Intervention | Criteria for Ethical Evaluation | ||||
---|---|---|---|---|---|
(1) Monitoring Technology | (2) Feature(s) to Enhance Patient Adherence | (1) Accuracy | (2) Stigmatization and Intrusiveness | (3) The Use of Incentives | (4) Balance of Individual and Public Good |
Direct monitoring technology (metabolite testing) (DM) | Follow-up by health care workers when non-adherent SMS reminders to take medication throughout treatment Reward incentives (e.g., in-kind goods, or reductions in insurance contributions)a conditional on good adherence Penalty incentives (e.g., insurance surcharges) when non-adherent | Most accurate: medication ingestion and metabolization is necessary for adherence detection | Least risk: urinalysis can be used with greater privacy and does not enable surveillance; respect for patient agency and autonomy | General risk of coercion with penalty incentives Incentive size: incentives that are too small may fail to address all relevant adherence barriers; incentives that are too large may have greater risk of coercion Incentive type: guaranteed rewards may have greater risk of coercion than lotteries and may be more likely to “crowd-out” intrinsic patient motivation Incentive frequency: less frequent incentives may increase patients’ susceptibility to present-biased preferences | General risk of violating patient freedom and privacy when using individual adherence data to develop a picture of population-level adherence or to assist in contact tracing |
Direct monitoring technology (embedded sensors) (DE) | Most accurate: medication ingestion is necessary for adherence detection, but patients could induce vomiting | Most risk: if visible, wearable hub is potentially stigmatizing; even if invisible, may enable location surveillance and identification of “problem” patients; restricted patient agency and autonomy | |||
Video observation of therapy (VOT) | Fairly accurate: swallowing is observed, but patients can feign ingestion or, where a human observer is required, collude to create false report | Least risk: can be used with greater privacy and does not enable surveillance; respect for patient agency and autonomy | |||
Direct observation of therapy (DOT) | Most risk: association of patient with health care worker can be stigmatizing; restricted patient agency and autonomy | ||||
Indirect monitoring technology (patient- and device-facilitated) (IP and ID) | Least accurate: swallowing not observed; patient can place false call or remove cap without taking medication | Least risk: can be used with greater privacy and does not enable surveillance; respect for patient agency and autonomy | |||
Recommended intervention | Follow-up by health care workers when non-adherent SMS reminders to take medication throughout treatment Reward incentives (e.g., in-kind goods, or reductions in insurance contributions) conditional on good adherence | Maximize accuracy by minimizing opportunity for patient deception and adherence overreporting | Minimize stigmatization and intrusiveness to preserve patient agency and promote autonomy | Use reward incentives, but minimize risk of coercion by using 2-way SMS or video conferencing between patients and providers Reward value should be carefully tailored to local social and economic context (smaller value to address patient factor barriers; larger value to address non-patient factor barriers) Daily/weekly lottery | Develop population-level picture of adherence to more efficiently use resources, learn about best practices and regions where improvement is needed, and ensure timely drug restocking Strive for anonymity, thus promoting public good while minimizing restriction of individual freedom and privacy |
↵a For additional examples, see CDC, 2012.38