About
Atrial fibrillation (AFib) is a chronic heart condition that affects millions of people worldwide. The most serious complication of AFib is thromboembolic stroke, which has devastating outcomes including paralysis, aphasia, and death. Oral anti-coagulant (OAC) medications are a primary approach to preventing stroke in AFib patients, yet adherence to prescribed therapy remains low in this population of patients. In this project we built a multi-pronged approach to enhance adherence to prescribed OACs through education, medication reminders (AdhereTech’s smart pill bottle), and personalized messaging through a patient portal (Epic’s MyChart).
We completed two phases of research with the following goals:
- Determine patient preference for content, timing, and delivery mode of tailored educational information about atrial fibrillation and anticoagulant therapy.
- Determine the impact of tailored messaging via personal health record on adherence to anti-thrombotic therapy and health outcomes in people living with atrial fibrillation.
- Determine the feasibility of measuring medication adherence with queries to electronic prescribing software and use of smart pill bottles.
Phase 1: Design
Using separate focus groups with patients who were newly diagnosed with AF and those who had lived with AF for more than one year, we developed an algorithm for tailoring educational messaging and medication reminder intervention for AF patients undergoing oral anticoagulant treatment. The following four categories emerged as important educational content: 1) Health & Healthcare Concerns; 2) Oral Anticoagulant Medication; 3) Lifestyle Modifications; and 4) AF in general. Focus group findings were refined using a survey of AF patients. Preferences for education content included learning about their stroke risk, their bleeding risk, the conditions that accompany AF, and activities that are safe. An algorithm was developed that incorporated tailored messaging using time since diagnosis and anticoagulant medication type. The goal of the intervention was to increase patient knowledge of atrial fibrillation, therapeutic purpose of oral anticoagulants, and necessary lifestyle changes as a means to improve oral anticoagulant adherence.
Phase 2: Technology Trial
The algorithm developed in phase 1 was tested as part of a randomized controlled trial with parallel groups to establish its effect on medication adherence for patients with AF. All participants used the Wireless Smart Pill Bottle manufactured by AdhereTech® to track medication adherence for the 6-month study period. We found that gender and time since diagnosis predicted adherence, with men showing lower adherence than women; and patients who had been diagnosed more than one year prior to study initiation demonstrating higher adherence than those with more recent diagnoses. Additionally, the interventions’ effects differed on the basis of participant age, medication type, and patient portal use prior to study. Younger participants benefited more from the intervention, according to their medication adherence. Specifically, at age 63 (z=-4.71, p<0.0001) and 71 (z=-3.02, p=0.003), intervention group participants were more adherent than control group members of the same age, but at age 79, this difference disappeared. Medication type also moderated the effect of the intervention. Intervention patients taking rivaroxaban demonstrated significantly higher medication adherence (z=-3.20, p=0.001) compared to those in the control group; these differences were not present for those prescribed warfarin or apixaban. Additionally, those with “low” patient portal use prior to study (less than 12 logins in 6 months) benefited from the intervention compared to their control group counterparts (z=-3.61, p=0.0003).
Top takeaways
- A combined intervention consisting of tailored patient education and adherence-related reminders was effective at maintaining high oral anticoagulant adherence among a randomized controlled trial of patients living with atrial fibrillation.
- This intervention was most effective for patients who were younger (i.e., in their 60s and early 70s) and for those who, before the study, were less active users of the online patient portal (MyChart) used to deliver the messaging.
- Patients in the intervention group demonstrated higher atrial fibrillation knowledge at the end of the study compared to the control group.
- Commercial “smart” pill bottles are a useful tool for tracking medication adherence within research, but do present some accuracy issues when considering their integration into realistic medication-taking routines.
- Suggestions for accurately capturing adherence include tracking when patients do not use the study-assigned bottle for legitimate reasons (i.e., medication hold, or use of a different container when traveling), as well as designing a “smart” weekly pill container for a more seamless fit into the routines of a typical patient managing multiple medications.
- Medication type moderated the effect of the intervention. Patients taking rivaroxaban demonstrated significantly higher medication adherence than the control group, perhaps due to the once-a-day dose routine.
