Key Takeaways (TLDR)

Based on a review of scientific publications examining medication adherence and app-based interventions, our key takeaways are:

Many of the barriers to medication adherence are related to psychology

Six of the eight most common predictors of medication non-adherence are related to patient psychology and education.

Positive impact of apps on medication adherence

A series of randomized controlled trials consistently showed a positive association between the use of mobile apps and improved medication adherence among individuals with chronic diseases.

Effectiveness of apps across different indications

The included studies showed that apps can be effective in increasing adherence to medication across a spectrum of diseases, including cardiovascular disease, stroke, diabetes mellitus, lung transplant, psoriasis, asthma, heart failure, hypertension, and HIV.

User satisfaction and acceptance of apps is high

Participants across the reviewed studies expressed high satisfaction with mobile apps, emphasizing their ease of use, user-friendliness, and positive impact on independence in managing medications.

User-centric design plays an important role

Tailored features such as medication reminders, information tracking, and personalized feedback contribute to the effectiveness of mobile apps, aligning with a user-centric design approach.

Introduction

The extent to which patients take their prescribed medications as directed, which is commonly referred to as “adherence”, is a multifaceted challenge that significantly impacts treatment outcomes and patient well-being.

Adherence is a composite of two things - persistence, which measures how long patients continue to take a drug before either switching to a new medication or discontinuing treatment altogether, and compliance, the extent to which patients adhere to the prescribed treatment plan (i.e. filling their prescribed doses on schedule in accordance with the approved product label). Medication adherence can also include patient compliance with disease or medication-related practices such as diet, exercise, or lifestyle changes (Jin et al. 2008). 

The factors contributing to non-adherence are diverse and multi-factorial, being a mix of personal, societal, and economic factors. Suboptimal adherence is associated with a wide array of adverse consequences, including reduced therapeutic efficacy, increased healthcare costs, and an elevated risk of complication. 

As technology advances, new solutions have emerged to try and address medication adherence, with behavior change interventions delivered via mobile applications being one of them. In this article we review the evidence for the effect of mobile-based interventions on medication adherence across a range of different therapeutic areas.

Why non-adherence to medication is a problem

Prescribed medicines are expected to be strictly followed by the patient to achieve their intended medical outcomes. According to the World Health Organization (WHO), however, approximately 50% of patients do not take their medications as prescribed (Brown et al. 2011). From a disease management point of view, a patient's failure to adhere to the prescribed medication regimen can result in serious and detrimental effects. Furthermore, non-adherence to medication is costly to the healthcare system and society at large (Furniss et al. 2013). 

Health Outcomes

‍Non-adherence to medication can significantly impact health outcomes, including faster disease progression, reduced functional ability, and a lower quality of life. This is particularly pronounced in the context of chronic conditions such as diabetes, hypertension, and asthma, where adherence to prescribed medications is vital for disease control and symptom management. For example, one study of non-adherent patients with diabetes mellitus, hypercholesterolemia, hypertension, or congestive heart failure found that patients face double the risk of hospitalization compared to the general population (Jimmy and Jose, 2011). Another study among patients with Chronic Obstructive Pulmonary Disease showed that poor adherence to drug therapy and disease management leads to increased emergency hospitalization. Nonadherence can contribute to treatment failures, deaths, and hospitalizations, accounting for up to 50% of treatment failures, 125,000 deaths, and 25% of hospitalizations annually in the United States (Kim, 2018).

Healthcare Costs

Of $500 billion total avoidable costs attributed to suboptimal medicine use globally each year, non-adherence contributes over half. Non-adherence to medications has been shown to lead to increased use of medical resources such as hospital visits, hospital admissions, and nursing home visits (Jimmy and Jose, 2011). The excess utilization of healthcare resources and additional medical interventions arising from non-adherence adds significantly to the overall cost of care and places a large financial burden on healthcare payers and society in general.

Factors that influence medication non-adherence

There are multiple, often interdisciplinary reasons, why patients don’t take their medications. These have been classified by WHO into five dimensions, including socioeconomic factors, factors associated with the healthcare team and system in place, disease-related factors, therapy-related factors, and patient-related factors (Burkhart et al. 2003). 

