Is mHealth the answer to solving poor patient adherence?

One of the pharma industry's biggest challenges is patient adherence. But does the rise in mobile health apps mean this problem will be solved?

Waiting for an organ transplant is a wrenching, tumultuous experience. The waiting list is long and unsure, the consequences of not receiving a donor organ are often fatal, the prospect of the operation itself is daunting. Lucky are those who come through this ordeal successfully.

And yet, roughly one out of four who do come through do not take their immunosuppressive drugs correctly, making non-adherence one of the principle causes of transplant rejection.

If this is the case with transplant, imagine adherence rates for medications treating depression, high blood pressure, COPD, or for non-insulin anti-diabetics. Patients on these therapies tend to average adherence rates around 50%. Even oral oncology treatments typically inspire only 60% adherence.

The pharmaceutical industry has long dabbled in patient adherence programs, with varying degrees of success, but it still invests infinitely less attention and resources to this issue than it does to trying to increase share of prescription. This is strange: if each prescription is really only generating half of the revenues it could, why does the industry still spend thirty times more fighting for market share? One of the reasons is that most pharma companies aren't exactly sure how to affect adherence, and are hesitant to be involved with anything that concerns direct patient contact, particularly outside of the United States.

The programs that do exist typically involve direct contact between healthcare professionals, usually nurses, and the patients. The nurses inform patients about the treatment and answer questions. These programs are useful and many have been shown to have a positive effect on adherence. They also prove that it is possible and mutually beneficial for pharma to be involved in programs that support patients. Unfortunately, these types of programs are relatively expensive and remain rare in Europe.

Why, though, restrict patient support to telephone calls with healthcare professionals and face–to-face contact when society as a whole is communicating by other means? The mobile revolution has come to healthcare and many mobile health platforms and applications have been developed: the impact of mobile health can be considerable, this approach offers a low-cost, modern channel by which to encourage adherence.

"Oh, right, you want to send text messages reminding patients to take their drugs..." Well, yes and no. Around 60% to 70% of non-adherence is actually voluntary, in other words, people decide not to take their drugs properly. Reminders can help, but nowhere near as much as a real, ongoing communication link. For a program to work to the fullest, it needs to incorporate algorithms that customize and vary messages. In the end, a simple message may be sent, but deciding which message, containing which information to send to each person is no simple matter.

Mobile adherence programs can work. Pr. Jacques Quilici and colleagues at the Timone hospital in France tested an automated SMS reminder system last year for patients who had received stents and found significant clinical benefit. According to Dr. Quilici: "While healthcare providers play a pivotal role in maximizing patient adherence, individually tailored, computer generated reminders can produce positive effects on patient's behavior. Such interventions are inexpensive, widely available, and offer the potential to both improve clinical care and impact health outcomes." Many such programs have been undertaken, many have been studied, and the results are impressive. When properly designed, their impact can be substantial, both in terms of adherence rates and clinical endpoints.

This makes sense. Our phones are no longer phones, they are personal assistants, we count on them to remind us of just about everything, and we use them to get information from the internet. For that matter, we will increasingly be using them to do much more...

In fact, we've reached the era of m-health. Before, we had e-health (and before that, simply health, I suppose) but now health has gone mobile. At one extreme, we have simple adherence programs that don't even require an app and can be used even with dumb phones (excuse the neologism, but I have to assume that if we have smart phones we also have dumb ones). Companies are using sophisticated messaging algorithms to provide a very simple service that has measurable impact without installing anything on the phone. On the other extreme, there are companies that are starting to push the envelope on smart phone potential, such as AliveCor, which markets a device that looks a lot like a simple phone cover but that actually turns the smart phone into an ECG, carried out by simply holding the phone with both hands. I've also seen researchers who are working on how to use the phones' various sensors to monitor mobility passively for patients with cognitive difficulties.

What does all this have to do with pharma? That's up to the pharmaceutical industry. Pharma companies could just sit on the side and watch, or they could get actively involved. Since adherence rates are in many ways just as crucial to pharma's results as are prescription rates, it would seem strange, if not irresponsible, if this were the attitude taken. Increasing adherence increases value to the patient and it also increases the value of the patient, and these days, adherence, as well as diagnosis and maintenance, is increasingly being affected through mobile devices.

About the author:

Kevin Dolgin is a consultant, entrepreneur and Associate Professor of marketing at the University of Paris. He has worked with more than twenty-five pharmaceutical companies in more than thirty countries and has published numerous articles on pharmaceutical sales and marketing in Europe, North America and Asia. He was one of the two founders of Areks and is currently the president of Observia, a French company providing patient compliance services in France. He can be reached at consulting@kevindolgin.com.

Can mHealth solve poor patient adherence?