Key Features of Smart Medication Adherence Products: Updated Scoping Review.

BACKGROUND: Older adults often face challenges in self-managing their medication owing to physical and cognitive limitations, complex medication regimens, and packaging of medications. Emerging smart medication dispensing and adherence products (SMAPs) offer the options of automated dispensing, tracking medication intake in real time, and reminders and notifications. A 2021 review identified 51 SMAPs owing to the rapid influx of digital technology; an update to this review is required. OBJECTIVE: This review aims to identify new products and summarize and compare the key features of SMAPs. METHODS: Gray and published literature and videos were searched using Google, YouTube, PubMed, Embase, and Scopus. The first 10 pages of Google and the first 100 results of YouTube were screened using 4 and 5 keyword searches, respectively. SMAPs were included if they were able to store and allowed for the dispensation of medications, tracked real-time medication intake data, and could automatically analyze data. Products were excluded if they were stand-alone software applications, not marketed in English, not for in-home use, or only used in clinical trials. In total, 5 researchers independently screened and extracted the data. RESULTS: This review identified 114 SMAPs, including 80 (70.2%) marketed and 34 (29.8%) prototypes, grouped into 15 types. Among the marketed products, 68% (54/80) were available for consumer purchase. Of these products, 26% (14/54) were available worldwide and 78% (42/54) were available in North America. There was variability in the hardware, software, data collection and management features, and cost of the products. Examples of hardware features include battery life, medication storage capacity, availability of types and number of alarms, locking features, and additional technology required for use of the product, whereas software features included reminder and notification capabilities and availability of manufacturer support. Data capture methods included the availability of sensors to record the use of the product and data-syncing capabilities with cloud storage with short-range communications. Data were accessible to users via mobile apps or web-based portals. Some SMAPs provided data security assurance with secure log-ins (use of personal identification numbers or facial recognition), whereas other SMAPs provided data through registered email addresses. Although some SMAPs were available at set prices or free of cost to end users, the cost of other products varied based on availability, shipping fees, and subscription fees. CONCLUSIONS: An expanding market for SMAPs with features specific to at-home patient use is emerging. Health care professionals can use these features to select and suggest products that meet their patients' unique requirements.

Medication Reviews and Clinical Outcomes in Persons with Dementia: A Scoping Review.

Persons diagnosed with dementia are often faced with challenges related to polypharmacy and inappropriate medication use and could benefit from regular medication reviews. However, the benefit of such reviews has not been examined in this population. Therefore, the current scoping review was designed to identify the gaps in the current knowledge regarding the impact of medication reviews on the clinical outcomes in older adults with dementia. Relevant studies were identified by searching three databases (Ovid MEDLINE, Ovid EMBASE, and Scopus) from inception to January 2022 with a combination of keywords and medical subject headings. After the removal of duplicates and ineligible articles, 22 publications of the initial 8346 were included in this review. A total of 57 outcomes were identified, including those pertaining to the evaluation of medication use (n = 17), drug-related interventions (n = 11), drug-related problems (n = 10), dementia-related behavioral symptoms (n = 8), cost-effectiveness (n = 2), drug-related hospital admissions (n = 1), as well as outcomes classified as other (n = 7). Gaps identified through this scoping review included the paucity of studies measuring the impact of medication reviews on the medication management capacity and medication adherence, quality of life, and mortality.

Exploring the Value of Real-Time Medication Adherence Monitoring: A Qualitative Study.

Smart adherence products enable the monitoring of medication intake in real-time. However, the value of real-time medication intake monitoring to different stakeholders such as patients, their caregivers, clinicians, and insurers is not elucidated. The aim of this study was to explore the value different stakeholders place on the availability of smart adherence products and access to real-time medication intake data. A qualitative study design using semi-structured one-on-one virtual interviews was utilized. Schwartz's theory of values provided the foundation for the interview questions, data were analyzed using Braun and Clark's thematic analysis framework, and findings were mapped back to the constructs of Schwartz's theory of values. A total of 31 interviews with patients, caregivers, healthcare providers, and representatives of private or public insurance providers were conducted. Three themes and ten subthemes were identified. Themes included perceptions of integrating smart medication adherence technologies and real-time monitoring, technology adoption factors and data management. Stakeholders place different values based on the motivators and goals that can drive product use for daily medication management. Stakeholders valued the availability of real-time medication taking data that allow clinicians to make timely data-driven recommendations to their patients that may improve medication management for patients and reduce the caregiver burden.

An In-Home Medication Dispensing System to Support Medication Adherence for Patients With Chronic Conditions in the Community Setting: Prospective Observational Pilot Study.

