In JAMA study, connected pill bottles, lotteries, and social support had no effect on adherence, outcomes

By Jonah Comstock
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A new study of 1,500 patients casts doubt on the effectiveness of several promising medication adherence technologies and strategies, including connected pill bottles and lottery-based incentives.

The study, called the HeartStrong Study, was recently published in JAMA Internal Medicine. It was a year-long single-blind study of heart failure patients taking some combination of statins, aspirin, beta blockers and anti-platelet agents. About 1,000 patients used Vitality Glowcap connected pill bottles, daily lottery incentives that paid up to $50 for taking medications on time, and the option of enlisting friends or family to be informed if the connected pill bottle showed they skipped a dose. Additionally, the intervention group had access to a staff engagement advisor.

Ultimately, the study showed no difference in readmissions, mortality, medication adherence, or medical costs between the intervention and control groups.

Researchers expected the technology intervention to be more effective, but in the discussion portion of the study they expressed a few possibilities for why they might have failed. One possibility is that the patient population, heart failure patients recovering from an acute myocardial infarction (AMI), weren’t the right group to benefit from the intervention.

“Perhaps the multiple medications required or use of electronic pill bottles makes adherence daunting,” study authors wrote. “Perhaps the goal of avoiding a subsequent AMI is maximally motivating, so that further efforts toward motivation are ineffective. Perhaps other 
patient concerns about potential adverse effects of these medications, such as impotence or fatigue, were not targeted by this engagement strategy.”

The authors also suggest that the flaw could lie with the current design sensibilities of electronic pill bottles, poor engagement with the technology, or selection bias — people who made it through the clinical trial enrollment process might be naturally more motivated.

“The fact that this intervention had negative results is important in highlighting that some of the approaches we might expect to significantly improve adherence do not in the context of a health plan-based intervention for patients after AMI,” researchers wrote. “Despite this intervention’s lack of success, further investigation in this area remains critical because the population value of therapeutic advances depends fundamentally on identifying ways to improve adherence to them.”

Still, these findings could lend credence to the idea that technology by itself is not enough to solve medication adherence problems. At a panel of pharma executives at last week’s HealthRefactored Conference in Boston, Eli Lilly Vice President of Drug Delivery Innovation Justin Wright said that pharma thinking has already moved on from these sorts of technology-driven adherence initiatives.

“We don’t talk about adherence anymore, it’s about patient engagement,” Wright said. “Personally I’ve been part of three or four large adherence projects in my time, with a tremendous amount of resources dedicated to understanding adherence better, and people always start with technology and they end up with behavior.”