Wednesday, July 2, 2014

Traditional Medication Adherence devices

List of currently available adherence devices

Medication adherence is the pharma industry largest problem because medication only works well if the prescribed pills are actually taken. Researchers and medical staff have been working on devices and techniques to improve medication adherence for a long time. 

Hereafter you can see a list of the most popular medication adherence devices:

Pill box dispenser

This is typically a plastic box with little compartiments containing the pills that are supposed to be taken every day. There is typically a little compartiment for Monday, another one for Tuesday and so on. Sometimes this box is filled in weekly by a family member or nurse.
Pill box dispensers

There are also hardware automatic pill box dispensers. 

Medication Event Monitoring Systems (MEMS)

The MEMS is a medication vial cap that electronically records the date and time of bottle opening. It is also known as the "imperfect gold standard," [7] due to its recording effectiveness in measurement of patient adherence. However, it could be time consuming, expensive, resource intensive and may not be suitable for all medications/formulations.

Bubble pack

In general, the packaging service removes the medications from their vials and instead groups them in “bubbles” packaged according to administration time. Rather than receiving a bag full of pill bottles, the patient receives a bubble pack with each bubble identifying the medication by the name, date, and time to be taken.

Sample bubble pack

Text Message reminders

In general, the hospital sets up a schedule for the patient's medication and the patient receives a Text Message on his cell phone art the scheduled time. Some Text Messaging systems allow a two-ways communication allowing the user to confirm he took the medication. Even though Scientific studies have proven adherence improvements in patients, the major barrier in using text messaging technology may is deterioration of interest.

Medication reviews

The providing pharmacist obtains a medication history and a current medication list, including nonprescription and herbal medications.
This information is obtained through patient interview and physician records and becomes a part of the patient’s personal medication record. This record should be printed and presented to the patient and faxed or e-mailed to physicians. It is valuable to reconcile the personal medication record at each physician appointment.

Comprehensive medication reviews are increasingly available at community pharmacies and hospitals and through private practice pharmacists. The reviews are known by other names as well, such as medication therapy management and pharmacist consultation.

Manuel Acevedo's personal opinion

On the one hand, none of the existing adherence techniques provide motivation to take meds. On the other hand, medication is such a personal thing that it belongs to a personal device such as your iPhone or wearable device. 

These two reasons imply that the ideal medication adherence device is an iPhone, iPad or wearable device with a nice color screen to turn medication into a positive experience.

Friday, June 27, 2014

Adherence to HIV Antiretroviral Therapy

Review of Edward Machtinger's research paper

Main researcher
Edward Machtinger, MD is a Professor of Clinical Medicine and Director of the Women’s HIV Program at the University of California, San Francisco (UCSF)

Research objective
HIV Antiretroviral Therapy 

Virologic Implications of Adherence

While the ultimate goal of ART is to reduce HIV-related morbidity and mortality, the initial goal is full and durable viral suppression. Full viral suppression allows for maximal reconstitution or maintenance of immune function and minimizes the emergence of drug-resistant virus selected by ongoing replication in the presence of antiretroviral drugs.

Clinical Implications of Adherence

The primary goal of treatment with ART is to prevent HIV-related morbidity and mortality. Many studies have shown a strong correlation between adherence and clinical outcomes and/or laboratory markers (notably CD4 count). Nonadherence has been found to diminish the immunological benefit of ART and increase AIDS-related morbidity, mortality, and hospitalizations.

Adherence Devices

A variety of devices that may help patients adhere to their treatment regimens are available. Most of them are simple, inexpensive, and easy to integrate into the routine care of patients on ART. Because these devices are often provided free of charge by pharmacies or pharmaceutical companies, it is usually possible for clinicians to provide these devices or for patients to obtain them on their own. The following are examples of commonly used adherence devices.

Medication Organizers

Medication organizers (eg, pillboxes, medisets) are readily available and come in many different shapes and sizes appropriate to the needs of individual patients. They allow patients to organize their weekly doses of medication in 1 convenient location instead of carrying multiple pill bottles, and to verify whether they have taken a given dose. Patients taking pillboxes to appointments helps clinicians monitor for recent non-adherence. When a new regimen is prescribed, clinicians commonly supervise patients as they set up their first medication organizer. Some pharmacies also provide medications prefilled into weekly organizers. Medication organizers are a staple of adherence case-management programs for HIV and other diseases.

Reminder Devices
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Reminder devices are particularly important given that patents cite "simply forgot" as the primary reason for missed doses.(74) Common devices include alarms on watches, beepers, or other electronic items that allow for multiple daily reminders. Calendars, paper or electronic, allow patients to document scheduled doses and note when they have been taken.

