Doctors have been trying to get their patients to consistently take medications since the advent of medicine. Even Hippocrates described how some of his patients would feign compliance to his treatment plans. It may seem like a simple concept, yet achieving compliance has been elusive in modern medicine despite iterations of potential solutions. Complex factors make up the barriers for medical compliance, and it is unlikely that there is one catch-all solution. Using advancements in mobile health to address these issues could potentially decrease the morbidity and mortality of noncompliance.

Aberrant dosing of immunosuppressive medications is a serious issue for transplant patients, who must maintain serum drug levels to prevent rejection of their transplanted organs. It is estimated that half of rejection episodes are due to medication noncompliance. Transplant patients usually have complex medication regimens, making compliance difficult for even the most organized patient.

The article “Exploring the usage of a mobile phone application in transplanted patients to encourage medication compliance and education” in The American Journal of Surgery explored the concept of using mobile health to increase medical compliance. The study enrolled new kidney and liver transplant recipients at the Montefiore Einstein Center for Transplantation in New York City.

Transplant Hero™ is a well rated compliance app marketed to patients taking immunosuppressive medications and was used by the experimental group in this study. Transplant Hero’s main function is an alarm system that reminds patients when to take specific medications. Users are encouraged to follow their routine by positive reinforcement with awards and various options for goal setting. 74 subjects were recruited for the study, which had an interesting way to select who was in the experimental arm. Transplant Hero ™ was available only for iOS devices at the time. Study participants self selected into the experimental arm if they owned an iOS device, and 21 subjects were selected to use Transplant Hero ™. Validated surveys were used to measure personal beliefs on taking immunosuppressive medications and gauging compliance patterns. Patients were also tested on the recall of their medication regimen. Serum drug levels of patients were measured during follow up to provide objective evidence of compliance.

This is one of the first papers to study the effect of mobile apps on compliance for transplant recipients. There were no statistical differences on compliance patterns, measured drug levels, or medication recall between the two groups. A higher medication recall trend was observed in app users, but this did not have statistical significance (p = 0.19). While there weren’t many changes detected by this paper, it is important to consider that this was a small sized study using a third party mobile app with a specific timing function. It’s hard to say whether the study was underpowered or just needed an app with more supportive functions.

A multi-faceted approach is required to improve compliance. This paper shows that addressing the issue by offering a timing function might not be enough. Many patients already develop their own systems, like setting reminders on their mobile phones to help with compliance. Transplant Hero ™ allows for an easier way to create a timing and reminder system, but more can be done through mobile health. Forgetting to take medications may be a factor for someone who is trying to create a routine for new medications, and this is where reminder apps can have the largest impact. As the management of disease becomes more rote for patients, the timing function loses its significance. Studies on smoking cessation have yielded similar mixed results. Mobile health can create opportunities for patients to manage their health efficiently with less reliance on medical providers. Personal bias, treatment fatigue, side effects, and provider miscommunication are factors that need to be addressed to better grapple with noncompliance. It would be interesting to see larger studies with apps that are tailored to specific diseases like Transplant Hero ™, but offer greater resources for education, communication, and support. Whether mobile health can help patients achieve greater compliance will be important to examine.

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