Apps don't work for patients who don't use them: Towards frameworks for digital therapeutics adherence

Objectives: Digital therapeutics such as mobile health applications (mHealth apps) are becoming part of patients’ treatment programs. Ensuring patients actually use (adhere to) an app as prescribed, effectively measuring and interpreting usage, and detecting clinical non-compliance are fundamental to effective treatment. Clinicians are not currently prepared to deal with issues of patients’ adherence to digital therapeutics (DTx). This study proposes and analyses potential frameworks for clinician-patient dialogue about DTx adherence. Methods: Purposive sampling is used to select three leading adherence frameworks, one at each of the micro (patient), mesa (physician), and macro (system) levels of healthcare. The ABC taxonomy of adherence stages; Osterberg and Blaschke's medication adherence framework; and the Morisky Medication Adherence Scale-8 (MMAS8). Each framework is deconstructed and analysed from the perspective of DTx adherence. Results: Modifications to ABC can improve suitability to conceptualize DTx adherence whilst maintaining the overall framework. Osterberg and Blaschke's framework provides many metrics adaptable to app assessment alongside some that are inapplicable. Significant modification of MMAS-8 appears necessary to build relevance to DTx adherence reporting. Specific reconceptualizations of each framework element are presented. Conclusions: A strong basis for studying and measuring DTx adherence exists in existing treatment adherence research and practice, and can help guide policy. However, important adaptations are needed to ensure the development of methods for use in clinical environments.