Partners
Funding
- Janssen Scientific Affairs, LLC: 39039039AFL4007
Publications and presentations
- Toscos, T., Coupe, A., Wagner, S., Ahmed, R., Roebuck, A., Flanagan, M., Drouin, M., & Mirro, M. (2020). Engaging patients in atrial fibrillation management via digital health technology: The impact of tailored messaging. The Journal of Innovations in Cardiac Rhythm Management, 11(8), 4209. [link]
- Toscos, T. R., Coupe, A., Wagner, S., Drouin, M., Roebuck, A. E., Daley, C. N., Carpenter, M. D., & Mirro, M. J. (2020). Can nurses help improve self-care of patients living with atrial fibrillation? A focus group study exploring patients' disease knowledge gaps. Nursing Open, 7(4), 998–1010. [link]
- Toscos, T., Drouin, M., Pater, J. A., Flanagan, M., Wagner, S., Coupe, A., Ahmed, R. & Mirro, M. J. (2020). Medication adherence for atrial fibrillation patients: Triangulating measures from a smart pill bottle, e-prescribing software, and patient communication through the electronic health record. JAMIA Open, 3(2), 233–242. [link]
- Mirro, M., Rohani Ghahari, R., Ahmed, R., Drouin, M., Toscos, T. (2019, June 27–29). Perceptions on tailored educational messaging to patients with atrial fibrillation: Towards increased patient engagement and medication adherence [Poster presentation]. American Association of Heart Failure Nurses, 15th Annual Meeting, Austin, TX , United States.
- Mirro, M., Wagner, S., Rohani Ghahari, R., Ahmed, R., Pfafman, R., Flanagan, M., Drouin, M., & Toscos, T. (2019, April 30 – May 2). Impact of tailored educational messaging on medication adherence for patients with atrial fibrillation [Podium presentation]. American Medical Informatics Association Clinical Informatics Conference, Atlanta, GA, United States.
- Toscos, T., Ahmed, R., Rohani Ghahari, R., Martin, E., Wagner, S., Drouin, M., & Mirro, M. (2018, November 3–7). Designing tailored patient education on atrial fibrillation [Poster presentation].American Medical Informatics Association Annual Symposium, San Francisco, CA, United States.
- Wagner, S., Martin, E., Skaggs, C., Ahmed, R., Rohani Ghahari, R., Roebuck, A., Toscos, T., & Mirro, M. (2018, September 14). Designing a tailored e-health intervention to empower patients living with non-valvular atrial fibrillation [Poster presentation]. Indiana Clinical and Translational Sciences Institute Annual Meeting, Indianapolis, IN, United States.
- Toscos, T., Mere, C., Ahmed, R., Martin, E., & Mirro, M. (2018, August 27–30). Give me s’more consumer health technology: A multi-platform intervention to support medication adherence [Podium presentation]. Epic User Group Meeting, Verona, WI, United States.
- Toscos, T. (2018, August 1–2). A multi-platform intervention to support medication adherence [Poster presentation]. Computing Community Consortium Early Career Researcher Symposium, Computing Research Association, Washington, DC, United States.
- Roebuck, A., Wagner, S., Skaggs, C., Ahmed, R., Rohani Ghahari, R., Toscos, T., & Mirro, M. (2017, October 1–4). “I don’t know how you can be the decision maker when you don’t understand”: Designing a tailored e-health intervention to empower patients living with non-valvular atrial fibrillation [Poster presentation]. Heart Rhythm Congress, Birmingham, United Kingdom.
- Roebuck, A., Carpenter, M., Daley, C., Rohani Ghahari, R., Wagner, S., Ahmed, R., Toscos, T., & Mirro, M. (2017, March 17–19). Designing tailored health messaging to enhance patient-centered care in non-valvular atrial fibrillation. American College of Cardiology 66th Annual Scientific Session & Expo, Washington, DC, United States.
- Roebuck, A., Wagner, S., Carpenter, M., Ahmed, R., Martin, E., Rohani Ghahari, R., Toscos, T., & Mirro, M. (2017, March 4). Designing tailored health messaging to enhance patient-centered care in non-valvular atrial fibrillation (Podium presentation). Parkview Research Symposium in Fort Wayne, IN, United States.
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