Mobile App Interventions to Improve Medication Adherence Among Type 2 Diabetes Mellitus Patients: A Systematic Review of Clinical Trials

Background: Medication adherence in type 2 diabetes mellitus (T2DM) patients is often suboptimal resulting in complications. There has been a growing interest in using mobile apps for improving medication adherence. Objective: The objective of this work was to systematically review the clinical trials that have used mobile app–based interventions in T2DM patients for improving medication adherence. Methodology: A systematic search was performed to identify published clinical trials between January 2008 and December 2020 in databases—PubMed, Cochrane Library, and Google Scholar. All studies were assessed for risk of bias using quality rating tool from the Cochrane Handbook for Systematic Reviews of Interventions. Results: Seven clinical studies having 649 participants were studied. The median sample size was 58 (range = 41-247) and the median age of participants was 53.2 (range = 48-69.4) years. All studies showed improvements in adherence; however, only three studies reported statically significant improvements in adherence measures. Selected studies were deemed as unclear in their risk of bias and the most common source of risk of bias among the studies was the absence of objective outcome assessment. Conclusions: Mobile apps appear to be effective interventions to help improve medication adherence in T2DM patients compared with conventional care strategies. The features of the App to improvise medical adherence cannot be defined based on the meta-analysis because of heterogeneity of study designs and less number of sample size. Systematically planned studies would set up applicability of mobile apps in the clinical management of T2DM.

An Interdisciplinary Collaboration to Improve Hypertension Medication Adherence for Older Adults

Hypertension is highly prevalent in older adults (74.5% in ≥60 years) with dire consequences, and adherence to hypertension medications is low (approximately 50%). With increased smartphone use among older adults (81% for 60-69 years, 62% for ≥70 years), technology innovations can improve medication adherence. This symposium highlights the efforts of an innovative interdisciplinary team of experts (clinical, cognitive aging, human factors, health technology) to develop and implement the Medication Education, Decision Support, Reminding, and Monitoring (MEDSReM) system to improve hypertension medication adherence for older adults. MEDSReM is a theory-based, integrated mobile application (app) and companion web portal that educates, supports missed dose decisions, reminds, monitors adherence, and incorporates blood pressure feedback. In this symposium, we describe the interdisciplinary development efforts. Insel et al. will present the theory-based intervention, technology translation, and advancement of the MEDSReM system. Lee et al. will describe the interdisciplinary team and describe the work by the decision support subteam that created the medication formulary and generated an algorithm to guide missed-dose decisions based on pharmacology of aging. Rogers et al. will discuss the education subteam’s development of educational information about hypertension, medications, and adherence for the MEDSReM system. Mitzner et al. will illustrate the instructional support sub-team’s efforts to ensure older adults can interact with both the smartphone app and online portal. Lastly, Hale et al. will describe the user testing subteam’s usability processes including the integration of blood pressure self-monitoring. These efforts will provide insights for other interdisciplinary teams developing technology interventions for older adults.

Pharmacist-Led Interventions to Improve Medication Adherence in Older Adults: A Meta-Analysis

As pharmacists work to ensure reimbursement for chronic disease management services on the national (e.g., Medicare) level, summative evidence of their impact on important health metrics, such as medication adherence, is needed. The objective of this study was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults. In April 2020, a comprehensive search was conducted in six databases for publications of randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. English-language studies with codable data on medication adherence and diverse adherence-promoting interventions targeting older adults (age 65+) were eligible. A standardized mean difference effect size (intervention vs. control) was calculated for the medication adherence outcome in each study. Study effect sizes were pooled using a random-effects meta-analysis model. Moderator analyses were then conducted to explore for differences in effect size due to intervention, sample, and study characteristics. The primary outcome was medication adherence using any method of measurement. This meta-analysis included 40 unique randomized trials of pharmacist-led interventions with data from 8,822 unique patients (mean age, range: 65 to 85 years). The mean effect size was 0.57 (95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size decreased to 0.41 (95% CI: 0.27-0.54). Moderator analyses showed larger effect sizes for interventions containing medication education and when interventions had components delivered at least partly in patients’ homes. In conclusion, this meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions.

