Texts Can Improve Drug Adherence for Chronic Disease

Marcia Frellick

February 02, 2016

Mobile phone text messaging doubles the odds of medication adherence for middle-aged people with chronic disease, according to a meta-analysis of 16 randomized clinical trials published online February 1 in JAMA Internal Medicine.

However, lead author Jay Thakkar, MBBS, MD, from the Department of Cardiology at Westmead Hospital in Sydney, Australia, and colleagues urge caution in interpreting these results, partly because they rely on self-reported data, which often overstate adherence, and the short duration of the trials (median intervention, 12 weeks).

The pooled analysis of 2742 patients (median age, 39 years) showed that text messages doubled the likelihood of adherence (odds ratio, 2.11; 95% confidence interval [CI], 1.52 - 2.93; P < .001). The effect was not sensitive to study characteristics (length of intervention or disease type) or as to whether the texts were personalized, involved two-way communication, or were sent daily or less frequently.

Researchers note that the findings on frequency were interesting, although hard to interpret without longer studies. There was no significant difference between daily texts (Cohen d, 0.48; 95% CI, 0.17 - 0.79) compared with less frequent messaging (Cohen d, 0.35; 95% CI, 0.13 - 0.57). Previous studies have raised concerns that messaging more frequently can lead to response fatigue.

"However, one possible explanation is that response fatigue may be a feature of longer-duration interventions, while the median length of studies in this review was 3 months," the authors write.

Adherence Just 50% in Developed Countries

The effectiveness of such interventions is important because adherence to long-term therapies in developed countries is typically only 50% at 1 year after starting therapy, and worse in lower socioeconomic groups and in developing countries.

Data from this meta-analysis show that text messaging improves adherence from approximately 50% (assuming this baseline rate for chronic disease) to 67.8%.

In addition to the implications for patients' health, low adherence increases healthcare costs about $100 billion a year in North America and $2000 per patient per year for excess physician visits.

Texting may be a more scalable solution than other interventions such as apps that require a certain kind of device and software. The technology is well-established and can be used on any mobile phone, which most people worldwide have.

"According to one estimate, there were approximately 7 billion mobile subscribers by the end of 2014, roughly corresponding to the global population," the authors write. "This technology is increasingly used by people from all socioeconomic classes, age groups, and continents."

The authors call for future studies that focus on appropriate patient populations, how long the effects last, and whether clinical outcomes improve.

Further Studies Needed

In an invited commentary, Robby Nieuwlaat, PhD, from the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada, and colleagues agree more studies are needed.

They echo the problems surrounding self-reporting and note, "Unobtrusive measurements such as pharmacy claims data would be more objective and accurate."

Knowing whether texting helps adherence and then outcomes is crucial to interpreting the benefit, they point out. Text messaging "has not been subjected to the acid test of whether it makes a clinically useful difference," they add.

They say texting may be helpful for patients who are busy or forgetful or have little knowledge about their condition, but will not necessarily help those not comfortable using mobile phones, those who cannot afford medication or do not believe medication will help them, or those who have ingrained cultural barriers against regular adherence.

They conclude, "As Thakkar et al show, [text messaging] has potential as a widespread, low-cost technology but will need more development and rigorous testing to determine if it has real, enduring, and patient-important benefits that are worth the investment."

Dr Thakkar reports receiving an Australian postgraduate award scholarship. Various coauthors report having fellowships with the National Health and Medical Research Council and Sydney Medical Foundation Chapman and receiving support from Roche, Amgen, Novartis, and the National Heart Foundation. The commentators have disclosed no relevant financial relationships.

JAMA Intern Med. Published online February 1, 2016. Article abstract, Commentary extract


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