title: Electronic messaging support service programs improve adherence to lipid-lowering therapy among outpatients with coronary artery disease: an exploratory randomised control study. Improving treatment adherence for blood pressure lowering via mobile phone SMS-messages in South Africa: a qualitative evaluation of the SMS-text Adherence SuppoRt (StAR) trial Mobile Health Medication Adherence and Blood Pressure Control in Renal Transplant Recipients: A Proof-of-Concept Randomized Controlled Trial A randomized controlled behavioral intervention trial to improve medication adherence in adult stroke patients with prescription tailored Short Messaging Service (SMS)-SMS4Stroke study Effect of a reminder system using an automated short message service on medication adherence following acute coronary syndrome Medication adherence patterns in adult renal transplant recipients. Improving adherence to cardiovascular disease medications with information technology. Impact of medication packaging on adherence and treatment outcomes in older ambulatory patients. A text messaging intervention to promote medication adherence for patients with coronary heart disease: a randomized controlled trial. Randomised Trial of Text Messaging on Adherence to Cardiovascular Preventive Treatment (INTERACT Trial) Randomized controlled feasibility trial of two telemedicine medication reminder systems for older adults with heart failure A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India
abstract: AIMS AND OBJECTIVES To compare drug adherence to lipid-lowering therapy among out patients with coronary artery disease who received information via short message service , via short message service and Micro Letter , or via phone only .  BACKGROUND Messaging applications and short message service are commonly used internationally . However , little is known about how coronary artery disease out patients in China may benefit from receiving health education through these technologies . DESIGN R and om sampling method . METHODS Data were collected from March-December 2013 . Subjects from Chengdu City , China , were r and omised to three groups : short message service , short message service + Micro Letter , and phone ( control ) . Appointment reminders and health information were delivered to patients in accordance with design ations . After six months , adherence to statin prescriptions was compared among the groups by using the Morisky Medication Adherence Scale . Logistic regression analysis was applied to determine those independent variables that were related to adherence . RESULTS The short message service and short message service + Micro Letter groups had better cumulative adherence ( lower Morisky Medication Adherence Scale scores ) after six months than phone group , and the short message service + Micro Letter group had better cumulative adherence ( lower Morisky Medication Adherence Scale scores ) than the short message service group . Female sex , older age and marriage show positive associations with adherence . CONCLUSIONS Short message service and messaging applications , such as Micro Letter , are effective means of providing discharged patients with reminders and coronary artery disease-related health information . Implementation of a short message service + Micro Letter program can improve outpatient adherence to medication . RELEVANCE TO CLINICAL PRACTICE This research offers useful information to help medical staff design effective interventions to improve medication compliance among coronary artery disease patients Background Effective use of proven treatments for high blood pressure , a preventable health risk , is challenging for many patients . Prompts via mobile phone SMS-text messaging may improve adherence to clinic visits and treatment , though more research is needed on impact and patient perceptions of such support interventions , especially in low-re source setting s. Method An individually-r and omised controlled trial in a primary care clinic in Cape Town ( 2012–14 ) , tested the effect of an adherence support intervention delivered via SMS-texts , on blood pressure control and adherence to medication , for hypertensive patients . ( Trial registration : Clinical Trials.gov NCT02019823 ) . We report on a qualitative evaluation that explored the trial participants ’ experiences and responses to the SMS-text messages , and identified barriers and facilitators to delivering adherence support via patients ’ own mobile phones . Two focus groups and fifteen individual interviews were conducted . We used comparative and thematic analysis approaches to identify themes and triangulated our analysis amongst three research ers . Results Most participants were comfortable with the technology of using SMS-text messages . Messages were experienced as acceptable , relevant and useful to a broad range