BACKGROUND: Innovative digital technology systems that support and monitor real-time medication intake are now available commercially; however, there is limited knowledge of the use of such technology in patients' homes. One such smart medication dispenser, spencer, provides alerts to patients to take their medications and allows for tracking and reporting real-time medication adherence data. OBJECTIVE: The objectives of this study were to examine the use of a smart medication dispenser as a medication adherence and self-management support tool for community dwelling adults over a 6-month period, in addition to usability, usefulness, satisfaction, and impact on caregiver support. METHODS: This prospective, observational study invited community-dwelling adults aged 45 years and older taking at least one chronic medication and their caregivers to use this smart medication dispenser for their medication administration for 6 months. Adherence was defined as a dose intake within 2 hours post scheduled time. Real-time adherence data were collected using the smart medication dispenser and the AdhereNet platform. Usability, usefulness, and satisfaction were measured using the System Usability Scale and the Usefulness, Satisfaction, and Ease of Use questionnaire, respectively. Caregiver burden was measured on a visual analog scale at baseline and at the end of the 6-month study period. RESULTS: A total of 58 participants were recruited, of which 55% (32/58) were female with a mean age of 66.36 (SD 11.28; range 48-90) years. Eleven caregiver participants were recruited, of whom 91% (10/11) were female. The average monthly adherence over 6 months was 98% (SD 3.1%; range 76.5%-100%). The average System Usability score was 85.74 (n=47; SD 12.7; range 47.5-100). Of the 46 participants who provided data, 44 (96%) rated the product as easy, 43 (93%) as simple to use, and 43 (93%) were satisfied with the product. Caregiver burden prior to and following smart medication dispenser use for 6 months was found to be statistically significantly different (P<.001; CI 2.11-5.98). CONCLUSIONS: Smart medication adherence products such as spencer, when connected and clinically monitored, can be a useful solution for medication management and have the potential to improve caregiver burden.

Integration of a smart multidose blister package for medication intake: A mixed method ethnographic informed study of older adults with chronic diseases.

Smart adherence products are marketed to assist with medication management. However, little is known about their in-home integration by older adults. It is necessary to investigate the facilitators and barriers older adults face when integrating these products into their medication taking routines before effectiveness can be examined. The aim of this study was to (a) examine the integration of a smart multidose blister package and (b) understand medication intake behaviour of adults with chronic diseases using an integrated theoretical model comprised of the Technology Acceptance Model (TAM), Theory of Planned Behaviour (TPB) and Capacity, Opportunity, Motivation and Behaviour (COM-B) Model. An ethnographic-informed study was conducted with older adults using the smart multidose blister package to manage their medications for eight weeks. Data was collected quantitatively and qualitatively using in-home observations, photo-elicitation, field notes, semi-structured interviews, system usability scale (SUS) and net promoter scale (NPS). The interview guide was developed with constructs from the TAM, TPB and COM-B Model. Data were analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL) framework to generate themes and sub-themes which were mapped back to TAM, TBP and COM-B Model. Ten older adults with an average age of 76 years, of which 80% were female, participated in the study. On average, participants reported five medical conditions, while the average number of medications was 11.1. The mean SUS was 75.50 and overall NPS score was 0. Qualitative analysis identified three themes; (1) factors influencing medication intake behaviour (2) facilitators to the product use and, (3) barriers to the product use. The smart blister package was found to be easy to use and acceptable by older adults. Clinicians should assess an older adult's medication intake behavior as well as barriers and facilitators to product use prior to recommending an adherence product for managing medications.

The Usability, Acceptability, and Functionality of Smart Oral Multidose Dispensing Systems for Medication Adherence: A Scoping Review.

BACKGROUND: Medication non-adherence is a leading cause of non-optimal disease management, resulting in poor health outcomes, poor quality of life, and increased healthcare costs. Smart oral multidose dispensing systems (SOMDS) are being developed to address non-adherence; however, little is known about their integration into daily use by patients. METHODS: Using Arksey and O'Malley's scoping review framework, relevant literature was searched for in electronic databases (PubMed, EMBASE, International Pharmaceutical Abstracts, and Scopus). Observational and interventional studies reporting the integration and impact on adherence from SOMDS in adults ≥18 years and published after 1960 were included. RESULTS: Thirteen articles including one case study, 8 cohort studies, and 4 randomized trials were eligible. SOMDS included smart blister packaging, automated dispensers, and electronic medication trays. The number of medications dispensed per SOMDS was one (n = 3), >1 (n = 2), placebo (n = 1) and not reported (n = 7). Reported outcomes included impact on medication adherence (n = 3), integration (n = 2) and both parameters (n = 8). CONCLUSION: Although most studies reported that SOMDS appear usable, there was significant variability in the SOMDS types, patient populations, medication adherence definitions, and measurements; impacting the interpretation of results. Future studies should be designed to address effectiveness of SOMDS on medication adherence in patients with multi-drug therapy and the utilization of real-time adherence data for informing clinical decision making.

