Use of Health Information Technology to Improve Medication Adherence

Volume 17: SP79-SP87 December 2011 Number SP

Use of Health Information Technology to Improve Medication Adherence

William M. Vollmer, PhD; Adrianne Feldstein, MD; David H. Smith, PhD, MPH; Joan P. Dubanoski, PhD, MPH; Amy Waterbury, MPH; Jennifer L. Schneider, MPH; Shelley A. Clark, RN; and Cynthia Rand, PhD

Objectives: To evaluate the effectiveness of an intervention based on health information technology (HIT) that used speech recognition software to promote adherence to inhaled corticosteroids (ICS) among individuals with asthma who were members of a large health maintenance organization.

Study Design: Pragmatic randomized clinical trial.

Methods: Adults with asthma enrolled in a large managed care organization (N = 8517) were randomized to receive either usual care or an interactive voice recognition (IVR) intervention designed to prompt medication refills and improve ICS adherence. The primary outcome was ICS adherence as measured by modified medication possession ratio calculated from the electronic medical record (EMR). Secondary measures included survey- and EMR-based measures of asthma morbidity.

Results: Our primary analyses found that ICS adherence increased modestly but significantly for participants in the intervention group relative to those in the usual care group (Δ = 0.02, 95% confidence interval 0.01-0.03), with a baseline adherence of 0.42 in both groups. No difference was observed in asthma morbidity measures. In post hoc analyses of participants receiving 2 or more direct IVR contacts or detailed messages, the intervention effect was more marked. The overall effect was triple that observed in the primary analyses (0.06 vs 0.02), and significant differences were observed between groups in asthma control.

Conclusions: An HIT-based adherence intervention shows potential for supporting medication adherence in patients with chronic diseases such as asthma. However, additional research is needed to determine how best to enhance the reach and effectiveness of such interventions.

(Am J Manag Care. 2011;17(12 Spec No.):SP79-SP87)

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Despite the proven efficacy of anti-inflammatory therapy in the management of asthma, patient nonadherence is common.^1-4The clinical implications of this nonadherence include treatment failure; unnecessary and dangerous intensification of therapy; and excess healthcare costs, hospitalizations, and deaths.⁵

Relatively few studies have examined strategies to improve adherenc with respiratory medications.^6-9 A review of primarily adult-focused adherence interventions stressed the need for innovative approaches to assist patients in following chronic medication regimens,¹⁰ while others have called for strategies that leverage health information technologies (HITs) to promote and sustain medication adherence.¹¹

Interactive voice recognition (IVR) technology has been widely used to deliver automated health education via telephone and to remind patients about appointments or health screening activities.^12-14 Such applications have been shown to have a significant effect on both behavioral and clinical outcomes.^15,16 The use of speech recognition software can further enhance the acceptance and effectiveness of this form of telephonebased interaction.^17,18 Linking IVR applications with electronic medical records (EMRs) offers additional opportunities to provide personalized adherence messages triggered by a patient’s own refill patterns. A lowcost, HIT-based adherence intervention, if successful, would have immediate application for improving chronic disease management across a wide range of medical conditions.

We report the main results of a randomized clinical trial designed to test the effectiveness of an HIT-based intervention using speech recognition software to promote adherence to inhaled corticosteroids (ICS) among adults with asthma.

METHODS

Study Design

We conducted a pragmatic clinical trial¹⁹ among patients receiving care in a routine clinical setting in which 8517 adults with asthma were randomized to receive either usual care or an IVR intervention designed to improve ICS adherence. The study was approved by the institutional review boards of each participating institution.

Research Setting

Kaiser Permanente (KP) is a group-model HMO that provides comprehensive, prepaid healthcare service to about 450,000 members of the Northwest region (KPNW) and 230,000 members of the Hawaii region (KPH). KPNW serves a population that is largely Caucasian (≈91%), while the KPH population includes about 27% Caucasians, 33% Asians, 12% native Hawaiians or Pacific Islanders, and about 24% of mixed heritage. Both KPNW and KPH utilize an EMR that includes pharmacy dispensings.

Study Population

The target patient population consisted of adult KPNW and KPH members with asthma who met the eligibility criteria in Table 1. To assure maximum generalizability, we did not exclude individuals with comorbid physical or mental health conditions.

For research-related logistical reasons (eg, to eliminate the need for multiple rounds of introductory mailings, to simplify the programming that would be required with a rolling enrollment) we “prerandomized” a patient pool who made up our potential sample. However, in keeping with how the intervention would be used in clinical practice, our analysis protocol prespecified an inclusion criterion that only those individuals who ever received (or for usual care participants, who would have qualified for) intervention calls were included in the analysis samples. Thus, while included in the randomization pool, patients who never qualified for a call did not receive an intervention and were not part of our primary (intention-to-treat) analysis; this design does not introduce bias because prerandomized control group patients were handled in the same way.

In order to be able to study adherence among both new ICS users and preexisting ICS users, we included in the target population members without an ICS dispensing prior to randomization. This article focuses on adherence among preexisting ICS users, who were the primary focus of the grant and were defined as having at least 1 ICS dispensing in the 12 months prior to their qualifying ICS dispensing or order. We also briefly describe findings for new ICS users.

Recruitment and Randomization

Of 15,164 individuals who were sent an invitation letter, 1100 (7.3%) opted out of the study and the remaining 14,064 were randomized to either the intervention or the usual-care arm, with randomization stratified by region and the clinic facility to which each patient was paneled. Over the 18 months of intervention calling, 8517 individuals qualified for 1 or more calls, of whom 6905 were preexisting ICS users and 1612 were new ICS users. The primary reasons for not qualifying for a call were the lack of a triggering ICS dispensing or order among potential new ICS users (52%) and perfect adherence to a monthly ICS regimen (33%). The Figure shows how the study sample was chosen.

Intervention

The intervention included 3 basic IVR call types, each of which typically lasted 2 to 3 minutes: a refill reminder call, a tardy refill call, and an initiator/restart call. Each month, we scanned the EMR to determine who was eligible for which type of call.

The refill reminder call went to participants whose last ICS dispensing was at least 1 month ago and who had fewer than 30 days of supply left, assuming appropriate use. The call reminded patients that they were due for a refill and offered a transfer to the automated pharmacy refill line and/or information about KP’s online refill service. The tardy refill call went to individuals who were more than 1 month past their projected refill date. It not only reminded patients that they were due for an ICS refill, but also assessed asthma control, explored ICS adherence barriers, and provided tailored educational messages. Patients in poor control who declined to be transferred to the automated pharmacy refill line were offered the option to speak to a live pharmacist. Finally, the initiator/ restart call was designed to provide support to patients who were either starting ICS for the first time (new users) or were lapsed users. These calls went to individuals with an ICS order or dispensing in the previous month and no other ICS dispensing in the previous 6 months, and were similar to the tardy refill calls in that they included probes for asthma control and adherence barriers and offered tailored educational messages.

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