Digital health technologies to support medication adherence in chronic kidney disease

Enhancing treatment adherence in dialysis patients through digital health interventions: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically assess the efficacy of digital health interventions (DHIs) for improving treatment adherence among dialysis patients through a meta-analysis of randomized controlled trials (RCTs).

METHODS

Five databases were systematically searched from inception to April 2024. Meta-analyses were performed to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) for adherence outcomes. Evidence quality was evaluated using the GRADE approach.

RESULTS

Seventeen RCTs involving 1,438 dialysis patients were analyzed. DHIs significantly improved overall adherence (SMD 1.88 [95% CI: 0.46-3.29]; 4 trials, low-certainty evidence). Specifically, DHIs demonstrated large improvements in medication adherence (SMD 1.45 [95% CI 0.38-2.52]; 4 trials, 300 patients; low-certainty evidence) and dialysis treatment adherence (SMD 1.88 [95% CI 0.46-3.29]; 4 trials, 245 patients; low-certainty evidence). Moderate improvements were observed in dietary adherence (SMD 0.58 [95% CI 0.25-0.91]; 4 trials, 344 patients; moderate-certainty evidence) and fluid management adherence (SMD -0.36 [95% CI -0.64 to -0.07]; 7 trials, 619 patients; moderate-certainty evidence).

CONCLUSIONS

Digital health interventions effectively enhance multiple dimensions of treatment adherence in dialysis patients, underscoring their value for incorporation into routine clinical practice.

Patient-reported usability challenges when implementing integrated EHR medication reminders for kidney transplant patients in a home setting: A pilot study

BACKGROUND

With an aging population and the increasing prevalence of chronic diseases such as chronic kidney disease (CKD), kidney transplantation is the preferred treatment for end-stage renal disease due to its superior clinical outcomes and cost-effectiveness compared to dialysis. Although EHR-integrated medication reminders have the potential to enhance adherence in transplant patients, their feasibility require further investigation.

OBJECTIVE

The objective of this pilot study was to assess the feasibility of an integrated medication reminder tool for kidney transplant patients in terms of experienced usability and satisfaction.

METHODS

A single-arm survey design was used to assess the usability and satisfaction in kidney transplant recipients using an EHR-integrated medication reminder tool through the patient portal at a large academic hospital in the Netherlands. Usability and satisfaction were evaluated using the validated Experienced Usability and Satisfaction with self-monitoring in the home Setting (GEMS) questionnaire comprising four subconstructs: Convenience of use, Perceived value, Efficiency of use, and Satisfaction. Quantitative data were analysed and assessed through descriptive statistics. Furthermore, six additional questions assessed logging into the system, ease of follow-up on reminder, satisfaction with reminder timing, perceived support for adherence, occurrence of incorrect reminders, and willingness to continue using the tool, using Likert scales and open-ended responses.

RESULTS

In total, forty-three patients participated in this study. The results showed mixed experienced usability and satisfaction, with a GEMS score of 65.0%. The Efficiency of use subconstruct revealed issues such as difficulties in checking off medication and accessing the patient portal. The Satisfaction subconstruct revealed limitations of the tool, as reminders cannot be customized, creating inconvenience for patients who had developed their own medication routines after transplantation. One third (35.7%) of the patients reported willingness to continue using the tool after the pilot program.

CONCLUSION

The experienced usability and satisfaction of an integrated EHR medication reminder tool were adequate for half of the patients. To facilitate large-scale implementation, improvements of the tool are needed to maximize its effectiveness for kidney transplant patients, particularly by enhancing customization of the notification system to better meet user needs and support medication adherence.

Effectiveness of Mobile Apps in Improving Medication Adherence Among Chronic Kidney Disease Patients: Systematic Review

BACKGROUND

Chronic kidney disease (CKD) is a serious condition affecting millions of individuals worldwide. Adherence to medication regimens among patients with CKD is often suboptimal, leading to poor health outcomes. In recent years, mobile apps have gained popularity as a promising tool to improve medication adherence and self-management in various chronic diseases.

OBJECTIVE

This study aimed to evaluate the effectiveness of mobile apps to improve medication adherence among patients with CKD (including end-stage and renal replacement therapy).

METHODS

A systematic search was conducted using Scopus, Cochrane, PubMed, and EBSCOhost to include eligible articles that studied mobile apps to improve medication adherence among patients with CKD. The quality of the selected studies was evaluated using the Newcastle‒Ottawa Scale and the Cochrane risk-of-bias tool.

