key: cord-0318713-syx55wxg
authors: Monterona, D. P.; Matinong, R. A.; De Silos, J. R.
title: The Effectiveness of Telephone Intervention for Improving Patient Adherence to Medication among Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Trials
date: 2021-06-25
journal: nan
DOI: 10.1101/2021.06.20.21259200
sha: 3cc420a21d09f38e1ebfdda92f9927f8b2762b48
doc_id: 318713
cord_uid: syx55wxg

Introduction: Diabetes is one of the chronic diseases that requires adherence to prescribed medications. With the current pandemic, mobile technology plays a role in caring for patients remotely. Objective: To determine the effectiveness of telephone intervention (phone call and text message) on medication adherence among diabetic patients. Methodology: Randomized controlled trials were searched in Cochrane Library, PubMed, Herdin, BMC Health Services Research using combination of terms through boolean operators (phone message OR phone call) AND (medication adherence AND diabetes) which compared telephone intervention vs usual care. mean, sample size and standard deviation of Medication Adherence in each study were extracted. Review Manager 5.4 software was used for statistical analysis. Results: Three trials met the inclusion criteria and were included in this study. The telephone intervention did not result in statistically significant improvement in medication adherence among diabetics (pooled mean difference: 0.05 95%CI -.08 to 0.17) Conclusion: The intervention was no more effective than the usual care. However, mobile use has potential application for remote care during this pandemic.

Diabetes is a major global health problem. It is a chronic, metabolic disease characterized by elevated levels of blood sugar which may cause damage to the heart, blood vessels, eyes, kidneys and nerves. According to the World Health Organization (WHO), between the years 2000 and 2019 there was 70% increase in deaths from diabetes globally, with an 80% rise in deaths among males. (1) Individuals with diabetes may not have enough insulin produced in the body or does not respond properly to insulin. The common types of diabetes are: Type 1 Diabetes, Type 2 Diabetes and Gestational Diabetes. In Type 1 Diabetes Mellitus, which usually occurs in childhood or early adulthood, the immune system destroys the cells of the pancreas that make insulin. Type 2 Diabetes Mellitus is caused by the body's ineffectiveness to use insulin properly. This type often results from lack of physical activity and obesity. The third type which occurs during pregnancy is Gestational Diabetes. (2) Controlling blood sugar is very important to prevent serious complications. There are so many ways to control blood sugar: diet therapy, regular exercise, weight control, cessation of smoking, maintaining normal blood pressure and medical therapy. (3) Chronic diseases are the major cause of death and disability worldwide. According to data from the World Health Organization, in the Philippines, chronic diseases accounted for 57% of all deaths in 2002. In that year alone, the total deaths in the Philippines were 449,000 and 253,000 deaths were due to chronic diseases: Cardiovascular disease 27%, Cancer 9%, Chronic Respiratory Disease 6%, Diabetes 3% and other chronic diseases 12%.(4) Medication non-adherence is a growing concern globally. In terms of managing chronic diseases like hypertension and diabetes, long-term adherence to medications is a vital component.

Adherence is defined by WHO as " The extent to which a person' s behaviortaking medication, following a diet, or making healthy lifestyle changes-corresponds with agreed-upon recommendations from a health-care provider."(5) Medication adherence can be assessed using direct or indirect methods. Direct methods include drug detection in biological fluid and directly observing intake of medication. Indirect methods are commonly used and may include interviews, surveys, pill counts and refill records. (6) Examples of these methods are The 8-Item Morisky Medication Adherence Scale, a selfreport validated assessment tool that measures non-adherence (7) and Medication Possession Ratio that is used to measure adherence thru refill records. The nonadherence can result to exacerbation of the chronic condition, hospitalization and even death.

Various methods can be implemented to improve non-adherence such as simplifying medication regimen, explaining key information when prescribing, providing behavioral support especially for the elderly, scheduling follow-ups to monitor medication adherence and use medication adherence improving aids like medication calendars and charts. (8) There has been a rapid growth in Mobile technology all around the globe for the past decade. In the Philippines, there were around 29.7M smartphone users for the year 2016. (9) Mobile telecommunication companies like Smart, Globe and SunCellular have various prepaid and postpaid plans giving customers unlimited text messages and calls. This technology has improved communication among healthcare providers. Abroad, phone call intervention is being used in healthcare system in following up patients that improves patient care, patient's satisfaction and health care providers as well. (10) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 25, 2021. ; https://doi.org/10.1101/2021.06.20.21259200 doi: medRxiv preprint Adherence to medications is integral to the management of Non-Communicable Diseases such as Diabetes. This is one of the most common types of chronic diseases seen in a primary care setting like the Family and Community Medicine outpatient clinic.

