Teresa Hagan Thomas
A reminder intervention consisting of a smart pill bottle paired with a smartphone app can improve medication adherence among breast cancer survivors receiving adjuvant oral antiestrogen therapy, according to a study published October 12 in Cancer Nursing. This is the first time that an intervention to promote adherence with smart pill bottles has been studied in breast cancer survivors, the investigators say.
Adherence is a clinical issue among breast cancer patients receiving oral adjuvant antiestrogen therapy such as tamoxifen or aromatase inhibitors. Estimates suggest that 60–80% of patients do not take their oral medications as prescribed, with adherence decreasing with each year of treatment. Of major concern is the increase in mortality associated with nonadherence, reported to be almost 50% after 5 years.
Previously identified patient barriers to adherence and nonpersistence to adjuvant oral antiestrogen therapy include adverse effects, inadequate information, forgetfulness, and lack of support. Medication self-efficacy and depression have also been reported to influence adherence.
Prior approaches to improving medication adherence have focused on providing educational materials, patient navigation programs, and text message reminder interventions. However, these interventions have had limited success at improving adherence and did not provide options for personalizing patients’ medication schedules.
Smart pill bottles are becoming increasingly popular tools to improve adherence. Several types of bottles are available commercially in the US; all track pill bottle opening and alert patients and physicians or another service electronically to missed doses. How they can change patient behavior has been already tracked in patients with multiple myeloma, cardiovascular disease, and HIV.
To evaluate the effects of a smart pill bottle in cancer survivors on adherence, Hyang Rang Park, RN, MS (Red Cross College of Nursing, Chung-Ang University) and colleagues in Seoul, South Korea, conducted a two-arm randomized trial in patients who attended the outpatient breast cancer surgical clinic of a single urban tertiary hospital.
Oncology nurses at the clinic recruited a total of 57 patients to participate in the study during routine clinic visits. All patients were aged 18 years or older, with Stage I-III breast cancer, prescribed oral antiestrogen therapy after surgical treatment, and owned a smartphone. Patients with a recurrence or cognitive impairment were excluded from the study.
Between April 2019 and June 2020, data were collected from 30 patients randomized to the smart pill bottle intervention and 27 randomized to a control group. Over 28 days, control participants received usual care and completed daily medication logs. participants in the intervention group were given a smart pill bottle and smartphone app developed by Pillsy (Seattle, WA).
The Pillsy smart pill bottle and app sync together to remind patients to take their medications. The pill bottle beeps and blinks at the time participants specified they wanted to be reminded to take their medication. The app also sends a notification via Bluetooth to take the medication, as well as a text message reminder 20 minutes after the designated time if the pill bottle had not yet been opened. If a dose is missed, one hour later a patient-designated “helper” receives a notification. The helper then provides phone counseling to address any barriers the patient is experiencing in taking their medication. For this study, all participants chose a researcher as their designated helper.
After 28 days, a higher proportion of the intervention group demonstrated medication adherence (taking a dose within 1 hour before or after the scheduled time) compared with the controls (97.3% vs 88.3%, based on smartphone records and medical logs, respectively).
Self-efficacy, measured using a medication self-efficacy scale, was also higher in the intervention group compared with the control group (37.3 vs 33.9 out of 40). This probably contributed in part to the difference in adherence between the 2 groups, the researchers suggest. However, depression symptoms, measured using the Center for Epidemiologic Studies Depression Scale modified for the South Korean population, did not differ significantly between the two groups (17.8 vs 20.4 out of 60, respectively).
These findings support those of other reminder-based interventions in women with breast cancer and in line with smart pill bottle interventions in other diseases, the researchers note. Their results were superior to education-based interventions or trials that depended on participant self-report or pill counting. suggesting that being able to schedule the medication reminder time and designate a healthcare provider (rather than a family member) as a helper may have contributed to the success of the intervention.
Ms Park and her colleagues acknowledge some limitations of their study, including the possibility that patients may open the pill bottle but not take the medication. The study was also unable to record when patients took the pill more than 1 hour before or after the scheduled time.
As the duration of the study was only 28 days and adjuvant oral estrogen therapies are taken for many years, longer-term studies are needed, the investigators note. The difference in medication self-efficacy suggests that assessing and monitoring self-efficacy in breast cancer patients should be incorporated into comprehensive care plans, they propose. Since the intervention did not improve depression symptoms and depression is associated with lower medication adherence, they also recommend psychological support as a supplement to reminder interventions in breast cancer survivors undergoing adjuvant oral antiestrogen therapy.
Ultimately, this type of smart pill bottle and app can help identify patients who are not taking their antiestrogen therapy so that they can receive early intervention. Such technologies appear to be feasible and acceptable among cancer survivors with potential for integration into patients’ social networks and healthcare providers’ electronic medical records. Additional financial support may be needed to help patients purchase the bottles, the study investigators add.