Health Information Technology: Text Messaging Interventions for Medication Adherence Among Patients with Chronic Diseases

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to chronic disease prevention.

Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, et al. Mobile telephone text messaging for medication adherence in chronic disease. JAMA Internal Medicine 2016;176(3):340-9.

The review included 16 randomized controlled trials (search period through January 2015). The team examined each of the studies included in the systematic review and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review, additional information from the included studies, and expert input from team members and the CPSTF.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 16 studies.

• Medication adherence improved significantly (16 studies).

Evidence from a subset of seven studies conducted in high-income countries was used as the basis for the CPSTF recommendation.

• Medication adherence, measured either by patient or dose, increased by a median of 13.8 percentage points (7 studies).

A systematic review of economic evidence has not been conducted.

• The CPSTF finding should be applicable to U.S. adults who are taking medications for a chronic condition.
• The CPSTF assessment on applicability focused on the subset of seven studies from high-income countries.
  • The subset of studies were conducted in the United States (2 studies), Denmark, England, France, The Netherlands, and Spain (1 study each).
  • Patients were recruited from hospitals or clinics (5 studies), pharmacies (1 study), and communities (1 study).
  • Studies evaluated interventions with patients who were taking medications for hypertension (1 study), heart disease (3 studies), diabetes (1 study), HIV (1 study), and asthma (1 study).
• Although evidence for specific settings and patient characteristics is limited or absent, the intervention is simple and focused on improving a basic patient self-management behavior.

The systematic review by Thakkar et al. identified the following areas for future research.

• Longer duration evaluations based on objective measures of medication adherence and inclusion of clinical outcomes
• Benefits of different features of text message interventions

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Are text messaging interventions effective when implemented and evaluated over longer periods of time (1-2 years)?
• Are these interventions also effective in improving clinical outcomes and health care use, and in reducing morbidity and mortality?
• How does intervention effectiveness vary when
  • Recruitment of clients occurs in workplaces or community settings?
  • Implemented for patients who vary by race, ethnicity, or socioeconomic status?
  • Implemented for patients at the initiation of medical management?
  • Implemented for patients with previously low adherence?
  • Based on new or existing mobile-phone applications?
  • Combined with additional interventions to improve patient self-management and clinical care?
• Are text messaging interventions effective when implemented and evaluated with larger samples of U.S. patients living with HIV?

• All of the included studies were randomized controlled trials.
• Studies examined the effectiveness of text messaging interventions in improving patients’ medication adherence.
• In all of the studies, text messaging interventions were implemented alone, without additional patient or clinical system interventions.
• Study participants had a variety of chronic medical conditions and lived in either developed or developing countries.
• Evaluated interventions sent text messages daily (8 studies), weekly (3 studies), or on a dose-timed frequency (4 studies).
• Interventions were of short duration (median 14 weeks).
• Studies sent automated text messages (10 studies), employed two-way communication with healthcare providers (8 studies), and sent patients personalized messages (5 studies).

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Analytic Framework [PDF – 99 kB]

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, et al. Mobile telephone text messaging for medication adherence in chronic disease. JAMA Internal Medicine 2016;176(3):340-9.

Studies Included in the Systematic Review (Thakkar et al., 2016)

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

da Costa TM, Barbosa BJ, Gomes e Costa DA, et al. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012;81(4):257 69.

*Hardy H, Kumar V, Doros G, et al. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDS 2011; 25(3):153 61.

Khonsari S, Subramanian P, Chinna K, Latif LA, Ling LW, Gholami O. Effect of a reminder system using an automated short message service on medication adherence following acute coronary syndrome. Eur J Cardiovasc Nurs 2015;14(2):170 9.

Lester RT, Ritvo P, Mills EJ, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010;376 (9755):1838 45.

Lua PL, Neni WS. A randomised controlled trial of an SMS-based mobile epilepsy education system. J Telemed Telecare 2013;19(1):23 8.

Lv Y, Zhao H, Liang Z, et al. A mobile phone short message service improves perceived control of asthma: a randomized controlled trial. Telemed J E Health 2012;18(6):420 6.

Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013;16(3):302 8.

*M rquez Contreras E, de la Figuera von Wichmann M, Gil Guill n V, et al. Effectiveness of an intervention to provide information to patients with hypertension as short text messages and reminders sent to their mobile phone (HTA-Alert) [in Spanish]. Aten Primaria 2004;34(8):399 405.

Mbuagbaw L, Thabane L, Ongolo-Zogo P, et al.The Cameroon Mobile Phone SMS (CAMPS) trial: a randomized trial of text messaging versus usual care for adherence to antiretroviral therapy. PLoS One 2012;7(12):e46909.

*Park LG, Howie-Esquivel J, ChungML, Dracup K. A text messaging intervention to promote medication adherence for patients with coronary heart disease: a randomized controlled trial. Patient Educ Couns 2014;94(2):261 8.

Pop-Eleches C, Thirumurthy H, Habyarimana JP, et al. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011;25(6): 825 34.

*Quilici J, Fugon L, Beguin S, et al. Effect of motivational mobile phone short message service on aspirin adherence after coronary stenting for acute coronary syndrome. Int J Cardiol 2013;168(1): 568 9.

*Strandbygaard U, Thomsen SF, Backer V. A daily SMS reminder increases adherence to asthma treatment: a three-month follow-up study. Respir Med 2010;104(2):166 71.

*Vervloet M, van Dijk L, Santen-Reestman J, et al. SMS reminders improve adherence to oral medication in type 2 diabetes patients who are real time electronically monitored. Int J Med Inform 2012;81(9):594 604.

*Wald DS, Bestwick JP, Raiman L, Brendell R, Wald NJ. Randomised trial of text messaging on adherence to cardiovascular preventive treatment (INTERACT trial). PLoS One 2014;9(12):e114268.

Wang K,Wang C, Xi L, et al. A randomized controlled trial to assess adherence to allergic rhinitis treatment following a daily short message service (SMS) via the mobile phone. Int Arch Allergy Immunol 2014;163(1):51 8.

*Studies included in the high-income nation subset analyses conducted by the CPSTF

Implementation Resources

• CDC’s Division for Heart Disease and Stroke Prevention developed an implementation resource to help communities and health systems implement telehealth interventions to improve chronic diseases.

Refer to the existing systematic review for information about the search strategy:

Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, et al. Mobile telephone text messaging for medication adherence in chronic disease. JAMA Internal Medicine 2016;176(3):340-9.

Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, et al.. Mobile telephone text messaging for medication adherence in chronic disease. JAMA Internal Medicine 2016;176(3):340-9..

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• The included studies provided few details on implementation and most were conducted prior to the availability of smart-phones. The rapid evolution of mobile device technology is likely to provide newer studies with opportunities for substantially enhanced or personalized message content and interactivity.
• The Million Hearts Initiative provides a medication adherence toolkit that detail organizational considerations and options to address medication adherence for cardiovascular disease prevention.
• CDC provides action guides for providers and a mobile application for use by patients with HIV.
• Implementers should understand state policies regarding application of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to electronic communications with patients.
• Use of text messages to encourage or remind patients to take their medications might reduce the number of outpatient visits needed to determine optimal medical management.
• Text messages may be a source of distraction for patients engaged in other activities.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of adults with chronic kidney disease who have elevated blood pressure — CKD-06
• Increase control of high blood pressure in adults — HDS-05
• Increase cholesterol treatment in adults — HDS-07
• Increase aspirin use for secondary prevention of atherosclerotic cardiovascular disease — HDS-08
• Increase viral suppression — HIV-05