Approaches to improving patient adherence: part 1
Dr Andree K Bates
Adherence is critical to improving patient health and to improving the economic health of the Pharmaceutical Industry. With reasons for non-adherence stretching across the spectrum of players and involving a heady mix of factors, tackling the problem can seem daunting.
Approaches that don’t work
Finding success with patient adherence programs is possible. For many companies, however, improving patient adherence has been a matter of trial and error, and has involved learning from mistakes. Things that most companies and managers agree are not working in adherence programs include:
• One-size-fits-all approaches. Adherence differs from patient to patient, so programs designed to improve adherence must be flexible and customized for a specific brand’s patients.
• Expecting others to do the work. Buy-in by all members of a team is absolutely crucial, as is accepting responsibility for each member’s tasks.
• Nagging direct mail reminders. Too much of a good thing hinders rather than helps. As we will discuss later in this chapter, direct mail can serve as a useful method to encourage adherence, but not when it comes too frequently. Also, impersonal direct mail is a big no-no.
• One-way communication. A two-way dialogue is critical to improve patient adherence, where patients can express their needs and desires along with Pharma Companies.
• Big ideas without execution. A lack of follow-through and smart implementation for patient adherence programs doom them from the start.
• Complex technology. Programs that use technology too complex for team members to understand will only discourage participation and continuation. In addition, if the technology used for patients is too complex, the company will not only lose the chance of improving adherence but probably lose the customers as well.
Approaches that work
What are the approaches that can improve adherence? Common methods that have been found to increase adherence, alone or in combination with other approaches, can be categorized into four areas: changes to the drug, technology, a focus on patient perspective, and a focus on the physician.
“Reducing the cost of drugs, assisting with co-payments and providing discounts or vouchers for drugs can help overcome some cost-related adherence issues.”
1. Changes to Drug
Reducing the cost of drugs, assisting with co-payments and providing discounts or vouchers for drugs can help overcome some cost-related adherence issues. In addition, companies can work with insurers to move their products to lower co-payment levels on formularies, reducing patients’ out-of-pocket costs. Studies also find that if patients talk to their doctors about the cost of medication, they are likely to be switched to lower-cost medication — an important consideration for companies whose brands are cost competitive.
Packaging can also help. Blister packs, like those used for birth control pills, quickly let patients see if they have missed a pill. Inhalers can also show the number of doses taken.Medication “reminder packaging”, which incorporates a date or time for a medication to be taken within the packaging, offers another proven option. An analysis of eight studies with 1,137 participants found such packaging increased the percentage of pills taken by 11 percent.
Pre-packaging dosages of several drugs together or as multi-day courses can also improve adherence, particularly in infectious diseases. A trial of pre-packaging of three-day courses of malaria medication in Ghana found 82 percent of those receiving the intervention were adherent, compared to 60.5 percent in the control group. The intervention group also cut their total cost of treatment and time spent waiting in the clinic by half.105
Most studies investigating the use of pill organizers or calendar packing to improve adherence also included patient education (discussed later in the chapter) as part of the intervention.
“Frequency of dose is an important factor regardless of condition and medication.”
Delivery Options and Dosing Regimens
Approximately 68 percent of medication in the United States is delivered orally. This creates its own adherence issues because of the frequency of administration typically required with oral drugs. Reducing the number of daily doses required increases medication adherence. An evaluation of adherence rates with bisphosphonates for osteoporosis found that patients using weekly dosing persisted with therapy far longer than those receiving daily therapy (69.2 percent vs. 57.6 percent, P ? 0.0001) with higher rates of retention at 12 months (44.2 percent vs 31.7 percent P <, 0.0001). Dosing frequency was the strongest predictor of time to discontinuation (P <, 0.0001).107
Once-monthly dosing results in even higher adherence rates. Frequency of dose is an important factor regardless of condition and medication. In epilepsy, a study using an event monitoring system found adherence rates dropped considerably between those taking medication once daily and four times daily. Patients also consistently note that the possibility of taking a daily medication once a day would probably increase their adherence.
The complexity of dosing regimen is also an important element in adherence. Studies show a significant difference between adherences when patients receive polytherapy (multiple drugs, such as HIV “cocktails”) versus monotherapy (single prescriptions). Adding the extra medication, often with their own individual set of instructions separate from the others, causes both intentional and unintentional non-adherence to spike.
Meanwhile, drugs administered through injections have adherence problems due to the pain associated with injections. Developing new delivery systems may increase adherence. Controlled drug delivery through new advances like transdermal patches is noninvasive, sustain consistent drug levels and eliminate the potential for missed doses.
“Automated telephone patient monitoring and counseling can significantly increase medication adherence.”