Visual Medication Schedules

A visual medication schedule (VMS) shows pictures of prescribed medications superimposed upon a weekly calendar. Images of many prescribed medications are available in sticker sets provided by drug makers or in computer programs. It is also possible to create a VMS by affixing actual pills to a paper calendar. A VMS can help ensure that the patient understands the prescribed regimen and can help other caregivers assist in medication adherence. A VMS provided at each clinic visit has been shown to improve outcomes in patients receiving anticoagulation therapy, another situation requiring chronic treatment and exact adherence.(104)

What is likely required, however, is a commitment to ask about and support medication adherence regularly in an open, nonjudgmental, and collaborative manner.

To support adherence in pediatric populations, the authors suggest a focus on supporting the family in a collaborative effort at adherence. Specific suggestions include helping achieve disclosure within the family and enrollment of the child in a dedicated adherence case-management program.

Additional links

Thursday, June 26, 2014

A quantitative systematic review of the efficacy of mobile phone interventions to improve medication adherence

Review of Linda Park's research paper of text messages interventions

Main researcher
Linda G. Park, Post-doctoral fellow, Division of Geriatrics, University California, San Francisco, VA Medical Center

Research objective
Evaluate efficacy of mobile phone interventions to improve medication adherence and explore acceptability and satisfaction of patients.

Review of existing studies to date.

Reviewed studies

All reviewed studies used text messaging. Studies that were based on calling patients on their mobile phones were excluded as one of the key features of mHealth is having less 'intrusive' methods.

Chronic diseases treated by the studies: HIV, diabetes, asthma, schizophrenia, hypertension, acne, atopic dermatitis, systematic lupus erythematosus and immunosuppression after pediatric liver transplant.

Positive effects on medication adherence occurred in all 8 studies that applied 'tailored' or 'personalized' messages.

Measures of med adherence include Morisky Medication Adherence Scale (MMAS).

One study did SMS on 5 domains: educational/motivational, med reminders, healthy living challenges, diabetes trivia.

Outcome of trials: High satisfaction in helpfulness of SMS, enjoying SMS, and recommending to others. Bad outcome: 33% people ignoring sms after 2 weeks and 26% found SMS to be 'annoying'.

Social support

Social support, communicating concern and providing assistance.

Young adult population sent interesting and light-hearted messages at random times from a virtual friend named 'Tim'.

'Mambo?' (How are you?) They felt like somebody cared.
Healthcare providers called participants who responded with Shida (I have a problem) and participants reported that they felt that someone cared about them.

Messages that were developed by the participants at the beginning of the study (e.g. 'Superman calling you', 'Take it or die'). A visual analogue scale and a 4-day recall of medication administration showed significant changes.

Motivation messages included religious (Bible) verses to vote. 


It is important to evaluate participant satisfaction.

eMedication Dispenser could be used to send reminders only if dispenser not opened. Discrepancy between self-reported and electronically monitored medication was evident.

Mixed methods with electronic devices, biomarkers, and self-report is important.

88% of patients used other co-interventions such as alternative alarm systems (alarm clock or mobile phone alarms).

A major barrier in using mobile technology may be deterioration of interest.

The total healthcare costs were not analyzed. Consideration of reimbursement models for medication adherence and mHealth interventions is also needed.

Real-time feedback on disease management will be instrumental in designing future interventions.

Theoretical basis are needed. Adherence theories: 

  • Transtheoretical Model
  • Social Cognitive Theory
  • Health Belief Model of Behavior Change
  • Behavioral Learning Theory
  • Theory of Planned Behavior


TextMessaging programs improve medication adherence but their major barrier is deterioration of interest over time.

The next decade will evolve into applying more smartphone apps in place of TM interventions. 58% of Americans own a smartphone in 2014.

Manuel Acevedo’s personal analysis

Text messaging reminders improve adherence because remembering is inhuman. Tech prompts reminders and never forgets.

Customized and tailored messages work better, but the major barrier is still deterioration of interest. Once the patient detects the pattern in the messages, they are not perceived as tailored anymore. 

Mobile apps allow ever-renewed high value tailored images and messages that clearly surpass the computer generated message.

88% of patients used other co-interventions such as alternative alarm systems (alarm clock or mobile phone alarms). In other words, patients prefer a decentralized system they can manage (iPhone app) than a Clinic managed SMS system.

Therefore, I agree with Dr Park when she says “The next decade will evolve into applying more smartphone apps in place of TM interventions”.

