Medicines adherence – the forgotten role of pharma marketing?

Jonny Duder

Atlantis Healthcare

With recent reports showing how costly the issue of medicines non-adherence, or non-compliance is to patients, pharma, and healthcare systems, Atlantis Healthcare thought it was time to speak to a cross-stakeholder panel to find out what the key issues are for patients in managing their treatments and identify some possible solutions.

With the publication of the recent IMS Institute for Healthcare Informatics report entitled ‘Advancing the responsible use of medicines’ stating that annual savings of half a trillion dollars could be made through better use of medicines, the issue of adherence has hit the headlines again.¹ This figure may seem unfeasibly large, but was reinforced by a recent Capgemini / HealthPrize study quoting $564 billion annual losses for pharma.²

However, addressing this complex problem is as an issue as big as the numbers in question and not one that we believe can be solved by any one group in isolation. Instead, directed collaboration across healthcare providers, patients and the industry is needed, based on clear understanding of the underlying issues.

So to find out exactly what these issues, and potential solutions, might be we spoke to a cross section of individuals from all these groups (plus two expert health psychology specialists) to hear their first-hand views (figure 1) with regards to five key questions on adherence.

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Figure 1: Question respondents, identified in this article by their initials.

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How clearly communicated is information around appropriate medicines use?

A common consensus here seems to be that more could be done to raise adherence issues at the point of prescription, with healthcare provider, Community Pharmacist – Graham Phillips (GP) pointing out that “GPs only have 10 minute consultation periods with patients, they have very limited time to tick all the boxes”, whilst also accepting that the circa 7.5% of hospital admissions due to poor-adherence may not even be on the GPs radar due to the primary care / secondary care divide.

However, it seems that explaining about adherence issues is not a trivial issue. Caroline Brocklehurst (CB) points out that, whilst it is generally assumed patients will be adherent, explaining appropriate medicines use at the point of prescription is not the same as pre-empting adherence issues, with Dr Christina Jackson (CJ) explaining that “it’s also important to understand the starting point of the patient and tailor information so that it suits their needs.” Dr Lina Eliasson (LE) goes on to elaborate that this needs to be part of a continual process, clarifying that “the key is not to provide the appropriate information at a single point, at prescription, but to monitor, follow up and address any issues that may affect adherence over time.

From the pharma perspective, Nick Jones (NJ) acknowledges that “responsibility lies equally with the patient, the health care professional and the pharmaceutical company that makes that medicine,” adding that “the industry has a critical role to play in ensuring that both patients and health care professionals have the information they require about the medication.

What are the key triggers for failing to take medicines as prescribed?

This is, of course, the million dollar question in medicines adherence, with no simple answer. The patient view, from CB, is that there are number of different factors at play here, including:

Practical issues: time taken for treatment administration, inconvenience where medicines need to be taken at a particular time or embarrassment from obvious or noisy treatments like nebulisers.

Access / storage issues: Some drugs can be hard to obtain and doctors may be unwilling to prescribe long courses of treatment. In addition, bulky medicines can be difficult to store leading to insufficient stockpiling.

Physical issues: Short and long-term side effects are obvious enemies of adherence, but also physical restrictions around some medicines, such as doxycycline – which requires the patient not to lie down for 30’ after dosing.

Psychological issues: Whilst patients know that medicines are prescribed to help manage their disease, this reminder of the disease itself can cause adherence issues, sometimes associated with the embarrassment of accepting the disease itself.

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“This is, of course, the million dollar question in medicines adherence, with no simple answer.”

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Both the healthcare professionals, Matt Hickey (MH) and GP, reiterated the psychological element and the impact of ‘health beliefs’ on adherence, which influences patients’ ‘intentional’ non-adherence, where they make a conscious decision to not take their medication (“I don’t need or won’t benefit from this drug”). The other category consists of the patients who miss their doses through ‘unintentional’ non-adherence (“I want to, but I can’t take this drug”) – the latter sometimes being as simple as inability to open difficult pill boxes.

Also, as LE explains, patients are rarely completely neither non-compliant nor 100% compliant when it comes to medicines use, using asthma as a good example. “Patients find it necessary to use their quick-relief inhaler if they have an attack, but most asthma patients think it unnecessary to take their long-term asthma control medication, which generally should be taken every day,” she explains, perhaps reflecting on the short-term nature of the human psyche!

As GP summarises, “focussing on the impact of health beliefs in the non-compliance equation is important,” as this is an area where “healthcare professionals can make a difference, by working in partnership with patients and helping them to buy into their treatment plan.

Whose responsibility is it to ensure medicines are taken as directed and why?

The general consensus here is that, ultimately, responsibility rests with the patient but that other groups play a vital role in supporting them, as “practitioners can prescribe, advise and monitor but cannot ‘force’ the patient to adhere,” (MH).

