Mobile App Improves Hypertension Medication Adherence, Not Blood Pressure

Kyle Morawski, MD, MPH

New study results have suggested that a mobile app for patients with poorly controlled hypertension significantly improves treatment adherence, but not systolic blood pressure when compared to a control group.

Even the most effective drug cannot help a patient who struggles to adhere to the prescribed course. Advocates for smartphone applications (apps) and other forms of mobile health (mHealth) interventions to increase adherence have promoted their use, but these tools have not been rigorously tested for efficacy.

Kyle Morawski, MD, MPH led the study evaluating the effects of the Medisafe mobile app on participants’ adherence to hypertension medication and their systolic blood pressure.

“Among modifiable risk factors, eliminating uncontrolled hypertension is estimated to have the single greatest potential to reduce cardiovascular mortality in women, and to have an effect that is second only to smoking cessation in men,” said Morawski. “While many factors contribute to poorly controlled hypertension, nonadherence is thought to account for nearly half of all such cases.”

The Medication adherence Improvement Support App For Engagement—Blood Pressure Trial was a randomized clinical trial of patients in the US with uncontrolled hypertension. The study included 411 participants, ages 18-75, with a systolic blood pressure of 140 mm Hg or greater and at least 1, but not more than 3 antihypertensive medications. Participants were randomly assigned to the intervention group (n=209) or the control group (n=202).

The study’s primary outcomes were change from baseline in self-reported medication adherence after 12 weeks and change in systolic blood pressure. Adherence was measured using the Morisky medication adherence scale (MMAS) (range, 0-8, with lower scores indicating lower adherence).

At baseline, mean (SD) adherence as measured by the MMAS-8 was 6.0 (1.8) among the intervention arm and 5.7 (1.8) among controls. At the 12-week follow-up, the mean (SD) adherence increased by 0.4 (1.5) in the intervention arm and remained unchanged among controls (between-group difference, 0.4; 95% CI, 0.1-0.7; P = .01).

At baseline, the mean (SD) systolic blood pressure was 151.4 (9.0) mm Hg in the intervention arm and 151.3 (9.4) mm Hg among controls. After 12 weeks of the study, the mean (SD) systolic blood pressure decreased by 10.6 (16.0) mm Hg in the intervention group and by 10.1 (15.4)mm Hg in the control group.

Previous studies indicated that mHealth interventions with SMS or voicemail and immediate physician feedback improved participant blood pressure. This study, however, evaluated a stand-alone app which included reminder alerts, adherence reports, and optional peer support, but no physician involvement.

“Medisafe has many positive features, including ease of set-up, relatively low cost, and promotion of medication self-management,” said Alexander G. Logan, MD and S. Vanita Jassal, MD in a commentary on the MedISAFE-BP trial. “However, patients also want a system that automatically offers immediate, personalized action messages about achieving or maintaining goals of care and prompts appropriate contact with the health care team, components lacking in Medisafe that may have contributed to its ineffectiveness.”

The study authors noted that medication adherence over the course of the 3-month trial was self-reported, possibly leading to overestimates of adherence.

“After exposure to an app that very clearly encouraged adherence, intervention arm participants may have been more likely to report being adherent without actually changing their medication-taking behavior,” said Morawski.

Additionally, all participants submitted home blood pressure readings over the course of the study, guaranteeing that all patients experienced some self-monitoring. Self-monitoring has been shown to have small positive effects on blood pressure control and medication adherence.

“How then could use of a smartphone app be enhanced to result in greater benefits for patients with hypertension?” asked Morawski. “One solution is to offer more disease-specific customization of smartphone tools. An alternative idea is to link the app to clinical care.”

The study, "Association of a Smartphone Application With Medication Adherence and Blood Pressure Control," was published online in JAMA Internal Medicine.