Medication non-adherence is a major societal problem with serious clinical and economic consequences, associated with 200,000 deaths and 125 billion euros of costs annually in Europe. Studies show that only about half of patients take their medicines as prescribed, leading to poor clinical outcomes and increased hospital admissions.
In recent years, various solutions have been developed to help patients take their medication as prescribed. Medication Adherence Technologies (MATech) include electronic devices that track medication intake, dose dispensers with instructions, and mobile applications that provide health information and reminders.
The COST Action "European Network to Advance Best Practices & Technology on Medication Adherence (ENABLE)" addresses medication non-adherence by engaging the private sector to promote innovative technology-based solutions. ENABLE is developing a knowledge base and promoting local "Medication Adherence Expertise Centres" to pool multidisciplinary knowledge at regional and national levels. By connecting technology engineers with healthcare providers, patients, and payers, ENABLE aims to create a fully integrated and personalised adherence strategy.
During the final conference of the Action in Istanbul in April 2024, COST interviewed Dr Job van Boven, Director of the Medication Adherence Expertise Center at the University Medical Center Groningen, Chair of the Action, and three of its WG Leaders. They talked about their experiences with COST, the advantages and disadvantages of the technological solutions available to address medication non-adherence, and shared their vision for the future of the field.
Examples of Medication Adherence Technologies (MATech)
Several MATech have been proven effective. For example, digital inhalers combined with an app have been shown to improve medication adherence and asthma control after one year. Advanced digital inhalers and spacers even measure inhalation quality and provide immediate feedback to patients and healthcare professionals.
Smart pill bottles and blisters measure when a pill is taken out of a package and connect to an app. Studies in tuberculosis patients have shown that smart pill bottles accurately monitor medication intake and provide reminders when a dose is being missed, thereby improving adherence.
There are also solutions with light and sound reminders for people with hearing or visual impairments.
Social networks can also be created for patients who need extra support.
Job van Boven emphasizes that the ideal MATech solution should integrate seamlessly into a patient's routine, provide personalized feedback only when necessary, and facilitate data sharing with healthcare professionals to improve decision-making. This hybrid model combines technology with professional supervision.
The ENABLE repository contains various MATech solutions and their evidence base, showcasing options available across Europe. It includes electronic devices that record medication intake, dose dispensers that instruct on time or mode of administration, mobile applications that provide information about a health condition or medication or reminders, etc.
Factors influencing medication adherence
Medication adherence is not only affected by forgetfulness, which can easily be solved with reminders. One of the more amusing findings of the Action is that Sunday is the most problematic day for medication adherence in Western European countries, while in Turkey it is Wednesday, the day of the bazaar.
Dr van Boven also points out that financial issues and concerns about side effects can also play a role. Digital solutions alone cannot address all the underlying factors that affect adherence. To achieve effective adherence, it is essential to work with experts from different fields, including medicine, pharmacy, psychology, nursing and patient organisations.
Regulatory and implementation pathways
According to Job van Boven, regulatory, payment, and implementation pathways at the local level remain crucial. Consequently, another key objective of ENABLE is to secure reimbursement from insurers and approval from regulatory bodies. For instance, in the Netherlands, hospitals have only recently begun to receive reimbursement for remote (digital) monitoring. The Action Chair anticipates that countries in Europe where no such reimbursement opportunities are in place will follow shortly.
Successful collaboration and future prospects
The collaboration between Action researchers, patient organisations, policymakers, and industry in developing MATech solutions has been highly successful. The Action's extensive network of over 250 members enabled it to conduct surveys with around 3,000 respondents. Having our ENABLE meeting, organised alongside the PhD defense of our Luxembourg MC member, being featured on national television in Luxembourg was also a great way to make a societal impact and reach the general public.
I am pleasantly surprised and impressed by the great motivation of people who want to invest time and effort in our Actions. COST is not a research project, but we have published and will publish around 25 papers. The Action plans to integrate ENABLE into the ESPACOMP association. In addition, strong links have been established with EuroDURG, highlighted by a joint training school in Bologna last year".
Dr. Job van Boven, Director of the Medication Adherence Expertise Center at the University Medical Center Groningen
Furthermore, young professionals, including PhD students and mid-career assistant/associate professors, are highly involved in the Action. "Four of the Core Group members were young researchers when we started the Action, and I think that's the key to our success. I could rely on them as the pillars of this Action and I had confidence in their ability to deliver," Job van Boven concludes.
The voices of the WG Leaders
Dr Tamas Agh of the Syreon Research Institute in Hungary, one of the WG leaders, has been elected Chair of the ISPOR Medication Adherence and Persistence Special Interest Group for 2024 and Chair-elect of the ESPACOMP International Society of Medication Adherence for the same year, with the chairmanship starting in 2025. "My participation in the ENABLE COST Action has significantly broadened my professional network," says Tamas. "This initiative has connected me with leading adherence researchers from over 40 countries across Europe. Through collaborative research projects, joint meetings, and training schools facilitated by ENABLE, I have fostered knowledge exchange and built lasting collaborations. The COST Action Dissemination Conference Grant was instrumental in enabling me to attend the ISPOR Europe conference in 2022, where I engaged with other experts in the field, further broadening my professional horizon."
A specific example of how ENABLE has contributed to advancing Tamas's research projects is a study funded by the GATEKEEPER Twinning programme. Tamas worked with Polish ENABLE member Professor Kardas, the Director of the Medication Adherence Research Centre (MARC) at the University of Lodz. The partnership between the University of Pécs, the Center for Health Technology Assessment and Pharmacoeconomic Research, and the Medical University of Lodz led to the introduction of the 'My Health Everyday' application in Hungary and the establishment of the first Hungarian medication adherence research center.
Dr Ines Potočnjak, a young WG leader from the Sestre Milosrdnice University Hospital Center; School of Medicine Catholic University of Croatia, was given the opportunity to coordinate a large, international, and multidisciplinary team at an early stage of her career through the ENABLE Action. She also co-edited two special editions of highly regarded journals, wrote papers, and organised meetings. "When I reflect on the past, I am struck by the remarkable developments in our professional and personal lives", Ines confided. "Some members of the group changed jobs, advanced in their careers, relocated to different countries, expanded their families, and along the way, we became friends. Despite these changes, we continued to progress professionally and personally and established an outstanding pan-European research group. I am extremely fortunate to work with these individuals, gain insights from them, and advance medication adherence research with them. Our work goes in line with a maxim quoted during our meeting: 'If you want to go fast, go alone; if you want to go far, go together.' I am confident that we will continue to work together on this project."
Dr Alexandra Lelia Dima is a WG leader and a health psychologist and Principal Researcher at the Avedis Donabedian Research Institute - Autonoma University of Barcelona (UAB), and Senior Researcher in the PRISMA Research Group, at the Fundació Sant Joan de Déu in Spain. She has been researching medication adherence as a set of behaviours performed by different people—medication users, health professionals, carers, etc.—and how it can be measured and supported. Her work in ENABLE has allowed her to integrate health psychology concepts and methods into the overarching framework developed by the Action, thereby defining the common ground of medication adherence as an applied area of research and practice. "This work will continue beyond the ENABLE project timeframe, and I am pleased to see that health psychology is well represented and integrated into the work of colleagues from other disciplines as they describe and plan their medication adherence interventions and tools," says Alexandra. "The ENABLE network reinforced my identity as a researcher and provided me with the tools to navigate this new environment."
In summary, the ENABLE COST Action has created a multidisciplinary network of relevant stakeholders working together towards an economically viable implementation of medication adherence-enhancing technologies in European healthcare systems.
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