Sticking to the pharmaceutical plan: the issue of patient adherence
You can take a horse to water, but you can’t make it drink as the saying goes. Apparently, you can’t make one take medication either. Patient adherence to treatment is an ongoing battle for pharmaceuticals, whose success or failure sits alongside the efficacy of their drugs. How can the sector influence patient adherence and just how bad is the problem?
The degree to which patients adhere to medical advice and take medicines as directed can have a significant impact on the ultimate success or failure of any pharmaceutical. But patient adherence depends on a variety of issues, from the costs of drugs to patient lifestyles, as well as patient acceptance of information about the health threat itself and the practitioner’s ability to persuade the patient that the treatment is worthwhile. The patient’s perception of the practitioner’s credibility, empathy, interest and concern also play a part.
It’s a significant issue for the sector: the National Council on Patient Information and Education (NCPIE) calls non-adherence "America's other drug problem". It estimates that non-adherence contributes to $290bn each year in avoidable medical spending. This figure equates to 13 per cent of total healthcare expenditures.
"NON-ADHERENCE CONTRIBUTES TO $290BN EACH YEAR IN AVOIDABLE MEDICAL SPENDING"
Non-adherence can affect conditions with longer term impact such as diabetes as well as those with immediate complications, including cancer. It’s a tough problem that apparently resists many attempts to solve it. Human behaviour is driven by deep-rooted and often poorly understood motives. Perhaps it is no wonder that a review of over 30 studies tracking patient adherence interventions over 30 years found that half of adherence interventions failed, and that non-adherence rates have remained nearly unchanged for decades.
The problem is endemic and affects not just the ongoing adherence to prescribed treatments, but also the initial filling of prescriptions. Thirty-three per cent of patients fail to even fill a first-time prescription, a problem with potentially lethal consequences: a total of 125,000 people die each year in the US alone thanks to non-adherence.
Defining the cause
Recommendations for patient adherence transformation include understanding patient leakages and their root causes. There are a few broad areas contributing to non-adherence. Some appear to be behavioural (such as forgetfulness), while others stem from material decisions such as the cost of the drug, or fear about its side effects.
CapGemini identifies six broad factors impacting patient adherence:
Patient-related: These include adequate knowledge of disease and treatment, a misunderstanding of treatment instructions, and forgetfulness.
Healthcare system-and provider-related: These include inadequate reimbursements, poor distribution systems, and inadequacies among providers who are unable to educate staff effectively. Also, poor relationships between patients and providers are to blame here.
Therapy-related: Sometimes the therapy itself can be flawed, and areas such as treatment generation, complexity of medical regimen, and frequent changes in treatment can cause problems with adherence.
Condition/disease-related: Symptom severity and progression rate can impact adherence levels. For example, some patients stop taking treatment during asymptomatic conditions. This can reduce patient adherence from 80 - 100 per cent to 20 - 40 per cent.6
Cost-related: Sometimes, patients are simply too worried about the cost of the drug, and maybe unable to pay.
Social-economic related: Patient demographics can have a bearing on adherence levels. These include age, race, gender, and income status. Such demographics can correlate with other influencing factors, such as the availability of an effective social support network.
These factors all influence non-adherence to varying degrees. A survey of 10,000 patients by Harris Interactive and the Boston Consulting Group revealed that a tiny percentage of non-adherence cases were due to patients not knowing how to use the drug, compared to another 10 per cent who were unable to get the prescription filled, picked up or delivered. Fourteen per cent didn’t believe they needed the drug, while 17 per cent thought it cost too much. One in five didn’t want side effects and 24 per cent simply forgot to use the drug or refill a prescription.
"24 PER CENT SIMPLY FORGOT TO USE THE DRUG OR REFILL A PRESCRIPTION"
Inadequate data flow
One of these causes is inadequate data flow through the system. Adherence initiatives feature two main stakeholders: the patient, and the physician. Each of them communicate through an adherence programme, which is also fed by various other data sources, including electronic medical records, laboratories, claims histories and electronic prescription data.
The NEHI (New England Healthcare Institute) identifies some key areas in which data flow is either weak, or difficult to implement. The communication of patient history from the physician to the adherence programme is a particularly weak area, as is the transmission of data from all third party sources. There are also several key areas in which the flow of data from the patients themselves is challenged. Their preferences and priorities, and their reasons for non-adherence are easily lost in the mix.
This is a crucial point, as monitoring and feedback has been found to be a critical part of improving patient adherence.
These organisations are key players in the patient adherence equation. Pharmaceutical companies rely heavily on the perceived efficacy of their drugs, and non-adherence can be a damaging factor, as it reduces treatment effectiveness. Patient non-adherence results in an average pro-drug loss of 36 per cent in potential sales for pharmaceutical companies.
Pharmaceutical companies are also looking for more accurate clinical trials, and anything that can more thoroughly document the journey that drugs go through from trial to market access is helpful. Pharmaceutical companies provide services around patient adherence, which can be a useful means of retaining patients. These firms spend a significant percentage of their marketing budgets capturing patients, which can leave limited funds for retaining those that they already have.
