EVIDENCE BASED PROJECT PROPOSAL

Aug. 21st, 2020

Implementing mHealth Systems to Improve Diabetes Medication Adherence

Abstract

This evidence-based project considers the effect of mobile health (mHealth) medication monitoring systems on medication adherence among home-dwelling patients. Specifically, the researcher will implement and evaluate mHealth systems for telemonitoring, electronic dose reminders, and medication organizers. Implementing this project will provide findings on the effectiveness and efficiency of mHealth systems in improving medication adherence.

Overview of the Problem

Drug adherence is a major contributing factor to increased life expectancy. Older adults (65 years or older) receive a prescription of more than five different drugs when they leave acute care for home-based care. The increasing number of drugs and the risk of medication's unwanted effects are considered to be associated with reduced adherence to drug treatment. Poor adherence to drug prescription has significant undesirable effects on treatment outcomes, treatment costs, and mortality. Non-adherence to prescribed medication accounts for at least 10 percent of all readmissions to acute care among older adults (Verloo et al., 2016). Although health information technologies hold the promise of improving remote monitoring of drug adherence among recently discharged older adults, the little amount of research is available to document the evidence of the effects of these systems on medication adherence.

Project Purpose Statement

This evidence-based project aims to investigate the effect of implementing electronic health records-based mobile health (mHealth) system on medication adherence among older adult diabetic patients in home-based care settings. The goal of the intervention is to enhance the effectiveness and efficiency of nurse-led care activities such as medication education, counseling, and medication evaluation, aiming to improve medication adherence, prevent unnecessary hospital visits and reduce care costs.

Background and Significance

As frontline hospital staff, a key observation I have made is that diabetic patients discharged from hospitals often go home with numerous medication prescriptions. This observation is particularly important when one looks at the complex nature of the life of older adults. The mind and time of an older person are often focused on aspects of life that takes away the focus on medication schedules. Thus, adhering to the prescriptions can be challenging, and many older adult patients stop taking medications in entirety as soon as they reach home. In contrast, others may decide to take only a small part of their medications. Medication adherence is a key determinant of the efficacy of treatment, patient safety, and healthcare costs. According to Whisehunt (2014), non-adherence can lead to worsening of clinical outcomes, including increased severity of the disease, re-hospitalization, and even death. The rate of readmission among recently discharged older patients is a significant issue for hospitals, non-adherence to medication responsible for as high as 10 percent of all readmissions (Verloo et al., 2017).

As frontline healthcare professionals with a major role in primary care, nurses can play a major part in enhancing medication adherence among recently discharged older adults. Preliminary research shows that mHealth systems' implementation represents a nurse-led intervention that produces enhancements in medication adherence. The system has the potential to address the risk of poor medication adherence, in the forms of missing doses, alteration of schedulers, or discontinuation of medication altogether. Complex treatment plans and medication regimens not communicated effectively are the principal contributors to medication non-adherence (Tao et al., 2015). Electronic medication reminders delivered via mHealth holds the potential to reinforce communication about medication prescriptions given to discharged patients and, thus, increasing medication adherence significantly.

PICOT Formatted Clinical Project Question

In home-dwelling older adult diabetics, how can mHealth-delivered electronic monitoring reminders differ from usual care in increasing adherence to prescribed medication?

· Population- Home dwelling older adult diabetes patients

· Intervention- mHealth-delivered electronic medication reminders

· Comparison- Usual care

· Outcomes- Increased rate of medication adherence

· Timeframe- Six months

Literature Review

To help answer the research question on whether mHealth-delivered electronic monitoring reminders differ from usual care in increasing adherence to prescribed medication among home-dwelling older adult diabetic patients, nursing- and medicine-related databases, including CINAHL with Full Text, PubMed, and Cochrane Library, were searched to identify peer-reviewed research articles. Search terms, including diabetes, mHealth, medication adherence, electronic monitoring, and medication reminders, were used, and the search was limited to full text and peer-reviewed. The review excluded publications older than five years.

