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Text-messaging reminders spur treatment adherence
New technology creates opportunities
Clinical trial treatment adherence is an ongoing issue for investigators, just as treatment adherence problems plague the clinical world.
Investigators have studied novel ways to improve adherence, and many of these have involved using new technologies.
One investigator has found that reminding patients to adhere to treatment through text messaging worked very well.
"The lack of adherence has multiple different factors, and we're not suggesting that reminding people is the only way to solve that problem," says Joseph C. Kvedar, MD, director of the Center for Connected Health at Partners Healthcare System Inc. in Boston, MA. Kvedar also is an associate professor of dermatology at Harvard Medical School in Boston.
"But we were intrigued by the idea of something as simple to implement as text messaging," Kvedar adds.
Researchers have experimented with other technological adherence prompts, including using emails and instant messaging features, but these require patients to be tuned in and receptive to receiving the message.
"Whereas, with a mobile phone, a text message is hard to ignore," Kvedar says. "You have it, it beeps, and you process the information right then and there — so it's a unique way to give someone a reminder."
Kvedar and co-investigators studied the use of text-messaging reminders in a study involving having patients apply sunscreen.
"Some research suggests that adherence with topical regimens is poorer than adherence with taking tablets," Kvedar says. "So we chose sunscreen because we could tie it to a very important public health need: the prevention of skin cancer."
Text variety a 'hook'
The six-week, randomized study had a control arm that received no reminders, and an intervention arm in which participants received mobile phone text messages with a weather report and a reminder to use their sunscreen, he explains.
"Those text messages varied," he adds. "We called that a hook."
The idea is that if someone is sent the same five-word message each day, then it would be easy to ignore. So investigators varied the message, including slang and catchy expressions in hopes of enticing participants to check the message each day.
Both the control and intervention groups used sunscreen containers that had a cap device that would record each time the cap was removed, presumably for the purpose of putting on sunscreen, Kvedar says.
"It wasn't a perfect measure," he notes. "If someone wanted to game the system they could just take the cap off and do nothing."
But the study's results showed a big difference between the two groups.
"Adherence in the control group was pretty abysmal," Kvedar says. "Adherence in the control group started off at about 60%, and then it plummeted quickly in the first couple of weeks until it fell to 20%."
The precipitous drop appeared to mirror a real life clinical adherence experience.
"These people were motivated enough to volunteer for the study and be part of the program, and they're paid to be part of the program," Kvedar says. "They receive a gift certificate at the beginning and at the end of the study, and they knew we were measuring their adherence since the cap device is obviously on the sunscreen tube."
On the other hand, the group receiving text message reminders also started at about 60% adherent, but remained constant at that rate throughout the six-week period, Kvedar adds.
"It was a statistically significant difference at week three, and it remained statistically significant," he says. "It was a striking story."
The preliminary evidence suggests the technological tool used to motivate participants improved adherence, Kvedar says.
"For some individuals, a daily reminder with some kind of cute language around it is a motivator," he adds.
Later, investigators attempted the use of technology to motivate participants and improve adherence with an exercise intervention, and this study demonstrated similar success, Kvedar notes.
"Our second scenario was measuring activity in people with a smart pedometer that sends a wireless message to one's computer," he explains. "You walk around with this device on."
The motivator in the not-yet-published study was an elaborate set-up that used a virtual computer avatar coach. Once or twice a week, participants would have a coaching session with the avatar coach, he adds.
"The same phenomenon was noted," Kvedar says. "Our control group rather quickly faded in terms of adherence to the activity goal, and the avatar group was stable throughout the program in terms of activity goal."
These study findings suggest that if investigators have a tool to measure something relative to the condition they are researching, then maybe 10% to 15% of the population will change behavior according to the findings, he says.
"Another 30% to 40% will respond to the same intervention if you have a coaching component," Kvedar adds.
Gold standard: DOT
The gold standard for maintaining treatment adherence is directly-observed therapy (DOT), Kvedar notes.
But the technological tools are good examples of reminder systems that are easy to implement, easy to scale, cheap, and which have impressive results, he adds.
Similar adherence aids include the class of products that send out a signal when patients open their pill bottles.
"When you either take the cover off the pill bottle or when you ingest the pill, that signal can be captured and used to create a report for the patient, family members, or doctor," Kvedar explains. "The idea is that if I ask you the patient to take a pill twice a day, and if there's someone you are accountable to through your social network, health plan, or doctor, then that will improve your compliance."
This method uses technology to assist with creating social network or peer pressure for better adherence.
"We have clinical trials going on now to test two products like that," Kvedar says.
"The other thing we're seeing is that products that will remind you by beeping or sending you some kind of message to take your medication are helpful," he says.
There even is new technology that will help patients make certain they're taking the correct medication.
"If someone is on a complex regimen of seven or more tablets per day, there's a high incidence of not getting this right," Kvedar explains. "So scanning technology shows that you've taken the right pill by comparing your pill to a database."
Some of these new technologies might enable investigators to design trials in which participants can be monitored without as many study visits, he suggests.
"You could recruit people from a wider geography and not have people come in for check-ins," Kvedar says.