of participants . The SMS-content , the respectful tone and the delivery ( timing of reminders and frequency ) and the relational aspect of trial participation ( feeling cared for ) were all highly valued . A subgroup who benefitted the most , were those who had been struggling with adherence due to high levels of personal stress . The intervention appeared to coincide with their readiness for change , and provided practical and emotional support for improving adherence behaviour . Change may have been facilitated through increased acknowledgement of their health status and attitudinal change towards greater self-responsibility . Complex interaction of psycho-social stressors and health service problems were reported as broader challenges to adherence behaviours . Conclusion Adherence support for treatment of raised blood pressure , delivered via SMS-text message on the patient ’s own phone , was found to be acceptable , relevant and helpful , even for those who already had their own reminder systems in place . Our findings begin to identify for whom and what core elements of the SMS-text message intervention appear to work best in a low-re source operational setting , issues that future research should explore in greater depth Background Mobile phone based programs for kidney transplant recipients are promising tools for improving long-term graft outcomes and better managing comorbidities ( eg , hypertension , diabetes ) . These tools provide an easy to use self-management framework allowing optimal medication adherence that is guided by the patients ’ physiological data . This technology is also relatively inexpensive , has an intuitive interface , and provides the capability for real-time personalized feedback to help motivate patient self-efficacy . Automated summary reports of patients ’ adherence and blood pressure can easily be uploaded to providers ’ networks helping reduce clinical inertia by reducing regimen alteration time . Objective The aim of this study was to assess the feasibility , acceptability , and preliminary outcomes of a prototype mobile health ( mHealth ) medication and blood pressure ( BP ) self-management system for kidney transplant patients with uncontrolled hypertension . Methods A smartphone enabled medication adherence and BP self-management system was developed using a patient and provider centered design . The development framework utilized self-determination theory with iterative stages that were guided and refined based on patient/provider feedback . A 3-month proof-of-concept r and omized controlled trial was conducted in 20 hypertensive kidney transplant patients identified as non-adherent to their current medication regimen based on a month long screening using an electronic medication tray . Participants r and omized to the mHealth intervention had the reminder functions of their electronic medication tray enabled and received a bluetooth capable BP monitor and a smartphone that received and transmitted encrypted physiological data and delivered reminders to measure BP using text messaging . Controls received st and ard of care and their adherence continued to be monitored with the medication tray reminders turned off . Providers received weekly summary reports of patient medication adherence and BP readings . Results Participation and retention rates were 41/55 ( 75 % ) and 31/34 ( 91 % ) , respectively . The prototype system appears to be safe , highly acceptable , and useful to patients and providers . Compared to the st and ard care control group ( SC ) , the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations . Physicians made more anti-hypertensive medication adjustments in the mHealth group versus the st and ard care group ( 7 adjustments in 5 patients versus 3 adjustments in 3 patients ) during the 3-month trial based on the information provided in the weekly reports . Conclusions These data support the acceptability and feasibility of the prototype mHealth system . Further trials with larger sample sizes and additional biomarkers ( eg , whole blood medication levels ) are needed to examine efficacy and effectiveness of the system for improving medication adherence and blood pressure control  after kidney transplantation over longer time periods . Trial Registration Clinical trials.gov NCT01859273 ; http:// clinical trials.gov/ct2/show/NCT01859273 ( Archived by WebCite at http://www.webcitation.org/6IqfCa3A3 ) Background The effectiveness of mobile technology to improve medication adherence via customized Short Messaging Service ( SMS ) reminders for stroke has not been tested in re source poor areas . We design ed a r and omized controlled trial to test the effectiveness of SMS on improving medication adherence in stroke survivors in Pakistan . Methods This was a parallel group , assessor-blinded , r and omized , controlled , superiority trial . Participants were central ly r and omized in fixed block sizes . Adult participants on multiple medications with access to a cell phone and stroke at least 4 weeks from onset ( Onset as defined by last seen normal ) were eligible . The intervention group , in addition to usual care , received reminder SMS for 2 months that contained a ) Personalized , prescription tailored daily medication reminder(s ) b ) Twice weekly health information SMS . The Health Belief Model and Social Cognitive theory were used to design the language and content of messages . Frontline SMS software was used for SMS delivery . Medication adherence was self-reported and measured on the vali date d Urdu version of Morisky Medication Adherence Question naire . Multiple linear regression was used to model the outcome against intervention and other covariates . Analysis was conducted by intention-to-treat principle . Results Two hundred participants were enrolled . 38 participants were lost to follow-up . After 2 months , the mean medication score was 7.4 ( 95 % CI : 7.2–7.6 ) in the intervention group while 6.7 ( 95 % CI : 6.4–7.02 ) in the control group . The adjusted mean difference ( Δ ) was 0.54 ( 95 % CI : 0.22–0.85 ) . The mean diastolic blood pressure in the intervention group was 2.6 mmHg ( 95 % CI ; −5.5 to 0.15 ) lower compared to the usual care group . Conclusion A short intervention of customized SMS can improve medication adherence and effect stroke risk factors like diastolic blood pressure  in stroke survivors with complex medication regimens living in re source poor areas .Trial registration Clinical trials.gov NCT01986023 last accessed at https:// clinical Background : Medication non-adherence leads to a vast range of negative outcomes in patients with coronary artery disease . An automated web-based system managing short message service ( SMS ) reminders is a telemedicine approach to optimise adherence among patients who frequently forget to take their medications or miss the timing . Aim : This paper sought to investigate the effect of automated SMS-based reminders on medication adherence in patients after hospital discharge following acute coronary syndrome ( ACS ) . Methods : An interventional study was conducted at a tertiary teaching hospital in Malaysia . A total of 62 patients with ACS were equally r and omised to receive either automated SMS reminders before every intake of cardiac medications or only usual care within eight weeks after discharge . The primary outcome was adherence to cardiac medications . Secondary outcomes were the heart functional status , and ACS-related hospital readmission and death rates . Results : There was a higher medication adherence level in the intervention group rather than the usual care group , ( χ2 (2)=18.614 , p<0.001 ) . The risk of being low adherent among the control group was 4.09 times greater than the intervention group ( relative risk = 4.09 , 95 % confidence interval ( CI ) 1.82–9.18 ) . A meaningful difference was found in heart functional status between the two study groups with better results among patients who received SMS reminders , ( χ2 ( 1 ) = 16.957 , p<0.001 ) . Conclusion : An automated SMS-based reminder system can potentially enhance medication adherence in ACS patients during the early post-discharge period Patient adherence to immunosuppressive medications adherence is crucial to survival of the patient and a transplanted kidney , yet adherence is variable . Using a prospect i ve , descriptive design , immunosuppressive medication adherence of 44 renal transplant recipients was followed for 6 months at a Midwestern transplant center using electronic monitoring . Four medication adherence patterns emerged from a hierarchical cluster analysis : those who took medications on time , those who took medications on time with late/missed doses , those who rarely took medications on time and who were late with morning and /or evening doses , and those who missed doses . This study is a step toward developing and implementing interventions targeted to specific patterns of poor adherence OBJECTIVES Evaluate the utility of 2 electronic medical record (EMR)-linked , automated phone reminder interventions for improving adherence to cardiovascular disease medications . STUDY DESIGN A 1-year , parallel arm , pragmatic clinical trial in which 21,752 adults were r and omized to receive either usual care ( UC ) or 1 of 2 interventions in the form of interactive voice recognition calls-regular ( IVR ) or enhanced ( IVR+ ) . The interventions used automated phone reminders to increase adherence to cardiovascular disease medications . The primary outcome was medication adherence ; blood pressure and lipid levels were secondary outcomes . METHODS The study took place in 3 large health maintenance organizations . We enrolled participants who were 40 years or older , had diabetes mellitus or atherosclerotic cardiovascular disease , and were suboptimally adherent .  