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Dissecting adherence to personalise patient support

Across the healthcare and pharmaceutical industries, the initiatives to better understand the patient journey and lower healthcare costs have been growing in magnitude. One solution that has repeatedly been raised is improving medical adherence among patients.

For the past fifty years, researchers have investigated adherence, but to this day, non-adherence continues to be a debilitating and persistent barrier for many patient populations. There is still huge room for improvement in the cost-efficiency and clinical effectiveness of adherence interventions, which highlights the need to intensify the industry’s focus on adherence.   

Understanding non-adherence
 
The World Health Organization defines adherence as, “the extent to which a person’s behaviour – taking medication, following a diet, or making healthy lifestyle changes – corresponds with agreed-upon recommendations from a healthcare provider.” It is a multiplicity of internal and external factors, and there is so much more to it than pharma might realise. Patients are influenced and motivated by various beliefs, thoughts, feelings, and processes.   

Non-adherence is thus a patient’s inability to stick to the recommended or prescribed treatment program. It is commonly attributed to the irrational nature of human behaviour wherein adequate, clear and highly informative instructions provided by healthcare professionals cannot accurately predict whether patients will comply.   

To improve health outcomes and deliver better patient services, pharma companies really need to dissect adherence (and non-adherence) in greater detail. This is particularly important for patients with chronic conditions, who need to be on a prescribed regimen over a prolonged basis, often a lifetime.

Two types of non-adherence 
There are actually two types of non-adherence: intentional and non-intentional. Pharma must have the ability to distinguish between these two, since they each have associated health risks and costs.  

Intentional non-adherence is when patients deliberately ignore, miss or alter doses to suit personal needs. This is often associated with the patient’s level of motivation. On the other hand, unintentional non-adherence is when, due to a lack of resources or capacity, the patient forgets to take medication. Basically, intentional non-adherence is influenced more by how the patient balances between the necessity for and concerns about taking medication. Unintentional non-adherence is more associated with patient demographic, rather than the balance of decisions.  An example of unintentional non-adherence is forgetting to take medication due to age-related cognitive decline.   

However, these two types of non-adherence are not mutually exclusive. For example, in a study comprising glaucoma patients using eye drops, both types of non-adherers reported lower perceptions in the necessity to use eye drops than adherers. Between the two types, unintentional non-adherence was associated with lower beliefs in the necessity to use eye drops, while intentional non-adherence was associated with higher concerns about using the drops.

The dynamic between the two types of non-adherence can also vary across therapeutic areas. In another study comparing adherence and non-adherence to a new chronic pain medicine, intentional non-adherers had lower beliefs in the need to use the medication while unintentional non-adherers were not significantly different from adherers. This implies that when chronic pain patients are introduced to a new treatment, intentional non-adherers must be treated differently from unintentional non-adherers and adherers.

Tailoring the approach to each distinct type 
Distinguishing between the two types of non-adherence can better inform patient compliance efforts and clinical practice. Intentional and unintentional non-adherers need to be treated separately. Additionally, companies and healthcare professionals need to know patients at the level of their beliefs, fears, priorities, motivations and other idiosyncrasies.  

Some unintentional non-adherers miss their doses due to a busy lifestyle, treatment complexity, lack of information, or lack of insurance coverage. Intentional non-adherers may choose not to follow their treatment plan to avoid some unpleasant side-effects or social stigma linked to the medication. Ultimately, one size does not fit all. Each patient will require an intervention strategy tailored to his or her unique beliefs and attitudes.   

For non-intentional adherers, habits must be built, designs of adherence efforts simplified to require less proactivity on the part of patient, and positive reinforcement from care providers and family members increased.   For intentional non-adherers, knowledge must be increased and the communication link with their physicians deepened. Patients will discontinue treatments, which they don’t fully understand or accept. In such cases, the necessity to take medication must override any concerns about taking it.

According to the IMS Institute for Healthcare Informatics, activating patients can solve non-adherence. Activation refers to how well a patient understands their role in the care process and willingness to manage their health. Again, IMS suggests a tailored and individualistic approach towards improving adherence. Given the industry’s capability to leverage data and technology and deliver more targeted patient services, pharma is in the best position to better understand and address adherence issues. 

In the US alone, non-adherence is estimated to cost healthcare as much as $290 billion per year. Adherence is a core component of a healthy, balanced and prolonged life for patients, and contributes towards a sustainable business for pharma companies and payers. Therefore, non-adherent behaviours among patients need to be categorised and addressed effectively, rather than approached with a uniform intervention that is designed with insufficient understanding about the deep beliefs and motivations of patients. 

References:
  1. EuroMed Info (2016). Causes for Non-adherence. Retrieved from http://www.euromedinfo.eu/causes-of-non-adherence.html/
  2. Molloy, G, et al. (2014). Intentional and unintentional non-adherence to medications following an acute coronary syndrome: a longitudinal study. J Psychosom Res. 2014 May; 76(5): 430–432. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4005033/
  3. Wroe, A. (2002). Intentional and unintentional nonadherence: a study of decision making, J Behav Med.2002 Aug;25(4):355-72. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12136497
  4. Reese, G. Leong, O., Crownston, J., and Lamoureux, E. (2010). Intentional and unintentional nonadherence to ocular hypotensive treatment in patients with glaucoma, 2010 may;117(5):903-8. Doi: 10.1016/j.ophtha.2009.10.038. Epub 2010 feb 13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20153902
  5. Clifford, S., Barber, N. and Horne, R. (2008). Understanding different beliefs held by adherers, unintentional non-adherers, and intentional non-adherers: application of the necessity-concerns framework. J Psychosom Res.2008 Jan;64(1):41-6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18157998
  6. IMS Institute for Healthcare Informatics (2016). Improving Type 2 Diabetes Therapy Adherence and Persistence in the United Kingdom
  7. Philipson, T. (2015). Non-Adherence in Health Care: Are Patients Or Policy Makers Ill-Informed? Retrieved from http://www.forbes.com/sites/tomasphilipson/2015/05/08/non-adherence-in-health-care-are-patients-or-policy-makers-ill-informed/#48caaf977a32
This blog was initially published on: http://www.wearecouch.com/blog/adherence-patient-support


15th April 2017

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