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Interesting Observations on Medication Adherence

June 28, 2010

A now famous report from the WHO asserts that medication adherence is about 50%.  That is, about half the time when a doctor prescribes a medication, the recipient actually takes the prescription as directed.  The WHO report further divides the problem of adherence into reasons that include forgetfulness, trust issues, cost concerns, lack of appreciation for the need, side effect avoidance, etc. I’m not aware that anyone has been able to quantify what contributions these variables make to the entire problem of adherence.

At the Center for Connected Health we have a great deal of interest in this problem.

We just released interim data on a study we’ve done in collaboration with a firm called RxVitality on a product called the Glowcap. The Glowcap has several features of interest that chiefly attack the forgetfulness component of adherence, but also some of the psychological aspects as well.  The core of the technology is a medication bottle cap that fits any standard pharmacy bottle.  The cap has a sensor in it that fires when the cap is removed. It also has a blinking light and can play a tune.

I’ve been using the Glowcap myself. I take a statin at bedtime.  I set the Glowcap to start reminding me to take my pill at 9 pm.  At that time the bottle cap flashes. A related night light attachment that can be put in a different room flashes as well.  At 10 PM if I haven’t taken my pill, the bottle cap starts to play a brief tune periodically. If I haven’t taken my pill at 11, I get a phone call from RxVitality reminding me.  The system also sends me a weekly email on my adherence and a monthly paper letter showing my adherence. These can be shared with others such as a loved one or a health care provider.

When we studied this system, we found that folks who used all components of the system – light and sound prompts and personalized reports –  had adherence rates of 98-99%.  Baseline adherence for another comparitive group was about 70%.  The results were statistically significant. We also offered a financial incentive to one group of participants, but their adherence was no different than the group that received just the complete Glowcap solution.

Several interesting conclusions can be reached.  Firstly, forgetting is a big component of non-adherence.  Of course our sample is biased in the sense that we recruited individuals who are willing to be studied.  This is a known problem with clinical studies. We never get the folks who are so checked out that the ingore their health completely.  It’s also safe to assume that we don’t have as many socioeconomic issues in our sample as the general population. Still, the result is amazing to me.

I was struck by my own behavior. I would have said I was 100% adherent to my regimen and have found since using the Glowcap that without it, I’d be more like 80-90% adherent.   In addition it is somewhat surprising that the financial incentive did not have more of an effect.

The results make the case that Glowcaps, or similar technologies, should be ‘standard issue’ with any prescription if we can get the price point low enough.  It Is not hard to calculate the ROI on medication adherence. While Glowcap does not solve all of the associated problems, it is none the less an impressive tool.

6 Comments leave one →
  1. July 9, 2010 2:57 pm

    I hate sounding like a Luddite, but does it have to be a new device? How much would something like that cost, anyway? An extra two dollars per bottle? $10? $15? How long would a glowcap last? One prescription? Two? Ten? If I have several meds, how much more is that for glowcaps on every bottle?

    It all sounds very helpful–the email notices, the two levels of urgency–but can’t we already do all of that? I put my drugs in my daily-reminder box. I can tell at a glance whether or not I’ve taken all of today’s drugs. As for the individual reminders, my iPhone lets me set alarms when I need to take pills during the day. If I want email alerts, I can set my calendar to send me alerts when each pill is due.

    Instead of creating yet another device and running up medical bills, why not just acknowledge what the glowcap has shown us (that we need to be reminded to take our pills) and move on. I apologize to the inventor, but I really think this is an unnecessary device.

    Rather than spending additional money per pill bottle to get alarms and email, why not approach this from a participatory-medicine angle. Enlist your patients to help themselves. Now that we have evidence that we all need a nudge in order to remind us to take our meds, give the nudge. Let’s put it this way, Dr. Joseph, instead of offering financial incentives, why not make a slightly less expensive modification in the way you pass out prescriptions. Next time you hand a scrip off to a patient with instructions to take the pills TID with meals, ask the patient, “How do you plan to ensure that you’ll remember to take these pills?” I don’t have a clinical trial to back this up, but I am a parent. I know that the best way to get my kids to do something is to have them demonstrate that they have a plan for accomplishing it. Not only does it give them a mechanism for accomplishing their task, it puts them in control, and gives them one more reminder and one more reason to succeed.

    Also, you’ll find that some of them will surprise you. Maybe they’ve thought of methods you haven’t.

    • July 10, 2010 7:22 pm

      These are thoughtful comments. I’ll start out conceding that health care providers do not make medication adherence as much of a participatory conversation as we should. It would be an interesting idea to formally study your hypothesis: that engaging patients, at the time of prescription, in a conversation around adherence, would improve adherence. My guess is that it is not that simple either. By your story, I’d conclude that you are one of the minority of folks who would find no value in a tool like the Glowcap. However, to conclude that a device like Glowcap is not needed or that the only missing component is a more in-depth conversation with the provider, are both premature I think. We are becoming more and more appreciative of the notion that no connected health solution is a ‘one size fits all’. So i expect that a certain percentage of patients would improve adherence by a more in depth conversation about this topic, a certain percentage are self-motivated to an extent that they’ll create their own adherence reminders and devices. I believe both of these will be a minority and that leaves a large group of folks who would welcome a reminder device like the Glowcap.

      • July 11, 2010 8:17 pm

        I am so glad you noted that “no connected-health solution is a ‘one size fits all.’ On the final point, as to how many patients fit into each slot, we might have to just agree to disagree.

        Both the glowcap solution and my “query to find motivation” solution are different varieties of effective nudges.

        Mine is a bit cheaper and involves motivating self-reliance through participatory medicine, so I’d rather see that attempted first. If the patient’s reaction is, “Gosh, I’m not very good at keeping track of things like that,” then maybe you should go the high-tech route.

    • September 2, 2010 3:35 pm

      For a person like you who uses an iPhone and email, your nudges are sufficient. My guess is that you are a very busy individual with a lot on your mind, and that you occasionally forget your pill. I read the information about Glowcap planning to investigate the product for my mother. She is doing very well at 80 years of age, and still lives alone in her own home. After several TIAs, however, she has some short-term memory loss, making it very difficult to remember to take her meds. I have provided a daily reminder box and leave it on her kitchen table. She still often forgets to take her pills. I think the Glowcap is something that would help her tremendously. It is definitely something I plan to try.

      • September 2, 2010 4:51 pm

        I am not sure Glowcap is still available on the consumer market. it used to be available on Amazon. if you can’t find it, and would like an intro to the company’s executive team, please let me know.

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