A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> Adherence to the medical regimen continues to rank as a major clinical problem in the management of patients with essential hypertension, as in other conditions treated with drugs and life-style modification. This article reviews the psychometric properties and tests the concurrent and predictive va <s> BIB001 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> BACKGROUND ::: Preventable drug-related morbidity and mortality represent a serious medical problem that urgently requires expert attention. The costs to society of the misuse of prescription medications, in terms of morbidity, mortality, and treatment, can be immense. To date, research has primarily documented increased rates of hospitalization secondary to medication noncompliance and/or adverse drug effects. ::: ::: ::: OBJECTIVES ::: To develop a conceptual model of drug-related morbidity and mortality, and to estimate the associated costs in the ambulatory setting in the United States. ::: ::: ::: METHODS ::: A probability pathway model was developed to estimate the cost of drug-related morbidity and mortality in the United States. Pharmacist practitioners were surveyed to determine conditional probabilities of therapeutic outcomes owing to drug therapy. Health care utilization and associated costs owing to negative therapeutic outcomes were estimated. ::: ::: ::: RESULTS ::: Drug-related morbidity and mortality was estimated to cost $76.6 billion in the ambulatory setting in the United States. The largest component of this total cost was associated with drug-related hospitalizations. When assumptions of the model were varied, the estimated cost ranged from a conservative estimate of $30.1 to $136.8 billion in a worst-case scenario. ::: ::: ::: CONCLUSIONS ::: The cost of drug-related morbidity and mortality in the ambulatory setting in the United States is considerable and should be considered in health policy decisions with regard to pharmaceutical benefits. Policies and services should be developed to reduce and prevent drug-related morbidity and mortality. <s> BIB002 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> As average life expectancy increases, so do the incidence of chronic diseases and the number of persons receiving long-term drug therapy. Thus elderly patients' noncompliance with medication regimens has the potential for sweeping medical and economic consequences and is likely to become increasingly important in the design of disease-management programs for this population. The author conducted a MEDLINE search of the English-language literature for the years 1962 to 1997 to identify articles concerning predictors of medication compliance in the elderly. A descriptive analysis of this literature indicated that there remains some uncertainty about the reasons for noncompliant medication-taking in the elderly. Clear associations have been established between elderly patients' medication adherence and race, drug and dosage form, number of medications, cost of medications, insurance coverage, and physician-patient communication. However, the findings are inconsistent with regard to the effects of patients' age, sex, socioeconomic status, living arrangement, comorbidities, number of physician visits, and knowledge, attitudes, and beliefs about health. Until the results of further comprehensive studies are available, the current knowledge should be considered when designing and implementing disease-management programs for the elderly. <s> BIB003 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> The effect of tools and methods designed to enhance medication adherence that have been evaluated in randomized controlled trials was studied. A literature search was performed with MEDLINE, International Pharmaceutical Abstracts, PsychLIT, ERIC, and EMBASE for the period from 1966 to December 2000. Only randomized, controlled trials with at least 10 subjects per intervention group were included. Of 484 articles evaluated, only 61 met the criteria for the meta-analysis. Multiple interventions or study samples were identified in 23 of the articles. Each intervention was counted as a separate study, yielding 95 cohorts totaling 18,922 subjects. Of these subjects, 9,604 (51%) received interventions and 9,318 served as controls. Cohorts reported between 1990 and 1999 accounted for 53% of the sample; 56% of all cohorts were based in physician offices and 26% involved hypertensive patients. Behavioral interventions accounted for 41 cohorts (8,885 subjects), educational interventions for 22 cohorts (6,392 subjects), and combined interventions for 32 cohorts (3,645 subjects). Homogeneity of groupings and effect sizes (ESs) were calculated for each type of intervention. Overall, the data were not homogeneous, so conclusions could not be derived from the entire body of data. The educational intervention and combined intervention cohorts were nonhomogeneous (p < 0.001 and p < 0.01, respectively); however, the behavioral intervention cohort was homogeneous (Q = 42.48, d.f. = 40, p = 0.36). The overall ES for behavioral interventions was 0.07 (95% confidence interval [CI] = 0.04-0.09). There were no significant differences among the behavioral interventions. Educational interventions had an overall ES of 0.11 (95% CI = 0.06-0.15); there were no significant differences among the educational interventions. The overall ES of the combined interventions was 0.08 (95% CI = 0.04-0.12). When stratifying the combined intervention group by type of behavioral intervention, mail reminders had the largest impact (ES = 0.38). Meta-analysis of studies of interventions to improve medication