Genome-Wide Association Study of Lithium-Induced Dry Mouth in Bipolar I Disorder

Dry mouth is a rather common unpleasant adverse drug reaction (ADR) to lithium treatment in bipolar disorders that often lead to poor adherence or early dropout. The aim of this study was to identify the genetic variants of dry mouth associated with lithium treatment in patients with bipolar I (BPI) disorder. In total, 1242 BPI patients who had ever received lithium treatment were identified by the Taiwan Bipolar Consortium for this study. The proportions of patients who experienced impaired drug compliance during lithium medication were comparable between those only with dry mouth and those with any other ADR (86% and 93%, respectively). Dry mouth appeared to be the most prevalent (47.3%) ADR induced by lithium treatment. From the study patients, 921 were included in a genome-wide association study (GWAS), and replication was conducted in the remaining 321 patients. The SNP rs10135918, located in the immunoglobulin heavy chain locus (IGH), showed the strongest associations in the GWAS (p = 2.12 × 10−37) and replication groups (p = 6.36 × 10−13) (dominant model) for dry mouth with a sensitivity of 84.9% in predicting dry mouth induced by lithium. Our results may be translated into clinical recommendation to help identify at-risk individuals for early identification and management of dry mouth, which will improve medication adherence.

Pharmacists’ and patients’ perceptions about the importance of pharmacist services types to improve medication adherence among patients with diabetes in Indonesia

Background Various pharmacist services are available to improve medication adherence, including consultation, brochure, etc. Challenges arise on which services are best implemented in practice. Knowledge about patients’ and pharmacists’ preferences can help to prioritize services. This study explores the pharmacists’ and patients’ perceptions about the importance of pharmacist services to improve medication adherence among patients with diabetes in Indonesia. Methods This questionnaire-based cross-sectional study involved adult outpatients with diabetes type 2 and pharmacists from community health centers (CHCs) and hospitals in Surabaya, Indonesia. Random sampling was used to identify 57 CHCs in the study. In addition, based on convenient sampling, three hospitals participated. All pharmacists working at the CHCs and hospitals, who were willing to participate, were included in the study. For patients, minimum sample size was calculated using Slovin’s formula. Patients and pharmacists were asked to rank five pharmacist service types (consultation, brochure/leaflet, patient group discussion, medication review, and phone call refill reminder) according to their importance to improve medication adherence. A face validity test of the self-developed questionnaire was conducted before the data collection. Rank ordered probit models were estimated (STATA 15th software). Results A total of 457 patients from CHCs, 579 patients from hospitals, and 99 pharmacists from both medical facilities were included. Consultation (CHC patients 56.0% vs hospital patients 39.7% vs pharmacists 75.2%) and brochure (CHC patients 23.2% vs hospital patients 27.5% vs pharmacists 11.9%) were the most preferred pharmacist services. Patients with experience getting medication information from pharmacists valued consultation higher than brochure and patient group discussions. Older patients ranked a brochure higher than other services. Patients without formal education in CHCs had a lower probability of giving a high rank to a brochure to improve medication adherence. There was significant positive correlation between the ranking of phone call refill reminder and medication review (0.6940) for patients in CHCs. Conclusion For both patients and pharmacists, consultation, brochure, and group discussion were the highest-ranked services. Education, age, experience with pharmacist services, and medical facility features need to be considered when evaluating which pharmacist services to implement in Indonesia.

Text Message Analysis Using Machine Learning to Assess Predictors of Engagement With Mobile Health Chronic Disease Prevention Programs: Content Analysis

