Increasing ICS compliance: The voice may be recorded, but the results are real

Automated phone calling may help physicians solve a perennial problem: patients who don't take medicine prescribed for chronic health conditions. Researchers at the Kaiser Permanente Center for Health Research, in Portland, Oregon, tested an automated calling service designed to encourage patients with asthma to fill or refill their prescriptions for inhaled corticosteroids (ICS).

The research will be presented on May 17 at the 105th International Conference of the American Thoracic Society in San Diego.

"The trial demonstrated a modest, but statistically significant, improvement in compliance," said William M. Vollmer, Ph.D., senior investigator at the center, who led the trial. "And even a small change in adherence can potentially produce a big public health benefit, especially when the disease is as prevalent as asthma."

According to the National Heart, Lung, and Blood Institute, about 22 million Americans have asthma, most need to take medicine daily for long-term control of the disease and ICS are the preferred medicines for gaining that control.

The 18-month-long trial involved approximately 8,600 members enrolled in the integrated health system in the Northwest United States and Hawaii. Member participants were randomized to usual care and to the phone calling system.

The study found that the calls increased estimated medication adherence two percent beyond the compliance of patients receiving usual care (40 percent versus 38 percent; p< .01). Among those 60 years of age and older, medication adherence rose four percent.

Dr. Vollmer's presentation at the ATS International Conference will focus on the study's primary outcome: medication adherence. Future analyses will assess the intervention's impact on healthcare utilization and quality of life, as well as the cost-effectiveness of the automated calling system.

The study used Kaiser Permanente's electronic medical records to identify who should be called and what message they should hear. One message was for those who had just become eligible for a refill. Another message targeted those who were past due for a refill. And a third message was designed for first-time users or those who had not had an ICS dispensing for at least six months.

The calls were short, typically lasting no more than two to three minutes. About 40 percent of calls made reached their target participant; messages were left for another 45 percent of calls.

While most of the calls were constructed around simple questions requiring a 'yes' or a 'no' response, Dr. Vollmer said the calls had "a lot of branching logic" to them. They were, for instance, able to explore level of symptom control and barriers to compliance.

For someone late in refilling his or her prescription, Dr. Vollmer noted that the computer might ask, "Many people with asthma don't take their controller medicines when they feel well. Is that ever true for you?" Those answering yes would then hear a brief message about the difference between relievers and controllers and why the latter should be taken every day.

Alternatively, Dr. Vollmer noted, the computer might ask if the participant's asthma wakes him/her up at night or interferes with daily activities. For someone who said yes, the computer might respond, "With regular use of ICS, this doesn't need to be the case."

During the call, participants could choose to refill their prescription through Kaiser's automated service. They could also choose to speak to a real person.

Part of the success of the calls, Dr. Vollmer noted, was how "natural" the voice of the caller sounded. Although those called were told they were speaking with a computer, the voice was a human one that captured the intonation and rhythm of speakers from the geographic areas of the HMO members.

Dr. Vollmer and his colleagues hope to conduct a similar study on patients with cardiovascular disease, reminding them to refill three different medications. In addition to phone message, the researchers are considering integrating e-mail messages into the automated outreach program. As Dr. Vollmer noted, "We want to be able to tailor the messages to fit the patient's preferred communication style."

Source: American Thoracic Society