An mHealth-Based Medication Reminder Program for Patients with Coronary Heart Disease

Problem and Purpose:

Coronary heart disease (CHD) is the second leading cause of death in China. The treatment of CHD typically involves long-term pharmaceutical therapy. For patients with CHD, cardio-protective medications can prevent the enlargement of harmful clots, cardiovascular symptoms, and poor therapeutic outcomes such as uncontrolled high blood pressure, hyperlipidemia, arrhythmia, heart failure, and sudden cardiac death. However, in China, poor adherence to cardio-protective medications has been cited as a public health concern. This poor adherence to cardio-protective medications has been linked to increases in healthcare costs due to poor therapeutic outcomes typically requiring major medical interventions, such as coronary angioplasty and coronary artery bypass grafting.

In China, local primary healthcare clinics are often not the first choice for treatment. Instead, patients with serious illnesses such as CHD prefer to utilize hospitals. Consequently, many of the 100 million people diagnosed with CHD in China receive prescriptions and medication-related knowledge in hospitals only without a primary care clinician to monitor their treatment. Under this healthcare utilization model, patients are often not provided with proper treatment maintenance and knowledge regarding their medication-taking behaviors. This lack of follow-up care decreases patients’ awareness of the importance of taking medications the way they were prescribed.

Mobile health, known as mHealth, is the use of portable electronic devices with software applications to provide healthcare services and manage patient information. China has 1.3 billion mobile phone users, and 97% of Chinese netizens access the Internet by using a mobile phone. These conditions in China are ideal for implementing an mHealth intervention to improve health and practice. The purpose of this study is to develop an mHealth intervention to improve medication adherence among patients with CHD.

Methods:

First, a pilot study with two phases was conducted in the Cardiology Department of West China Hospital, located in Chengdu, China. Phase I was conducted to inform the development of an mHealth intervention by integrating two mobile applications. The content of reminders and educational materials, the frequency and timing of the intervention were developed in this phase. Based on Phase I, the mHealth intervention was refined and an exploratory randomized controlled trial was conducted in Phase II to evaluate the feasibility and acceptability of using mHealth as a tool to assist CHD patients to take their cardio-protective medications. The cohorts of participants in the two phases were mutually exclusive. Next, a larger scale study with 196 participants was conducted to assess if the mHealth intervention could improve medication adherence and relevant health outcomes (systolic blood pressure, diastolic blood pressure, and heart rate) among patients with CHD in comparison to a control group that receives general educational materials over a period of 60 days.

Results:

In the larger scale study, we recruited 230 participants and randomized 116 to the experimental group and 114 to the control group. Of the 230 participants, 34 participants did not provide their baseline data, thus they did not receive the allocated intervention; we collected baseline data from 196 participants. Of the 196 participants, six participants dropped out of the study and nine were lost during the follow-up period. Finally, 181 participants completed the study, 97 in the experiemental group, 84 in the control group. The majority of the participants were married (92.4%), male (80.1%), Han Chinese (93.9%), and living in urban China (82.1%). Participants’ average age was 61 years old, and half were retired (53.9%). Three out of five participants (61.7%) were prescribed at least five medications. The total medication non-adherence score decreased at 60 days and 90 days in both groups when compared to baseline. At 60 days, the mean of the decrease in medication non-adherence score in the experimental group (M = −1.21, SD = 2.59, N = 103) was greater than the decrease in the control group (M = −0.42, SD = 2.63, N = 93), meaning that the medication adherence improved more in the experimental group. Likewise, at 90 days, the mean of the decrease in medication non-adherence score in the experimental group (M = −1.58, SD = 2.49, N = 103) was greater than the decrease in the control group (M = −0.08, SD = 3.15, N = 93). This difference between the two groups was statistically significant at both 60 days (t = 2.04, df = 179, P = 0.04) and 90 days (t = 3.48, df = 155, P < 0.01).

Heart rate decreased at 60 days and 90 days in both groups compared to baseline, but the mean of the decrease was not statistically significant between the two groups at either 60 days (t = -0.28, df = 148, p=0.78) or 90 days (t = 0.32, df = 145, p=0.75). Systolic blood pressure and diastolic blood pressure decreased in the experimental group, but increased in the control group. The mean of the decrease in diastolic blood pressure was statistically significant at both 60 days (t = 2.07, df = 160, p=0.04) and 90 days (t = 2.21, df = 164, p=0.03). The mean of the decrease in systolic blood pressure was statistically significant at 90 days (t = 3.12, df = 165, p < 0.01), but not significant at 60 days (t = 1.92, df = 161, p=0.06). In addition to comparing the mean of the decreases in health outcomes, we also compared the proportional rates of normal systolic blood pressure, diastolic blood pressure, and heart rate between the experimental group and the control group. The proportional rates of normal systolic and diastolic blood pressures in both groups increased at 60 days and 90 days compared to baseline, but the difference between the two groups at both times was not statistically significant. The proportional rate of normal heart rate in both groups decreased at both times, but the difference between the two groups at both times was not statistically significant.

Conclusion:

In this dissertation, a mobile-phone based mHealth intervention was developed for patients with CHD through integrating two mobile applications to improve medication adherence. The intervention delivered medication-taking reminders and educational materials using two mobile applications. The results showed that the mHealth intervention can increase medication adherence, and potentially lower blood pressure among patients with CHD. These findings can serve as a reference for future research to increase medication adherence and lower blood pressure.