Integration of Smart Multidose Blister Packaging for Medication Management

Abstract

Medication non-adherence can lead to non-optimal management of chronic diseases and poor health outcomes. Numerous innovative dispensing products offering real-time medication intake monitoring are being developed and marketed to address medication non-adherence and support the in-home medication management process. The integration of emerging medication dispensing devices with real-time medication intake monitoring by patients with chronic diseases for in-home medication administration and within the workflow of community pharmacies is unknown. The overall goal of this thesis was to investigate the medication-taking behaviour and in-home medication management processes of patients with chronic diseases (including storage, organization and administration of medications), examine the integration (described as usability, acceptability, and functionality) of a prototype smart technology-based smart multidose blister package (SMBP) in patients’ homes and explore the feasibility of implementation of a real-time adherence monitoring, multidose dispensing system in community pharmacies.

This thesis is comprised of five studies and one reflexivity activity. The first two studies identified and analyzed relevant literature on the integration of smart oral multidose dispensing systems into the daily use of patients and the features and characteristics of smart medication adherence products for in-home patient use respectively. These two literature reviews identified various smart adherence products with variable features, however there was limited evidence related to in-home integration of such products. The third study aimed to understand the meanings associated with in-home medication management processes and storage practices of older adults with chronic diseases. This study was a qualitative study that utilized a modified ethnographic approach via digital photography walkabouts, observation protocols, and field notes to document in-home medication organization and storage locations. Data consisting of digital photos and observation protocols were analyzed thematically. Ten older adults with an average age of 76 years, of which 80% were female, participated in the study. On average, participants reported five medical conditions, while the average number of medications was 11.1. The thematic analysis of 30 photographs, 10 observation protocols, and field notes resulted in three themes and five sub-themes for the in-home medication management study. Themes included choice of storage location, knowledge regarding appropriate medication storage conditions, and systems to manage in-home medication intake.

The fourth study was a mixed-method study in which study participants who were recruited for the first study, used the SMBP to manage their medications for eight weeks. To examine the integration of SMBP, data was collected using qualitative methods such as in-home observations, photo-elicitation, field notes, and semi-structured interviews along with quantitative methods, including System Usability Scale (SUS) and Net Promoter Score (NPS). The interview guide was developed with constructs from the Technology Acceptance Model (TAM), Theory of Planned Behaviour (TPB), and Capability, Opportunity, Motivation, Behaviour (COM-B) Model. Interview data were analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL) framework to generate themes and subthemes, which were mapped back to TAM, TPB, and COM-B Model. The qualitative analysis identified three themes and 17 sub-themes including factors influencing medication intake behaviour, facilitators to the product use, and barriers to the product use. The average SUS score was 75.50 and the overall NPS score was 0.

The fifth study was conducted at the respective community pharmacies of patients. Pharmacists and pharmacy assistants packaged and dispensed medications in SMBPs and monitored real-time medication intake via the web portal. This was a mixed-method study, where pharmacy staff participated in semi-structured interviews, and completed the SUS to assess usability. The interview guide was developed with constructs from the TAM, TPB, and COM-B Model. Interview transcripts were analyzed thematically utilizing Braun & Clark’s thematic analysis framework, and findings were mapped back to the TAM, TPB, and COM-B Model. Three pharmacists and one pharmacy assistant with a mean of 19 years of practice were interviewed. Three themes and 12 subthemes were generated. Themes included: pharmacy workflow factors, integration factors, and pharmacist perceived patient factors. The mean SUS was found to be 80.63.

The sixth and the last chapter of this thesis was comprised of a reflexivity activity conducted by the pharmacist-researcher during the ethnographic fieldwork. This study provided reflection of a practicing pharmacist and the benefit of reflexivity practice to identify a clinician-researcher's assumptions and beliefs and their impact on the research. The findings from this thesis indicated that in-home medication management reflects older adults’ perspectives regarding privacy, medication-taking routine, knowledge about safe and effective storage, and organization systems. The SMBP was found to be easy to use and acceptable by older adults. However, clinicians should assess an older adult’s medication intake behavior and barriers and facilitators to product use before recommending a technology-based adherence product for managing medications. Future research should be designed to understand the impact and effectiveness of these products on health outcomes and examine the sustainability of product induced behaviour change in patients managing complex therapies on regular basis. This research project identified that although pharmacists valued products with real-time adherence monitoring capabilities, it is imperative to carefully assess the infrastructure, including pharmacy workload, workforce, and financial resources, for the successful implementation of such interventions in a community pharmacy setting. Future research should focus on developing frameworks for full-scale implementation of such products in the community pharmacy settings.