In-home medication management by older adults: a modified ethnography study using digital photography walkabouts.

BACKGROUND: Medication mismanagement can lead to non-optimal management of chronic diseases and poor health outcomes. OBJECTIVE: The purpose of this study was to better understand meanings associated with in-home medication management and storage practices of older adults with chronic diseases. METHODS: A modified ethnographic approach using digital photography walkabouts, observation protocols and field notes were used to document in-home medication organisation and storage locations. Thematic analysis was used to generate themes and sub-themes. RESULTS: Data from multiple home visits of 10 participants (mean age = 76 years; 80% females) including 30 photographs, 10 observation protocols and field notes were analysed. The average number of medications used was reported to be 11.1 (range: 5-20). Themes and sub-themes include choice of storage location (sub-themes: impact on medication behaviour, visibility of medications and storage with other items), knowledge regarding appropriate medication storage conditions (sub-themes: impact on safety of patient and impact on stability of medications) and systems to manage in-home medication intake. DISCUSSION: In-home medication management reflects older adults perspectives regarding privacy, medication taking routine, knowledge about safe and effective storage and organisation systems. The lack of knowledge causing inappropriate medication storage not only impacts the stability of medications, but also increases risk of medication errors and safety, ultimately affecting medication intake behaviours.

A review of features and characteristics of smart medication adherence products.

BACKGROUND: Smart medication adherence products (smart MAPs) capture and transmit real-time medication intake by using various means of connectivity, allowing for remote monitoring. Numerous such products with different features are available to address medication nonadherence. A comparison of the features of these products is needed for clinical decision-making. Therefore, the objective of this review was to compare smart MAPs available for in-home use. METHODS: We searched grey and published literature and videos to identify smart MAPs. To be considered smart, products required 2 features: connectivity (the ability for collected data to exist outside the physical device) and automaticity (the ability for data to be analyzed or processed automatically). Products were excluded if product descriptions were not available in English, not for in-home use and unable to dispense medications. RESULTS: Of the 51 products identified, 38 commercially available and 13 prototypes met the definition. Of these, 75% (n = 38) contained alarms, 24% (n = 12) were unit-dose, 63% (n = 32) were multidose, 43% (n = 22) had locking features, 41% (n = 21) were portable and 88% (n = 45) sent notifications to patients. The cost of marketed products, excluding subscriptions, ranged from $10 to $1500 USD. Some products required a monthly (n = 16) or yearly (n = 1) subscription ranging from $10 to $100 USD. DISCUSSION: There is a growing market of smart MAPs for in-home patient use with variable features. Clinicians can use these features to identify and recommend products according to the specific needs of their patients to address medication adherence. Can Pharm J (Ott) 2021;154:xx-xx.

Implementation of a Real-Time Medication Intake Monitoring Technology Intervention in Community Pharmacy Settings: A Mixed-Method Pilot Study.

Innovative dispensing products offering real-time medication intake monitoring are being developed to address medication non-adherence. However, implementation of these interventions within the workflow of a community pharmacy is unknown. The purpose of this study was to explore factors affecting implementation of a real-time adherence-monitoring, multidose-dispensing system in community pharmacies. A mixed-method study was conducted with pharmacy staff, who packaged and dispensed medications in smart multidose packages and monitored real-time medication intake via web-portal. Pharmacy staff participated in semi-structured interviews. The Technology Acceptance Model, Theory of Planned Behaviour and Capability, Opportunity, Motivation, Behaviour Model informed the interview guide. Interview transcripts were analyzed thematically and findings were mapped back to the frameworks. The usability was assessed by the System Usability Scale (SUS). Three pharmacists and one pharmacy assistant with a mean of 19 years of practice were interviewed. Three themes and 12 subthemes were generated. Themes included: pharmacy workflow factors, integration factors, and pharmacist-perceived patient factors. The mean SUS was found to be 80.63. Products with real-time adherence monitoring capabilities are valued by pharmacists. A careful assessment of infrastructure-including pharmacy workload, manpower and financial resources-is imperative for successful implementation of such interventions in a community pharmacy setting.

