Using technology, statistics and the INCA device to improve people’s health

In 2015, Dr Frank Doyle and Professor Ronan Conroy, based at the Royal College of Surgeons in Ireland, received an Irish Research Council New Horizons Interdisciplinary Grant for research to develop new analysis techniques for adherence to recommended behaviours using modern technology. More specifically, their work looks at the use of the novel Inhaler Compliance Aid in patients with chronic obstructive pulmonary disease. They join us today to explain their research and its benefits.

Adherence to medication, that is, taking medication exactly as prescribed by your doctor, is a fascinating area to study. You very likely know someone who does not take their medication as prescribed – for example, not finishing a 10-day course of antibiotics for a chest infection, only taking blood pressure tablets some days instead of every day, or only using a preventive inhaler when feeling breathless, or not knowing how to use an inhaler properly. It is thought that around half of medications are not taken as prescribed. Unfortunately, there are consequences of non-adherence – the chest infection could get worse, the blood pressure could stay high (and lead on to stroke or heart attack), or someone could have an asthma attack or severe breathlessness. Furthermore, doctors may think that the therapy is not working, and prescribe a stronger drug, which may cost more and have stronger side-effects, but not actually be needed.

There are several reasons why this is fascinating – all we have to do is ask ‘why?’ – why don’t people take their medications as prescribed? The answers are varied and complex – and provide a deep insight into human nature: we often forget things, we sometimes find it difficult to learn new ways of doing things, we distrust and are suspicious of medications, we are afraid of side-effects, we are optimistic that such horrible events as stroke or heart attack could not happen to us, we (or our families and friends) have our own beliefs about what causes our illnesses and how we can treat these – irrespective of what health professionals tell us!

Up to relatively recently, it has been difficult to measure the extent to which people take their medications as prescribed. However, modern technology has begun to change this. We are fortunate to work with a new device called the ‘Inhaler Compliance Aid^TM’ (INCA^TM), which allows us to measure not only when someone takes their inhaler (which several devices can do), but also whether it is taken properly. The ability to determine if someone has made a mistake when using the inhaler (e.g. loading two doses of the drug, not inhaling strongly enough) is what makes this device unique. This means that we can now investigate, in detail, reasons why someone may not be taking their inhaler as prescribed. The figure below shows some examples of different types of adherence, according to the INCA^TM (note that in these examples the patient should be taking their preventive inhaler twice a day, approximately 12 hours apart).

Data like this are important – we can provide an appropriate intervention based on a person’s own behaviour. For example, people can think they are taking their inhaler correctly, but they may not be (top right in figure). We now know that this person needs to be re-trained in how to take the inhaler properly. We also know that the person in the top left does not need to be reminded to take their inhaler, as they are already taking it at the correct time – sending reminders to this person is likely to be a waste of time, and rather irritating! However, we might need to consider sending reminders to the person in the bottom left panel. We might also guess that we need to have a discussion about the preventive inhaler and why it is needed for this person – it may be that they are forgetting, or that they do not believe they need the inhaler every day. If we did not have such data, we would not have the structure in place to be able to have such an important discussion. These discussions lead us to the ‘why’ – and when we know the reasons for behaviour we can then try to address these. Current results suggest that using this type of feedback is improving adherence in asthma.

One drawback is that data like this is very complex to analyse, and we need to develop new ways to communicate this data in a form that people can understand. We have been funded by the IRC to develop new ways to analyse this type of data so that it can help better manage health. In this way, we hope to show that combining technology, statistics and our own beliefs and behaviours can improve people’s health – which is exciting as it can improve health and lower costs.