Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults.
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BACKGROUND Cardiovascular disease CVD is a major cause of disability and mortality globally Premature fatal and non fatal CVD is considered to be largely preventable through the control of risk factors via lifestyle modifications and preventive medication Lipid lowering and antihypertensive drug therapies for primary prevention are cost effective in reducing CVD morbidity and mortality among high risk people and are recommended by international guidelines However adherence to medication prescribed for the prevention of CVD can be poor Approximately 9 of CVD cases in the EU are attributed to poor adherence to vascular medications Low cost scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity mortality and healthcare costs associated with CVD OBJECTIVES To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults SEARCH METHODS We searched CENTRAL MEDLINE Embase and two other databases on 21 June 2017 and two clinical trial registries on 14 July 2017 We searched reference lists of relevant papers We applied no language or date restrictions SELECTION CRITERIA We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD We only included trials with a minimum of one year follow up in order that the outcome measures related to longer term sustained medication adherence behaviours and outcomes Eligible comparators were usual care or control groups receiving no mobile phone delivered component of the intervention DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane We contacted study authors for disaggregated data when trials included a subset of eligible participants MAIN RESULTS We included four trials with 2429 randomised participants Participants were recruited from community based primary care or outpatient clinics in high income Canada Spain and upper to middle income countries South Africa China The interventions received varied widely one trial evaluated an intervention focused on blood pressure medication adherence delivered solely through short messaging service SMS and one intervention involved blood pressure monitoring combined with feedback delivered via smartphone Two trials involved interventions which targeted a combination of lifestyle modifications alongside CVD medication adherence one of which was delivered through text messages written information pamphlets and self completion cards for participants and the other through a multi component intervention comprising of text messages a computerised CVD risk evaluation and face to face counselling Due to heterogeneity in the nature and delivery of the interventions we did not conduct a meta analysis and therefore reported results narratively We judged the body of evidence for the effect of mobile phone based interventions on objective outcomes blood pressure and cholesterol of low quality due to all included trials being at high risk of bias and inconsistency in outcome effects Of two trials targeting medication adherence alongside other lifestyle modifications one reported a small beneficial intervention effect in reducing low density lipoprotein cholesterol mean difference MD 9 2 mg dL 95 confidence interval CI 17 70 to 0 70 304 participants and the other found no benefit MD 0 77 mg dL 95 CI 4 64 to 6 18 589 participants One trial 1372 participants of a text messaging based intervention targeting adherence showed a small reduction in systolic blood pressure SBP for the intervention arm which delivered information only text messages MD 2 2 mmHg 95 CI 4 4 to 0 04 but uncertain evidence of benefit for the second intervention arm that provided additional interactivity MD 1 6 mmHg 95 CI 3 7 to 0 5 One study examined the effect of blood pressure monitoring combined with smartphone messaging and reported moderate intervention benefits on SBP and diastolic blood pressure DBP SBP MD 7 10 mmHg 95 CI 11 61 to 2 59 DBP 3 90 mmHg 95 CI 6 45 to 1 35 105 participants There was mixed evidence from trials targeting medication adherence alongside lifestyle advice using multi component interventions One trial found large benefits for SBP and DBP SBP MD 12 45 mmHg 95 CI 15 02 to 9 88 DBP MD 12 23 mmHg 95 CI 14 03 to 10 43 589 participants whereas the other trial demonstrated no beneficial effects on SBP or DBP SBP MD 0 83 mmHg 95 CI 2 67 to 4 33 DBP MD 1 64 mmHg 95 CI 0 55 to 3 83 304 participants Two trials reported on adverse events and provided low quality evidence that the interventions did not cause harm One study provided low quality evidence that there was no intervention effect on reported satisfaction with treatment Two trials were conducted in high income countries and two in upper to middle income countries The interventions evaluated employed between three and 16 behaviour change techniques according to coding using Michie s taxonomic method Two trials evaluated interventions that involved potential users in their development AUTHORS CONCLUSIONS There is low quality evidence relating to the effects of mobile phone delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD some trials reported small benefits while others found no effect There is low quality evidence that these interventions do not result in harm On the basis of this review there is currently uncertainty around the effectiveness of these interventions We identified six ongoing trials being conducted in a range of contexts including low income settings with potential to generate more precise estimates of the effect of primary prevention medication adherence interventions delivered by mobile phone