► Real Time Medication Monitoring provides detailed and accurate data on patients’ medication use. ► SMS reminders sent only if patients forget medication improve adherence to oral antidiabetics. ► SMS reminders are appreciated by patients. ► Real Time Medication Monitoring with SMS reminders provide opportunities for other patient groups as well.
The prevalence of diabetes is high and increases rapidly. In 2007, 740,000 patients were diagnosed with diabetes in The Netherlands, 90% of these patients with type 2 diabetes [1]. On the long-term, elevated blood glucose levels in type 2 diabetes patients can cause both macrovascular complications such as cardiovascular disease and stroke, and microvascular complications such as renal disease, blindness, foot ulcerations and nerve damage [1], [2]. An important goal in the treatment of type 2 diabetes is to achieve good glycaemic control (lowering the blood glucose to a level close to normal), thereby reducing the incidence of these complications. One of the key strategies in achieving glycaemic control is long-term adherence to oral antidiabetics [3], [4], [5]. However, many patients experience difficulties in following the treatment as agreed with the health care provider. Reported adherence to oral antidiabetics ranges from 36% to 93% [6]. Although patients’ reasons for not following the prescribed treatment are diverse, one of the most commonly reported barriers to adherence in type 2 diabetes patients is forgetfulness [7], [8]. Reminding patients of their medication intake can help them overcome this barrier [9], [10]. Studies investigating the effect of reminder packaging (incorporating a date and time for medication to be taken in the package) and audiovisual reminders on medication devices revealed improved adherence rates, but the effects were only modest [11], [12], [13]. Nowadays, as the number of mobile phone connections exceeds five billion worldwide [14], reminding patients of their medication intake through Short Message Service (SMS) is increasingly being implemented in interventions aimed at improving adherence. SMS allows for instantaneous delivery of short text messages to individuals at any time, place and setting. As such, SMS-reminding is a relatively simple method with low intrusiveness and relatively low costs [9]. Previous studies evaluating the effect of SMS reminders on adherence showed positive results. Improved adherence rates to e.g. inhaler treatment in asthma patients [15], antiretroviral therapy in HIV patients [16], [17], [18], and immunosuppressive medication in liver transplant recipients [19] were demonstrated. In these previous studies, SMS reminders were sent regardless whether or not the medication was taken. This method may cause annoyance and may eventually lead to loss of effectiveness when the automated reminders become a routine. Pop-Eleches et al. found that daily reminders, as opposed to weekly reminders, did not improve adherence to antiretroviral therapy. They considered habituation to a frequent stimulus or intrusiveness of daily messages as possible explanations [18].
In our study, Real Time Medication Monitoring (RTMM) was introduced to avoid sending reminders to patients who already took their medication. RTMM combines electronic monitoring with SMS reminders. Like other electronic monitoring devices such as the Medication Event Monitoring System (MEMS®), RTMM uses an electronic medication dispenser that records each date and time of dispenser opening at a central server, providing accurate and detailed data on actual medication use. However, RTMM registers these data in real time, making it possible to identify a missed dose as it happens. Because of the real time registration of patients’ medication use, the RTMM system has the unique feature to remind patients only if they forget to take their pills, thus to intervene only when this is necessary. In practice, this means that when a dispenser opening is registered, no SMS reminder is sent, but when the dispenser is not opened in time, the patient receives a SMS as a reminder to take the medication. As such, habituation or a high intrusiveness can be avoided.
Two pilot studies involving HIV patients on antiretroviral therapy in Uganda used real time monitoring with Wisepill [20] and the Med-eMonitor [21]. However, the real time monitoring was not combined with an intervention (such as reminding) when patients miss a dose. Both studies did show that these devices were feasible to use and accepted by patients.
Our study is, to our knowledge, the first to evaluate this new Real Time Medication Monitoring system with customized SMS-reminding. Furthermore, up to now, no study has investigated the use of SMS reminders to support type 2 diabetes patients in their medication use. Therefore, the main aim of this study is to evaluate the effect of SMS reminders on the adherence to oral medication in type 2 diabetes patients. The use of an electronic monitoring device can already contribute to a higher adherence because of patients’ awareness of being monitored [22]. To eliminate this effect, all patients in this study were electronically monitored with RTMM.
Patients’ experiences with receiving SMS reminders are important aspects when it comes to patients’ acceptance of the system and its integration in everyday life. For example, patients who perceive the reminders as disturbing are less likely to use RTMM in daily life than patients who perceive the reminders as a support in their medication use. The second aim of this study is thus to assess patients’ experiences.
Data for this study were collected in a Randomised Controlled Trial (RCT) with two intervention groups and one control group involving type 2 diabetes patients with suboptimal levels of adherence (pharmacy refill rate of their oral antidiabetic medication of less than 80%). Patients were recruited in 40 pharmacies belonging to Mediq, a large Dutch pharmacy chain. In both intervention groups, patients received their oral antidiabetics in the RTMM medication dispenser and had their medication use
A total of 104 type 2 diabetes patients participated in the study, 56 patients in the SMS group and 48 patients in the control group (Fig. 1). No significant differences in baseline characteristics were found between the two groups (Table 1). Patients in both groups were predominantly male and the average age was 55 years. Co-medication was comparable between the groups. At baseline, the refill adherence (number of days for which oral antidiabetics were dispensed during the eleven months
The Real Time Medication Monitoring system tested in this study registers patients’ medication use in real time, making it possible to intervene only when this is necessary: only if patients forget to take their medication, they receive a SMS to remind them. This study investigated the effect of RTMM with SMS reminders on the precision with which type 2 diabetes patients adhere to their prescribed oral medication. Our results show that RTMM with SMS reminders has positive effects on patients’
Type 2 diabetes patients who use Real Time Medication Monitoring (RTMM) and receive SMS reminders if they forget to take their medication have higher adherence levels with respect to timing than patients who are only monitored with RTMM. Overall, patients’ experiences with the RTMM system are positive. Since other patient groups have difficulties in following prescribed therapy as well, the RTMM system may provide opportunities for increasing adherence to medication for other chronic diseases.
LvD and JS designed the Randomised Controlled Trial. MV, LvD, JS and BvV were involved in the implementation of the study. MV prepared the data and performed the analyses. MV, LvD, MB and DdB contributed to the interpretation of the data. MV drafted the manuscript. LvD, JS, BvV, PvW, MB and DdB critically revised the manuscript. All authors read and approved the final version of the manuscript.
The author(s) declare that they have no conflict of interest. Summary points What was already known on the topic: Adherence to oral antidiabetics is low. Mobile phone technology can be successful in improving health behaviour. What this study adds to our knowledge: Real Time Medication Monitoring provides detailed and accurate data on patients’ medication use. SMS reminders are useful in improving adherence to oral antidiabetics, especially the precision with which patients adhere to their prescribed
This study was supported by an unrestricted grant from Achmea Healthcare Foundation. The RTMM system was provided by Evalan and partly financed by Achmea Healthcare Foundation. Both Achmea Healthcare Foundation and Evalan had no role in the study design, nor in analysis and interpretation of the data, nor in the writing of this manuscript.
The authors would like to thank the pharmacies and the patients for their participation in this study.