adherence revealed an increase in adherence of 4-11%. No single strategy appeared to be best. <s> BIB004 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> The full benefit of many effective medications will be achieved only if patients adhere to prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and “nonadherent” to patients who do not consume every pill at the desired time can stigmatize them in their future relationships with health care providers. This article on medication adherence (or compliance) reviews strategies to assess and enhance this important aspect of patient care. <s> BIB005 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> In this paper, we present UbiMeds, a mobile application and architecture that aims at supporting prescription medication adherence for aging and disabled population. We review the problem of medication adherence in general and from the accessibility perspective. We describe the design process guided by the accessibility issues identified in the non-adherence phenomenon. We present a proposed comprehensive architecture (including an iPhone application) aimed at improving accessibility in the practice of medication taking from patients, and supporting the intake tracking and monitoring by physicians and family members. <s> BIB006 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> The treatment of chronic illnesses commonly includes the long-term use of pharmacotherapy. Although these medications are effective in combating disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Factors contributing to poor medication adherence are myriad and include those that are related to patients (eg, suboptimal health literacy and lack of involvement in the treatment decision–making process), those that are related to physicians (eg, prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and those that are related to health care systems (eg, office visit time limitations, limited access to care, and lack of health information technology). Because barriers to medication adherence are complex and varied, solutions to improve adherence must be multifactorial. To assess general aspects of medication adherence using cardiovascular disease as an example, a MEDLINE-based literature search (January 1, 1990, through March 31, 2010) was conducted using the following search terms: cardiovascular disease, health literacy, medication adherence, and pharmacotherapy. Manual sorting of the 405 retrieved articles to exclude those that did not address cardiovascular disease, medication adherence, or health literacy in the abstract yielded 127 articles for review. Additional references were obtained from citations within the retrieved articles. This review surveys the findings of the identified articles and presents various strategies and resources for improving medication adherence. <s> BIB007 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> OBJECTIVE ::: There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. ::: ::: ::: DESIGN ::: A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. ::: ::: ::: METHODS ::: Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. ::: ::: ::: RESULTS ::: In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). ::: ::: ::: CONCLUSION ::: These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings. <s> BIB008 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> Several technologies have been developed to support people's medication management, including pillboxes, specialized software applications, reminders and paper-based medication lists. Several of these technologies were discovered in older adults' homes during user studies carried out with the main purpose to help them to manage their medications and recall challenges. We confirm that a considerable number of older adults integrate their medication treatments into their daily life routines, and that the lack of knowledge, caregiver's support, medicine outside the home, forgetting medication intake, complexity of medication regimen were equally important challenges. One of the major findings was the issue related to substitutions, as older adults get confused due to the volatile information that they receive regarding their medications. We define basic requirements in order to address these issues towards the design of a personalized medication management system. We further describe our initial stage in a participatory design process as part of the ongoing Lev Vel Consortium. <s> BIB009 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> Preventing and ameliorating chronic conditions has long been a priority in the United States; however, the increasing recognition that people often have multiple chronic conditions (MCC) has added a layer of complexity with which to contend. The objective of this study was to present the prevalence of MCC and the most common MCC dyads/triads by selected demographic characteristics. We used respondent-reported data from the 2010 National Health Interview Survey (NHIS) to study the US adult civilian noninstitutionalized population aged 18 years or older (n = 27,157). We categorized adults as having 0 to 1, 2 to 3, or 4 or more of the following chronic conditions: hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, chronic obstructive pulmonary disease, or current asthma. We then generated descriptive estimates and tested for significant differences. Twenty-six percent of adults have MCC; the prevalence of MCC has increased from 21.8% in 2001 to 26.0% in 2010. The prevalence of MCC significantly increased with age, was significantly higher among women than men and among non-Hispanic white and non-Hispanic black adults than Hispanic adults. The