Running head: MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

Improving Medication Adherence Using Electronic Reminders

Joshua Jenkins
University of South Florida

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

Abstract
Clinical problem: Patients with chronic conditions requiring daily self-administration of
medications have suboptimal adherence to a medication regimen.
Objective: To determine whether using electronic reminders, such as text messages or shortmessage service (SMS) are an effective method of improving medication administration in
patients with poor adherence to a prescribed regimen. PubMed and Google Scholar were used
to gather randomized, controlled trials (RCT) about different utilization of text message
interventions to improve medication adherence. The website for the Agency for Healthcare
Research and Quality (AHRQ) was used to acquire a guideline about the current
recommendations regarding the use of text message interventions in improving medication
adherence. Key search terms included SMS reminders medication, chronic conditions
medication adherence, text message reminders, antiretroviral medication adherence,
tuberculosis medication reminders, and diabetic medicine reminders.
Results: Clinical guidelines recommend the use of text message reminders for improving
medication adherence in patients at risk for poor compliance with a prescribed regimen. Three
RCTs support using text messages to aid patient compliance with regimens, and patients may
benefit from additional electronic interventions. Results showed electronic reminders to be
low-cost and low intensity interventions that helped patients improve medication adherence.
Conclusions: Electronic reminders improve the patients with chronic diseases to adhere to
medication regimens. Text messages are most frequently used, but other low-cost electronic
interventions used in conjunction with text messages are proving to be most beneficial.
Further research is necessary to determine best practices.

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

Improving Medication Adherence Using Electronic Reminders

According to the Centers for Disease Control and Prevention (CDC) (2015), records in
2012 indicate one out of every two American adults live with a chronic condition, and one out
of every four live with at least two chronic conditions. In 2010, CDC records show 86% of
expenditures by healthcare were spent on individuals living with at least one chronic
condition.
Many chronic conditions require daily medication administration for maintenance and
successful disease management. Individuals with type 2 diabetes are often prescribed oral
medications to help achieve proper glycemic control. Infectious diseases such as tuberculosis
(TB) and human immunodeficiency virus (HIV) quickly adapt and mutate to develop
resistance against medications when used inconsistently. The development of drug resistant
forms of these diseases leads to increased healthcare spending. Failure to maintain compliance
with medication prescriptions results in increased healthcare interventions, such as
hospitalizations, reconfiguring medication regimens, and sensitivity testing.
Chronic conditions are often treated with oral medications given daily, and in some
cases several times daily. Patients must remember to take medications every day or increase
risk for complications. Patients with HIV report forgetfulness as the top reason for not taking
antiretroviral therapy (ART) medications (Garofolo et al., 2015). The same reason is reported
for diabetic patients not taking doses of anti-diabetic medication (Vervloet et al., 2012).
Interventions to address forgetfulness are required to mitigate the effect forgetfulness has on
medication adherence among populations living with chronic conditions.

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

The ubiquity of mobile devices, the low cost of text message, and short-message
service (SMS) support interventions to reduce forgetfulness as the cause of poor medication
regimen adherence. Before investigating new ways to increase patient adherence to
medication regimens, it is important to consider: how do clinicians improve medication
adherence for patients with chronic conditions? If patients have better medication adherence,
will they hospitalizations be decreased? This paper aims to evaluate the use of electronic
interventions to aid patients with chronic conditions in remembering to take prescribed
medications. How does the utilization of daily electronic reminders such as text message
reminders, compared with self-reliance, improve patient adherence to a medication schedule
over one year?
Literature Search
PubMed and Google Scholar were used to locate randomized controlled trials (RCT)
about using electronic reminders to remind patients to take medications to manage chronic
conditions. The CDC website was accessed to determine the current guidelines for treatment
of diabetes type 2, HIV, and TB. The key search terms used were SMS reminders medication,
chronic conditions medication adherence, text message reminders, antiretroviral medication
adherence, tuberculosis medication reminders, and diabetic medicine reminders.
Literature Review
Three RCTs were used to evaluate the effectiveness of text message reminders in
patients with chronic illness. Garofolo et al. (2015) designed a study focusing on whether text
message reminders were beneficial for poorly compliant HIV-positive adolescents and young
adults in Chicago. One hundred and five HIV-positive individuals who had demonstrated
suboptimal medication adherence were randomly divided into two groups, in which the

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

intervention group (n=55) received daily medication reminder messages and the control group
(n=54) did not receive text messages. The messages were pre-programed to be delivered at a
certain time, and were written by the individuals to ensure privacy of their conditions. The
results of the study showed the intervention group improved from 28% of participants,
reporting at least 90% medication adherence before the study, to 61% of participants reporting
over 90% adherence. Limitations of the study were that the study relied on self-reporting to
collect the data, and it required participants to have personal cell phones. The study also used
viral load levels to ensure medication adherence, but funding did not allow for the 6-month
follow up appointments to test viral loads of the individuals. It is likely that persons without
such technology are less likely adhere to their medication schedules.
Lui et al. (2015) explored the use of medication monitoring dispensers and text
messaging reminders to evaluate the level of compliance among patients in China with active
tuberculosis infections. This study divided 4,173 patients with active TB infections in China
into four groups randomized to a control group (n=1104), who received care under Chinas
National Tuberculosis Control Program, and three intervention groups. In intervention group
one (n=1008), participants received text messages to remind them to take their medications.
Intervention group two (n=997) used an electronically monitored medication dispenser, which
reminded patients to take their medication with an audio signal at a prescribed time, and
intervention group three (n=1064) received both interventions. The results of the study
showed 29.9% of patients in the control group missed at least 20% of doses, compared to
27.3% in the text message group, 17.0% in the medication dispenser group, and 13.9% in the
combined group. Notable is that 56.5% of participants in text message intervention arms of
the study reported having trouble with mobile phones receiving messages, due to network

