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Creative control

Patient empowerment through technology may help concordance

An abstract imagePatients who do not take their medicine as prescribed – whether intentionally or not – lose healthcare systems vast amounts of money. Various estimates are bandied about of the cost of unused tablets languishing in bathroom cabinets and of the financial burden, caused by worsening health and hospitalisations, of patients not taking drugs that could manage their conditions. In reality, it is impossible to measure precisely but it is generally accepted that less than half of all patients take their medicine exactly as prescribed.

Some patients do understand how their medicine should be taken but choose not to do so; because they are unhappy with side effects, do not feel that they are gaining much benefit from their treatment regimen, or have chosen to reject the very concept of conventional medicine. This is of great concern to healthcare professionals and to the pharma industry, but everyone on the prescribing side of the fence needs to appreciate that some patients will choose not to follow medical advice. Austyn Snowden, a lecturer at the School of Health Nursing and Midwifery, University of West of Scotland confirms that "50 per cent of patients do not take medication as prescribed and perhaps this is their right".

The problem with such cases is in establishing that this non-concordance is an informed decision, which is difficult as these are the very patients least likely to be swayed by the medical evidence.

Prioritising patients
One patient group that Snowden agrees is of particular concern is teenagers who start to reject previously adhered to regimens because parental presence, and thereby influence in their day-to-day care, lessens. Young adults spend more time away from the family home and can also be inclined to adolescent rebellion.

"You need to prioritise patients who are at high risk [of non-adherence] and if you find out a method that actually works for people then that is concordance in itself. The best thing to do is to ask them. We don't spend enough time listening."

The internet is very much part of everyday life for this age group and it would be illogical not to have an online resource to support them. The 'Rise and Shine' project is one such concordance initiative for Genotropin, a growth hormone that is to be taken regularly by children through to adulthood. Older patients and parents of younger children  are all likely to be familiar with the online environment.

The challenge here was to ensure that all age groups were catered for. It is technically possible to automatically direct patients to the appropriate elements for them, using information provided when they register but, in this case, the tailoring of information is user-led. Parents and patients guide themselves to the section of the site best suited to them by clicking on the appropriate picture, age and group description. The programme also has magazines that are tailored to different age groups.

One important aspect of the market research carried out for this project was to establish when patients were most likely to stop adhering to their treatment regimen and ensure that they were prompted, to try to keep them on board. For the pharma company, Pfizer, it was essential that this initiative had the support of healthcare professionals and it was careful to involve them in its development.

Pfizer was not able to offer superiority in terms of efficacy or ease of use for Genotropin over five other similar treatments available. However, the Rise and Shine site enabled it to distinguish its product by offering other benefits to both patients and prescribers. Richard Smith, new media director at Huntsworth Health, the agency that worked with Pfizer on this project, says:

"Pfizer was able to differentiate this product by offering better support to the patient and the healthcare professional than any of its competitors. The patient won out by having a better concordance programme and the healthcare professional was therefore more likely to recommend the product because their patients were better supported. In addition, the healthcare professional was also supported with a concordance programme that they had been involved in right from the start. Pfizer was providing them with the tool they wanted."

Adverse events
One area yet to be fully explored in the online environment is the capacity to provide early warning of potentially adverse events to be passed on to the pharma company. This could enable concerns to be addressed in a timely manner and would be in keeping with calls for more transparency. An online reporting tool may sound like a good idea in theory but is problematic in practice.

For Smith it depends on the disease area and the resources available. In general terms he feels that the danger in offering such a service is that patients may post a query about a serious medical problem online, rather than alerting the emergency services that are able to respond much more quickly and safely.

If an appropriate disclaimer is put in place it is possible to enable patients to request a call back from a nurse and this service has been offered on some sites. However, this is resource-heavy and therefore costly.

A broader approach
Text message services have been used in some campaigns but they can be expensive and it may be more useful and cost-effective to use email to remind patients about appointments. There are also options to use RSS feeds and podcasts as reminder services and these channels are likely to be used more frequently as the technology becomes familiar to a broader patient group.

Snowden believes: "Any single intervention may be effective in a certain element of the population, I think there is a place for absolutely everything. It is all down to individual care."

He advocates offering a range of initiatives which can be tailored to the individual and feels that there is place for e-media initiatives within this. However, he believes that face-to-face interaction, even a short meeting, will win out.

One project that was determined not to neglect those patients who may not yet be fully conversant with internet technology was organised by the patient group AntiCoagulation Europe (ACE) and Roche Diagnostics. ACE has an informative website and yet chose to support an educational bus tour across the UK and Ireland to raise awareness of the benefits of self-testing for patients on long-term warfarin. ACE advocates self-testing of blood clotting (international normalised ratio) to enable patients to better manage their condition and to ensure they are getting the correct dose of warfarin.

Eve Knight, chief executive of ACE, explains why: "The reason we decided to take this out into the community was because people view patient self-testing as something quite new, when in fact it has been around for a good number of years. It is perfectly validated and reliable, and used in near-patient testing in hospitals and GP surgeries as well as patient self-testing and management."

"We are aware that a website is a very good way to get information out but that not everybody has access to a computer."

Andy Braddock, marketing manager at Roche Diagnostics said that, ahead of each of the bus' 30 scheduled stops, local media were contacted to publicise the event. Letters were sent out to haematological nurses and doctors, with posters that they could put up in their surgeries. The prominent locations the bus visited also enabled patients to 'drop in' even if they had not been aware of the event in advance.

