What empirical evidence is there to with regards to methods, techniques and strategies to improve treatment noncompliance among individuals whose noncompliance is characterised by a tendency to have difficulty recalling if they have correctly adhered with their physician's dosing instructions?
The literature is scant. However, one strategy to improve treatment adherence that is both simple, inexpensive and supported by peer-reviewed empirical evidence is the use of a pillbox.
The following relates to the use of pillboxes with respect to compliance with HART medications:
Pillbox Organizers are Associated with Improved Adherence to HIV Antiretroviral Therapy and Viral Suppression: a Marginal Structural Model Analysis
Background. Pillbox organizers are inexpensive and easily used; however, their effect on adherence to antiretroviral medications is unknown.
Methods. Data were obtained from an observational cohort of 245 human immunodeficiency virus (HIV)–infected subjects who were observed from 1996 through 2000 in San Francisco, California. Adherence was the primary outcome and was measured using unannounced monthly pill counts. Plasma HIV RNA level was considered as a secondary outcome. Marginal structural models were used to estimate the effect of pillbox organizer use on adherence and viral suppression, adjusting for confounding by CD4+ T cell count, viral load, prior adherence, recreational drug use, demographic characteristics, and current and past treatment.
Results. Pillbox organizer use was estimated to improve adherence by 4.1%–4.5% and was associated with a decrease in viral load of 0.34–0.37 log10 copies/mL and a 14.2%–15.7% higher probability of achieving a viral load ⩽400 copies/mL (odds ratio, 1.8–1.9). All effect estimates were statistically significant.
Conclusion. Pillbox organizers appear to significantly improve adherence to antiretroviral therapy and to improve virologic suppression. We estimate that pillbox organizers may be associated with a cost of ∼$19,000 per quality-adjusted life-year. Pillbox organizers should be a standard intervention to improve adherence to antiretroviral therapy.
However, caution should be exercised before inferring that there might be benefit to the use of pillboxes in relation to other pharmacotherapies e.g. antihypertensives.
With regards to polypharmacy involving three or more agents e.g. chronic or more complicated conditions, the following meta-analysis seems to suggest that there is no benefit of reminder devices on medication adherence relative to the use of pillboxes:
Effect of Reminder Devices on Medication Adherence: the REMIND Randomized Clinical Trial Links
Objective: To compare the effect of 3 low-cost reminder devices on medication adherence.
Design, Setting, and Participants: This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient's targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population.
Main Outcomes and Measures: The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants.
Results: Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results.
Conclusions and Relevance: Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence.
Importance: Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.
In the above analysis, we do note that use of a standard pillbox does seem to improve adherence when compared with a pill bottle strip (OR = 1.10).
However, as meta-analyses are susceptible to regression to the mean, caution must also be exercised as well.
It's prudent to note that no peer reviewed evidence will be able to demonstrate that pillboxes or any other method, technique or strategy does or does not not work for any one individual for any variant of pharmacotherapy for any period of time in their life.
In short: individual differences, bro.