Treatment algorithms are well in place for most, if not these chronic diseases. However, there are various factors that may affect treatment outcomes. In the context of a developing country like the Philippines, there are a multitude of reasons for failure to help patients with chronic diseases. A very vital factor to treating such diseases and oftentimes overlooked is the patients' adherence to medications.

With the present Covid-19 pandemic, the use of telehealth has been found to be very useful in reaching out and helping the communities, the families and individuals with their health concerns in a remote setting.

There are randomized controlled trials conducted on the effect of phone interventions on medication adherence among patients with chronic diseases but no systemic reviews nor meta-analysis done on diabetic patients. This study aims to determine the effectiveness of telephone intervention (text message or phone call reminder) in helping diabetic patients adhere to their medications. Probably this can be used in the hospital or clinics as a way of helping the patients with diabetes to ensure that they take their medications which will lessen hospitalizations, emergency calls and other complications.

Reviews of Interventions and written in accord with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA).

Trials with the following criteria were included: 1) randomized clinical trials evaluating telephone intervention (text message or phone call reminder) to promote . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Electronic databases were searched which included PubMed, Herdin, Cochrane Library, and BMC Health Services Research. For the electronic search, combination of terms through boolean operators ("phone message" OR "phone call" AND ("medication adherence" AND "diabetes"). The bibliographies of included studies and any relevant systematic reviews identified were checked for further references to relevant trials.

Titles and abstracts published from January 2000-October 2020 were downloaded, screened and duplicates removed. The two reviewers read the full text articles and evaluated if to be included or not. Information extracted from each study included study design, country, age, population characteristics, sample size, intervention and the specific outcomes of interest.

Extraction of data from each study included the mean, sample size and standard deviation of Medication Adherence. Review Manager 5.4 software was used for statistical analysis.

The investigators assessed the risk of bias using Cochrane Handbook for Systematic reviews of Interventions as a guide.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 25, 2021. ;

A total of 5679 unique citations were identified through the electronic databases.

After title and abstract screening, 5661 articles were excluded. Eighteen articles were assessed for eligibility. After full text screening, thirteen articles were excluded. Two CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 25, 2021. ; https://doi.org/10.1101/2021.06.20.21259200 doi: medRxiv preprint articles were excluded during data extraction since they lack the outcome to be measured in the meta-analysis. Three articles were finally included in the study for analysis. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 25, 2021. ; https://doi.org/10.1101/2021.06.20.21259200 doi: medRxiv preprint adherence). Treatment allocation was not mentioned in 2 studies and would be considered as high risk. 

This study aims to determine the effectiveness of telephone intervention (phone call and text message reminders) in helping patients adhere to their medications. Three randomized controlled trials were included and pooled effect showed the intervention is not significant in improving medication adherence among diabetic patients.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 25, 2021. 

In conclusion, this meta-analysis showed that telephone intervention did not result in statistically significant improvement in medication adherence among diabetics. The intervention was no more effective than the usual care.

There are several trials on the effectiveness of telephone intervention on medication adherence but few focused on diabetics. Exploring other interventions for patient adherence such as video calls, mobile applications like viber, messenger and twitter in the Philippine context should be considered in a future study. Other outcomes such as dietary adherence, physical activity adherence, follow-up attendance and quality of life may also be included. Type, number and cost of medications that may influence medication adherence can be further evaluated. To add power to the phone calls or text messages, using the local language or vernacular of the communities may be used for communication. This will be valuable especially to those who cannot speak English or Tagalog. Moreover, all studies included in the systematic review are done prior to the COVID-19 pandemic, and given the health system in general is transitioning to a more virtual approach as part of the adaptive strategies in the new normal, the potential . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 25, 2021. ; https://doi.org/10.1101/2021.06.20.21259200 doi: medRxiv preprint application of mobile communication for treatment adherence will become more popular and a pertinent option for doctors and patients alike

The authors are grateful to Dr Anna Guia Limpoco for her insights, patience, time and reviewing the manuscript.

The authors declare that they don't have conflict of interest.

1. Adherence -"The extent to which a person' s behavior-taking medication, following a diet, or making healthy lifestyle changes-corresponds with agreedupon recommendations from a health-care provider" 2. Diabetes -is a chronic, metabolic disease characterized by elevated levels of blood sugar which may cause damage to the heart, blood vessels, eyes, kidneys and nerves, 3. The 8-Item Medication Adherence Scale -a self-report validated assessment tool that measures non-adherence 4. Medication Possession Ratio -used to measure adherence thru refill records = total number of days of medication supplied number of days between 1st prescription fill & last day of supplied drug from last prescription (12) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 25, 2021. ;

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