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Demystifying compliance

Cutting through the myths of why people do or do not take medications is vital, from both a research and commercial perspective
demystifying

There are many beliefs held and assumptions made about why people do or do not take their medications and cutting through the myths is vital, from both a research and commercial perspective, as understanding the motivations behind patients' actions is one of the most crucial pieces of post-launch intelligence a brand can have

In the past, when the pharmaceutical industry looked at product uptake, the prescribing physician was the focus of attention. Now, with so many changes to, and constraints on, healthcare systems, a more holistic perspective has been adopted. Compliance has emerged as a critical consideration, with many brands losing millions each year owing to lack of filled prescriptions and patient drop-out. Consequently, insight into patient behaviour has become much more important and this trend is set to continue.

Non-compliance means hard-won patients are lost.  According to the Medicines Partnership, the proportion of patients classified as non-compliant at six and 12 months was 61 per cent and 68 per cent, respectively. As this is an ongoing issue that marketers in the industry face year in, year out, this article examines five of the most universal myths and assumptions around compliance.

Myth 1: Compliance is always linked to the severity of the condition, i.e. the more severe a condition, the more likely a patient is to comply.

Despite extensive research, a definitive link between compliance and severity of condition remains elusive. Research has shown that compliance can be a significant issue in a whole variety of therapy areas, including life-threatening conditions such as cancer, transplant rejection, HIV and heart failure. As with much in life, reasons for non-compliance are not straightforward, but are multi-faceted.   

The reality of living with a severe illness, the burden of the regimen, the emotional distress and stigmatisation, among many other factors, can strongly influence compliance, irrespective of disease severity. In situations such as transplant rejection, the side effects of the drugs can lead to patients covertly missing doses. In HIV, despite advances in treatment making it now more an area of chronic disease management, issues such as denial, stigma and many cultural and lifestyle concerns can lead to frequent missed doses.  

So, although disease severity is undoubtedly a motivator towards better adherence to treatment, it is not the only factor.

Myth 2: Compliance always improves with less frequent dosage

As the pharmaceutical industry strives to develop ever more infrequent dosing schedules, there is a tacit belief that it will improve compliance. As many of us have experienced personally, compliance is a lot easier when it is once daily rather than three times daily. There is a considerable volume of evidence demonstrating that reducing daily pill burden can have a significant impact on compliance. However, at what point does prolonging the dosing interval become counterproductive?

Often a daily preparation can be simpler to remember than a bi-weekly one; it fits more naturally into a patient's routine. In addition, people's fears start to increase about having 'foreign chemicals' in their bodies for such a long duration. This can lead to reluctance either to comply or accept the product at all. So, in many cases, reducing dosing frequency can benefit compliance but there appears to be a law of diminishing returns if the interval becomes too infrequent. Indeed, there have been examples where yearly administration was expected to revolutionise the market, but in fact quarterly administration was found to be more suitable for patients in that therapy area.

Drivers of non-compliance

Myth 3: A sensible patient equals a compliant patient

From a recent discussion forum on Insight's market research online community, eVillage, many doctors admit they themselves are not compliant with medication.

Despite this, doctors often make assumptions about patients' compliance based on their perceived class or education level, as has been found with the TriSight approach, where doctors have been overseen observing group discussions with patients. They were surprised when they heard directly about patients' non-compliance. In some cases the reasons for non-compliance were deliberate, but in a number of cases it was accidental, i.e. patients had simply misunderstood the instructions and their understanding had not been checked. 

Evidence shows that doctors are not asking patients routinely how they are getting on with the medications that they are taking in the long term. This is critical in improving compliance rates as it is often the case that patients feel that it is inappropriate, they are embarrassed or they think that the doctor is too busy to raise any issues and simply stop treatment or miss doses instead. Similarly, patients can feel inhibited regarding asking about a medicine's side effects or raising any reservations about them, preferring to keep the sealed pack in a closed drawer never to be opened. 

So, it may be thought that most rational, sensible people take their medication as prescribed, but the reality is that non-compliance is widespread, with even GPs being human and not necessarily following instructions.

Myth 4: Non-compliance can be improved simply by reminding patients to take their medication

There have been numerous compliance programmes adopted over the years that provided a simple reminder service to patients to take their medication. These were particularly popular for chronic preventative conditions where there was little obvious reward for taking the medication (and consequently compliance rates could be particularly poor). While some of these services did show at least some short term gain, many were destined for failure. 

Without really understanding the barriers to non-compliance, it is difficult for marketers to design a programme effectively.  A reminder service is not going to overcome the feeling of ostracism felt by a teenager who wants to fit in but has to do a blood glucose reading when out with friends, nor will it overcome the denial of some patients with high blood glucose levels or high cholesterol. So, while in certain situations and for certain patients a reminder service may be sufficient, it is clear that a one-size-fits-all approach is not going to be the answer given the complexity of the issues affecting compliance.

Myth 5: More information means a more compliant patient

As with the reminder services, the concept of providing information to improve compliance has been highly appealing as a solution for pharmaceutical marketers in the past. Although understanding the condition and treatment is important, provision of information alone does not often provide the solution. There have been studies in chronic conditions, such as asthma, hypercholesterolemia and diabetes, that have seen no change in compliance irrespective of the knowledge levels of the patients (including understanding of the consequences of non-compliance).

Improving compliance often involves complementary use of educative, practical and emotionally and behaviourally supportive interventions rather than just information alone.  There is evidence that, regardless of specific knowledge imparted, self-management programmes which help to raise people's sense of ownership and confidence are more effective in promoting better medicine-taking. 

Bearing all of this in mind, it is clear to see that education of patients and doctors must remain an important part of the marketing strategy. With no easy answer to hand when it comes to compliance, it is vital to understand the products, their side effects and the reasons for non-compliance to motivate behaviour change in both patients and healthcare professionals alike.

Improving compliance rates can be an attractive strategy for a pharmaceutical company, providing a win-win scenario.

In summary, the benefits of improved compliance give businesses four clear advantages:

  • Greater income for the company

  • Increased medication costs offset by lower total healthcare and social costs; people are more healthy

  • Better patient outcomes and experience; good relationships with brand

  • Prescriber satisfaction.

However, as has been shown when exploring some of the myths above, it is important when considering compliance not to make assumptions and jump to conclusions. This can lead to costly interventions that provide little return on investment. It is only by really understanding the issues driving poor compliance that marketers can design the optimal programme that will really work for the brand and its patients.




Jane Shirley

The Author
Jane Shirley
is joint group managing director at Insight Research Group

To comment on this article, email pme@pmlive.com

 

 

 

10th October 2011

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