Summaries of Research Studies

Nursing scholars have attempted to answer various research questions on the effect of electronic reminders delivered via m-Health systems on medication adherence. Verloo et al. (2017), in the form of a meta-analysis of randomized controlled trials, considered whether electronic monitoring reminders increase medication adherence rates among recently discharged home-dwelling patients (65 years or older). The study aimed to compare medication adherence rates as the effect of electronic monitoring reminders to the adherence rates in usual measures. In total, the review looked at the findings of 14 randomized controlled studies (Verloo et al. (2017). These authors found that nurse-led electronic monitoring of discharged patients moderately improved medication adherence. The study explores electronic monitoring reminders, which is the key functionality of mHealth systems and, hence, relevant to the study topic. To ensure the validity of the studies included in the review, the authors reported the results using Cochrane's PRISMA statement, a validated instrument of testing validity and reliability of studies. The study is a meta-analysis of randomized controlled trials, which represents a higher level of evidence, i.e., level I evidence, and a high rating of evidence quality. Thus, the study's main strength is its design, i.e., a meta-analysis of randomized controlled trials. The weakness, however, is that the small sample size used does not allow the authors to measure changes in clinical indicators, such as blood sugar, total cholesterol, and blood pressure.

Heuckelum et al. (2017) considered the efficacy of obtaining and acting on feedback via electronic monitoring systems on enhancing medication adherence. Specifically, the researchers wanted to assess whether the utilization of electronic monitoring feedback leads to changes in dose adherence and key clinical outcomes. This systematic review included 10 studies with individual samples ranging from 10 to 205 (Heuckman et al., 2017). The study's primary finding is that 66 percent of the randomized controlled studies analyzed showed significant improvement in dose adherence as an effect of electronic monitoring feedback. In relation to relevance, the authors investigate electronic monitoring, a key application of EHR-based mHealth systems. To ensure the validity of the review, the authors employed random-effects analysis to assess the studies' heterogeneity using a validated model. A key strength of this study is its higher level of evidence, i.e., level I evidence since it is a meta-analysis of randomized controlled trials. Heuckelum et al. (2017) used the term electronic monitoring broadly without focusing on the specific mHealth technologies or devices used to monitor medication adherence and provide reminders of medication remotely. The problem with this generalization is that making periodic telephone contacts with patients may not produce the same medication adherence effect as other electronic reminders that provide continuous access to patient management systems, such as electronic health records.

Another study, Tao et al. (2015), also looked at the effect of a mHealth system on the rate of adherence to medication in the care of chronic diseases. Specifically, the researchers looked at electronic alarm device-triggered reminders, analyzing results from 22 randomized controlled trials. The study utilized a random-effects model to pool together outcome data and determined the pooled Cohen's effect (Tao et al., 2015). In terms of results, Tao et al. (2015) observed a small but significant increase in medication adherence. The study's recorded pooled Cohen's d was 0.29. The main strength of the study is in its high-quality rating and high level of evidence, i.e., level I evidence as it is a meta-analysis of randomized controlled trials. The main limitation, however, is that the study included used a small sample of 22 studies. The issue with small sample sizes in meta-analysis is that it creates a high probability of publication bias, as there is a tendency of researchers to include only studies with desirable results and exclude studies with undesirable results.

Whisehunt (2014), using a sample of 12 studies, explored the effectiveness of interventions involving text message reminders on adherence to medication among older adults (65 years or older). The outcome variable used to estimate the effect on medication adherence in the study was the clinic appointment attendance. Whisehunt (2014) observed that text messaging increased clinic appointment attendance, an indicator of medication adherence, by 50 percent. The study is highly relevant to the capstone project's research question both in terms of the topic of improving medication adherence with the use of mHealth systems. The authors investigate text message reminders, which is a key functionality of mHealth systems. The strength of Whisehunt (2014) is on the strength of its evidence level, i.e., level I evidence. Although positive changes in clinical outcomes and quality of life outcome measures are considered the ultimate goals of interventions meant to improve medication adherence, the primary and sole focus in the author is the measurement of adherence to medication. The study does not measure changes in clinical indicators, such as blood sugar, total cholesterol, and blood pressure, because of the small number and heterogeneity of studies included.

Zhang et al. (2015), employing the cluster-randomized trial design, considered the effect of text messaging and medication monitors on adherence to medication among tuberculosis patients. Zhang et al. (2015) sampled and studied 300 active pulmonary tuberculosis patients. The study, which followed up the participants for 6 six months, evaluated an intervention that provided electronic reminders for patients to take medication and attend monthly follow-up visits. To enhance validity, the authors employed a cluster-level CONSORT diagram to guide the eligibility determination of participants. To determine the effect, the researchers compared the dose adherence rate and the monthly visit rate between the study and control groups. The finding was that 13.9 percent of participants in the study group missed 20 percent of doses compared to 29.9 percent in the control group, indicating an improvement in adherence. The study's focus on text messaging and medication monitors are relevant to the focus of the project. This study's main strength is that it uses a high sample size of 300 patients, involving older adults. The study is level I evidence as it is a randomized controlled trial. Weaknesses?

