Hello my name is Kathryn Murray (@kmmurray97)and I am Stroke and Clinical Trials Pharmacist at Cardiff and Vale University Health Board, and I will be hosting this chat around the use of apps to support patient adherence to medicines. The purpose of this discussion is to find out:

1. How pharmacists assess patient adherence to medication
   
2. How pharmacists help patients increase adherence to medication
   
3. Whether any pharmacists are already recommending apps to their patients
   
4. The potential role of smartphone technology and social media in improving patients adherence to medication
5. How can we help patients leverage technology and what can healthcare providers do to support empowering and engaging patients?

I first became interested in the use of mobile phones to aid adherence with medication in 2003 while I was working as a Clinical Pharmacy Lecturer at the University of Otago, New Zealand. I was planning a PhD project that aimed to investigate whether a pharmacist could improve outcomes in patients with cardiovascular disease by providing information about prescribed medication, diet, exercise and smoking cessation.

While preparing my PhD proposal I came across research being performed by Dr David Green in South Africa. Dr Green introduced system where selected patients with tuberculosis (TB) were sent short messaging service (SMS) messages on a daily basis reminding to take their medication.

It is hard to believe now but at that stage the majority of mobile phones could only be used for calling and for SMS messages. When I became aware of his work Dr Green had recruited over 300 patients with TB from deprived areas of Cape Town in a pilot study. Instead of attending daily directly observed treatment (DOT) clinics the patients were sent a daily SMS to remind to take their medication. Amazingly 71% patients attending Dr Green's DOT clinics in Cape Town had mobile phones and the intervention only cost R11.80 (less than £1) per patient per month. There were only 5 treatment failures in the pilot population. (1,2)

Around the same time researchers at the University of Auckland were developing the Stop Smoking with Mobile Phones Trial (STOMP) which aimed to investigate whether a package of mobile phone based support could improve smoking cessation rates at 6 weeks (3).

I decided to include the best bits of the STOMP trial and Dr Green's work in South Africa in my PhD project proposal. I rather cheekily approached Dr Green to see if I could adapt his system and he agreed to act as a collaborator in my PhD. In 2004 I became the 1st pharmacist to be awarded a New Zealand National Heart Foundation Small Project Grant. Unfortunately life intervened and I returned to the UK in 2005 without performing my PhD project.

Fast forward 11 years to 2016 and I am working as Stroke Pharmacist at the University Hospital of Wales. As I have limited time available to cover the acute stroke unit I spend most of my time on the ward ensuring that medicines reconciliation is performed within 24 hrs, the patients are prescribed recommended stroke treatments and patients with a nasogastric tube receive appropriate formulations of medicines. Although I try to provide patients with some information when they are started on new medication I do not do this consistently and I rarely have time to provide counselling on discharge.

When new patients are able to speak to me after their stroke only a small minority are engaged enough with their pre-admission treatment to be able to tell me exactly what medication they take at home. The standard response from married men is that 'the wife sorts out the tablets' and they have no idea what they take. What I find even more worrying is the increasing number of patients in their 40s and 50s admitted with a disabling stroke who had recently suffered from a transient iscahemic attack (TIA) and had not taken any of the medication they had been prescribed for secondary prevention of cardiovascular disease. As the risk of a vascular event may be as high as 25% within three months of a small stroke or TIA it is important that patients who have totally recovered normal function after their 1st vascular event are engaged with the treatment they are prescribed (4).

The challenge is how to engage this patient population and increase their adherence with medication.

Two major systematic reviews of adherence support programs (5,6) found that the interventions used in randomised controlled trials varied greatly. Although medication adherence was an outcome measure in the majority of trials, the methods used to measure adherence were not consistent between the trials. In addition, not all trials included changes in clinical outcome (e.g. blood pressure, lipid values or resource utilisation)as an outcome measure.

Although these reviews have shown that pharmacist led interventions can improve patient adherence to prescribed medication and may improve clinical outcomes, the interventions used are time consuming and are unlikely to be transferable into routine clinical practice.

During the summer I was prescribed medication that only needed applying twice a week. To help me remember to use it I decided to see if there was a mobile phone application (app) that I could use to remind me when I needed to apply the patch. I tried a number of apps but the one I found easiest to set up and use was the Smart Patient 'MyTherapy' app. Since starting to use the 'MyTherapy' app 2 months ago I know that I have taken 93% of all my prescribed medication (I do not always remember to take my evening dose of Symbicort).

Mobile phone technology has developed a huge amount in the last decade and the vast majority of the patients I see have a smartphone that they can use to access apps and social media. I believe that apps could revolutionise how patients engage with the medication they take and can be used by healthcare professionals to monitor adherence to treatment. In addition I think there is also a role for pharmacist led support groups on social media to provide patients with more support and information about their medication.

The purpose of this discussion is to find out:

1. How pharmacists assess patient adherence to medication
   
2. How pharmacists help patients increase adherence to medication
   
3. Whether any pharmacists are already recommending apps to their patients
   
4. The potential role of smartphone technology and social media in improving patients adherence to medication
5. How can we help patients leverage technology and what can healthcare providers do to support empowering and engaging patients?

I am very pleased that Linda Liang from SmartPatient, the company behind MyTherapy, has agreed to join me in the discussion to add the technical bits that I do not understand.

MyTherapy – a support tool forempowering the patient

With mobile phones improving at an exceptional rate and more and more people from all age groups and social backgrounds using them these days, the healthcare system has plenty of room and possibilities to catch on as we move towards a digital world. Medical apps for health tracking and education have great potential in helping people manage their medications, log their progresses and keep a personalised record of their health. Apps are not only useful for the individual and their health, but also healthcare professionals who can leverage these tools for patient care and education. With over 165,000 medical apps these days and more to come, mobile apps appear to be an innovative outlet for improving so-called adherence and empowering patients. The questions that will become more relevant are how to determine which apps are reliable, “trustworthy” and how we can help patients empower themselves.

References

1. South Africa: a novel approach to improving adherence to TB treatment. In WHO Essential Drugs Monitor No 033 (2003) http://apps.who.int/medicinedocs/en/d/Js4941e/3.2.html(accessed 24/10/16)

2. Text Messages Prove a lifesaver BBC News website 29/1/2003 http://news.bbc.co.uk/1/hi/technology/2698533.stm(accessed 24/10/16)

3. STOMP. Stop Smoking with Mobile Phones Trial https://datasets.nihi.auckland.ac.nz/page/completed-research/stomp-stop-smoking-mobile-phones-trialaccessed 24/10/16

4. Royal College of Physicians National Clinical Guideline for Stroke 5th Edition 2016 http://strokeaudit.org/Guideline/Full-Guideline.aspxaccessed 24/10/16

5. Interventions for enhancing medication adherence. Nieuwlaat R et al. Cochrane Database of Systematic Reviews 2014.Issue 11 Art No CD000011 DOI: 10.1002/14651858.CD000011.pub4

6. Delivery of patient adherence support:a systematic review of the role of pharmacists and doctors. Anderson M et alPatient Intelligence 2014:6;31-42 DOI https://dx.doi.org/10.2147/PI.S46647(accessed 24/10/16)