All posts tagged medication adherence

By Kelly Grindrod BSc(Pharm), ACPR, PharmD, MSc

Hype is a big concept in tech. Roy Amara was a futurist who is credited with saying that “we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”(1) This concept has come to be known as Amara’s Law and is particularly useful in health care right now, where we have a love/hate relationship with technology and innovation.

We often flip-flop between feeling that we are held back by old systems only to realize that the new system comes with a new set of challenges. Pharmacists, for example, who cannot access a provincial electronic health record (EHR) may feel they work in an information vacuum, while pharmacists who do have access to an EHR can feel overwhelmed by information overload.

The Gartner Hype Cycle nicely demonstrates the ups and downs of innovation.(2) It starts with the “innovation trigger,” where a new technology or tool becomes available, and slowly our optimism grows. In health care right now, for example, there is growing interest in patient decisions aids, 3D printing of transplant organs, and nanomedicine.(3)

As the hype cycle continues, our expectations of the innovation rise until we reach a “peak of inflated expectations.” We then fall into a “trough of disillusionment” as the innovation fails to live up to our unrealistic expectations. Eldercare robots and pharmacogenomics appear to be at the peak, for example, while software programs for care coordination are sliding into the trough. The trough is where many companies fail.

As the surviving companies learn from industry failures, the innovations get better and we move towards a “plateau of productivity” where we start to see broad adoption of the innovation. The patient portal, which is a means for patients to access their own EHR, is one of the best examples of a productive innovation in health care right now. Nova Scotia has just launched MyHealthNS, which gives patients access to their lab values, diagnostic imaging and some specialist reports. Alberta is also launching a similar portal called MyHealthAlberta.

The pharmacy hype cycle

Interest in boosting medication adherence and medication safety is growing, with medication management apps, smart pill bottles/boxes, online refills, and referral services and text message reminders. But which options are useful and which are still hype?

We should start by recognizing that most pharmacy innovations aim to increase pharmacy business, improve pharmacy workflow efficiency or improve patient outcomes—rarely do they aim to improve all three. However, it’s never clear whether the tools actually achieve these goals.

A recent study casts serious doubt on the effectiveness of smart pill bottles to improve patient outcomes. The one-year randomized, controlled HeartStrong study, involving more than 1,500 participants recovering from an acute myocardial infarction, compared the effects of Vitality Glowcap electronic pill bottles to usual care.(4) Glowcaps are smart caps for pill bottles that can monitor adherence remotely and remind patients to take doses. Researchers also combined the smart pill bottles with a lottery incentive, where patients could win money by taking their medication, and social support where patients could have friends and family members sign up to receive alerts about missed doses. Surprisingly, none of the interventions had any effect on adherence, hospitalization or medical costs. One possible reason is that the smart pill bottles didn’t address the root causes of nonadherence following an acute myocardial infarction, such as concerns about medication side effects or medication costs.

The research is slightly more promising for medication apps. A 2016 systematic review examined the effectiveness of medication adherence apps.(5) Of the nine included studies, seven also provided direct feedback to participants through phone or text message. Overall, the review found that there were significant clinical improvements in seven studies, including improved glycated hemoglobin (A1C) in four diabetes studies, improved walking score in the heart disease study, and improved lung function for asthma and chronic obstructive pulmonary disease in two studies.

It will be interesting to look at the pharmacy hype cycle five years from now. By that point, we should have the national e-prescribing system in place and we’ll be reaching a plateau of productivity for EHRs. Pharmacy computer systems should be better aligned with our changing roles and even more patients will have better access to their own health information. Hopefully, by that time, we’ll also have a better understanding of what a good medication reminder app looks like and when smart pill bottles should be used.

But then again, while a lot can happen in five years, a lot can stay the same. These hopes may turn out to be nothing more than inflated expectations.

Kelly Grindrod, BSc(Pharm), ACPR, PharmD, MSc, examines new and emerging trends in social media and mobile technologies from a pharmacist’s perspective.

References

1. Wikipedia. Roy Amara. https://en.wikipedia.org/wiki/Roy_Amara (accessed July 6, 2017).
2. Gartner Inc. Gartner’s 2016 hype cycle for emerging technologies identifies three key trends that organizations must track to gain competitive Advantage. August 16, 2016. www.gartner.com/newsroom/id/3412017 (accessed July 6, 2017).
3. Shaffer V, Craft L. Hype Cycle for Healthcare Providers, 2016. Stamford, CT; Gartner Inc: July 14, 2016. https://www.gartner.com/doc/3371741/hype-cycle-healthcare-providers (accessed July 6, 2017).
4. Volpp KG, Troxel AB, Mehta SJ, et al. Effect of electronic reminders, financial incentives, and social support on outcomes after myocardial infarction: The HeartStrong randomized clinical trial. JAMA Internal Medicine; published online June 26, 2017. http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2633258?amp%3butm_source=JAMA+Intern+MedPublishAheadofPrint&utm_campaign=26-06-2017 (accessed July 6, 2017).
5. Whitehead L, Seaton P. The effectiveness of self-management mobile phone and tablet apps in long-term condition management: a systematic review. J Med Internet Res 2016;18(5):e97. https://www.jmir.org/2016/5/e97/ (accessed July 6, 2017).