Patient characteristics and behaviors

Patient-related factors contribute to variations in medication adherence among individuals. Factors such as age, forgetfulness, cognitive impairment, and busy lifestyles have been identified as common causes of nonadherence. Patients' lack of understanding of their diseases and treatment plans, as well as the failure to recall physician instructions, have also been recognized as significant factors affecting adherence.

Other patient-related factors include anxiety about potential adverse effects, lack of involvement in treatment decisions, low treatment expectations, and poor medical literacy. Additionally, factors like gender, personality, and cultural differences may further influence adherence rates.

As shown in the figure below, six of the eight most common predictors of medication nonadherence are related to patient psychology and education (Aljofan et al. 2023).

‍

Medication-related factors

Medication taking behavior is influenced by various therapy-specific factors too, including cost, side effects, complexity of regimens, dosing frequency, and the purpose of therapy. Patients may be deterred from adhering to therapies due to concerns about expense or side effects. Complex medication regimens, improper timing of drug administration, and frequent dosing have also been linked to nonadherence.

Adverse effects of medications have been reported as one of the most common causes of nonadherence. To address these issues, it is crucial to provide patients with comprehensive information about their medications, including their names, purposes, dosing frequency, administration instructions, potential adverse effects, and how the treatment plan may be adjusted if side effects occur (Aljofan et al. 2023). 

Characteristics of the disease

The severity of disease symptoms, disease duration, and the availability of effective treatments also play a role in medication adherence, especially among patients with chronic illnesses. Disease duration has been found to significantly influence medication adherence, with longer periods of illness correlating with higher nonadherence rates.

Patients' perceptions of their symptoms and the absence of unpleasant symptoms during nonadherence periods have been associated with lower adherence in conditions like hypertension. Furthermore, comorbidities have been identified as a factor contributing to nonadherence, particularly among elderly patients with multiple health conditions (Aljofan et al. 2023).

Socioeconomic factors

Socioeconomic-related factors have also been identified as contributors to patient nonadherence in chronic disease management. For example, research on patient adherence to open-angle glaucoma medication highlighted that more than 65% of patients were non-adherent, with factors such as educational levels, lifestyle, and monthly income attributed to the low adherence rate. 

Moreover, the effect of socioeconomic and environmental factors on childhood asthma and patient adherence was studied, revealing associations between poverty status, family size, maternal smoking, low birth weight, and maternal age at childbirth with increased rates of childhood asthma. These factors were suggested to influence adherence through various mechanisms, including inconsistent access to primary healthcare, financial constraints, transportation barriers, family dysfunction, and substance abuse (Aljofan et al. 2023).

Healthcare team

The physician-patient relationship is a complex dynamic influenced by the health beliefs of both individuals. Reduced patient satisfaction with their treating physician has been recognized as a significant factor contributing to medication nonadherence. Other issues contributing to nonadherence include poor pharmacy services, communication breakdowns between departments, misalignment in prescription refilling times, and a lack of patient education about medications (Aljofan et al. 2023).

Effectiveness of mobile applications on adherence

Some mobile health interventions, such as SMS and electronic pillboxes, have demonstrated improved medication adherence. However, their availability within usual health care is low and presents a challenge for use in real-world settings.

Mobile apps are more diverse and interactive than SMS and cheaper and more convenient than electronic pillboxes, with widespread mobile adoption and daily app use meaning they are a great way to reach patients. They provide a means to deliver targeted and customizable education, interventions and support, based on individual adherence drivers and aligning with patient-specific needs, opening up new opportunities for improved medication adherence.

Importantly, they have been shown to work too, with one recent systematic review and meta-analysis examining the effectiveness of mobile applications on medication adherence in adults with chronic diseases finding significant improvement in patient adherence to medication (Peng et al. 2020). 

The review included 14 unique individual randomized controlled trials, with a total of 1,785 participants, 940 of whom were randomized to a mobile app intervention group and 845 to the usual care group, across medications treating cardiovascular disease, stroke, AIDS, diabetes mellitus, lung transplant and psoriasis. 

Of the 14 trials, 3 measured medication adherence through the proportion of adherent patients, 5 used average adherence scores, and 6 assessed adherence by the proportion of medication taken as prescribed. Self-report was the most common method for assessing adherence, followed by pill count and medication event monitoring system.

The features of the apps included appointment reminders, clinical decision support, medication reminders, education, data statistics, data sharing, documentation and feedback messages. The included studies examined participants with a mean age between 48 and 71 years, and assessed adherence from periods ranging from 4 weeks up to 12 months (Peng et al. 2020).

