Technology improves patients’ medication, doctors’ guideline adherence

Patients with hypertension who utilized the app Medisafe improved their medication adherence, and a built-in alert helped doctors be compliant with American Heart Association recommendations, according to two new studies recently published in JAMA Internal Medicine.

“The availability of smartphone health apps has expanded quickly... However, there has been a lack of rigorous evaluation to date, with most studies relying on self-report and not including a clinically important outcome,” Kyle Morawski, MD, MPH, of the Center for Healthcare Delivery Sciences at Brigham and Women’s Hospital and Harvard Medical School, and colleagues wrote in the first study.

To see if an app could help improve medication adherence and control BP, researchers randomly assigned 412 patients taking medication for uncontrolled hypertension in a 1:1 ratio to receive instructions on downloading and using the Medisafe app or not. Those assigned to utilize the app also were the benefactors of reminder alerts and adherence reports, and had the option of receiving peer support. The control group received no support.

Morawski and colleagues found that 3 months later, patients who had downloaded the app saw their Morisky medication adherence score improve by 0.4 points. The score remained unchanged in the control group (between-group difference = 0.4; 95% CI, 0.1-0.7). In addition, the mean systolic BP level decreased by 10.6 mm Hg in those who had been assigned to utilize the app and 10.1 mm Hg in the control group (between-group difference = –0.5; 95% CI, –3.7 to 2.7).

Researchers wrote that all patients engaged in some form of self-monitoring may have played a role in the mixed results, as could several other factors.

“It is possible that the reductions in blood pressure from baseline to the end of follow-up that we observed in both the intervention and control arms may have resulted from fluctuations in these home blood pressure readings and/or regression to the mean and that the magnitude of these changes was larger than the a priori hypothesized effect from the smartphone app,” Morawski and colleagues wrote.

“[In addition,] while we observed a statistically significant improvement in adherence from the intervention, the magnitude of this change was likely too small to translate into improvements in blood pressure.”

In a related editorial, Alexander G. Logan, MD, and S. Vanita Jassal, MD, of the division of nephrology at Mount Sinai Hospital in New York, wrote that apps allow patients and doctors to set real-time goals, evaluate responses to therapy, and sometimes find changes in diseases earlier than other mechanisms. They also wrote that though in some instances apps are usually affordable and encourage medication self-management, there are some potential setbacks regarding the technology that still must be addressed.

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“For physicians, the lack of remuneration, increased workload and legal liability are critically important issues. There are also a host of organizational, regulatory, and privacy and security matters that may act as barriers to implementation,” Logan and Jassal wrote.

“With these challenges in mind, the study by Morawski, et al is pertinent, timely and of interest because it reminds us of the strengths and limitations of current ‘state-of-the-art’ of mHealth interventions.”

In the second study, Douglas Einstadter MD, MPH¸ of the Center for Health Care Research and Policy at Case Western Reserve University in Cleveland and colleagues had an advisory alert installed into EHRs to serve as a cue to take a second reading when a patient’s BP was greater than 140/90 mm Hg, as encouraged by American Heart Association guidelines. Their study included 80,864 office visits in 38,260 patients.

Einstadter and colleagues found that the initial BP was at least 140/90 mm Hg at 31,531 visits, and an initially elevated BP was remeasured at 26,089 of these visits. The median change of the final minus initial reading, was –8 mm Hg (interquartile range, 2-17 mm Hg). The researchers also found the higher the initial systolic BP, the greater the difference in final systolic BP. In all the patients who had a repeated BP measurement, 9,358 of final BP readings were lower than 140/90 mm Hg, with those nearest the threshold more likely to be controlled on the second measurement.

“While much of the change in systolic BP may be attributed to regression to the mean, the observed decrease remains clinically important, comparable with that associated with addition of an antihypertensive medication,” Einstadter and colleagues wrote.

“As the health care system moves toward value-based care initiatives, such as accountable care organizations and shared savings programs, implementing routine repeated measurement for an initially elevated BP may contribute to improved decision-making around [hypertension] management and should be considered a standard component of programs to improve BP control.” – by Janel Miller

Disclosure: None of the authors report any relevant financial disclosures.