Approaches to improving patient adherence: part 2

Dr Andree K Bates


Continued from “Approaches to improving patient adherence: part 1

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. Having looked at approached that don’t work in part one, here I further discuss methods that do work with a focus on the patient and physician perspective.

1. Focus on Patient Perspective

Patient education

The patient should always be at the center of any effort to improve adherence, with education forming the core of any adherence efforts. Education pieces, including direct mail, brochures, advertisements, websites, online communication and contact centers, can provide valuable information to patients on the medication, as well as the disease or condition. Carefully constructed educational efforts aimed at the individual, demonstrating how important the medication is for their health, and answering key questions about efficacy, safety and administration, can go a long way towards improving adherence.

Studies find patient education, one-on-one counseling, group educational counseling or telephone counseling through programs such as “nurse on call” can all increase patient adherence. However, they are most effective if developed to address segment-relevant patient needs rather than taking a generic approach.


“The patient should always be at the center of any effort to improve adherence, with education forming the core of any adherence efforts.”

For instance, in one study in which 276 asthma patients were assigned to an educational intervention, adherence scores jumped 44 percent after one year compared to a control group. In an intervention in patients diagnosed with depression, participants received up to four telephone counseling calls and five educational mailings focused on the importance of medication adherence, barriers to medication adherence, quality of life, symptoms, and satisfaction with the program. The intervention group was significantly more likely to adhere to their medication regimen during acute (89.0 percent vs 67.7 percent, P &lt, .001) and continuation treatment phases (81.1 percent vs 57.6 percent, P &lt, .001) than a control group (Figure 6). They were also significantly more likely to continue their therapy after seven months (77.8 percent vs 49.5 percent, P &lt, .001) and to refill their prescriptions on a timely basis (0 vs 18 days, P &lt, .001).

Direct-to-consumer advertising

DTC advertising acts as a means to educate the patient on the drug and condition as well as troubleshoot, helping to prevent unintentional non-adherence. The advertising can take the form of direct mail, TV ads, radio spots, print ads, web promotions and more. A 1999 survey by Prevention magazine found that one- third of those surveyed were reminded to refill their prescriptions from Direct-To-Consumer advertising (DTC). Those who saw a DTC ad for their medication also were significantly more likely to say they felt more confident about taking their medication.

DTC advertising also acts to encourage patients and increase faith in the drug and the Industry. The survey found that providing risk information in a DTC message could actually increase consumer confidence in the product. Trust was another key component, with respondents saying they were more likely to fill the initial prescription if they trusted the DTC promotion.123

Marketers are responding to this influence of DTC ads by increasing long-term usage messaging as a proportion of total spending. While the majority of ads are focused towards new patient acquisition, companies are increasingly seeing the benefits of using DTC for existing patients over the lifetime of a drug. Specific tactics include continuing to use DTC promotions as patient education regarding the product, and using DTC ads as a stimulus for building relationships with patients.

Patient assistance programs

Given that cost is such a major component in non-adherence (as noted earlier), it stands to reason that patient assistance programs – such as discounted prescription cards – would improve adherence. One of the few published studies focused on improving adherence through patient assistance programs occurred in organ transplant patients. The transplant center created a formalized program within an outpatient pharmacy that included a medication counselor to help patients find assistance for pre- and post-transplant medication. The effort reduced non-adherence rates from 25 percent to 10 percent (P &lt, .01) compared with those transplanted before the program began.

Another study evaluated the effects of an on-site pharmacy in a community health center to improve access to medication for indigent patients, including Pharmaceutical Company programs for low-income patients. In this interaction, the average number of prescriptions filled in the six months after the program was implemented increased from 219/month to 838/month. The program also improved therapeutic outcomes in patients with chronic conditions. Unfortunately, patient assistance programs are under-utilized, according to a 2000 US Government Accounting Office report. This remains an area for companies to explore in improving adherence.


“Unfortunately, patient assistance programs are under-utilized…”


Drug discount loyalty card programs

These programs, in which Pharmaceutical Companies offer discounts on drugs regardless of income, also have the potential to increase adherence with medication and boost brand loyalty. The programs, which are much more widely used than the previously mentioned patient assistance programs, can involve price discounts in the form of debit cards, checks, rebates and pharmacy loyalty cards.