This may explain why patient adherence teams in pharma companies are boosting budgets for patient adherence in 2012 on digital tools that they hope will increase adherent behaviour . Significantly, budgets for conventional adherence programmes (print, patient access programmes and patient advocacy relations) are static.12
Retail pharmacies lost an estimated $8bn a year from unfilled prescriptions. The drivers for this stakeholder group are clear: persuading patients to fill and refill prescriptions as part of a regular treatment regimen will help to support their businesses.
Payers are constantly driven by cost containment requirements. They are continually driven by outcomes, rather than trial results, as a means of measuring the effectiveness of drugs. Payers will increasingly move towards incentive models, rewarding patient adherence in order to achieve better outcomes from treatment regimes.
Physicians, too, are driven by better outcomes. Primary health care providers want to reduce the number of readmissions, as this will free up objects to better care for other patients. Thus, patient adherence is a crucial success factor for healthcare providers.
Employers are constantly driven by fact to employee health and attendance. They seek lower insurance premiums, and yet 20 - 25 per cent of employers' health care expenses stem directly from patient non-adherence to medication.
Collaboration between stakeholders
How can these stakeholders work together to create better adherence interventions? A CapGemini survey found that 86 per cent of stakeholders predict a more collaborative approach between each other to tackle adherents in the coming years. It also found that pharmaceutical companies will be instrumental in unifying payers, employers, and pharmacies to help this happen.
What can be done to improve patient adherence? Recommendations include maximising patient touchpoints, enrichment of the patient experience, and creating a feedback and continuous improvement loop.
Mobile technology has been shown to be effective in patient adherence interventions. Communications methods such as text messages and phone calls have proven highly effective[Am J Prev Med. 2009]. For example, Dutch researchers found that text messaging and mobile video strategies created a marked rise in patient adherence.
Studies suggest that significant improvements to patient behaviour can be found when using text-message delivered interventions. Significant positive behavioural changes were found in eight studies, while a further five studies demonstrated positive behavioural trends.
Studies show that mobile technology can be instrumental in improving adherence rates. The George Washington University Medical Center collaborated with several players in a Pill Phone Hypertension Medication Adherence Study, in which 50 hypertension patients in Washington DC were given a 3G wireless handset preloaded with an application called the Pill Phone. The app used audiovisual medication dosage reminders for patients, and would track and store their feedback. It also included image displays of prescription pills and access to real-time information about potential drug side effects and interactions, thereby covering at least two different intervention methods: reminders, and education.
The study found that patients have a high level of acceptance and sustained use of the Pill Phone application. Blood pressure was low among patients participating in the trial, and the average rating on the Morisky Style of Medication Adherence (a scaled questionnaire to assess adherence with antihypertensive treatment) improved.
Significantly, however, the use of text messaging technology for patient adherence interventions comes with a caveat: health messages must be personalised, adapted for the individual's own treatment and lifestyle, to be truly effective. All but two studies in a review of multiple text-message based adherence interventions used tailored messages. The two studies that didn't experienced the highest participant attrition.
Patient engagement successes
Further patient engagement using medical technology can also yield positive results. Jennifer Dyer, a physician working with Eproximiti, experienced successes in patient adherence when working with teenaged diabetes sufferers. She developed the “EndoGoddess” smartphone app, which combined different mobile technology uses to help maintain teenaged adherence to diabetes treatment programmes. She combined preprogrammed text messages reminding teenagers to take diabetes treatments, while also including educational videos in the app to help remind patients about key procedures. Patients responded by asking for more reminders and motivation messages to help them stay focused on their fight against diabetes, Dyer said.
Dyer also capitalised on social media, using techniques such as gamification to help leverage mobile technology as a motivational tool for teams. Patients' friends and family were able to sponsor them with iTunes points, rewarding them for adherence to diabetes treatment programmes.
Conclusion: a mixture of approaches
Although adherence rates may not have changed significantly in the past few decades, mobile technologies are relatively new to the scene, and could have a marked effect in the future.
However, barriers to patient adherence programmes identified by survey respondents include a one-size fits all approach, a lack of patient engagement, and siloed programmes. A joined-up approach mixing technology with personalised patient engagement and a socio-economic understanding of the patient is vital to success. Recommendations for patient adherence transformation include ensuring that investments focus on the right patients.
"BARRIERS TO PATIENT ADHERENCE PROGRAMMES IDENTIFIED BY SURVEY RESPONDENTS INCLUDE A ONE-SIZE FITS ALL APPROACH, A LACK OF PATIENT ENGAGEMENT, AND SILOED PROGRAMMES"
It is important to note that simply using technology to remind patients to take their drugs, or using e-prescriptions to better facilitate first-fills, will not alone solve the problem. There are other factors, such as the ease of prescription renewal and the added education and feedback provided by specialist pharmacy providers (SPPs). IMS Specialty Solutions found a marked increase in patient adherence when using SPPs vs retail pharmacies, for example . But feedback and education are also areas where mobile technology can play an important part.
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