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Mobile telephone text messaging is a simple potential solution to the failure to take medications as directed. There is uncertainty over the effectiveness of 1-way text messaging (sending text message reminders only) compared with 2-way text messaging (sending reminders and receiving replies confirming whether medication has been taken) as a means of improving medication adherence.
Methods
A meta-analysis of 8 randomized trials (1994 patients) that tested the effectiveness of text messaging on medication adherence was performed. The trials were divided into 2 groups: trials using 1-way text messaging versus no text messaging and trials using 2-way text messaging versus no text messaging. The summary estimates of the effect of the 2 methods of text messaging (1-way or 2-way) were compared.
Results
The summary relative risk estimate was 1.04 (95% confidence interval, 0.97-1.11) for 1-way text messaging and 1.23 (95% confidence interval, 1.13-1.35) for 2-way text messaging. The difference in effect between the 2 methods was statistically significant (P = .007).
Conclusions
Two-way text messaging is associated with substantially improved medication adherence compared with 1-way text messaging. This has important implications in the provision of mobile-based messaging in the management of patients taking medication for the prevention of chronic disease.
Two-way text messaging (reminder plus patient reply) improves medication adherence by 23% (95% confidence interval, 13-35), whereas 1-way text messaging (reminder only) has little or no effect.
It has been estimated that approximately half of all patients prescribed medication for the treatment or prevention of chronic disorders do not take it as prescribed.
World Health Organization (WHO). Adherence to long-term therapies: evidence for action. WHO website. Available at: http://www.who.int/chp/knowledge/publications/ adherence_report/en/index.html. Accessed December 10, 2014.
In the United Kingdom, the annual cost of prescription medications in 2012 was approximately £10 billion, and in the United States, it was approximately $325 billion, so the likely cost of nonadherence, in both wasted medicines and hospitalization through avoidable illness, is substantial.
IMS Institute for Health Informatics. Declining medicine use and costs: for better or worse? A review of the use of medicines in the United States in 2012. Available at: http://static.correofarmaceutico.com/docs/2013/05/20/usareport.pdf. Accessed December 10, 2014.
and the use of text messaging is increasing as a means of communication between patients and their physicians to arrange appointments, increase immunization, and adjust treatment.
It also may improve medication adherence by reminding patients to take their medication and identify who has not taken their medication, so the cause for not doing so can be corrected. Randomized trials testing the use of text messaging on medication adherence have been published and yield conflicting results, some suggesting a benefit and others no benefit. The studies divide into those in which text messages were sent as reminders to take a medicine at a specific time (1-way messaging) and those in which a text message was sent and a reply requested to remind and to determine whether the medication had been taken (2-way messaging). It is not known how the 2 approaches compare and whether one is worthwhile but not the other. Clarifying this is important because there are now more than 160 different mobile telephone applications designed to improve medication adherence, all using 1-way rather than 2-way messaging.
This prompted us to conduct a meta-analysis of randomized trials assessing the value of text messaging on medication adherence to see whether the uncertainty could be resolved.
Materials and Methods
We searched medical databases (PubMed, Embase, Ovid, and Cochrane Library) for randomized controlled trials that assessed the extent to which text messaging improved adherence to medication over time. The search terms used were [“adherence,” “persistence,” “compliance,” or “concordance”] and [“text-messaging,” “mobile phone,” “SMS,” or “smartphones”].
Studies were included that reported medication adherence in terms of the number of doses taken as a proportion of the total number of doses prescribed over a specified time period and classified participants in each randomized group as adherent or nonadherent according to whether the percentage of doses taken, exceeded a specified cutoff (eg, adherent to medication if >80% of prescribed doses were taken over the previous 28 days). We also sought information on whether the text messaging was 1-way messaging (text message reminders sent but no reply requested) or 2-way (text message reminders sent and a reply requested as to whether the medication had or had not been taken as prescribed).
The primary search generated 243 citations that reduced to 58 on inspection of the titles and review of the abstracts and to 9 on review of the published reports. An additional 3 articles were identified through hand-searching the citation lists of relevant studies and review articles, and 4 were excluded because relevant data were not reported, yielding 8
Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert).
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.
Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
studies for inclusion in the analysis. Data were abstracted independently by 2 investigators who assessed for risk of bias using the Cochrane Collaboration tool,
For each study, estimates of adherence in each randomized group were extracted from trial results or determined from the reported data. The relative differences in adherence between the text and no text groups (equivalent to a relative risk) were determined for each trial. A fixed-effects meta-analysis was used to combine the relative differences, separately for trials using 1-way messaging and trials using 2-way messaging, and the summary estimates of effect were compared using meta-regression, taking a difference to be statistically significant at P <.05. Meta-regression was also used to examine possible sources of heterogeneity including, percentage cutoff used to define adherence, method of assessing adherence (self-report vs pill counting), duration of assessing adherence, mean age of patients, and proportion of patients who were male. All analyses were performed using Stata version 12. (StataCorp LP, College Station, Tex).
Results
Table gives details of the studies in the meta-analysis, including data on 1994 patients (mean age, 64 years; 49% were male). Five studies were on patients receiving treatment for human immunodeficiency infection, 2 studies were on patients receiving blood pressure or lipid-lowering treatment, and 1 study was on individuals receiving malaria prophylaxis. The overall risk of bias was low for all trials, apart from 2; 1 trial had an unexplained imbalance in the number of participants in each randomized group,
Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert).
