Low-Cost Reminders Fail to Improve Medication Adherence

Suboptimal medication adherence is a significant problem in psychiatry and throughout the health care system. Simple and inexpensive options to remind patients to take their medications daily are widely available, but can such simple reminders improve adherence?

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A large-scale clinical trial published February 27 in JAMA Internal Medicine suggests reminder devices alone may not be enough to improve adherence in patients who have a history of not taking their medications.

This study, named the Randomized Evaluation to Measure Improvements in Nonadherence (REMIND) trial, was carried out by a joint team of investigators from Brigham and Women’s Hospital in Boston and CVS Health. The researchers enrolled 53,480 participants aged 18 to 64 whose prescriptions were managed by CVS and compared three low-cost adherence devices: a standard pillbox, a pill bottle with seven daily toggles that can be flipped between no/yes positions, and a pill bottle cap with a digital timer displaying the time elapsed since last medication.

The participants, which included 15,948 people taking antidepressants, were all chosen based on a 12-month prescription history of suboptimal adherence. They were randomized to receive one of the three devices in the mail—along with instructions and a number to call for assistance—or no device. Over the next 12 months, the researchers measured medication adherence using pharmacy claims data.

At study’s end, the investigators found no discernable difference between medication adherence in the groups that received any of the interventions and those in the control group. In each study arm, about 15 percent of the participants became optimally adherent to their prescribed treatments (taking 80 percent of their doses or more) during the follow-up period. These findings held true for the patient cohort overall as well as among patients taking only antidepressants or medications for cardiovascular disease. Reminders also failed to improve adherence in patients taking medications that required multiple doses per day.

“Influencing adherence through simple, easy-to-implement, and affordable interventions offers intriguing potential as a public health approach to solving [nonadherence],” Ian Kronish, M.D., M.P.H., and Nathalie Moise, M.D., of Columbia University wrote in a related editorial. “Unfortunately, the authors found that providing patients with these devices alone was not the answer to nonadherence.”

Lead study author Niteesh Choudhry, M.D., Ph.D., the founding executive director of Brigham and Women’s Center for Healthcare Delivery Sciences, said more research is needed to understand why the devices alone were not enough to improve medication adherence.

“Our results could imply that these devices do not help, but it could also be that forgetfulness is not a major reason for chronic nonadherence in our study population,” he told Psychiatric News. “These simple reminders may be more suited for people who are fairly compliant and just need a little extra nudge to be fully adherent,” Choudhry said. Such reminders may also be useful to older adults where forgetfulness may be more common, he said.

In an effort to make the trial as reflective as real-world conditions as possible, Choudhry and colleagues deliberately did not coordinate the mailing of devices and instructions with prescription refills. As a result, he said, patients may have had trouble transitioning to the device in the middle of a prescription fill or may have not used them at all if their medication refill had lapsed.

“Such real-world testing is important,” Choudhry said. “You run a greater risk of negative results, but the potential generalizability of the findings is a trade-off one should be willing to make.”

Even though these reminders may not be a widespread solution for nonadherence, Choudhry does not think his study’s results suggest such devices should be dismissed. They are inexpensive, simple to use, and have no drawbacks such as making adherence worse, he said. Additionally, it’s possible the devices increase patient safety.

“What we did not capture, nor could we capture, in our analysis was did these devices make pill-taking safer? Did it prevent double dosing, for example? That is another important consideration that would make these devices worthwhile even if adherence stays the same.”

The REMIND trial was supported by a grant from CVS Health. ■