Background SMS text messages as a form of mobile health are increasingly being used to support individuals with chronic diseases in novel ways that leverage the mobility and capabilities of mobile phones. However, there are knowledge gaps in mobile health, including how to maximize engagement. Objective This study aims to categorize program SMS text messages and participant replies using machine learning (ML) and to examine whether message characteristics are associated with premature program stopping and engagement. Methods We assessed communication logs from SMS text message–based chronic disease prevention studies that encouraged 1-way (SupportMe/ITM) and 2-way (TEXTMEDS [Text Messages to Improve Medication Adherence and Secondary Prevention]) communication. Outgoing messages were manually categorized into 5 message intents (informative, instructional, motivational, supportive, and notification) and replies into 7 groups (stop, thanks, questions, reporting healthy, reporting struggle, general comment, and other). Grid search with 10-fold cross-validation was implemented to identify the best-performing ML models and evaluated using nested cross-validation. Regression models with interaction terms were used to compare the association of message intent with premature program stopping and engagement (replied at least 3 times and did not prematurely stop) in SupportMe/ITM and TEXTMEDS. Results We analyzed 1550 messages and 4071 participant replies. Approximately 5.49% (145/2642) of participants responded with stop, and 11.7% (309/2642) of participants were engaged. Our optimal ML model correctly classified program message intent with 76.6% (95% CI 63.5%-89.8%) and replies with 77.8% (95% CI 74.1%-81.4%) balanced accuracy (average area under the curve was 0.95 and 0.96, respectively). Overall, supportive (odds ratio [OR] 0.53, 95% CI 0.35-0.81) messages were associated with reduced chance of stopping, as were informative messages in SupportMe/ITM (OR 0.35, 95% CI 0.20-0.60) but not in TEXTMEDS (for interaction, P<.001). Notification messages were associated with a higher chance of stopping in SupportMe/ITM (OR 5.76, 95% CI 3.66-9.06) but not TEXTMEDS (for interaction, P=.01). Overall, informative (OR 1.76, 95% CI 1.46-2.12) and instructional (OR 1.47, 95% CI 1.21-1.80) messages were associated with higher engagement but not motivational messages (OR 1.18, 95% CI 0.82-1.70; P=.37). For supportive messages, the association with engagement was opposite with SupportMe/ITM (OR 1.77, 95% CI 1.21-2.58) compared with TEXTMEDS (OR 0.77, 95% CI 0.60-0.98; for interaction, P<.001). Notification messages were associated with reduced engagement in SupportMe/ITM (OR 0.07, 95% CI 0.05-0.10) and TEXTMEDS (OR 0.28, 95% CI 0.20-0.39); however, the strength of the association was greater in SupportMe/ITM (for interaction P<.001). Conclusions ML models enable monitoring and detailed characterization of program messages and participant replies. Outgoing message intent may influence premature program stopping and engagement, although the strength and direction of association appear to vary by program type. Future studies will need to examine whether modifying message characteristics can optimize engagement and whether this leads to behavior change.

Can Digital Health Interventions Improve Adherence to Antiretroviral (ART) for Patients Living with HIV/AIDS in Sub-Saharan Africa? Systematic Review

BACKGROUND: Human Immunodeficiency Virus (HIV) infection is one of the most devastating human pandemics in Sub-Saharan Africa (SSA) and this is the region most hit by pandemic. Adherence to Antiretroviral Therapy (ART remains challenging and varies between 27% and 80% compared to the required level of 95%. Lack of adherence is of one the major causes of treatment failures. Given the increase in the use of mobile phones in Africa, text messaging is seen as a potential strategy to improve medication adherence although there is little evidence to support this argument. The aim of this review is to evaluate the efficacy of text messaging interventions to improve adherence to antiretroviral treatment. METHODS: The Effective Public Health Practice Project (APHPP) tool was used to ensure that included Randomized Controlled Trials (RCT) studies follow vigorous methodological standards including selection bias, study design, confounders, blinding, data collection methods, and withdrawal and dropout. Selected bibliographic databases MEDLINE, Web of Science, and CINAHL Plus were searched for relevant articles published in English and dated between 2005 and 2018. Six trials met the inclusion criteria as set out in the protocol. Due to the inconsistency and the likely observed heterogeneity, narrative synthesis of evidence was carried out. RESULTS: The results from 2/3 of included studies provided evidence that text messages reminders improve adherence to antiretroviral treatment whereas 1/3 produced contradictory results. Nevertheless, weekly Short Messaging Service (SMS) reminders were more effective than daily (SMS) in achieving 95% self-reported adherence to antiretroviral treatment and in reducing the frequency of treatment interruptions. The results indicated that patients receiving text messages had their plasma HIV viral load suppressed, median CD4+ cell counts increased and were on 100% on time picking up monthly ART refills compared to the control. CONCLUSION: Included studies in this review provided evidence that simple SMS reminders were important in improving and sustaining optimal ART adherences. Text messaging is seen as potential strategy to improve medication adherence. Therefore, it should be included in health systems strategies to help improve sustainable development goals. The results suggest that preventing treatment failure can be achieved by SMS reminders in a resource limited setting.