Patients were classified as adherent if (number of medication doses taken/number of medication doses prescribed) × 100 over specified time period before end of trial exceeded the specified percentage cutoff.
Patients were classified as adherent if (number of medication doses taken/number of medication doses prescribed) × 100 over specified time period before end of trial exceeded the specified percentage cutoff.
Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert).
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.
Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
BP = blood pressure; HIV = human immunodeficiency virus; MEMS = Medication Event Monitoring System (electronic date and time record of doses removed from pill bottle).
∗ Patients were classified as adherent if (number of medication doses taken/number of medication doses prescribed) × 100 over specified time period before end of trial exceeded the specified percentage cutoff.
Figure is a meta-analysis plot showing the effect of text messaging on medication adherence in each trial, according to whether 1-way or 2-way messaging was used; the summary relative risk estimates were 1.04 (95% confidence interval, 0.97-1.11) for 1-way messaging and 1.23 (95% confidence interval, 1.13-1.35) for 2-way messaging. One-way messaging had little, if any, effect, but 2-way messaging was effective. The difference in effect between 1-way and 2-way messaging was statistically significant (P = .007). Meta-regression analysis showed no effect of text messaging on adherence according to the percentage (proportion of all pills taken) cutoff used to define adherence, duration of assessment of adherence, mean age, or proportion of patients who were male.
FigureMeta-analysis plot of randomized trials of text messaging on medication adherence according to use of 1-way messaging and 2-way messaging. CI = confidence interval.
Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
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.
Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert).
; there was no evidence of heterogeneity between trials using these different methods (P = .321). Self-reporting was used in all 2-way messaging trials,
The results of this meta-analysis show a clear effect of text messaging on improving medication adherence when 2-way text messaging was used but not when 1-way text messaging was used, a 23% improvement (13% to 35%) compared with a 4% improvement (−3% to 11%), respectively. The contrasting effects were consistent across trials of different medications and medical disorders.
This result has important implications. It indicates that most medication adherence applications available for downloading onto mobile smartphones (160 such applications were available and reviewed in 2012)
are of little or no use because they use 1-way message reminders. The findings from this meta-analysis do not exclude a small useful effect of 1-way messaging (a 4% improvement with an 11% upper confidence limit) but show that a 2-way communication is better. The results indicate that patients are approximately 20% more likely to adhere to medication if 2-way messaging is used compared with 1-way messaging.
Generally, failure to take medication as prescribed is classified as intentional or unintentional. One-way messaging may be helpful in the latter category, providing a simple reminder, but not the former, which requires a further enquiry into the reason for not taking a medication and action to resolve this. Two-way messaging provides the opportunity for both. In the INTERACT trial, which tested the effect of text messaging on the use of blood pressure or lipid-lowering treatment, patients were contacted by phone if their text message reply indicated they had not taken their medication as prescribed, and this led to 20 of 23 patients who had discontinued treatment because of concerns over the benefits or harms of their medication, resuming treatment. In the trial by Maduka and Tobin-West,
which tested the effect of text messaging on adherence to antiretroviral therapy in Nigeria, patients were asked to acknowledge the text message reminders and indicate their need for further counseling or information that was provided by phone. In the WelTel Kenya1 trial,
which also assessed adherence to antiretroviral treatment, patients were asked to confirm their health status, and those who reported a problem were phoned within 2 days to assist with medical issues, in most reported cases.
In all but 3 trials, adherence was assessed by self-reporting, which relies on an accurate recall of doses missed over a time period and is prone to reporting error. The accuracy of electronic monitoring (Medication Event Monitoring System) or pill counting depends on medication actually being taken when the pack is opened and the monitored package being the patient's only source of drug. Notwithstanding these inherent limitations, there is no reason to expect such error to differ systematically between the 2 randomized groups in a trial, so the relative differences in adherence within trials are likely to be unbiased. There was also no evidence of heterogeneity between assessment methods used, although the power to detect small effects was limited. No trial directly compared 1-way with 2-way messaging in a single study, but this should not detract from the evidence from our prespecified analysis comparing the 2 approaches in different trials.
Conclusions
Two-way text messaging is a useful method for improving medication adherence and confers benefit across a range of therapies, but 1-way text messaging has little or no effect.
Appendix.
Supplementary TableAssessment of Risk of Bias in Trials of Text Messaging on Medication Adherence
Trial (First Author)
Random Sequence Generation
Allocation Concealment
Binding of Participants
Power Analysis
Missing Data
Selective Reporting
Other Sources of Bias: Intention-to-Treat Analysis Used
Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert).
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.
Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
World Health Organization (WHO). Adherence to long-term therapies: evidence for action. WHO website. Available at: http://www.who.int/chp/knowledge/publications/ adherence_report/en/index.html. Accessed December 10, 2014.
IMS Institute for Health Informatics. Declining medicine use and costs: for better or worse? A review of the use of medicines in the United States in 2012. Available at: http://static.correofarmaceutico.com/docs/2013/05/20/usareport.pdf. Accessed December 10, 2014.
Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert).
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.
Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
Wald et al1 compared 1-way vs 2-way text messaging for medication adherence, and conclude that 2-way text messaging improves medication adherence, whereas one-way text messaging has little or no effect. Two issues caught our attention. The first is that the trial by Mbuagbaw et al2 is grouped as a 1-way trial even though it is a 2-way trial; participants were offered the opportunity to respond to the text messages by text or by calling. The second issue is that the numbers don't add up. We used the numbers reported in the Wald paper1 and found slightly different results.
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