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FIP 2008: Adherence technology is no magic bullet

Imogen Savage reports on a session on medicines information held at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences by the Community Pharmacy Section and the Pharmacy Information Section

by Imogen Savage

Imogen Savage reports on a session on medicines information held at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences by the Community Pharmacy Section and the Pharmacy Information Section

 

Can technology help improve medicines-taking behaviour? Maybe, but adherence is a partnership and knowing the patient is probably much more important. That was the message from a session on technology and adherence, chaired by Eva Sjökvist Saers, from Apoteket AB, Sweden.

Opening the session, she told delegates that poor adherence is worth tackling. The World Health Organization has estimated that addressing it will have a bigger impact on public health — and the economic consequences of illness — than any specific drug intervention.

There is a tendency to think that technology is the ultimate solution, but non-adherence can be linked to a lack of understanding of or a denial of the need for treatment, treatments that are complicated or unpleasant, or to a loss of faith in treatment. Cost can also be a factor. To improve adherence, “we need to understand where the patient is”, she said.

Claus Møldrup: pharmacists will provide monitoring services too

Claus Møldrup, from the University of Copenhagen, Denmark, explained that most adherence devices are based on visible prompts that help patients to remember.

Showing a picture of a finger with a “don’t forget” piece of string tied around it, he commented: “So far I haven’t seen many technologies proving to be a lot better than this old one”.

Classic systems include Dosette boxes holding all medicines due at a particular time, calendar packs and alarm clocks. Newer devices range from “remember to take your medicine” SMS text messages to electronic packs that record when they are opened and a voice-activated device that can be set up to monitor outcome measures and provide lifestyle information.

These new technologies are appealing but there is not much clinical trial evidence for a positive effect on adherence. A recently updated Cochrane review on reminder packs found only eight trials, of which only four had measured adherence using “pill counts” (counting any remaining pills to find the number of doses left).

In those four studies, the reminder packs had increased the number of people adhering, but the effect was small and there were not enough data to say that better adherence had improved their health.

Dr Møldrup’s own, as yet unpublished, work with text message reminders in a 240-patient trial, which monitored symptom control and frequency of s with the health care system, has produced similar findings. He found no statistically significant change in any health outcome measure.

The way forward is not to develop yet more gadgets to control what patients do, but to develop the way in which existing technologies are used in a counselling context, he believes. Technologies, such as micro-electromechanical systems (MEMS) bottle tops, are useful because they give a picture of the patient.

“This is where we have the future,” he said. These devices contain electronic chips that log the date and time of each opening and the data can be uploaded to a secure website.

In the future, he thinks pharmacists will be dispensing not only medicines but providing monitoring services too, as part of a single package. Pharmacists will provide the technology as part of a “caring service” and could pass encrypted patient data to manufacturers.

A member of the audience pointed out that “the biggest problem of all” — that the elderly often do not use computers and often have visual problems — had not been addressed. Dr Møldrup agreed, but said: “For many years it will be good business just to talk. But the young people today will be elderly soon, and they will use the technology”.

Motivations should be explored

Marie-Paule Schneider, from the University of Lausanne, Switzerland, presented her experience with MEMS in patients at her polyclinic. Approved healthcare professionals can view and comment on reports (of the device data), then print them out to use in patient consultations.

Patients were usually referred from nearby oncology, HIV and medical outpatient departments. In the clinic, they first had their medicine-taking behaviour monitored for two weeks using MEMS, and then beliefs about medication were explored.

The MEMS printouts helped Dr Schneider to “talk facts” with the patient. Sometimes the changes in compliance could be striking, resulting in lower doses or fewer drugs, but it could take time to tease out what was behind a particular pattern of behaviour. Illustrating this, she described a patient on lipid-lowering, heart and hypoglycaemic medicines.

MEMS monitoring revealed that he almost never took the evening doses of his medicines. Interviewing revealed that he had no idea what his medicines did, but also feared that taking them in the evening would over-sedate him and spoil his social life. His regimen was changed and, six months later, his lipid profile was much better.

However, Dr Schneider warned that MEMS is not the answer for every patient. It is not a quick fix and will only work if used as part of an interdisciplinary intervention that involves motivational interviewing over several months.

Bodil Lidstrom, from Apoteket AB, Sweden, tried to persuade the audience that unit dose dispensing could be a tool to improve adherence in primary care. The automated dose dispensing system she described had all solid dose forms for a particular administration time packed in individually labelled blister pouches.

However, the blisters are not held in a rigid cassette but presented on a roll, from which patient or carer tears off a pack, so unless the empty pouches are kept, there is no way of checking for missed doses, or when they had been missed.

Bill Felkey, known as “professor gadget” at Auburn University, Alabama, US, where he is professor of pharmacy care systems, said that blister packs do not help patients to remember but they do reduce complexity and could help to show that someone has taken a dose.

He said that people looking for technology could check the range available on www.epill.com. He is currently tracking 160 different adherence technologies, from low-cost reminders to high tech web-linked devices that can be programmed to dispense and to record medication and send messages to key s.

“We are starting to see industries helping us with closed loop systems — data that help us to monitor what the patient actually does,” he said. The next generation of devices will be wearable and will interact with the body, he predicted.

Hanne Herborg, from Pharmakon, Denmark, said that the rapidly growing compliance technology market is an opportunity for pharmacists because they are independent from drug manufacturers. But she warned: “There is no magic bullet here. We need to know patients to find the right tool.”

Her group is user-testing examples of each type of device. At the moment her team of 10 volunteers is trying out examples of Dosette boxes, text reminders, automatic dose dispensers and MEMS data recorders all with and without “home made reminders” .

Volunteers tried each device for up to four weeks, giving back online. One thing that has already emerged is that “just seeing the device sitting there” acts as a visible reminder. This suggests that many adherence problems could be solved without the need for high technology.

Other users found the technology irritating and thought it would be most useful on days when their normal routine changed, for example, when they went on holiday.

Citation: Electronicjuice URI: 10040987

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