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Reminder devices not superior to usual care for medication adherence

Among nonadherent patients who were taking up to three medications for common chronic conditions, low-cost reminder devices did not improve adherence to medications, according to research published in JAMA Internal Medicine. An accompanying editorial said the study should be a reminder to clinicians that improving medication adherence among patients will require a multi-faceted approach.

“Suboptimal adherence to medications for chronic conditions, such as hypertension and diabetes, results in potentially avoidable morbidity, mortality, and health care spending,” Niteesh K. Choudhry, MD, PhD, from the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital and Harvard Medical School, and colleagues wrote. “A variety of factors are responsible for patients not taking their medications as prescribed, but up to 60% of individuals identify forgetfulness as their primary explanation.”

To determine if tools that remind patients to take their prescribed medications through visual or auditory cues improve adherence, Choudhry and colleagues evaluated three low-cost reminder devices’ effect on medication adherence in comparison with a control group. Eligibility criteria included age between 18 and 64 years, taking one to three oral medications for long-term use and suboptimal adherence to all of their therapies, defined as having a medication possession ratio of 30% to 80% in the 12 months prior to randomization. The researchers classified participants into two groups based on the types of medications they were using: the chronic disease stratum and the antidepressant stratum.

They randomized 53,480 enrollees (mean age, 45 years; 56% female) of CVS Caremark to receive either a pill bottle strip with moveable toggles to indicate if a dosage was taken, a pill bottle with a digital timer cap, a standard pillbox or no device or notification at all (control group). Within each stratum, participants were randomized within blocks based on daily medication dosage since the pill bottle with toggles could only hold medications dosed once per day.

Optimal adherence was defined as having a medication possession ratio of at least 80% during 12 months of follow-up. The researchers confirmed adherence using pharmacy claims data. Similar rates of optimal adherence to prescribed medications were seen in the primary analysis among patients in the chronic disease stratum who were assigned to the standard pillbox (15.5%), the digital timer cap (15.1%), the pill bottle strip with toggles (16.3%) and the control arm (15.1%). The difference in odds of optimal adherence between the control and any of the reminder devices were not statistically significant. Similar results were observed in the secondary analyses.

“In a large, pragmatic, comparative-effectiveness randomized clinical trial of patients across a broad range of chronic conditions, low-cost devices did not measurably improve medication adherence,” Choudhry and colleagues concluded. “Future research should focus on effective strategies to ensure uptake and sustained use of these interventions.”

In an accompanying editorial, Ian M. Kronish, MD, MPH, and Nathalie Moise, MD, MS, both from the Center for Behavioral Cardiovascular Health at Columbia University Medical Center, wrote that Choudhry and colleagues are to be commended for testing the effectiveness of low-cost reminder devices using a pragmatic trial; however, the detection of nonadherence needs to be improved to make intensive interventions economical and feasible.

“Adherence researchers and practicing clinicians need to acknowledge that there is unlikely to be a ‘magic pill’ that will solve medication nonadherence,” they concluded. “Routinely inquiring about medication adherence in a nonjudgmental manner remains essential to uncovering nonadherence when objective measures are unavailable. When nonadherence is suspected, clinicians are encouraged to explore the reasons for nonadherence and to incorporate behavior-change techniques from effective, multicomponent interventions into their practice. These techniques may include providing feedback on self-monitoring, enlisting social supports, and recommending use of reminder systems. Partnering with allied health professionals, such as pharmacists or care managers, with expertise in these techniques is recommended when possible. Tackling nonadherence is challenging but not insurmountable, and this work helps inform our strategies.”

A recent study published in JAMA Cardiology found that reminders tied to life or calendar events also failed to increase medication adherence. – by Alaina Tedesco

Disclosures: Choudhry and colleagues report being supported by an unrestricted grant to Brigham and Women’s Hospital from CVS Health. Kronish and Moise report no relevant financial disclosures.