Potential Benefits to Patients and Providers

Objectives: To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps. Practice description: Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful. Practice innovation: Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medicationtaking behavior. Main outcome measures: Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. Results: 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality. Conclusion: Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice. Medication Adherence Epidemiology of Nonadherence According to the International Society for Pharmacoeconomics and Outcome Research (ISPOR), adherence is "the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen."[1] Medication nonadherence can affect patient health adversely, negatively impact a patient's relationship with his/her care provider, skew results of clinical therapy trials, and increase health resource consumption.[2,3] Medication nonadherence remains a common health care problem. Poor adherence causes approximately 33% to 69% of medication-related hospitalizations and accounts for $100 billion in annual health care costs.[4] Irrespective of disease, medication complexity, or how adherence is measured, the average adherence rate to chronic medication therapy is approximately 50%.[5] Adherence monitoring should be performed routinely to ensure therapeutic efficacy, avoid unnecessary dose and regimen changes, contain health care costs, and in certain cases, prevent resistance to therapy from emerging.[6,7] Measurement of Adherence Methods to measure adherence, including patient self-reports, pill counts, refill rates, biological monitoring, and electronic monitoring, have limitations and are only proxy measures.[6,8,9] Patient self-reports rely on memory and are prone to inaccuracies and recall bias.[7] Pill counts are unreliable if patients fail to return bottles or dump pills before the count.[4] Smartphone Medication Adherence Apps Lindsey Dayer, Seth Heldenbrand, Paul Anderson, Paul O. Gubbins, Bradley C. Martin J Am Pharm Assoc. 2013;53(2):172-181. Biological monitoring (e.g., sampling blood, urine) is either impractical, invasive, or intrusive and does not measure adherence unless the time and dose administered before sampling are verified. Refill rates or electronic monitoring cannot determine whether patients actually take the medication. Although the process of cap removal does not necessarily reflect dose ingestion, medication electronic monitoring systems are useful for calculating adherence rates for dose taking and dose timing and often are viewed as the best method to measure adherence.[10–13] Nonetheless, despite their limitations, all of these methods are adequate for documenting nonadherence, but in general, only self-report methods can distinguish among the various types of nonadherence described below. Types of Nonadherence The cause of medication nonadherence varies among patients and is broadly categorized as unintentional or intentional. Unintentional nonadherence involves intending to take a medication as instructed but failing to do so for some reason (e.g., forgetfulness, carelessness). Unintentional nonadherence is influenced by patient characteristics, treatment factors, and patient–provider issues.[14,15] In contrast, intentional nonadherence involves making a reasoned decision not to take a medication as instructed based on perceptions, feelings, or beliefs.[14–16] Intentional nonadherence reflects a rational decisionmaking process by the patient whereby the benefits of treatment are weighed against any adverse effects of the treatment.[14,15] Broadly characterizing nonadherence may oversimplify the complexities involved with nonadherence, but it is practical and illustrates that mitigating nonadherence requires different interventions.[6] Behavioral Models of Adherence Most medication adherence models are based on several social cognition models, including the health belief model,[17] social cognitive theory,[18] and theory of planned behavior.[19] These models are similar, and all assume that beliefs developed by individuals shape how they interpret information and experiences and ultimately influence their behavior.[20] Accordingly, health behavior (e.g., medication taking) results from rational decisions based on all available information.[15] Methods to Improve Medication Adherence Many methods to improve medication adherence have been studied. Most methods attempt to change patient behavior by using reminders, counseling, reinforcement, education, dosage simplification, or a combination of these methods.[21,22] Generally, adherence interventions are categorized as behavioral, educational, or organizational based on modifying the patient's environment or incentives, providing more information, or lifting barriers associated with medication complexity and communication with care providers.[22] Traditional Reminders Intuitively, pill reminder systems (e.g., weekly pill boxes, packaged calendars, unit-of-use packaging), are helpful adherence aids, especially when nonadherence is unintentional.[10,23] Current traditional reminder systems minimally involve the patient in the self-medication process and do not provide them access to their adherence data or other educational information. Although pill reminder systems have been tested and shown to be useful across many medications, these systems are cumbersome for complex regimens and only passively remind patients to take their medication.[24,25] Electronic systems proactively deliver reminders by telephone, pager, and audiovisual devices but may be impractical for widespread use and more efficacious if combined with alternative behavioral strategies.[26] Counseling and Other Behavioral Interventions Most studies on improving adherence involve behavioral interventions.[27–29] Data suggest that patient education is one of the best methods for improving adherence, especially for those simultaneously managing more than six medications. Depending on the type of nonadherence and patient characteristics, using a combination of tailored interventions such as patient education, patient self-monitoring of specialized care, and stimuli to take medications have the greatest potential for improving adherence.[22,28–30] Medication Adherence and Mobile Devices Smartphones are Internet-ready multipurpose devices that allow constant access to communication and information and perform many tasks. Most tasks are performed by specialized applications (apps) that consumers can easily download and use to assist them in a variety of functions. Using a smartphone app is a novel approach to improving adherence and patient behavior; it is constantly accessible, involves and educates the patient, and provides a repository for patientand medicationspecific information. A smartphone medication adherence–oriented app (adherence apps) can potentially consolidate all of the user's medication-specific information and thereby provide a more streamlined process to educate the individual about his/her disease or care. Adherence apps can be downloaded for little to no cost, and their benefits may be realized by anyone taking prescription medications. However, these apps may prove most beneficial for patients with complex medication regimens or for caregivers of others or family members. The growing prevalence of smartphones in the United States and their constant, easy accessibility make adherence apps appealing to many because they cost little and can provide user-specific information. The number of apps aimed at aiding the user in organizing and taking their medications is increasing across the dominant smartphone platforms. Among the currently marketed adherence apps, features include reminders that can be set for consumption and refills, doses that can be logged, data logs that can be accessed by patients or uploaded to care providers, and medication information (e.g., dosages, adverse effects, toxicities, specialized provider notes), all of which can be immediately accessible with the touch of a finger. In addition, these apps may also include calendar-based alarm reminders with specific dosage or functionality that integrates medication lists with specific drug information or combines pharmacy and primary care contact information or includes prescription drug discount cards. Efforts are under way to integrate smartphones with health-monitoring devices that transmit the output data directly to patients or physicians. Literature on the clinical application of the smartphone