Electronic Medical Records (EMR)
The global movement towards EMR provides another opportunity for improving adherence. A good example comes from the United States Veterans’ Health Administration (VA), which has an electronic record system that pulls data from scheduling, laboratory, radiology, consults and clinic notes into a single integrated system.
Among other benefits, the system allows providers to check on the frequency and timing of patient refill requests.
Although the VA is a closed system, i.e. patients are required to fill their prescriptions through system-approved providers, direct observation and content analysis of videotaped interactions between providers and patients showed that the EMR facilitated discussions about medication, including adherence. Such programs could help physicians monitor and address adherence issues with patients.
This instant messaging system, in which short text messages are sent to cell phones, PDAs or computers, is being used for numerous medically related reasons, including improving medication adherence.
Since SMS communications are secure, the technique is appropriate for medical dialogue. One method sends a message from the cap of the pill bottle, when it is opened, the signal goes to a computer system. If a certain amount of time has passed with no signal being sent, a signal is relayed to the patient’s phone, a family member, or the physician.
Studies find such technology can reduce hospitalization in schizophrenia patients by identifying early signs of the prodrome that often precede symptoms and improve attendance rates in outpatient clinics. The aforementioned trial of SMS in HIV patients also found adherence improvement. In another pilot program, a vaccine company losing 85 percent of its patients before the second dose initiated a microsite for physicians to enroll patients in a cellular reminder program, 70 percent of the patients enrolled returned for their second injection.
A study of SMS technology utilized in South Africa among patients suffering from tuberculosis was so successful that the method has been identified by the World Health Organization as a best practice. The TB regimen for these patients involved multiple pills on multiple days for six months. SMS messages were sent to over 300 patients reminding them to take their pills, out of the entire study population, only five people had treatment failure.
Call Center Support
Automated telephone patient monitoring and counseling can significantly increase medication adherence. In one study evaluating its effects on blood pressure control, patients who used a computer-controlled telephone system in addition to receiving the usual medical care over six months improved their medication adherence a mean of 11.7 percent (P = .03) while their mean diastolic blood pressure dropped 5.2 mm Hg compared to 0.8 mm Hg in controls (P = .02). The majority of telephone system users were satisfied with the system and most physicians involved integrated it into their practices.
The system was also cost-effective, especially for non-adherent patient users.
A study testing the use of telephone calls to HIV-positive patients found that, while serial telephone calls (16 calls during 96 weeks) did not improve the virological outcome, they did elicit an improvement in self-reported medication adherence compared to a control group.115 Meanwhile, a pilot study found that using cell phone reminder calls helped HIV-infected adolescents and young adults better adhere to highly active antiretroviral therapy.
IVR (Interactive Voice Response) technology can be incorporated in call center systems. This method includes a series of outbound messages that can alternate and be customized. The menu of options discussing motivation, prescription details and common issues simulate conversation and respond to specific needs. IVR technology can also act as a powerful reminder of the true effects of the medication. In the MERET (Memory Enhanced Retrospective Evaluation of Treatment) study, patients recorded details about their conditions and the effects on functioning in an automated phone interview. With the IVR system, this baseline information was saved along with the patient’s voice, vernacular and affect. After four weeks of treatment, the recording was played back to remind patients of their baseline status. This type of personal and intimate reminder of how far patients have come over a treatment period enhances the potential for continued commitment and treatment adherence.
“…technology can reduce hospitalization in schizophrenia patients by identifying early signs of the prodrome that often precede symptoms and improve attendance rates in outpatient clinics.”
A website dedicated entirely to a brand, and to the patients using that brand, can be a powerful adherence vehicle. Brand websites often include extensive information resources about the condition, the drug, how to take the drug, as well as interactive features like reminders that can aid in adherence. Users of the product who visit brand websites are engaged and involved in their care, choosing to come to the website on their own. In addition, many visitors are new customers who have just recently received their prescriptions, presenting an opportunity to influence them early, and when they are receptive to messaging. Brand websites can help establish relationships with the target audience and create even more opportunities over time to reach the audience with key messages through e-newsletters, updates and more. Websites also offer companies a means to measure performance, analyze and optimize programs. Finally, brand websites are an attractive method to include in adherence programs due to their cost-effectiveness.
Providing reminder systems
Another successful intervention occurs when pharmacists provide patients with reminder aids along with prescriptions. These can include simple tools like medication calendars and organizers, or technologically savvy aids like electronic caps and alarms. Both types of takeaway items remind patients to take and refill their prescriptions.
Part 2 of this article can be viewed here.
About the author:
For more information, please contact the author, Dr Andree K Bates, at Eularis, http://www.eularis.com
What approaches do you think improve patient adherence?