Abstract
Background
Current methods of improving medication adherence for health problems are mostly complex, labour-intensive, and not reliably effective. Medication ‘reminder packaging’, which incorporates a date or time for a medication to be taken in the packaging, can act as a reminder to improve adherence. This review of reminder packaging is an update of our 2006 Cochrane review.
Objectives
The objective of this review was to determine the effects of reminder packaging aids for self-administered medication/s taken for at least one month, on adherence and other outcomes.
Search methods
We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library Issue 9, 2010), MEDLINE, EMBASE, CINAHL and PsycINFO from the database start dates to September 2010. We searched Current Controlled Trials to identify trials in progress. We performed a cited reference search on the Science Citation Index to identify papers that had cited the original systematic review.
We also searched the Internet, contacted packaging manufacturers, and checked abstracts from the Pharm-line database and reference lists from relevant articles. We did not apply any language restrictions.
Selection criteria
We selected randomised controlled trials with at least 80% follow up. We intended to do a sensitivity analysis of those studies that analysed their data on an intention-to-treat basis. Included studies compared a reminder packaging device with no device, for participants taking self-administered medications for at least one month.
Data collection and analysis
Three review authors independently assessed studies for inclusion, assessed quality, and extracted data from included studies. Where considered appropriate, data were combined for meta-analysis, or were reported and discussed in a narrative.
Main results
We included twelve studies containing data on 2196 participants; four of these studies were newly included in this 2011 update of our 2006 Cochrane review.
Six intervention groups in four trials provided data on the percentage of pills taken. Reminder packaging increased the percentage of pills taken (mean difference (MD) 11% (95% confidence interval (CI) 6% to 17%)). Notable heterogeneity occurred among these trials (I2 = 96.3%). Two trials provided data for the proportion of self-reported adherent patients, reporting a reduction in the intervention group which was not statistically significant (odds ratio = 0.89 (95% CI 0.56 to 1.40)). We conducted meta-analysis on data from two trials assessing the effect of reminder packaging on blood pressure measurements. We found that reminder packaging significantly decreased diastolic blood pressure (MD = -5.89 mmHg (95% CI -6.70 to -5.09; P < 0.00001; I2 = 0%). No effect was seen on systolic blood pressure (mean change -1.01, 95% CI -2.22 to 0.20; P = 0.1, I2 = 0%). We also conducted meta-analysis on extracted data from two trials that looked at change in glycated haemoglobin. We found that reminder packaging significantly reduced glycated haemoglobin levels (MD -0.72; 95% CI -0.83 to -0.60; P < 0.00001; I2 = 92%), although there was considerable heterogeneity.
No appropriate data were available for meta-analysis of remaining clinical outcomes, which included serum vitamin C and E levels, and self-reported psychological symptoms (one trial each). We reported remaining data narratively. In one study the presence of a reminder packaging aid was found to be preferred by patients with low literacy levels.
Authors’ conclusions
Reminder packing may represent a simple method for improving adherence for patients with selected conditions. Further research is warranted to improve the design and targeting of these devices.
Plain language summary
Reminder packaging to help people take long-term medications
People often miss taking prescribed medication, because of forgetfulness, changing medication schedules or busy lifestyles. It is estimated that between 40% and 60% of people do not take medication as prescribed, which can lead to worse health outcomes. Packaging of medications with reminder systems for the day and/or time of the week is an attempt to help people take long-term medications. We assessed twelve studies involving 2196 participants who were taking self-administered medications for at least one month. The studies involved different types of packaging, and different medications for various health problems. We found that reminder packaging increased the proportion of people taking their medications when measured by pill count; however, this effect was not large. We also found some evidence that reminder packaging may be beneficial in improving clinical outcomes such as blood pressure. Reminder packing for certain individuals may represent a simple method for improving the adherence to medications; further research is needed to improve the design and targeting of these devices.