RESULTS

Out of 231 relevant articles, only 9 studies were selected for this systematic review. Based on Newcastle‒Ottawa Scale, 7 were deemed to be of high quality, while others were of fair quality. The Cochrane risk-of-bias tool indicated a low to moderate risk of bias across the included studies. Most of the included studies had a randomized controlled design. Of the 9 selected studies, 3 papers represented medication adherence by a coefficient of 10 variability of tacrolimus, 3 papers used adherence measurement scales to calculate the score for assessing medication adherence, 2 papers represented medication adherence by self-reporting, 2 papers represented medication adherence using electronic monitoring, and 1 represented medication adherence by pill count. The mobile apps were identified as Transplant Hero (Transplant Hero LLC), Perx (Perx Health), Smartphone Medication Adherence Saves Kidneys (developed by John McGillicuddy), Adhere4U (developed by Ahram Han), My Dialysis (developed by Benyamin Saadatifar), Kidney Love (developed by National Kidney foundation), and iCKD (developed by Dr Vivek Kumar). Of these apps, 3 focused on evaluating Transplant Hero, while the remaining investigated each of the other mentioned apps individually. The apps use various strategies to promote medication adherence, including reminders, gamification, patient education, and medication monitoring. A majority, 5 out of 9 mobile apps, had a statistically significant (P<.05) effect on medication adherence. There was strong evidence for a positive effect of interventions focusing on games and reminders combined with electronic medication tray monitoring and patient education.

CONCLUSIONS

Mobile apps effectively improved medication adherence in patients with CKD, but low evidence and short intervention duration warrant caution. Future research should identify ideal features, provider costs, and user-friendly, secure apps.

Impact of text message reminders on immunosuppressive medication adherence among kidney transplant recipients: A randomized controlled study

BACKGROUND

One of the most common problems encountered in transplant patients is nonadherence with immunosuppressive drugs, one of the most important reasons for graft rejection.

OBJECTIVE

The study aimed to assess the impact of text message reminders on medication adherence among kidney transplant recipients.

DESIGN

A randomized controlled trial.

PARTICIPANTS

The study was conducted from January to October 2021. This study included a total of 100 patients receiving a kidney transplant, 50 in the intervention group and 50 in the control group.

MEASUREMENTS

Patients in the intervention group were sent text message reminders four times a day during the 6th-9th months after transplantation. Control patients received no such intervention. Tacrolimus concentrations in the bloodstream were monitored for all participants through measurements taken at Months 7, 8 and 9. Data collection tools included Sociodemographic Form and Immunosuppressive Medication Adherence Scale.

RESULTS

Patients were homogeneously distributed among the groups. Sending daily text message reminders to transplant recipients caused an independent positive effect on medication adherence scale scores at the end of the study. Mean pretest medication adherence score of all patients was 45.18 ± 4.22 and posttest score was 47.4 ± 3.6. The intervention group exhibited a significantly higher mean posttest adherence score compared to controls, with values of 48.68 ± 2.58 and 45.62 ± 4.42, respectively (p < 0.001). Findings demonstrated a substantial improvement in the final medication adherence scores of transplant patients when they received daily Short Message Service reminders, acting as an independent factor (β = 0.356, p < 0.001).

CONCLUSION

Sending text message reminders to kidney transplant recipients is a statistically and clinically effective intervention to improve immunosuppressive medication adherence.

Unveiling the digital future: perspectives of Hungarian physicians under 35 years old on eHealth solutions

Background

The COVID-19 pandemic has catalysed the emergence of digital solutions in all areas of medicine. Our prior study on the digital health related experiences and opinions of Hungarian physicians highlights the crucial role of age in shaping attitudes towards digital health solutions among medical doctors. Our aim was to examine how under 35-year-old Hungarian physicians relate to digital technologies, the advantages and disadvantages they perceive, and how they would like to incorporate these technologies into their everyday medical practice.

Methods

As part of the "E-physicians and E-patients in Hungary" study, we conducted an online representative survey among medical practitioners in Hungary between July 2021 and May 2022 (n = 1,774). The main target group of our research were physicians under 35 years of age: n = 399 (25.3%). Besides descriptive statistical analyses, cluster analysis and binary logistic regression were applied to analyse the digital health related attitudes of the young age group.

Results

Our cluster analysis confirmed that younger doctors perceived more advantages (on average 7.07 items vs. 8.52 items) and disadvantages (on average 4.06 vs. 4.42) of digital health solutions. They also demonstrated greater familiarity with (8.27 vs. 9.79) and use of (1.94 vs. 2.66) a broader spectrum of technologies. Proficiency and active utilization of diverse technologies correlates with a more comprehensive understanding of both pros and cons, as well as a more realistic self-assessment of areas of further improvement. Doctors under 35 years express a notable demand for significantly increased incentives, both in terms of knowledge transfer/training and infrastructure incentives. Multivariate analyses revealed that young doctors, compared to their older counterparts, perceived enhanced patient adherence as one of the greatest benefits of digital health solutions. Additionally, young doctors expect that digital health solutions could reduce burnout.

