Text alerts 'help prompt people to take their pills'

Monday December 8 2014

"A text messaging service could help people remember to take the medicines they have been prescribed," BBC News reports, after a small trial scheme in London helped increase drug adherence in people with cardiovascular disease.

Lack of adherence – not sticking to a recommended treatment plan – is a known problem in some people with chronic diseases, such as heart disease.

The BBC reports up to half a billion pounds a year is wasted as a result of people not taking medication and resulting complications that could have been avoided.

The study recruited 303 adults who were taking blood pressure tablets such as Perindopril, or pills to lower their cholesterol (statins).

Half the participants received text messages over a six-month study period and the other half did not – more people in the text group took their medication as prescribed compared with the "no text" group (91% versus 75%).

The main difference between the groups appeared to be related to people being telephoned by a healthcare professional if they did not respond to the text, or if they replied they had stopped taking their medication.

This telephone call resolved medication issues in almost all cases. In contrast, it does not appear any such measures were in place for the other group.

Text messages could be a cost-effective method of improving adherence and could potentially be used for other chronic conditions, such as HIV.

Where did the story come from?

The study was carried out by researchers from Queen Mary University London and was funded by AstraZeneca, Barts Hospital Special Trustees and Queen Mary Innovation.

The authors stated that: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

It was published in the peer-reviewed medical journal PLOS One. This is an open-access journal, so the study is free to read online.

The BBC reported the news accurately and included an informative video interview with the lead researcher, though they did not discuss any of the study's limitations.

What kind of research was this?

This was a randomised controlled trial (RCT) that aimed to see if the use of text messaging improved adherence to taking medication.

Non-adherence is a relatively widespread problem, especially in people with chronic diseases, who are often required to take a range of different drugs.

An RCT is considered the "gold standard" in assessing how effective an intervention or treatment is. But this RCT wasn't double blinded, which does increase the risk of (often unconscious) bias. 

What did the research involve?

The researchers recruited people from seven GP practices in London. To be eligible, they had to have a mobile phone number on the GP records and be taking blood pressure or lipid-lowering medication.

A text was sent to 6,884 suitable people to see if they were interested in the trial. In the end, 303 people agreed to participate.

Half the participants were randomly assigned to receive text messages and the other half were not. The groups were similar in terms of gender, smoking status, the reason for taking the medication, and the types of medication used.

There was no description of concealing the allocation of the treatment groups (blinding) to medical staff assessing adherence or those carrying out data analysis of the two groups. This may be a source of bias.

It wasn't possible to blind the participants to their treatment allocation – obviously, people are going to know if they are getting text messages or not.

Those in the text group had:

  • daily texts at the specified pill-taking time for the first two weeks
  • texts on alternate days for the next two weeks
  • weekly texts for 22 weeks

The participants in the text group were asked to respond to say if:

  • they had taken their medication
  • the text had reminded them as they had forgotten
  • they had not taken their medication

These responses were automatically received. A computer programme then alerted a healthcare worker to call the participant if they had not taken their medication or had not responded to the text.

During the call, the reason why the person wasn't taking their medication was discussed with a view to resolving any issues or concerns.

Medication use at six months was assessed at clinic visits in most cases, although a small group was assessed by looking at prescription records.

At the end of the trial, people who were using blood pressure-lowering medications had their blood pressure recorded, and those using lipid-lowering medication had their cholesterol measured.

What were the basic results?

By six months, more people in the text group were taking medication than in the "no text" group (91% adherence versus 75% adherence). In the text group, 65% had been reminded to take their medication on at least one occasion.

At some point during the six-month window, 15% did not take their medication on at least one occasion. The reasons for this were either:

  • uncertainty over the need for treatment
  • concern over side effects
  • another medical illness meant the medication was discontinued

This prompted a telephone discussion, after which almost all (20 out of 23) started taking their medication again. In comparison, 11% (16) of the "no text" group stopped medication.

Counterintuitively, despite the differences in adherence to the medicines, there was no difference between the groups in terms of average blood pressure or cholesterol level at the end of the trial.

How did the researchers interpret the results?

The researchers concluded that: "In patients taking blood pressure or lipid-lowering treatment for the prevention of cardiovascular disease, text messaging improved medication adherence compared with no text messaging."

They further say it may be a result of the "bidirectional texting", as this then prompted a discussion so the reasons for not taking medication "could be determined and advice provided".

Conclusion

This randomised study found a text messaging reminder service led to more people taking medication as prescribed.

It appears this was because not taking the medication or not responding to the text led to a discussion with a healthcare professional, which influenced people to continue taking their medicines.

The study was clearly reported and was of adequate size to find a difference between the two groups, if there was one. But, as with all studies, there are some limitations to consider.

  • The results of the study may not be applicable to everyone. The recruitment process meant the participants were already interested in receiving text prompts to remember to take their medication. There could be many reasons for this, but perhaps the most obvious one is they already recognised they sometimes forgot to take their pills and were keen on a reminder.
  • There was no clinical difference between the two groups in terms of blood pressure or cholesterol. But these measurements were only taken on one occasion at the end of the trial. As there was no baseline level, we do not know if there was any improvement in the levels because of their use of medication during the trial period.
  • The study did not blind the treatment allocation to either the clinical assessors of medicine adherence or the researchers analysing the data. Although unlikely, the medical assessors could have introduced bias into the results, especially if they had preconceived ideas about whether text messaging would help their patients. It is unlikely the data analysis was biased, as almost all the data was analysed. Only two people of the 303 starting the trial were not included in the final analysis.
  • Although plausible, these results do not automatically mean text messaging reminder services would work for all medicine regimes, such as those used to treat tuberculosis or HIV. Different regimes are likely to present different challenges and reasons for non-adherence. These may or may not be able to be addressed via a text or phone call, as was the case in this trial.

In conclusion, text message prompts similar to those used in this trial may help some people take their medicines as prescribed.

The trial also indicates it is useful to talk to your GP if you decide not to take your medication as prescribed so you can discuss the reason for this.

If the results of this trial are anything to go by, your GP may be able to reassure you, and you might be able to continue taking your medicines. Or there may be more suitable alternative medicines available, which can also be discussed.

Analysis by Bazian
Edited by NHS Choices