most common dyad identified was arthritis and hypertension, and the combination of arthritis, hypertension, and diabetes was the most common triad. The findings of this study contribute information to the field of MCC research. The NHIS can be used to identify population subgroups most likely to have MCC and potentially lead to clinical guidelines for people with more common MCC combinations. <s> BIB010 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> Healthcare activities in private home settings that are not supervised by a healthcare professional can challenge older adults. To support such unsupervised care activities, an increasingly number of reminders and monitoring systems are designed. However, most of these systems target a specific treatment or a specific condition. In this paper, we discuss experiences from designing the tablet-based application MediFrame. MediFrame is a personal medication management system to support older adults in non-clinical settings such as the home. The paper describes the user-centered design process and the resulting tablet application. We show how MediFrame can be used to support adherence in medical treatments through fieldwork informed use scenarios. Based on early qualitative feedback, we also discuss lessons learned and how designers can support a holistic medication experience for an older adult's everyday life. <s> BIB011 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> Abstract Several aspects of older adults’ life can benefit from recent technological developments, but success in harnessing this potential depends on careful design and accessible, easy to use products. Design and development must be centered on the elderly and adequately consider interaction. In this paper we follow this design approach and put it to the test in developing a concrete application, aimed to contribute to lower the high levels of non-adherence to medication in the elderly population. The “Medication Assistant” application was developed following an iterative method centered, from the start, on the elderly and interaction design. The method repeats short-time development cycles integrating definition of scenarios and goals, requirements engineering, design, prototyping and evaluation. Evaluation, by end-users, of the increasingly refined prototypes, is a key characteristic of the method. The evaluation results provide information related to strengths and weaknesses of the application and yield suggestions regarding changes and improvements, valuable support further development. Results regarding evaluation of the second prototype of “Medication Assistant” are presented. <s> BIB012 </s> A Survey of Tablet Applications for Promoting Successful Aging in Older Adults <s> IV. CHRONIC CONDITION MANAGEMENT <s> BACKGROUND ::: Older persons following a prolonged complex drug regimen often make mistakes when taking their medication. Currently, the widespread use of tablets and smartphones has encouraged the development of applications to support self-management of medication. ::: ::: ::: OBJECTIVE ::: The aim of this study was to design, develop and assess an app that transforms medication-associated ean-13 (barcodes) and Quick Response codes (QR) into verbal instructions, to enable safer use of medication by the elderly patients taking multiple medications. ::: ::: ::: METHODS ::: Meetings were held in which participated a total of 61 patients. ::: ::: ::: RESULTS ::: The results showed that patients appreciated the application and found it useful for safer use of medicines. ::: ::: ::: CONCLUSIONS ::: The study results support the use of such technology to increase patient safety taking multiple medications safety. <s> BIB013
The management of chronic conditions involves a number of tasks including adhering to a medication regimen and managing disease symptoms. In this section, we focus on describing medication management applications because the majority of older adults take a large number of prescribed medications  , arising from multiple chronic conditions BIB010 . The multiple chronic conditions and the high number of prescribed medications often result in a complex medical regimen, which often leads to medication non-adherence BIB003 - BIB007 . Medication non-adherence can affect physical health of the older adults because it precludes the intended therapeutic benefits of the prescribed medications and often results in co-morbid chronic conditions. Further, it also increases healthcare costs BIB004 and the rates of hospital readmission BIB002 . VOLUME 4, 2016 There exist many direct and indirect measures of medication adherence BIB005 . Some of the direct methods include measurement of biological markers in blood and direct observation therapy. While these direct methods provide accurate estimation of medication adherence, they are quite expensive and could be invasive. The indirect methods include electronic medication dispensers and pill counting. These methods are fairly inexpensive and can act as a good proxy for estimating medication adherence. However, these have a dependency on the reliability of the users because there is neither tracking of the actual intake of the medication nor any involvement of direct physiological measurement. Prior to the introduction of iPad in 2010 and the subsequent popularity of tablets, mobile phone applications were developed for medication management. The majority of these applications were standalone with no integration with the care providers. Text-based mobile-based medication reminders have been proven to be effective in improving medication adherence BIB008 . One of the earliest smartphone application for medication