Across the individual studies, 13 found a standard mean difference in medication adherence rate that favored the app intervention group compared to usual care. Additionally, the meta-analysis showed that the use of mobile apps was associated with a significant improvement in patient adherence to medication, with no evidence of publication bias or substantial heterogeneity. In the subgroup analyses, the effect was not sensitive to study characteristics or app features. In addition, in those studies where user app acceptability was reported,  91.7% were satisfied with all aspects of the apps (Peng et al. 2020).

Interestingly, the adherence effect size of apps in this study was higher than previously reported in meta-analyses of other traditional (non-mHealth) interventions, suggesting that mobile apps may play a more significant role in medication adherence for patients with chronic diseases in the future. The effect of apps on adherence found in this study were also higher than previously reported for electronic reminders, which included SMS, alarm devices, pagers, and beepers (Peng et al. 2020). 

A second systematic review aimed to assess the perceived utility of mobile apps in managing medication at home and their impact on treatment adherence (Perez-Jover, 2019). The review included both quantitative and qualitative research, as well as research with descriptive and experimental approaches. The apps covered various medications and conditions, including for asthma, heart failure, hypertension, and HIV, while some apps were not condition-specific. Of the 11 studies analyzed, 7 evaluated both the perceived usefulness and treatment adherence when using a mobile app. 

All studies found that the mobile app examined increased treatment adherence, enhanced patient safety, and reduced errors in medication administration. In 5 studies, the before and after adherence measures suggested significant statistical improvements, when comparing self-reported adherence and missed dose with a percentage increase ranging between 7% and 40%. Key app features contributing to effectiveness included medication reminders, medication information, and tracking histories. Beyond medication management, apps supported adherence to various therapeutic regimens, promoting a healthy lifestyle, reminding of appointments, and managing health information (Perez-Jover et al. 2019).

Conclusion

Medication non-adherence is a multi-faceted and complex problem that contributes to cost of care, and results in worse clinical outcomes for patients. The reasons why patients do not adhere often have a basis in psychology, providing opportunities for interventions to target behavior change. Based on the clinical evidence, the integration of mobile applications into patient care holds promise for optimizing medication adherence and ultimately improving patient outcomes.

References

Aljofan M, Oshibayeva A, Moldaliyev I et al. The rate of medication nonadherence and influencing factors: A systematic Review.  Electronic Journal of General Medicine. 2023; 20(3), em471.

Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-14.

Burkhart PV, Sabaté E. Adherence to long-term therapies: Evidence for action. J Nurs Scholarsh. 2003;35(3):207.

Choudhry NK, Krumme AA, Ercole PM, et al. Effect of reminder devices on medication adherence: the REMIND randomized clinical trial. JAMA Intern Med. 2017;177(5):624-31.

Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990. Apr;150(4):841-845 10.1001/archinte.150.4.841

DiMatteo MR, Giordani PJ, Lepper HS, et al. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811.

Furniss, D., Barber, N., Lyons, I., Eliasson, L., & Blandford, A., 2013. Unintentional non-adherence: can a spoon full of resilience help the medicine go down?. BMJ Quality & Safety, 23, pp. 95 - 98.

Jin J, Sklar GE, Oh VMS, Li SC. Factors affecting therapeutic compliance: A review from the patient’s perspective. Ther Clin Risk Manag. 2008;4(1):269-86.

Jimmy and Jose. Patient Medication Adherence: Measures in Daily Practice. Oman Med J. 2011 May; 26(3): 155–159.

Keidong H and Volmer D. Improved medication adherence with smart applications and medication dispensers a literature review. Acta Poloniae Pharmaceutica – Drug Research, Vol. 79 No. 4 pp. 451-454, 2022

Peng Y, Wang H, Fang Q, et al. Effectiveness of Mobile Applications on Medication Adherence in Adults with Chronic Diseases: A Systematic Review and Meta-Analysis. Journal of Managed Care & Specialty Pharmacy. 2020; 26(4).

Perez-Jover et al. J Med Internet Res. 2019 Jun; 21(6): e12505.

Thakkar J, Kurup R, Laba TL, et al. Mobile telephone text messaging for medication adherence in chronic disease: a meta-analysis. JAMA Intern Med. 2016;176(3):340-49