Wednesday, June 25, 2014

A qualitative study HIV Antiretroviral Adherence Counseling and Support in Community Pharmacies - Jen Cocohoba

Review of Jennifer Cocohoba’s research paper on ART adherence in Community pharmacies

Main researcher
Jen Cocohoba is HIV Clinical Pharmacist in the Department of Clinical Pharmacy UCSF

Research objective
Dr Cocohoba’s primary interest was to examine the pharmacist-patient dynamic and facilitators and barriers of pharmacy-based ART adherence support.

Recorded interviews with patients and HIV-focused pharmacies

Adherence support comments by patients and pharmacists

Patients said...
Patients often highlighted the pharmacist role in facilitating access when insurance or other health-system delays happen. Patients expressed frustration regarding complicated insurance systems  and axiety about not being able to receive medication in a timely manner.

Patients had difficulty imagining how a pharmacist could have adequate time to support adherence and most did not include their pharmacist as an integral member of the adherence team. Most patients could not recall their pharmacist ever speaking with them about ART adherence.

Patients perceived pharmacists as unapproachable and too busy.

Patients find valuable to have a personal relationship with the pharmacist (first name and treatment knowledge) and more privacy.

Pharmacists said...
They reported adherence support in the form of automatic refill programs, patient telephone or text refill reminders, preparation of reminder packaging such as med boxes or bubble packages.

Pharmacists reported that detecting non-adherence and providing counseling and support was as important as dispensing the ART correctly.

Pharmacists stated that time stress was a major barrier to discussing adherence with patients.

Pharmacists were more confident providing adherence reminder devices and services such as reminders and home delivery and they appeared less confident regarding their effectiveness in adherence counseling.  


Jennifer Cocohoba acknowledges the patients low expectations with regards to pharmacists providing adherence support and suggests pharmacies to invest more time and establishing a deeper personal connection with patients and increase the frequency with which they assess ART adherence.

Pharmacist counseling efforts should strive to influence more complex adherence issues such as motivation.

Manuel Acevedo’s personal opinion

Patients perceive pharmacists as too busy for adherence support and they don’t think the pharmacist role is to provide adherence support (they believe it’s the patient’s role). Pharmacists would like to provide more counseling but they report time stress as a major barrier, thus confirming the patients perception of them being too busy. Obviously time stress comes from economic efficiency pressure from the pharmacy top management and it is hard for the pharmacist to convince management that spending more time (thus money?) will be a better choice for the store.

Interviewed pharmacists are more confident providing adherence devices and services and are less confident about adherence counseling. Thus, besides trying to encourage pharmacists to spend more time with patients we should also provide pharmacists with whatever they are actually asking: better devices and services.

Additional links:

What is medication adherence ?

Adherence - Wikipedia definition (summarized)

In medicine, adherence (also compliancecapacitance) describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance.

Worldwide, non-adherence is a major obstacle to the effective delivery of health care. Estimates from the World Health Organization (2003) indicate that only about 50% of patients with chronic diseases living in developed countries follow treatment recommendations.[1] In particular, low rates of adherence to therapies for asthmadiabetes, and hypertension are thought to contribute substantially to the human and economic burden of those conditions.[1] Compliance rates may be overestimated in the medical literature, as compliance is often high in the setting of a formal clinical trial but drops off in a "real-world" setting.[4]

Some figures are available from the UK on non-adherence:
  • up to 90% of diabetes patients do not take their medication well enough to benefit from that medication.[citation needed]
  • 33-50% of some cancer patients take less of their anti-cancer medicine than required.[citation needed]
  • only 75% of coronary heart disease (CHD) patients take sufficient medicine for it to be effective.
  • Up to 75% of hypertensive patients do not adhere to their medicine.
  • 41-59% of mentally ill patients take their medication infrequently or not at all.[17]
  • 33% of patients with schizophrenia don’t take their medicine at all, and 33% are poorly adherent.[18]
  • Less than 27% depressed patients adhere to their medication.[19]
In the UK, it has been estimated that if CHD patients adhered to their medication, each year 40,000 – 50,000 fewer people would have a stroke and 25,000 would not have a heart attack.[citation needed]

The financial cost to the UK National Health Service (NHS), and thus to society, is also high:
  • CHD costs the NHS in excess of £2billion on medicines; 50% of which is wasted through poor understanding and poor adherence.[citation needed]
  • Economic studies consistently show that the costs incurred with poorly controlled asthma are higher than those for a well-controlled patient with the same severity of disease. For severe asthma, it has been estimated that the savings produced by optimal control would be around 45% of the total medical costs.[20]

Additional links: 

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