IVR participants received automated phone calls when they were due or overdue for a refill . IVR+ participants received these phone calls , plus personalized reminder letters , live outreach calls , EMR-based feedback to their primary care providers , and additional mailed material s. RESULTS Both interventions significantly increased adherence to statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers ( ACEIs/ARBs ) compared with UC ( 1.6 to 3.7 percentage points ) . Adherence to ACEIs/ARBs was also significantly higher for IVR+ relative to IVR participants . These differences persisted across subgroups . Among statin users , IVR+ participants had significantly lower low-density lipoprotein ( LDL ) levels at follow-up compared with UC ( Δ = -1.5 ; 95 % CI , -2.7 to -0.2 mg/dL ) ; this effect was seen mainly in those with baseline LDL levels ≥ 100 mg/dL ( Δ = -3.6 ; 95 % CI , -5.9 to -1.3 mg/dL ) . CONCLUSIONS Technology-based tools , in conjunction with an EMR , can improve adherence to chronic disease medications and measured cardiovascular disease risk factors OBJECTIVE To evaluate medication adherence and treatment outcomes in elderly out patients using daily-dose blister packaging ( Pill Calendar ) compared with medications packaged in bottles of loose tablets . DESIGN R and omized controlled trial . SETTING Ambulatory care clinics at Ohio State University Medical Center , Columbus ; University of Arizona Health Science Center , Tucson ; and Riverside Method ist Hospital Family Medicine Clinic , Columbus , Ohio , from July 1 , 2002 , to December 31 , 2004 . PATIENTS 85 individuals 65 years of age or older being treated with lisinopril for hypertension . INTERVENTION Patients were r and omly assigned to receive lisinopril in either daily-dose blister packaging ( Pill Calendar ) or traditional bottles of loose tablets . MAIN OUTCOME MEASURES Adherence was assessed by prescription refill regularity and medication possession ratio ( MPR ) . Treatment outcome and use of medical services were assessed by medical record review of blood pressure and morbidity associated with poorly controlled hypertension . RESULTS Patients receiving lisinopril in the daily-dose blister packaging ( Pill Calendar ) refilled their prescriptions on time more often ( P = 0.01 ) , had higher MPRs ( P = 0.04 ) , and had lower diastolic blood pressure ( P = 0.01 ) than patients who had their medications packaged in traditional bottles of loose tablets . CONCLUSION Providing medications in a package that identifies the day each dose is intended to be taken and provides information on proper self-administration can improve treatment regimen adherence and treatment outcomes in elderly patients OBJECTIVE Pharmacologic treatment for secondary prevention of coronary heart disease ( CHD ) is critical to prevent adverse clinical outcomes . In a r and omized controlled trial , we compared antiplatelet and statin adherence among patients with CHD who received : ( 1 ) text messages ( TM ) for medication reminders and education , ( 2 ) educational TM only , or ( 3 ) No TM .  METHODS A mobile health intervention delivered customized TM for 30 days . We assessed and analyzed medication adherence with electronic monitoring devices [ Medication Event Monitoring System ( MEMS ) ] by one-way ANOVA and Welch tests , two-way TM response rates by t-tests , and self-reported adherence ( Morisky Medication Adherence Scale ) by Repeated Measures ANOVA . RESULTS Among 90 patients ( 76 % male , mean age 59.2 years ) , MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken ( p=0.02 ) , percentage number of doses taken ( p=0.01 ) , and percentage of prescribed doses taken on schedule ( p=0.01 ) .  TM response rates were higher for antiplatelets than statins ( p=0.005 ) . Self-reported adherence revealed no significant differences among groups . CONCLUSION TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses . PRACTICE IMPLICATION S Feasibility and high satisfaction were established . Mobile health interventions show promise in promoting medication adherence Background About one third of patients prescribed blood pressure or lipid-lowering drugs for the prevention of coronary heart disease and stroke do not take their medication as prescribed . We conducted a r and omized trial to evaluate text messaging as a means of improving adherence to cardiovascular disease preventive treatment . Methods 303 patients taking blood pressure and /or lipid-lowering medications were r and omly assigned to being sent text messages ( Text group , 151 ) or not being sent them ( No text group , 152 ) . Texts were sent daily for 2 weeks , alternate days for 2 weeks and weekly thereafter for 22 weeks ( 6 months overall ) , using an automated computer programme . Patients were asked to respond on whether they had taken their medication , whether the text reminded them to do so if they had forgotten , and if they had not taken their medication to determine if there was a reason for not doing so . At 6 months , use of medication was assessed . Results Two patients were lost to follow-up , providing data on 301 for analysis . In the No text group 38/151 ( 25 % ) took less than 80 % of the prescribed regimen ( ie . stopped medication completely or took it on fewer than 22 of the last 28 days of follow-up ) compared to 14/150 patients ( 9 % ) in the Text group – an improvement in adherence affecting 16 per 100 patients ( 95 % CI 7 to 24 ) , p<0.001 . The texts reminded 98/151 patients ( 65 % ) to take medication on at least one occasion and lead to 20/151 ( 13 % ) who stopped taking medication because of concern over efficacy or side-effects , resuming treatment . Conclusions In patients taking blood pressure or lipid-lowering treatment for the prevention of cardiovascular disease , text messaging improved medication adherence compared with no text messaging . Trial Registration Controlled-Trials.com IS RCT We conducted a feasibility study of a telehealth intervention ( an electronic pill box ) and an m-health intervention ( an app on a smartphone ) for improving medication adherence in older adults with heart failure . A secondary aim was to compare patient acceptance of the devices . The participants were 60 adults with HF ( 65 % male ) . Their average age was 69 years and 83 % were Caucasian . Patients were r and omized using a 2 × 2 design to one of four groups : pillbox silent , pillbox reminding , smartphone silent , smartphone reminding . We examined adherence to 4 medications over 28 days . The overall adherence rate was 78 % ( SD 35 ) . People with the telehealth device adhered 80 % of the time and people with the smartphone adhered 76 % of the time . Those who received reminders adhered 79 % of the time , and those with passive medication reminder devices adhered 78 % of the time , i.e. reminding did not improve adherence . Patients preferred the m-health approach . Future interventions may need to address other contributors to poor adherence such as motivation Background — In rural areas in China and India , the cardiovascular disease burden is high but economic and healthcare re sources are limited . This study ( the Simplified Cardiovascular Management Study [ SimCard ] ) aims to develop and evaluate a simplified cardiovascular management program delivered by community health workers with the aid of a smartphone-based electronic decision support system . Methods and Results — The SimCard study was a yearlong cluster-r and omized , controlled trial conducted in 47 villages ( 27 in China and 20 in India ) . Recruited for the study were 2086 individuals with high cardiovascular risk ( aged ≥40 years with self-reported history of coronary heart disease , stroke , diabetes mellitus , and /or measured systolic blood pressure ≥160 mm Hg ) . Participants in the intervention villages were managed by community health workers through an And roid-powered app on a monthly basis focusing on 2 medication use and 2 lifestyle modifications . In comparison with the control group , the intervention group had a 25.5 % ( P<0.001 ) higher net increase in the primary outcome of the proportion of patient-reported antihypertensive medication use pre- and post-intervention . There were also significant differences in certain secondary outcomes : aspirin use ( net difference : 17.1 % ; P<0.001 ) and systolic blood pressure ( –2.7 mm Hg ; P=0.04 ) . However , no significant changes were observed in the lifestyle factors . The intervention was culturally tailored , and country-specific results revealed important differences between the regions . Conclusions — The results indicate that the simplified cardiovascular management program improved quality of primary care and clinical outcomes in re source -poor setting s in China and India . Larger trials in more places are needed to ascertain the potential impacts on mortality and morbidity outcomes . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01503814
target: Limitations of trials included small sample sizes , short duration of follow-up , self-reported outcomes , and insufficient assessment of unintended harms and financial implication s. Current evidence suggests that mHealth tools can improve medication adherence in patients with cardiovascular diseases .
background: Cardiovascular disease is a leading cause of morbidity and mortality worldwide , and a key barrier to improved outcomes is medication non-adherence .
  The aim of this study is to review the role of mobile health ( mHealth ) tools for improving medication adherence in patients with cardiovascular disease .