InterventionA text messaging intervention to promote medication adherence for patients with coronary heart disease: A randomized controlled trial
Introduction
Coronary heart disease (CHD) is the leading cause of death and loss of disability-adjusted life years worldwide [1]. Yet among patients who have experienced a myocardial infarction (MI), rates of medication nonadherence range from 13 to 61% [2]. The adherence rate among individuals who live with chronic diseases in the developed world is 50% [3].
Numerous observational studies have documented a strong association between medication nonadherence among patients with CHD and adverse clinical outcomes such as rehospitalization, morbidity, and mortality [1], [4], [5], [6]. A study on adherence to medications for secondary prevention of CHD including antiplatelet and statin therapy showed nonadherence was associated with 50–80% increased hazard of mortality and 10–40% increased hazard of cardiovascular-related hospitalization [6].
Specifically, premature discontinuation of antiplatelet medications (i.e., clopidogrel) has been associated with a 2-fold increase in rehospitalization and a 9-fold increase in annual mortality [7], [8]. Failure to adhere to antiplatelet therapy may cause in-stent thrombosis and death; however, 1 in 5 Medicare patients do not fill their prescriptions by 7 days after percutaneous coronary intervention (PCI) with a drug-eluting stent and 1 in 7 fail to do so by 3 months [11]. Moreover, sustained use of statins has been associated with at least a 45% risk reduction in mortality among patients with and without history of CHD, thereby demonstrating their cardioprotective properties [9], [10]. However, the rate of adherence with statins is poor, with less than half of the patients continuing their medication after 1 year of initiation [12].
Using technology to promote behavioral strategies such as self-monitoring, positive reinforcement, and coaching can facilitate adoption and integration of medication taking into daily life patterns [13]. The use of technology may provide an innovative, practical, and inexpensive means to promote medication adherence when compared to other behavioral and educational strategies that have had disappointing results [14]. Mobile phones are the most commonly used form of technology worldwide and have the potential to influence large populations [15]. Overall, mobile phone interventions can offer tailored, convenient, and regular contact with patients to help sustain medication adherence.
Over the past decade, mobile health (mHealth) interventions have been applied to promote management of acute and chronic disease, although their efficacy is still being established. Research specifically focusing on medication adherence has demonstrated a trend toward positive results; however, the data are inconsistent [16], [17], [18], [19], [20], [21]. Caution is necessary when comparing results from different patient populations who received a variety of mHealth interventions with differing content and dosages (i.e., frequency and duration). For example, mHealth interventions have been tested in studies of healthy women using oral contraceptives and older adults managing multiple chronic diseases [16], [18], thus making it difficult to establish the efficacy of this relatively new intervention modality.
The primary intervention for this research study was based on Self-Efficacy Theory by Bandura. Briefly, this theory postulates that belief in one's capability to successfully perform certain behaviors influences level of motivation, affective states, and action [22]. We proposed that receiving TM about medication reminders and educational messages on cardiovascular risk reduction including self-care of CHD would increase patients’ self-efficacy (or confidence) to take medications as prescribed.
No studies have been reported to date on the use of mobile technology exclusively for patients with CHD, which generally include relatively older adults. Furthermore, no research has been published to date about mHealth interventions to promote medication adherence among acutely ill patients who were recruited from a hospital setting. The potential for mobile phone use in health care is currently being defined and remains a significant opportunity for future research.
We examined the efficacy of a mHealth intervention using text messaging to improve adherence to antiplatelet and statin medications among patients with a history of MI and/or PCI. The primary aim was to compare medication adherence among three groups: (1) patients who received text messages (TM) for medication reminders and health education (TM Reminders + TM Education), (2) patients who received TM for health education (TM Education Alone), and (3) patients who did not receive TM (No TM). The secondary aim was to explore feasibility and patient satisfaction with mobile phone use to improve medication adherence among patients who received TM. The hypothesis was that patients who received TM for medication reminders and/or education would have better adherence to their medication regimen as compared to patients who did not receive TM and/or education. In addition, patients who received TM for medication reminders and/or health education would consider mobile phones to be positive and effective in improving medication self-administration.
Section snippets
Research design
The research design of this study was a prospective, randomized controlled trial (RCT) that used a quantitative approach to collect and analyze data. This longitudinal study included two experimental groups (TM Reminders + TM Education and TM Education Alone) and a control (No TM) group with follow-up conducted at 30 days. A three group design was planned to determine whether the content and frequency of TM would make a significant difference between the two experimental groups compared to the
Characteristics of study participants
Ninety patients were recruited to participate and completed baseline questionnaires; however, six patients withdrew or were lost to follow-up. Fig. 1 displays patient screening and recruitment according to the CONSORT guidelines [34]. No differences in sociodemographic, clinical, or psychosocial characteristics were found among groups (Table 1). Overall, the sample characteristics included a mean age of 59.2 years (SD 9.4, range 35–83), 24% female, 22% non-White, 29% Medicare-insured, and 70%
Discussion
The MEMS data showed better medication adherence in the two experimental groups who received TM for antiplatelet medications compared to those who did not. The lack of difference in adherence among groups for statins may be consistent with the poor adherence that is generally seen with statin medications as well as the challenge of taking medications more than once daily, particularly statins that are generally prescribed for the evening [12].
Two-way messaging with the TM Reminders + TM Education
Conflict of interest
None declared.
Funding
Funding for research materials was provided by a grant from the Graduate Division of University of California, San Francisco and a scholarship from the UCSF/Hartford Center of Geriatric Nursing Excellence. CareSpeak Communications provided the use of the mobile Health manager platform, which is designed to improve medical therapy adherence using two-way text messaging.
Acknowledgements
We would like to thank Steven Paul, PhD for his expert guidance in the statistical analyses, James Kahn, MD for his mentorship, and John Muir Health colleagues, patients, and families who supported this study.
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