We are a technology-obsessed society. Many of us most likely have experienced that disoriented feeling when accidentally leaving the house without our phone. According to a 2015 Pew Research Center report, 68% of United States adults own a smartphone.
One of the most prominent features of smartphones, with which many in our generation in particular are infatuated, are mobile applications, colloquially referred to as “apps.” Recent studies suggest that 90% of total time on mobile phones is being spent on apps and that individuals may spend an average of 30 hours per month on apps. Such preoccupation raises the question of whether these personal devices could be utilized by health care providers and their patients when forming and implementing treatment plans. There is promising evidence indicating that this may indeed be the case.
Treatment of nonadherence is a pervasive issue in the health care system, with estimates of yearly expenditures in the hundreds of billions of dollars. Adherence is defined as the degree to which patients are able to follow treatment recommendations. Patients are generally considered adherent to therapy if they follow their given treatment regimen greater than 80% of the time. Approaches for measuring this have included surveys of patients and/or caregivers, pill counting, examining records of pharmacy refills, medication dispensers with recording sensors and adding markers to given medications which can subsequently be measured in urine or blood. A meta-analysis of 569 studies indicated an average nonadherence rate of 25%. Other studies have shown that as many as 40% of patients fail to adhere to treatment recommendations, depending on their disease conditions and the complexity of the treatment plan prescribed. When regimens are particularly complex, or require lifestyle modifications, nonadherence can be up to 70%. These percentages may vary based on specific conditions or the method of data collection; however, it is clear that nonadherence is an obvious target for quality improvement and economic-related interventions.
Reasons for Nonadherence
There are many reasons for medical nonadherence, but in general they can be categorized as either intentional or unintentional. Intentional nonadherence typically refers to a process by which the patient actively decides not to take a medication. Explanations for this may include skepticism over drug efficacy and fear of drug side effects, dependency or masking of other conditions. Other explanations may include alarm propagated by hearsay, as in cases where the patient had an acquaintance that had a negative experience with a medication.
Unintentional nonadherence is a passive process by which the behavior is unplanned. Explanations for this include poor understanding of care instructions, forgetting instructions, an uneasy therapeutic alliance between patient and physician, low health literacy and lack of engagement with treatment planning. Other contributing factors include the patient’s general beliefs regarding the health care system, previous experience with therapies, medication cost, accessibility to transportation, lack of social support, pharmacy wait times and poor mental health.
Targets for Improvement of Nonadherence
In the World Health Organization’s 2003 report on long-term therapy adherence, they note “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.” The current practice of examining resource utilization and intervention efficacy to measure health outcomes is inaccurate without accounting for treatment adherence rates to inform planning. Inexpensive modifications for improving adherence have been repeatedly found to decrease health care expenditures and increase medical intervention efficacy.
Due to the spectrum of factors which contribute to treatment nonadherence, interventions must be individualized for each patient. These include simplifying dosing regimens, setting up reminders, improving communication between patient and physician and introducing or improving patient counseling. However, arguably one of the most important factors that can affect adherence is actively involving the patient in their care, as studies have shown that patient adherence and overall satisfaction are increased when they are encouraged to participate in their treatment.
Mobile Technology and Increasing Self-adherence
Enter: smartphones. Mobile phones are increasingly being used to improve nonadherence, particularly those believed to be due to unintentional etiologies. Frequently, such interventions have involved electronic reminder systems via Short Message Services (SMS) to prompt patients of impending medication dosages. A randomized controlled trial of 431 adult HIV patients using SMS to promote adherence to anti-retroviral therapy displayed statistically significant decreases in treatment interruptions in the intervention group as compared to the control group during a 48-week study period.
Utilizing mobile applications specifically to improve patient adherence remains a relatively new strategy. Mobile application development is increasing exponentially, with some sources projecting the app market to be a $77 billion industry by 2017. Per a 2015 health informatics report, there are currently over 165,000 medicine and health-related apps available between the Apple and Google stores, which include apps that target both health care providers and patients. Obviously, this number presents an overwhelming amount of options for consumers; however, only 36 apps comprise over 50% of total downloads. Thus, the question arises as to how certain apps become widely used while other arguably similar ones are essentially ignored.
Is Medical App Use in Health Care Beneficial?
Ultimately, the question of medical app use in treatment planning is a question of its overall efficacy, which is largely based on patient’s readiness to utilize such means. In a survey of 100 rheumatoid arthritis (RA) patients with mean age of 57 years old (+/- 11.9), 82% were willing to pay for an RA self-management application. Perhaps even more encouraging to health care providers is the report by the IMS Institute that 30-day retention rates for mHealth apps prescribed by providers is 10% higher than average and 30% higher for fitness apps.
Studies of app utilization for medical management have shown promising results. In a 2016 systematic review which reviewed 9 randomized controlled trials examining the use of apps in the self-management of various chronic conditions, 3 out of 5 interventions involving apps alone as an intervention — versus apps plus a second component such as a support group or phone call reminder — displayed significant positive changes in symptom management. In a 2013 randomized controlled trial involving 72 patients with Type 1 diabetes, those who received a glucose buddy app/text message instruction feature in addition to usual care had significantly improved glycemic control as compared to the control group at the 9 month follow-up.
However, other studies have been less conclusive. In a February 2016 systematic review of 26 mobile apps for inflammatory bowel disease (IBD) self-management, it was determined that despite their appeal, the evidence regarding the role of apps in IBD self-management is limited and their ideal use to facilitate self-management remains indeterminate. A 2013 Cochrane review examining the use of apps in asthma self-management drew a similar conclusion. Clearly, this remains an auspicious, novel medical approach.
Disadvantages of Current App Market and Use
Despite their benefits as presented above, the app market has several limitations that must be addressed before their widespread use in the field can be trusted. Studies have indicated that 65% to 86% of medical apps available on the market had no expert involvement in their development, causing major concerns for quality and patient safety in regards to their use. In addition, although the FDA initially announced plans to regulate medical apps for quality purposes, they have since specified that they would actively regulate only those apps that qualify as medical devices, “whose functionality could pose a risk to a patient’s safety if the mobile app were to not function as intended.” Finally, evidence-based studies of interventions using apps currently available for wide-spread purchase appear to be lacking, with many studies using apps specifically designed by the research group for the intervention in question.
The use of mobile applications to engage patients in their personal medical management is a promising possibility in the future of health care. Many questions remain as to exactly how such interventions would be implemented in day-to-day care, but opportunities appear limitless. Personalized components such as medication reminders, symptom logs, and diaries appear important to patients, as does the ability to easily transmit information to be seen and reviewed by providers. Regardless of the legitimate questions of quality standards in the current medical mobile application market, patients continue to use this software as a resource for managing their health. As budding practitioners, we owe it to our patients to educate ourselves on this software so as to provide sound advice concerning it.