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Original Investigation |

Mobile Telephone Text Messaging for Medication Adherence in Chronic Disease A Meta-analysis

Jay Thakkar, FRACP1,2,3; Rahul Kurup, MBBS1; Tracey-Lea Laba, PhD2,3; Karla Santo, MD2,3; Aravinda Thiagalingam, PhD1,3; Anthony Rodgers, PhD2,3; Mark Woodward, PhD2,3,4,5; Julie Redfern, PhD2,3; Clara K. Chow, PhD1,2,3
[+] Author Affiliations
1Department of Cardiology, Westmead Hospital, Sydney, Australia
2The George Institute for Global Health, The University of Sydney, Sydney, Australia
3The University of Sydney, Sydney, Australia
4The George Institute for Global Health, University of Oxford, Oxford, England
5Department of Epidemiology, Johns Hopkins Blumberg School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2016;176(3):340-349. doi:10.1001/jamainternmed.2015.7667.
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Importance  Adherence to long-term therapies in chronic disease is poor. Traditional interventions to improve adherence are complex and not widely effective. Mobile telephone text messaging may be a scalable means to support medication adherence.

Objectives  To conduct a meta-analysis of randomized clinical trials to assess the effect of mobile telephone text messaging on medication adherence in chronic disease.

Data Sources  MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL (from database inception to January 15, 2015), as well as reference lists of the articles identified. The data were analyzed in March 2015.

Study Selection  Randomized clinical trials evaluating a mobile telephone text message intervention to promote medication adherence in adults with chronic disease.

Data Extraction  Two authors independently extracted information on study characteristics, text message characteristics, and outcome measures as per the predefined protocol.

Main Outcomes and Measures  Odds ratios and pooled data were calculated using random-effects models. Risk of bias and study quality were assessed as per Cochrane guidelines. Disagreement was resolved by consensus.

Results  Sixteen randomized clinical trials were included, with 5 of 16 using personalization, 8 of 16 using 2-way communication, and 8 of 16 using a daily text message frequency. The median intervention duration was 12 weeks, and self-report was the most commonly used method to assess medication adherence. In the pooled analysis of 2742 patients (median age, 39 years and 50.3% [1380 of 2742] female), text messaging significantly improved medication adherence (odds ratio, 2.11; 95% CI, 1.52-2.93; P < .001). The effect was not sensitive to study characteristics (intervention duration or type of disease) or text message characteristics (personalization, 2-way communication, or daily text message frequency). In a sensitivity analysis, our findings remained robust to change in inclusion criteria based on study quality (odds ratio, 1.67; 95% CI, 1.21-2.29; P = .002). There was moderate heterogeneity (I2 = 62%) across clinical trials. After adjustment for publication bias, the point estimate was reduced but remained positive for an intervention effect (odds ratio, 1.68; 95% CI, 1.18-2.39).

Conclusions and Relevance  Mobile phone text messaging approximately doubles the odds of medication adherence. This increase translates into adherence rates improving from 50% (assuming this baseline rate in patients with chronic disease) to 67.8%, or an absolute increase of 17.8%. While promising, these results should be interpreted with caution given the short duration of trials and reliance on self-reported medication adherence measures. Future studies need to determine the features of text message interventions that improve success, as well as appropriate patient populations, sustained effects, and influences on clinical outcomes.

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Figure 1.
Study Selection Process

RCTs indicates randomized clinical trials.

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Figure 2.
Meta-analysis of the Effect of a Mobile Telephone Text Message Intervention on Medication Adherence

aThe text message intervention significantly improved adherence (odds ratio, 2.11; 95% CI, 1.52-2.93; P < .001). The effect remained significant after excluding 2 studies with extreme outcomes (Hardy et al30 and Kohnsari et al31) (odds ratio, 1.78; 95% CI, 1.35-2.35; P < .001).

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