Electronic and Telephone Reminders Increase Medication Adherence in Adults With Uncomplicated Hypertension

Problem Addressed

• A common condition, leading to increased risk: An estimated one in three Americans has hypertension, with even higher prevalence in certain groups, including African Americans and those over 65. Although hypertension produces few if any symptoms, persistently high blood pressure can damage the heart, kidneys, and other organs, and contributes to nearly half of all cardiovascular disease–related deaths in the United States.¹
• Forgetfulness as driver of poor adherence: Up to half of patients with chronic conditions such as hypertension do not take their medications as recommended.² Although various reasons for nonadherence exist (e.g., high costs, difficulties in following complicated regimens, adverse side effects, inadequate provider–patient communication),¹ patient forgetfulness remains the number one reason for not taking medications.³
• Leading to unnecessary loss of life and high costs: Nonadherence to hypertension medications (defined by clinicians as adherence below the recommended goal of 80 percent⁴) increases the risk of hospitalization and death. Nearly 90,000 deaths occur annually in the United States due to poor medication adherence in patients with hypertension.²

Description of the Innovative Activity

• Provision of pill-bottle system: Patients received a specially designed pill-bottle cap (known as GlowCap) for use during the 6-month program. Patients set up to alert them to take their medication at the appropriate time(s). The cap, which has a radio chip and light, replaced the standard pill-bottle cap. The system also included a device to be plugged into a wireless router, thus allowing it to connect to the Internet. The center offered technical support by telephone to assist patients in setting up and using the system, although few reported any difficulties in this area during the initial 6-month trial of the system.
• Visual and auditory reminders: Based on the information entered by the patient at setup, the pill cap and Internet device provided a series of visual and auditory reminders to patients to take their medication, as outlined below.
  • At medication time: At the appropriate time to take the medication, the pill cap and reminder device flashed, giving the patient a visual reminder to take their medication. When the patient removed the cap (suggesting he or she was going to take the medicine), the radio chip sent a signal through the Internet indicating the medicine had been taken.
  • One hour after medication time: If the pill-bottle cap was not opened within 1 hour of the designated time, the pill cap beeped as an auditory reminder that the patient should take the medication.
• Telephone alerts for missed doses, refills: The system generated an automated phone call to the patient's desired number (also programmed into the system at setup) in the following circumstances:
  • Missed dose: If the patient did not remove the cap within 1 hour of the appointed time, the system automatically called to remind him/her to take the medication.
  • Prescription refill: The system automatically called the patient whenever a refill was due. If the patient confirmed that he or she needed more medication during this call, the system connected the patient to the pharmacy to place the order.
• Weekly and monthly adherence reports: Each week, patients received e-mail reports showing their rate of adherence for the preceding 7 days. Each month, patients received by mail a calendar-style report that showed when they took their medication each day and any missed doses. Program developers urged patients to share these reports with providers and/or caregivers to show their progress and to discuss and resolve any challenges they may have been facing.

References/Related Articles

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Results

• Greater adherence: In an RCT of 139 patients with uncomplicated hypertension, patients receiving the auditory reminders, telephone alerts, and progress reports achieved 86.3-percent compliance, well above the 61-percent adherence rate in a similar group of patients not participating in the program. Adding financial incentives to the alert system ($15 per month to each patient who achieved 80 percent or higher adherence during the month) improved adherence to nearly 96 percent.
• No significant change in blood pressure: Blood pressure readings among the three groups did not differ significantly. This finding might be due to the short duration of the study and the fact that those not participating also had fairly high adherence rates (61 percent).

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Refinement of product based on earlier trial: An earlier trial used the globe to remind patients to take their medications (with the globe being red if the patient had not yet done so). When that trial (never published) showed signs of success, the developers came up with the idea of combining the globe with the pill bottle top.
• Development of study design: The Center for Connected Health staff designed the study to test the effectiveness of the pill bottle system on adherence. They chose uncomplicated hypertension because standard treatment consists of a simple, one-pill regimen, and adherence rates often fall below the recommended level of 80 percent.
• Recruitment of participants: The center advertised in various media outlets around Boston to recruit patients with uncomplicated hypertension and no comorbid conditions. Recruitment focused on those with Internet access and a wireless router (which the device needed to operate at that time; newer versions operate over cell phone networks). This requirement resulted in a lengthy (year-long) recruitment process, with most participants being fairly young (mean age of 50) and relatively affluent.

Resources Used and Skills Needed

• Staffing: Two staff—a research coordinator and assistant—oversaw the RCT, although these individuals would not be needed in the absence of such a study. As noted, technical support staff at the Center for Connected Health offered patients telephone assistance with setting up the system in their homes, although few patients needed such help.
• Costs: The system currently costs $10 plus a $15 monthly connectivity charge. The RCT cost $150,000, including staff and technical support. Vitality supplied the pill-bottle systems during the study.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Do not overlook value of simple solutions: Many factors may play into a patient's adherence—including health beliefs, insurance status, financial status, and possible adverse affects. However, patients most often cite forgetfulness as the reason for nonadherence, and simple reminders can be effective if delivered in a nonjudgmental, patient-centered manner.
• Position as empowerment, not surveillance: The pill-bottle system should be positioned as a way of empowering patients with information, not monitoring them. Patients should be made to understand that privacy provisions within the Health Insurance Portability and Accountability Act generally prevent third parties from getting access to their data without permission.
• Focus on those taking four or fewer medications: The system works best for patients taking four or fewer medications each day. Although newer versions can accommodate more than once-a-day regimens, the system is not designed for extremely complex medication schedules.
• Target situations in which adherence matters most: To employ this approach most effectively, target it at conditions and medications where adherence matters most. For example, patients suffering from depression often do not take any of their medications, including those for other conditions. Therefore, using the system with daily antidepressant medications may improve adherence to other medications as well. For some conditions, lack of adherence may have significant consequences and costs, including potential public health implications. For example, adherence to human immunodeficiency virus (HIV) or tuberculosis medications can reduce the risk of transmitting the disease to others while also improving health outcomes for the patient.

Sustaining This Innovation

• Fine-tune approach over time: Since the end of the RCT, the developers of GlowCaps have further refined the product. Instead of communicating through a device plugged into a wireless Internet router, the reminder light now contains cellular technology and relays adherence information directly to a central point via a phone network. This approach makes setup simpler but requires a monthly charge to maintain access to the network.
• Approach stakeholders about potential funding: Although the pill-bottle system is relatively inexpensive, monthly charges can add up and someone has to pay them. To keep the program going, consider approaching potential stakeholders about supporting the ongoing costs, including patients, pharmacy benefit managers, insurance companies, and/or providers.