Mobile medication manager application to improve adherence with immunosuppressive therapy in renal transplant recipients: A randomized controlled trial

Abstract

BackgroundNonadherence to immunosuppressive therapy after renal transplantation is associated with poor graft outcomes. We aimed to evaluate whether the use of the Adhere4U mobile medication manager application could improve adherence among renal transplant recipients ≥1 year posttransplantation. Adhere4U can provide medication reminders, monitor medication use, and provide information on immunosuppressants.MethodsWe conducted a prospective randomized controlled study to compare the rate of nonadherence to index immunosuppressant (tacrolimus or cyclosporine) in a group using the Adhere4U app (mobile group) and in another group receiving conventional care (control group). The primary outcome was the nonadherence rate, which was evaluated using an electronic medication event monitoring system during the 6-month intervention period. Our secondary outcome included self-reported adherence using the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS) and the visual analog scale (VAS) based on a 4-week recall on days 28, 90, and 180. Longitudinal data of repeated measures of self-rated adherence were analyzed using generalized estimating equations (GEE) to compare the between-group difference in adherence change over time.ResultsBetween November 2013 and May 2015, 138 renal transplant recipients were randomly allocated to the control (n = 67) or the mobile group (n = 71). The overall nonadherence rate over the 6-month study period by electronic monitoring was 63.6%, with no between-group difference [mobile group, 65.0% (n = 39/60); control group, 62.1% (n = 36/58); odds ratio 1.14; 95% confidence interval 0.53–2.40; p = 0.89]. Self-rated nonadherence assessed using the BAASIS and VAS at baseline was 53.7% and 51.5%, respectively. Although the self-rated nonadherence by BAASIS of the mobile group was lower than the control group throughout the study period, there was no between-group difference in the change of nonadherence over time (χ2 = 2.82, df = 3, p = 0.42 by logistic GEE). There also was no significant between-group difference in the nonadherence by VAS (χ2 = 1.71, df = 3, p = 0.63 by logistic GEE) over time. The main limitation of this study was the low rate of patient engagement with the app among the mobile group. The rate of app use was 47.6% (31/65) at 28 days, 33.9% (19/56) at 90 days, and 11.5% (6/52) at 180 days.ConclusionsThe Adhere4U application did not improve adherence to immunosuppressive therapy. Our evidence is limited by the high rate of attrition. Further studies on strategies to facilitate patient engagement with mobile interventions are warranted.

Association of Self-Reported Medication Adherence with Potentially Inappropriate Medications in Elderly Patients: A Cross-Sectional Pilot Study

“…Second, the VAS is a subjective adherence measurement tool and has never been validated in Japan. We defined a VAS score of 100% as a self-reported full medication adherence, as previously described [52,53]; however, previous studies have used a cut-off value of 80% to divide medication adherence into good or poor [48][49][50][51]. The evaluation of medication adherence from the perspective of a pharmacist and the application of an objective measurement tool could not be performed in this study.…”

“…The VAS tool was presented to each patient with a continuous line ranging from 0% to 100%, and he or she was asked to mark the line at his or her best guess about self-medication adherence. A VAS score of 100% was defined as full medication adherence, as described previously [52,53].…”

“…Although medication non-adherence is an important drug-related issue in all populations, it is particularly problematic for elderly patients, who often experience a variety of medical conditions and use more medications compared to other patients [36]. The medication adherence of patients is assessed by evaluating medical/dispensing records and pharmacy claims data, such as the Medication Possession Ratio [37,38] and the Proportion of Days Covered [39][40][41][42]; using electronic monitoring devices [43,44]; using patient self-reports [45], such as the Morisky Medication Adherence Scale [46,47] and the visual analogue scale (VAS) [48][49][50][51][52][53]. The VAS is a tool that helps clinicians or pharmacists assess the medication adherence of patients in routine clinical practice.…”

“…Selinger et al (2019) assessed four adherence measurement tools, including VAS, Medication Adherence Report Scale, Medication Possession Ratio, and blood level of thiopurine metabolites in inflammatory bowel disease (IBD) patients and found that all four methods significantly associated with each other [54]. In some of the previous studies, a cut-off value of 80% was used to divide medication adherence into good or poor [48][49][50][51], while other studies used a cut-off value of 100% [52,53]. The VAS is quick, inexpensive, and easily applicable during medical visits and has been validated against pharmacy refills for patients with chronic diseases [48][49][50][51][52][53].…”

“…In some of the previous studies, a cut-off value of 80% was used to divide medication adherence into good or poor [48][49][50][51], while other studies used a cut-off value of 100% [52,53]. The VAS is quick, inexpensive, and easily applicable during medical visits and has been validated against pharmacy refills for patients with chronic diseases [48][49][50][51][52][53]. Because we believe that VAS is more advantageous than other tools from this point of view, we have incorporated it into our clinical practice.…”