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

failure, account balances, and changed phone numbers. Possible implications of this finding
may be due to proximity to the medication at the time of the reminder. Strenghts of the study
were its large population sample, random assignment, inclusion of reasons for patient
discontinuing of the study, and follow up assessments were done long enough to evaluate
success. Limitations include a lack of blinding on the side of the physician and variation
between demographics of the intervention groups. This large study demonstrated how home
medication administration interventions can help increase compliance with low-cost solutions.
Vervloet et al. (2012) designed a study to explore the effects of a real-time medication
monitoring and text message reminders on the administration and medication adherence to
anti-diabetic drugs. The design was such that diabetic individuals from the Netherlands were
divided into a control group and an intervention group, in which the control group received no
reminders or real-time medication monitoring. This study focused on the intervention group
and did not compare data to those participants not receiving any intervention. The intervention
group (n=104) received a medication dispenser that electronically monitored when the
dispenser was opened to have the medicine removed, and sent that signal to a central
monitoring system. The intervention group was then divided into two further groups, one
group (n=56) that would receive a text message reminder if the monitoring dispenser was not
opened within the predetermined time, and a group (n=48) that would not get the text
message. The results of the study showed 50% of participants receiving the text message
dosed within a 1 hour window of the predetermined time, while 39% dosed in the same
window(p=.003), and 81% of patients receiving text message reminders dosed within 4 hours,
with 70% of those not receiving the text message dosed within the same window (p=.007).

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

Patients also responded positively toward receiving these reminders to take their medications.
Limitations of this study are primarily the small sample size, but the results warrant further
research. Furthermore the participants demonstrated appreciation of the reminders to maintain
the medication regimen.
Current clinical guidelines published by the Cincinnati Childrens Hospital Medical
Center (CCHMC) (2012) utilizes RCTs and literature reviews of RCTs to support the evidence
based practice of using text message interventions to improve medication adherence. The
guidelines demonstrate the benefits outweigh the costs of the interventions, strongly
recommending the use of electronic reminders to improve medication adherence.
Synthesis
High quality research demonstrates improvement in the management of chronic
disorders when the patient is reminded to take prescribed medication.
Garofolo et al. (2015) found that the use of text message reminders in HIV-positive
adolescents and young adults that were personalized for the participants were 2.6 times more
likely to have a 90% or higher medication adherence (p=.05). Lui et al. (2015) demonstrated
how using an audio reminder built into the medication dispenser combined with text message
reminders provided the best improvement in patients remembering to take anti-tuberculosis
medication. While the auditory message from the dispenser improved adherence, text
messages alone were not statistically significantly beneficial for patients. However, 56.5% of
the participants that received text message interventions experienced technical difficulties
with mobile phones. Vervloet et al. (2012) used real-time medication monitoring to
demonstrate text message interventions improved medication adherence within 1 to 4 hours of
predetermined time windows, with participants receiving text messages taking 50% of doses

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

within one hour of the scheduled time, and 81% within four hours, compared to 39% of
particpants not receiving the text messages dosing within one hour and 70% within four hours
(p=.003 and p=.007, respectively).
Research demonstrates support for the use of electronic reminders to assist poorly
compliant patients with adherence to medication regimens. Text messaging is most frequently
used in studies due to the pervasiveness of the technology, and the relative low cost of text
message systems in comparison to other interventions. Additional research is needed to
demonstrate the advantage of text message reminders and the inclusion of other electronic
reminders, such as RTMM and auditory medication dispensers.
Clinical Recommendations
Guidelines recommend using text message interventions to help patients remember to
take medications for management of chronic illness. Research supports the use of text
messages, RTMM, and electronic medication dispensers with built-in audio reminders, benefit
patients in remembering to adhere to prescribed therapy regimens. Text message reminders
are recommended as a low-cost intervention to improve medication adherence in patients with
chronic conditions.

MEDICATION ADHERENCE AND ELECTRONIC REMINDERS

References
Cincinnati Children's Hospital Medical Center. (2012). Electronic reminders to address
adherence. Best evidence statement (BESt). Cincinnati (OH). Retrieved July 2, 2016,
from http://www.guideline.gov/content.aspx?
id=36877&search=text+message+medication+reminder#Section424
Garofalo, R., Kuhns, L. M., Hotton, A., Johnson, A., Muldoon, A., & Rice, D. (2015). A
randomized controlled trial of personalized text message reminders to promote
medication adherence among HIV-positive adolescents and young adults. AIDS and
Behavior, 1-11. Retrieved from
http://link.springer.com.ezproxy.hsc.usf.edu/article/10.1007/s10461-015-1192x/fulltext.html
Liu, X., Lewis, J. J., Zhang, H., Lu, W., Zhang, S., Zheng, G., . . . Liu, M. (2015).
Effectiveness of electronic reminders to improve medication adherence in tuberculosis
patients: A cluster-randomised trial. PLoS Med, 12(9). Retrieved from
http://journals.plos.org/plosmedicine/article?
id=10.1371/journal.pmed.1001876#sec029
Vervloet, M., van Dijk, L., Santen-Reestman, J., Van Vlijmen, B., Van Wingerden, P., Bouvy,
M. L., & de Bakker, D. H. (2012). SMS reminders improve adherence to oral
medication in type 2 diabetes patients who are real time electronically
monitored. International Journal of Medical Informatics, 81(9), 594-604. Retrieved
from
http://www.sciencedirect.com.ezproxy.hsc.usf.edu/science/article/pii/S1386505612000
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