The bus provided an opportunity to speak to a nurse, a patient representative and a Roche employee. Yet Eve Knight was keen to point out: "We made it very clear that they had to speak to their own clinic, their own doctor."

Face-to-face initiatives, such as this, present an environment in which additional questions or problems – not within the immediate scope of the original project – may be addressed. This can be of great benefit to the patient.

"Whatever the main message you are taking out, you always get a lot of people who have other questions that they don't bring up [with their doctor]," Knight said.

Personal approach
For Snowden it is vital to establish each individual patient's understanding of their medication by, "getting to know each patient and seeing how their medication affects them individually". He feels it is important to remember that over-compliance can be as dangerous as non-adherence:

"Older patients in particular can tend to take everything as prescribed regardless of side effects."

The CoaguNation project prompted a move from compliance to concordance by improving awareness of the opportunity for patients to gain more control over their condition by managing their own testing.

"The main thing is that the [CoaguChek XS] self-testing device is easy to use and has been independently shown to be accurate and reliable. The main barrier to using self testing was found to be that patients had not heard of it. So we wanted to increase awareness," says Knight.

Demonstrating any sort of medical device is bound to be easier to do when the patient is actually in front of you and the bus offered this facility.

Freedom and empowerment
CoaguNation was a face-to-face awareness programme, but the motivation behind it was to allow patients more freedom through the use of technology (a self-testing device). By taking more control over management of their condition, patients were able to reduce the frequency of hospital or clinic attendance.

This idea of freedom through the use of technology is at the heart of the initiatives being worked on by t+ Medical Disease Management Systems. This spin-off from Oxford University has two divisions, one for long-term conditions and one for clinical trials.

The company's "Think Positive" system collects data using a mobile phone, and presents it to the patient and their healthcare professionals in an easy to interpret manner. There is also a nursing support team that observes patient information using a secure website and gives feedback and advice. This can help reduce the complications that can arise from long-term conditions. There are currently four programmes for asthma, blood pressure, COPD and diabetes. Marketing manager Anna Griffiths explains the benefits of a mobile-phone led intiative: "A household may have one computer but everyone [in that household] may have a mobile phone."

"It leads to a lot more freedom, the whole concept is that the patient need not be at home in order to monitor their condition, but because they have the option to fill in their diaries online as well, it gives them the flexibility to do either."

Griffiths recognises that it is not possible to make "one option fit all" but says: "We do have a broad age range, and it depends on the person, one of our oldest users is in their 80s. I think what you find is that, with an older person, if they are given a task they complete it [although] they might not use their phone to take photos or download ringtones.

"It is basically an interactive service, so we have nurses here that monitor the patient. The data comes in and they act upon it, based on agreed protocols. We try to spot trends and make sure that these don't turn into exacerbations."

She was keen to point out that this technology goes beyond the SMS reminder services offered by some other initiatives: "It is not a texting service, it is a disease management system and patients input information about their condition. We look at it, we monitor it and if needs be, we can intervene – in agreement with their GP or nurse who can also view the information. We are not trying to replace anybody. It helps healthcare professionals establish who needs their help and automatically prioritises them."

The company is working with a number of Primary Care Trusts (PCTs) in the UK and has also been chosen as one of the partners involved with the NHS' 'whole system demonstrator'. This initiative looks at the possibilities offered by integrated health and social care supported by technologies such as telehealth and telecare. The company reaches the patient through the PCT and does not approach patients directly. The PCT pays for the system which is free for the patient.

There is a minimum requirement in terms of phone technology – it must have a colour screen and have an internet connection. The system is compatible with more than 100 of the most popular mobile phones in the UK and the company does its best to keep updated with new phones as they enter the market.

"If somebody does not have a compatible phone there is the web option and they can also buy phones from us at cost," says Griffiths.

At the moment the company has no real involvement with pharma, however, as it now also offers data collection through mobile phones for use in clinical trials, it is likely that links will be made. The technology could prove a useful tool for the pharmaceutical industry as the system could be used to feedback patient education needs to companies and thereby improve concordance.

Across Europe
Online patient concordance projects have been rolled out across Europe, although often these were initiated in the UK or US and adapted to the major EU markets. Internet access and mobile phone coverage is improving across the continent and the age range of patients likely to use this technology is broadening. Concordance initiatives that make use of new media and can be used to meet the needs of individual patients more closely, wherever they are in Europe, will become an essential element within marketing.

Meredith Abreu Ressi, vice president of research at Manhattan Research believes: "European consumers of all ages are already actively engaged in managing their health online. Condition information, lifestyle management, and information regarding prescription drugs are all hot topics... making this market an excellent candidate for online patient education and [concordance] programmes.

"In the absence of direct-to-consumer advertising, these programmes are a great way for companies to interact and engage with their patient base... to provide truly customised one-to-one interactions with patients."

Snowden feels that it remains the job of the prescriber to establish the information an individual patient needs to know and to make sure this is presented in the most appropriate way for them.

"True concordance is impossible, as long as one person is prescribing and another person is taking the medication, it is an unequal relationship," he admits.

There are areas, such as mental health, where any level of concordance is extremely difficult. However, this is not to say it should not be something to aim for. As Snowden points out there are also patients who are: "clearly competent and want to know every in and out of their medication, they are likely to find out their own information and make their own minds up".

The chances of achieving concordance between prescriber and patient can only be improved by the increase in tools and methods available to aid communication and interaction. However, such initiatives must always be shaped to fit the patient, not the other way round.

The Author
Kerry Holmes is editor of Pharmaceutical Marketing Europe at PMGroup

1st December 2008


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