GP goes on to accept that healthcare professionals must shoulder some responsibility, accepting that “both the industry and the professions are doing an appalling job to ensure medicines are taken as prescribed,” before going on to explain that “research shows that in any long term condition compliance is approximately 50% – yet for patients to receive clinical benefit from their treatments they need to be taking the correct dose, in the right way most of the time, a common estimate states for at least 80% of the time. There is much more work that needs to be done in this space.” Furthermore, he asserts that the pharmacist has a key role to play here, as they are generally in more frequent contact (once a month) with the patient, compared with once a year with their GP.

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“…practitioners can prescribe, advise and monitor but cannot ‘force’ the patient to adhere…”

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The health psychology specialists reinforce the importance of a supportive network, with CJ clarifying that “it is the responsibility of healthcare professionals and the healthcare system to ensure that patients’ decisions are based on a true understanding of their illness and the treatment offered. It is also the responsibility of health care professionals to find ways to support patients in challenges they may face in taking their medicines.

How is the issue of non-adherence normally identified and by whom?

Interestingly, CB was the only respondent here to identify the ‘patient’ as the key person to identify non-adherence, but speaking from experience she admits that “I have a very open relationship with my clinical team and so am able to admit where and why I struggle with adherence.” MH explains that one of the following four groups typically picks up on non-adherence:

Practitioners: though patient assessment and re-presentation as symptomatic.

Pharmacists: As above, or simply through failing to collect repeat prescriptions.

Emergency services: Due to an acute episode through non-adherence.

Family members: Who notice worsening symptoms or earlier non-adherence.

A more proactive approach is certainly recommended by the health psychology specialists, with LE proposing that “the first question that should be asked if a patient is not responding to treatment is whether they take their treatment as prescribed.” Furthermore, she explains that “Healthcare professionals are becoming more aware of the problem of non-adherence, however, they are also becoming better at identifying non-adherent patients,” but adds that “nurses and pharmacists are particularly suited at identifying non-adherent patients as they have a different and less paternalistic relationship to the patients.

How can pharma better support patients in addressing adherence issues?

It seems that the industry can help itself, healthcare providers and patients in a number of ways when it comes to adherence, with LE stating that “the issues of adherence should be considered all the way from conception of the drug through formulation and packaging to marketing and distribution,” citing common examples of pills that are simply too large to easily swallow. As CJ elaborates “pharmaceutical companies often focus on the healthcare professional’s perspective, and would do well to gain a deeper understanding of the challenges that patients face from in-depth consultation with patients and patient groups.

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“…both the industry and the NHS need to stop looking at a medicine as just an acquisition cost…”

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This view is reinforced by the healthcare providers, with MH identifying “bi-directional engagement with the patient through proactive, predictive and dynamic patient support,” as key and GP stressing the importance of realising that “when so much is spent on drug development, we need to consider how treatments are actually being used in a real world setting and the health outcomes they are delivering for patients.

Liaising with patients can offer practical solutions, for example CB explains that a quicker (premixed, fewer doses per day), quieter (more portable, subtle drugs and technology) and easier to obtain and store medical interventions as key. In addition, she urges pharma to “look at patients as a whole rather than looking at the one treatment they are involved in” – to properly understand the real-world drug use. Technology could also play a crucial part here, with CB proposing that “adherence which is tracked remotely by pharmaceuticals or clinicians would give both patients and clinicians an accurate overview of adherence.

As there seems to be much that pharma can do, it seems only fair to leave the last word to the industry itself. NJ accepts that “both the industry and the NHS need to stop looking at a medicine as just an acquisition cost and thinking about a medicine as an opportunity to drive great patient outcomes whilst reducing the cost of the rest of the healthcare system.” He also sees partnership as key to the right solutions here, with the industry playing a valuable part due to its “wealth of information and expertise” about its medicines.

Slowly, but surely, progress is being made, with NJ going on to use the OneHeart programme (initiated and funded by AstraZeneca) as one such example. Here, “patients on the programme receive a number of personalised interventions,” including “a series of health magazines with content designed to target their key treatment beliefs that may cause them to miss-take their meds, access to a personalised web experience to guide them through the information most relevant to them, and access to a clinical contact centre if they would like to speak with a nurse.

References

1. Advancing the responsible use of medicines, IMS Institute for Healthcare Informatics, October 2012.

2. Estimated Annual Pharmaceutical Revenue Loss Due to Medication Non-Adherence, Capgemini Consulting / HealthPrize, November 2012.

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About the author:

Atlantis Healthcare employs the latest developments in health psychology and communication technologies to address the issue of medicines non-adherence and improve health outcomes for patients.

With 15 years of experience designing and delivering innovative, award winning support programmes, Atlantis Healthcare have supported over 750,000 patients around the world. They have implemented solutions across 51 different therapeutic areas spanning different cultures and markets and have won 8 global patient communication awards.

Jonny Duder is Director of Global Marketing &amp, Sales at Atlantis Healthcare.

Based in London, Jonny is responsible for the direction and growth of the Atlantis Healthcare businesses globally. Joining Atlantis Healthcare in 2003, Jonny now oversees the marketing and sales functions, with his main focus being intellectual property development and assisting with key projects across the markets in which Atlantis Healthcare operates.

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