In conclusion, the review showed that mHealth systems produce small to significant improvement in medication adherence among home-dwelling diabetic older adults. The studies showed text messaging, and medication monitors, electronic device-triggered alarms, and other functionalities of mHealth systems significantly reduce the number of people with diabetes who miss prescribed medication doses and improve the attendance of clinic appointments. Although the studies reported important findings on the effect on medication adherence, they do not report the effect of mHealth-delivered electronic reminders on clinical outcomes, reduction of care costs, improvement of quality of life, and improvement of revenues. Thus, future studies should include an analysis of the effect of mHealth systems on these outcomes.

EBP Standard and Implications

As a result from the review of evidence from Heuckelum et al. (2017), Tao et al. (2015), Verloo et al. (2015), Whisehunt (2014), and Zhang et al. (2017), two evidence-based practice interventions are recommended as practice standards, in relation to the use of mobile health (mHealtth) technologies to improve medication adherence among home-dwelling recently discharged type 2 diabetes patients. The first recommendation is for hospitals to implement mHealth-delivered electronic reminders for medication adherence in patients with type 2 diabetes (reference – remember that EBP interventions have to be based on research so cite the reference that supports this recommendation). The second recommendation is for hospitals to provide patients with real-time access to their electronic health records (EHR) via EHR-based mHealth technological systems (reference – remember that EBP interventions have to be based on research so cite the reference that supports this recommendation). Through remote monitoring of medication use and EHR access for recently discharged home-dwelling diabetes mellitus patients, individual patient preferences become easy to identify and address. For example, through the access, patients can consult clinicians about their challenges with and preferences for prescribed medication, allowing for prompt changes.

The findings of the review have implications for nursing practice and research. As frontline personnel in medication prescription, patient education, pre-discharge counseling, and adherence monitoring, nurses have EHR-based electronic medication reminders as an additional tool for medication adherence monitoring and patient safety. As recent evidence shows, the nursing practice can significantly address the poor rate of medication adherence among recently discharged older adult patients by enlisting them in EHR-based mHealth systems that provide medication reminders. The unintended effect on the privacy and other ethical concerns arising from access to electronic patient records is an area that requires attention. As an implication of the problem of small sample size in the few studies analyzed, further nursing research uses greater samples and multiple settings to produce more reliable findings.

Conclusion

Poor medication adherence among recently discharged patients calls for nurse-led interventions to provide medication adherence monitoring and prompt corrective action. The problem accounts for as high as 10 percent of hospital readmissions among recently discharged old patients. The proposed EBP research project aims to assess the effect of EHR-integrated mHealth systems in increasing medication adherence, reducing re-hospitalization, and lowering health care costs in the stated patient category. The findings of the study will have implications for medication adherence monitoring and patient safety.

References

Heuckelum, M., van den Ende, C. H., Houterman, A. E., Heemskerk, C. P., van Dulmen, S., & van den Bemt, B. J. (2017). The effect of electronic monitoring feedback on medication adherence and clinical outcomes: A systematic review. PLoS ONE, 12(10), e0185453.

Tao, D., Xie, L., Wang, T., & Wang, T. (2015). A meta-analysis of the use of electronic reminders for patient adherence to medication in chronic disease care. Journal of Telemedicine & Telecare, 21(1), 3-13.

Verloo, H., Chiolero, A., Kiszio, B., Kampel, T., & Santschi, V. (2017). Nurse interventions to improve medication adherence among older adults: A systematic review. Age & Ageing, 46(5), 747-754.

Whisehunt, A. (2014). Social work and medical care: Electronic reminders to address adherence. Journal of Evidence-Based Social Work, 11, 248-255.

Zhang, H., Liu, X., Lewis, J. J., Lu, W., Zhang, S., & Zheng, G., et al. (2015). Effectiveness of electronic reminders to improve medication adherence in tuberculosis patients: A cluster-randomized trial. PLoS Med, 12(9): e1001876.