One review of 11 studies found that financial incentives improved medical adherence more than alternatives in 10 of the studies. However, just two of the studies focused on improving medication adherence, one provided rewards to patients who followed therapy,128 the other provided a monetary incentive to encourage medication adherence.129 Neither involved the use of drug discount loyalty card programs, which provide discounts or free prescriptions regardless of whether a patient has taken his/her medication. However, programs that provide information into prescription fulfillment patterns can be used to identify interventions that may prove effective in increasing patient adherence.130

Next-generation loyalty programs are technologically savvy enough to have insight into individual prescription fulfillment behavior. At the time of refill, loyalty programs can adjust discounts based on the patient’s insurance benefit structure in real time. The programs also can provide targeted and timely communications supporting prescription behavior through the phone, web, direct mail and IVR systems. Finally, the programs collect enough prescription data to allow comprehensive analyses of adherence rates and ROI.

Changing Patient Beliefs

As described earlier, patient beliefs are instrumental in predicting adherence. Patient beliefs about their condition, about medication in general and about the specific drug they’ve been prescribed are often strong, but may not be based on accurate information.

The key point to remember – patients’ beliefs can be changed.

Through patient education materials and efforts, mistaken ideas can be corrected and helpful information provided. Going further, behavioral therapy and motivational interviewing, such as asking patients why they think the medicine doesn’t work and then correcting any misconceptions, can improve adherence over the long term. Changing patient beliefs through action is also powerful. In one study, patients who monitored their own blood pressure at home were more adherent with their medication. The researchers contended patients could see the cause-and-effect between the medicine and a typically asymptomatic condition, and came to believe in the need for medication.


“Through patient education materials and efforts, mistaken ideas can be corrected and helpful information provided.”


Involving Family Members

This approach works best for conditions in which the patient may be unable to manage his or her medication, such as psychiatric disorders and dementia. These individuals often rely on family members for support. Thus, enhancing family functioning can enhance a patient’s adherence. In one study of patients with schizophrenia, family members received therapy and instruction on the importance of adherence. After six months, just one-fifth of patients whose families received the therapy were non-adherent, compared to the majority of those who received individual counseling.

The involvement of family is also important for child and adolescent patients. Parental involvement and support significantly increases the potential for adolescents to adhere to their treatment regimen. This is dependent, of course, on parents who understand their children’s conditions and medication needs.

Patient Experience Programs

Patient experience programs build on the notion that individuals have many options when it comes to treating their condition, including seeing a doctor, talking to peers and learning more about specific medication. An effective patient experience program is an all-encompassing outreach strategy and uses a system to manage the entire patient experience. It considers patients as key stakeholders in the Industry and the drug, a group with influence that can drive a product’s success. It’s a two-way dialogue where companies learn the patient’s needs, preferences and values, and patients learn they have a vested interest in working with the company or purchasing their products.

These programs aren’t a singular method but refer instead to a greater system of approaches. When companies discuss patient experience approaches, they usually refer to a package of methods that involve a variety of items described in this chapter, including education, technology and physician interaction. These patient experience programs may lead to bigger efforts at changing mistaken beliefs, involving family, and offering other individual solutions. Patient experience programs offer the potential to improve adherence, and there are many case studies published that attest to the power of these programs when used with appropriate brands. In addition to these benefits, the programs can also provide physicians with specific information on their patients’ views of the medication they are taking and the effects they are experiencing, to provide an opportunity for the clinician to better assess patient adherence and make any necessary changes in the therapeutic relationship and recommendations.

2. Working with Physicians and Medical Staff

Reminder Systems

Certain tools can help physicians and other healthcare providers improve patient adherence. In one study, physicians maintained a flow sheet for each depression patient, including co-morbidities and whether or not they took their medication. Adherence dramatically improved when coupled with patient education and diligent follow-ups. Study authors theorized that using the flow sheet might have increased awareness and physician education about their patients which, in itself, may have led to better adherence.