Conclusion

Our results underscore the inevitable transformation of the 21st-century physician role: the success of digital health solutions hinges on active patient involvement and management, which requires proper patient education and professional support in navigating the digital space. Digital health solutions can be a bridge between different generations of doctors, where young people can help their older colleagues navigate the digital world.

Barriers to early diagnosis of chronic kidney disease and use of sodium-glucose cotransporter-2 inhibitors for renal protection: A comprehensive review and call to action

Chronic kidney disease (CKD) affects approximately 13% of people globally, including 20%-48% with type 2 diabetes (T2D), resulting in significant morbidity, mortality, and healthcare costs. There is an urgent need to increase early screening and intervention for CKD. We are experts in diabetology and nephrology in Central Europe and Israel. Herein, we review evidence supporting the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for kidney protection and discuss barriers to early CKD diagnosis and treatment, including in our respective countries. SGLT2 inhibitors exert cardiorenal protective effects, demonstrated in the renal outcomes trials (EMPA-KIDNEY, DAPA-CKD, CREDENCE) of empagliflozin, dapagliflozin, and canagliflozin in patients with CKD. EMPA-KIDNEY demonstrated cardiorenal efficacy across the broadest renal range, regardless of T2D status. Renoprotective evidence also comes from large real-world studies. International guidelines recommend first-line SGLT2 inhibitors for patients with T2D and estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m2, and that glucagon-like peptide-1 receptor agonists may also be administered if required for additional glucose control. Although these guidelines recommend at least annual eGFR and urine albumin-to-creatinine ratio screening for patients with T2D, observational studies suggest that only half are screened. Diagnosis is hampered by asymptomatic early CKD and under-recognition among patients with T2D and clinicians, including limited knowledge/use of guidelines and resources. Based on our experience and on the literature, we recommend robust screening programmes, potentially with albuminuria self-testing, and SGLT2 inhibitor reimbursement at general practitioner (GP) and specialist levels. High-tech tools (artificial intelligence, smartphone apps, etc.) are providing exciting opportunities to identify high-risk individuals, self-screen, detect abnormalities in images, and assist with prescribing and treatment adherence. Better education is also needed, alongside provision of concise guidelines, enabling GPs to identify who would benefit from early initiation of renoprotective therapy; although, regardless of current renal function, cardiorenal protection is provided by SGLT2 inhibitor therapy.

The emerging role of digital health in the management of asthma

The most common reasons seen for lack of asthma control include misconceptions about disease control, low controller treatment adherence, poor inhaler technique, and the resulting underuse of controllers and overuse of short-acting beta2 agonists (SABAs). Narrowing these care gaps may be achieved through well-designed patient education that considers the patient's motivation, beliefs, and capabilities regarding their asthma and its management and empowers the patient to become an active participant in treatment decisions. Digital health technologies (DHTs) and digital therapeutic (DT) devices provide new opportunities to monitor treatment behaviors, improve communication between healthcare providers and patients, and generate data that inform educational interactions. DHT and DT have been proven effective in enhancing patient self-management in other chronic conditions, particularly diabetes. Accelerated integration of DHT and DT into the management of asthma patients is facilitated by the use of digital inhalers that employ sensor technology ("smart" inhalers). These devices efficiently provide real-time feedback on controller adherence, SABA use, and inhaler technique that have the strong potential to optimize asthma control.

Evaluating the understandability and actionability of online educational videos on pre-dialysis chronic kidney disease

AIM

It remains undetermined whether online education videos for Japanese patients with chronic kidney disease (CKD) are easy to understand and allow adoption of behavioural changes. This study quantitatively assessed the understandability and applicability of online education videos for patients with CKD.

METHODS

In September 2021, we identified 200 videos on YouTube using the Japanese translations of the keywords 'kidney,' 'kidney disease,' 'CKD,' and 'chronic kidney disease.' We used the Japanese version of the Patient Education Materials Assessment Tool to evaluate the understandability and usability of webpages on a scale of 0% to 100%. The cut-off was set at 70%.

RESULTS

A total of 54 videos were evaluated. The overall understandability and actionability of the materials were 57.6 (SD = 22.6) and 53.7 (SD = 33.4), respectively. Approximately 70% and 60% of the materials were considered insufficiently understandable and actionable, respectively. Most videos lacked a summary and had difficulty in using only everyday language. Most videos included at least one action for the audience to take. However, many failed to break down the action into sequential steps. They also lack visual aids to encourage the audience to take action.

CONCLUSION

Our results suggest that current information on pre-dialysis chronic kidney disease was not presented in a manner that can be applied by laypeople.

Digital health technologies to support medication adherence in chronic kidney disease

Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.