Development and Content Validation of an Instrument to Measure Medication Self-Management in Older Adults.

BACKGROUND: For older adults, the capacity to self-manage medications may be limited by several factors. However, currently available tools do not permit a comprehensive assessment of such limitations. The Domain Specific Limitation in Medication Management Capacity (DSL-MMC) was developed to address this need. This study aimed to establish the face and content validity of the DSL-MMC. METHODS: The DSL-MMC tool consisted of 4 domains and 12 sub-domains with 42 items including: 1. physical abilities (vision, dexterity, hearing); 2. cognition (comprehension, memory, executive functioning); 3. medication regimen complexity (dosing regimen, non-oral administration, polypharmacy); and 4. access/caregiver (prescription refill, new prescription, caregiver). Pharmacists assessed each item for relevance, importance, readability, understandability, and representation. Items with content validity index (CVI) scores of <0.80 for relevance were examined for revision or removal. RESULTS: Twelve pharmacists participated in the study. CVI scores for relevance and importance of domains were 1.0; of the sub-domains, two were below 0.80. Among the 42 items, 35 (83%) and 30 (71%) maintained CVI scores above 0.80 for relevance and importance, respectively. Five items were removed, three were merged and seven were modified due to low CVI scores and/or feedback. CONCLUSION: The DSL-MMC has been validated for content.

Lessons in reflexivity of a pharmacist conducting ethnographic research.

The practice of reflexivity is widely recognized in ethnographic research as a strategy to identify and explore a researcher's self-knowledge, beliefs, experiences, and their influence on research. In this article, I explore my journey from a practising pharmacist to a researcher within an ethnographic informed study pertaining to patients with chronic diseases and their medication intake behaviour. Ethnography allowed me to explore the lived experiences of ten participants using a smart medication adherence product. Through in-depth at home observations, photo-elicitation and semi-structured interviews over a period of 6 months, I was able to gather the invisible meanings associated with their in-home medication intake process. Extensive field notes were written after each home visit in addition to a reflexive journal documenting my inner thoughts, questions and reflections. A key finding of this activity was the intersectionality of my profession with race and gender, something I had not anticipated. Secondly, my social location as a woman and person of color resulted in questions being asked of me that was unexpected and at times left me feeling uncertain and uncomfortable. I entered this study believing that the boundary I erected between my roles of pharmacist and researcher would ensure clarity, and perhaps a sense of protection to some degree. I now realize this may have been naive and by relinquishing control of these roles, I was able to gain a deeper understanding of myself, my role as a clinician/researcher, and the older adults I serve as a pharmacist. Being reflexive during the study period offered me an opportunity to first identify and then analyze my beliefs and how they may impact the information I gathered during fieldwork. The practice of reflexivity is a critical tool for clinician-researchers and should be practiced throughout the course of fieldwork.

Pharmacist interventions for persons with intellectual disabilities: A scoping review.

INTRODUCTION: Persons with intellectual disabilities (ID) often have complex health needs due to the development of multiple comorbidities. Given the higher associated use of problematic medications, such as antipsychotics, and polypharmacy, persons with ID may be particularly vulnerable to adverse side effects. With their medication expertise, pharmacists have the potential to address medication related challenges experienced by this population. OBJECTIVE: Explore what is known about the care pharmacists provide to persons with ID. DESIGN: Following Arksey and O'Malley's 5-stage framework for scoping reviews, searches of the PubMed (MEDLINE), Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Scopus and APA PsycINFO databases were conducted in January 2019 with no limits on publication date. Studies of participants diagnosed with ID or healthcare providers/caregivers of persons with ID that referenced a pharmacist care intervention were included. Studies with non-human populations and editorials, commentaries, letters to the editor or discussion papers were excluded. RESULTS: Twenty-six studies were included in the review. Seventy-six pharmacist care interventions were identified in cognitive pharmacy services (n = 46); educational and advisory services (n = 20); and medication prescription processing (n = 10). Fifty-one outcomes were referenced including drug-related interventions (n = 14), drug related problems (n = 9), cost/time-effectiveness (n = 7), secondary symptoms (n = 6), other outcomes (n = 5), general medication usage (n = 4), caregiver and healthcare team satisfaction levels (n = 3), and educational/knowledge (n = 3). CONCLUSION: Pharmacists perform a variety of health care services to persons with ID but the impact of these interventions cannot be accurately measured due to a lack of: 1) universal definitions for ID; 2) reporting of multifactorial conditions contributing to a spectrum of ID severity; and 3) standardized reporting of ID-specific outcomes. Addressing these gaps is necessary for the development of a comprehensive evidence base regarding pharmacist involvement for medication challenges in persons with ID.