management developed for older adults is UbiMeds BIB006 . Its design was based on the literature review of the issues associated with medication non-adherence. This iPhone-based application provides automated reminder with an image of the medication, directions, dosage and a button for confirming intake. If a medication is missed, it informs the physician. The application is linked to the user's personal health record (PHR) where prescription/medication information can be directly updated by the clinician. Further, it provides information on side effects and additional dosage instructions for the prescribed medications. The application was not evaluated for usability and effectiveness in improving medication adherence. A few tablet-based medication management applications have been specifically developed for older adults BIB011 - BIB012 . The majority of these applications have been developed using an iterative, user-centered design approach with the older adults as the target users. For example, prior to the development of Mediframe BIB011 , a quantitative study with 360 older adults and a qualitative study with nine older adults were conducted for identifying the issues with medication adherence BIB009 . These studies have found that forgetting to take medication, lacking knowledge about a medication and not getting support from a care provider are some of the important challenges in adhering to medication regimens. The primary feature for these applications is to provide reminders when a medication is due. Some of these applications allow users to customize these reminders BIB011 . Usually, these reminders provide a list of the medications due at a particular time, along with the dosage information, image of the medication and warnings (if any). The user is required to confirm the intake of a medication. Only one application (ALICE) has been evaluated for its effectiveness in improving medication adherence  . A randomized control trial was conducted for 3 months with 102 older adults, equally divided into experimental and control groups. The participants having multiple chronic conditions and taking multiple medications, and capable of managing their medications by themselves, were included in the study. The participants filled out a custom questionnaire for evaluating the rate of missed does and medication errors, 4-item Morisky Medication Adherence Scale (MMAS-4) BIB001 , and perceived health status at the beginning and at the end of the study. The participants in the experiment group received the ALICE application installed either in a Wi-Fi enabled Android or iPad tablet. The participants in the control group, on the other hand, only received information on the risks associated with their medications and the common medication errors. Even though the majority of the participants required assistance in navigating ALICE despite initial training, they felt that using ALICE has improved their medication intake habit. The study found an increase in treatment adherence (as measured by MMAS-4) and a decrease in number of missed doses among the participants in the experiment group at the end of the study. However, there was no statistically significant difference in the reduction of medication errors from the beginning of the study, when compared to that at the end of the study for both experimental and control groups. Further, a statistically significant difference in cholesterol levels were observed, even though there was no change in the levels of glycated hemoglobin, blood pressure and perceived health status for all the participants at the end of the study. A positive and significant correlation (Pearson's) measuring patient compliance was observed between MMAS-4 and the medication reminders generated by ALICE. A few applications, specifically for older adults have been developed for minimizing medication errors and improving knowledge about medications. Studies have shown that if a person has knowledge about his/her medications, he/she would take medications as directed, thereby adhering to his/her medical regimen BIB005 . One such application for minimizing medication errors is Colorado Care Tablet (CCT)  ,  . CCT, a tablet-based application for medication management during care transitions, was developed using an iterative, participatory design approach for minimizing medication errors. A user can enter medications by scanning the barcode for the medication, manually using the code or selecting recently picked ones from the pharmacy. The user can easily access information related to a medication (retrieved from National Library of Medicine's MedlinePlus). The application can generate memo (containing the list of current medications and related potential questions that the user may ask) for promoting effective communication with the physician. Further, it can generate notifications for critical care assistance. Tumedicina (YourMedicine), a smartphone-based and tablet-based application, allows older adults to scan the EAN-13 (barcodes) and QR codes on the medication packaging BIB013 . Upon scanning, the application displays the name, dosage, instructions for use, warnings if any, expiration date and the next visit to the physician. This information is also available in audio format. A study with 61 older adults (average age of 68 years) was conducted for user evaluation of this application. The participants found Tumedicina easier to use and verbal messages simple and clear. There was no difference in satisfaction between participants with no or previous technology experience. The application was best valued by participants who had used pillbox or packaging notes for managing their medications.