title: Packaging interventions to increase medication adherence: systematic review and meta-analysis.
abstract: OBJECTIVE
  Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics.
  
  
  METHODS
  Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses.
  
  
  RESULTS
  Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures.
  
  
  CONCLUSIONS
  Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.
authors.affiliation: University of Missouri , Columbia, MO , USA.
authors.forename: Vicki S
authors.initials: VS
authors.lastname: Conn
authors.forename: Todd M
authors.initials: TM
authors.lastname: Ruppar
authors.forename: Keith C
authors.initials: KC
authors.lastname: Chan
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Dunbar-Jacob
authors.forename: Ginette A
authors.initials: GA
authors.lastname: Pepper
authors.forename: Sabina
authors.initials: S
authors.lastname: De Geest
mesh_terms: D004349:Drug Packaging; D006801:Humans; D055118:Medication Adherence
keywords: Intervention; Medication adherence; Medication compliance; Meta-analysis