Stakeholder Feedback of Electronic Medication Adherence Products: Qualitative Analysis.

BACKGROUND: Medication management among older adults continues to be a challenge, and innovative electronic medication adherence products have been developed to address this need. OBJECTIVE: The aim of this study is to examine user experience with electronic medication adherence products, with particular emphasis on features, usefulness, and preferences. METHODS: Older adults, caregivers, and health care providers tested the usability of 22 electronic medication adherence products. After testing 5 products, participants were invited to participate in a one-on-one interview to investigate their perceptions and experiences with the features, usefulness, and preference for electronic medication adherence products tested. The interviews were audio recorded, transcribed, and analyzed using exploratory inductive coding to generate themes. The first 13 interviews were independently coded by 2 researchers. The percentage agreement and Cohen kappa after analyzing those interviews were 79% and 0.79, respectively. A single researcher analyzed the remaining interviews. RESULTS: Of the 37 participants, 21 (57%) were older adults, 5 (14%) were caregivers, and 11 (30%) were health care providers. The themes and subthemes generated from the qualitative analysis included product factors (subthemes: simplicity and product features, including availability and usability of alarms, portability, restricted access to medications, and storage capacity) and user factors (subthemes: sentiment, affordability, physical and cognitive capability, and technology literacy and learnability). CONCLUSIONS: Electronic medication adherence products have the potential to enable independent medication management in older adults. The choice of a particular product should be made after considering individual preferences for product features, affordability, and the sentiment of the users. Older adults, caregivers, and health care providers prefer electronic medication adherence products that are simple to set up and use, are portable, have easy-to-access medication compartments, are secure, and have adequate storage capacity.

A Prospective Study of Usability and Workload of Electronic Medication Adherence Products by Older Adults, Caregivers, and Health Care Providers.

BACKGROUND: A decreased capacity to self-manage medications results in nonadherence, medication errors, and drug-related problems in older adults. Previous research identified 80 electronic medication adherence products available to assist patients with self-management of medications. Unfortunately, the usability and workload of these products are unknown. OBJECTIVE: This study aimed to examine the usability and workload of a sample of electronic medication adherence products. METHODS: In a prospective, mixed methods study, a sample of older adults, health care professionals, and caregivers tested the usability and workload of 21 electronic medication adherence products. Each participant tested 5 products, one at a time, after which they completed the system usability scale (SUS) and NASA-task load index (NASA-TLX), instruments that measure the usability and workload involved in using a product. Higher SUS scores indicate more user-friendliness, whereas lower NASA-TLX raw scores indicate less workload when using a product. RESULTS: Electronic medication adherence products required a mean of 12.7 steps (range 5-20) for the appropriate use and took, on average, 15.19 min to complete the setup tasks (range 1-56). Participants were able to complete all steps without assistance 55.3% of the time (103 out of the 186 tests were completed by 39 participants; range 0%-100%). The mean SUS and NASA-TLX raw scores were 52.8 (SD 28.7; range 0-100) and 50.0 (SD 25.7; range 4.2-99.2), respectively, revealing significant variability among the electronic medication adherence products. The most user-friendly products were found to be TimerCap travel size (mean 78.67, SD 15.57; P=.03) and eNNOVEA Weekly Planner with Advanced Auto Reminder (mean 78.13, SD 14.13; P=.049) as compared with MedReady 1700 automated medication dispenser (mean 28.63, SD 21.24). Similarly, MedReady (72.92, SD 18.69) was found to be significantly more work intensive when compared with TimerCap (29.35, SD 20.35; P=.03), e-pill MedGlider home medication management system (28.43, SD 20.80; P=.02), and eNNOVEA (28.65, SD 14.97; P=.03). The e-pill MedTime Station automatic pill dispenser with tipper (71.77, SD 21.98) had significantly more workload than TimerCap (P=.04), MedGlider (P=.03), and eNNOVEA (P=.04). CONCLUSIONS: This study demonstrated that variability exists in the usability and workload of different electronic medication adherence products among older adults, caregivers, and clinicians. With few studies having investigated the usability and workload of electronic medication adherence products, no benchmarks exist to compare the usability and workload of these products. However, our study highlights the need to assess the usability and workload of different products marketed to assist with medication taking and provides guidance to clinicians regarding electronic medication adherence product recommendations for their patients. Future development of electronic medication adherence products should ensure that the target populations of patients are able to use these products adequately to improve medication management.