Pharmacy Interventions

Numerous studies find that counseling and education provided by pharmacists can improve adherence. Pharmacists already receive training in patient education and they also have patient-focused information available in the form of pamphlets and leaflets. One of the most effective forms of pharmacist education appears to be weekly or monthly counseling appointments.136 In one study, pharmacist counseling, monitoring and education provided during each refill resulted in an average adherence rate of 88 percent after 4 months compared to 74 percent in a control group (P &lt, 0.05).


“Poor communication, or a lack of a trusting, open relationship, is a predictor of non-adherence.”


Training Physicians

As noted earlier, patient / physician communication plays a major role in patient adherence. Poor communication, or a lack of a trusting, open relationship, is a predictor of non-adherence. Training physicians involves reminding them about the importance of adherence and nudging them towards a closer relationship with their patients.

Studies show that a strong relationship between patients and physicians improves adherence. Patients who feel their physicians communicate well with them and encourage them to be involved in their own care are more motivated to adhere.138 Patients who have a high level of trust in their physicians, along with a belief that the physician knows the patient as a whole person, are also more likely to adhere to medication regimens, adherence rates among this group are nearly three times higher than patients without this trust. Research has also shown that patients who actively participate in determining their care are more likely to adhere – even to antidepressant medication, the area of highest non-adherence. Finally, a study of epilepsy patients in Norway showed that patients benefit from having regular opportunities to discuss their condition, showing marked improvements in quality of life.139 Overall, a better relationship with better communication means greater patient satisfaction with medical care, which often leads to higher levels of adherence.

Increasing Access Also Increases Adherence

When patients have more opportunities to visit the doctor or office for follow-ups, adherence jumps. However, the accessible person does not necessarily need to be the physician. Patients who can visit or stay in contact with nurses, specialists or pharmacists also increase their adherence.

What should training for physicians and other medical staff entail?

Pharma Companies can improve adherence by offering physicians simple educational pieces and helpful discussion aids. These value-added interventions can serve two purposes: encourage more prescriptions on the part of the physician, and develop fuller adherence with patients. Training can be through a variety of media, and can cover:

• The need for training. Physicians, just like patients, need to understand the importance of adherence. They should be made aware that with small changes in their approach, patient health can improve and organizational outcomes enhanced.

• Methods of listening and eliciting discussions. Physicians should learn methods of promoting open discussion, exploring: patients’ understanding of their conditions, their options for treatment, their beliefs and concerns about the condition and treatment options, the challenges they anticipate in adherence, and practical ways to help them with these difficulties.

Physicians should also be encouraged to adopt non-judgmental attitudes to patients, allowing them to describe their worries, their actual behaviors, and their thoughts and feelings about medication.

• Methods of talking about adherence. Sales representatives can provide simple, easy-to-use tools for physicians to help discuss adherence and improve it amongst their patients. For instance, one four-item questionnaire has proven effective in assessing and predicting adherence in hypertensive patients. The questions:

Do you ever forget to take your medication? Are you careless at times about taking medication? When you feel better, do you sometimes stop taking medication? Sometimes, when you feel worse, do you stop taking your medication?

• Methods of explaining risk. As mentioned previously, physicians may often skate over the topic of risk. However, patients who engage in an informative and helpful discussion about risks are more likely to adhere. Marketers can develop aids to help physicians discuss safety risks for a particular drug.

• Methods of explaining the drug (and evidence for efficacy). Marketers can help improve adherence by training physicians on how to effectively explain the drug and how it works. Training aids can discuss how physicians should:

o Limit instructions to 3/4 major points during each discussion

o Use simple, everyday language, especially when explaining the diagnosis and giving instructions

o Supplement oral teaching with written material

o Involve the patient’s family members and friends

o Reinforce the concepts discussed

Physicians may worry that additional discussions and enhanced relationships may cause a drain on already limited time. While physicians may need to invest more time initially, studies show that physicians who check patient concerns and understanding of medication instructions increased consultation time by an average of only 37 seconds. An increase in skill in asking questions and developing adherence can actually improve time control.

With this overview of successful approaches to increasing patient adherence, we can now turn to effectively creating the optimal program for specific brands.

About the author:

For more information, please contact the author, Dr Andree K Bates, at Eularis,

What physician and patient based approaches do you think can improve patient adherence?