner.

Conclusions

The Adherence Radar can be used to increase the acceptance rate of digital solutions targeting adherence. For a patient-centric design, an app should be adapted to the individual patient’s needs. According to our results, this application should be based on gender and educational background as well as the individual physician-patient relationship. If used in a proper, individualized manner, digital adherence solutions could become a new cornerstone for the treatment of chronically ill individuals.

New digital adherence devices could prevent millions of strokes from atrial fibrillation by the end of the next century

The effectiveness and safety of a pharmacologic intervention is highly dependent on patient's capability to follow the recommended treatment regimen. Non-adherence to pharmacologic treatments is associated with worsening conditions including hospitalization and death. This is a significant burden to healthcare systems on a global scale with non-adherence rates being as high (or higher) as 50% in the first treatment year. The most common causes for non-adherence are forgetfulness, busy lifestyle or complexity and changes in therapeutic schedules. In conditions like atrial fibrillation (AFib) this leads to a drastic increase in event rates, e.g. strokes. Patients diagnosed with AFib are strongly recommended to receive anticoagulant treatments for stroke prevention. Treatments with Vitamin K antagonists or novel oral anticoagulants (NOACs) can dramatically lower the risk of ischemic strokes in the presence of AFib. Non-adherence can expose the patients to an increased stroke risk. This is especially true for NOACs, due to their short half-life. Patients have to take these medications once or twice daily for adequate stroke prevention, i.e., single non-use of the medication can already diminish or reset the anticoagulative effect. Adherence devices could help improve patient's compliance by reminder or feedback function. They have shown to be successful in a number of clinical trails. Especially, newer devices that make use of digital technologies show promising results but are not used broadly in clinical practice. Here we provide evidence for our hypothesis that newly available adherence devices might increase adherence rates and thereby reduce the number of strokes in patients with AFib.