Ten years ago, an NEJM article on medication adherence cited Everitt Koop’s famous observation that “drugs don’t work in patients who don’t take them”. It’s a statement of the obvious, but a decade later the challenge of non-adherence remains significant. Non-adherence costs the EU approximately €125bn and nearly 200,000 lives every year. On a global level, the WHO estimates that up to 50% of patients don’t take their medications as prescribed. Non-adherence is a global epidemic.
Collaborative solutions
The battle to improve adherence is a collective responsibility. Success requires an integrated approach that bridges prescribers, payers, patients and pharma. Moreover, since care pathways facilitate patient engagement with other HCPs and support networks, developing collaborative strategies that exploit interactions across the care continuum is critical. Currently, many measures to combat non-adherence appear disparate and fragmented. Although pharma brand teams are developing tools to support adherence, these are often quick-fix, digital efforts that lack a cohesive, solution-oriented approach in their implementation. Many deliver only marginal gains.
Maintaining legacy approaches to medication adherence will not solve the problem. Pharma has a real opportunity to lead a collaborative effort to not only combat non-adherence, but to also redefine thinking and approach the problem from a different perspective. Identifying and responding to the drivers of non-adherence is a complex exercise, but it begins and ends with the patient.
Fundamentally, adherence is about changing behaviours. As such, progressive pharmaceutical companies are exploring the world of behavioural change and turning to user experience methodologies and behavioural economics to unlock the answers. Undoubtedly, more must be done to identify personal barriers to adherence and develop responsive services that trigger appropriate behaviour change. Ironically, pharmaceutical companies may themselves need to change some behaviours of their own.
Defining issues
The language of adherence has long fluctuated. Terms such as compliance, adherence and persistence are often used interchangeably. In 2010 an EU project around medication adherence established some common definitions. Bernard Vrijens, chief science officer at MWV and a member of one of seven academic groups that contributed to the EU project, explains the outcomes: “Medication adherence is the process by which patients take their medications as prescribed, but there are three elements to it; initiation, implementation and persistence. Primarily patients have to initiate treatment. Data shows that an estimated 25% of newly issued adult prescriptions are not filled. Patients then have to implement the correct dosing regimen. And finally, they need to persist with treatment accordingly. However, evidence shows that up to 50% of patients will discontinue treatment within the first year.
“Most adherence programmes developed by pharma are oriented towards the initiation phase. They’re largely based on education and training. However, we do a very poor job on achieving appropriate implementation and maintaining long-term persistence. This is about building habits into patients – and to do that you need to identify what triggers the intake of medication and understand the patients’ world through suitable measures.”
Changing behaviours
Improving adherence depends on the ability to change complex behaviours. “Behaviours that impact health decisions are determined by a range of factors that vary across individuals. Sustainable behaviour change requires understanding what it is that drives a certain behaviour and then adopting the appropriate technique to help address it,” says Professor John Weinman, professor of psychology at King’s College London and clinical advisor at Atlantis Healthcare. “The most dominant interventions, including many of pharma’s present-day solutions, have been based on two limited approaches; programmes have tended to be one-size-fits-all and reminder-based. The latter assumes the main drivers of non-adherence are people having insufficient information or simply forgetting to take their treatments. This is a huge over-simplification. Research into the determinants of treatment adherence, comprising reviews of literature and studies in this area, has identified three broad groups of behavioural factors – and each provides an umbrella for related sub-groups.
“The first is ‘Capability’, both psychological and physical. What is a patient’s capacity to understand, remember and plan their treatment? Are there physical factors that constrain their ability to administer treatment? A high percentage of interventions have focused on addressing capability factors, but though they are important, they are not the dominant group. Secondly, ‘Opportunity’ factors – chiefly those that exist outside of the individual. Strong support networks from healthcare providers, family and social influencers play a valuable role in driving behaviour change. Finally, there are ‘Motivation’ factors, both conscious and unconscious. Patients have a range of beliefs that determine non-adherence – ie anxieties about their disease, a drug’s side effects, low self-esteem or belief that they are better. These beliefs are powerful. These factors form the well-known COM-B framework of behaviour change, based on an understanding of how Capability, Opportunity and Motivational factors can influence Behaviour. This framework is now being applied to healthcare. Applying COM-B to medication adherence, examines how psychological modelling can be used to support patients in using their treatments as prescribed. To support it, behaviour change experts have identified around 100 psychologically-based techniques for improving health-related behaviour – and they’re increasingly being used today. The challenge is to leverage these techniques to develop adherence interventions that are based on sound understanding and personalised sufficiently to reach out to the largest number of patients.”
Maintaining legacy approaches to medication adherence will not solve the problem
Breaking bad?
Understanding the triggers, habits and beliefs that influence adherence requires a holistic approach. “Our research indicates that adherence can be an issue where patients feel isolated from their healthcare professional,” says Elisa del Galdo, head of customer experience at Blue Latitude Network. “If patients don’t understand their disease, they don’t feel a partner in their treatment. If you give them confidence, they can take more responsibility for their care – but if you don’t, they are more likely to not engage in their treatment and not understand its value. This is classic behaviour change territory. Patients need to understand their condition, and the rational implications of their treatment and with content to support emotional influence. Just telling patients to take medication is not always enough to change established behaviours. The challenge is not to change a bad habit but to replace it with a better one – and that means identifying the right triggers and rewards.
“It’s all about the patient experience – and that means ensuring that patients understand all perspectives; understand from the drug company what the drug does; understand from HCPs how it will be administered and how the healthcare service will support them. To get patient buy-in, we need to connect all the dots and build solutions around a shared understanding of the therapeutic area, the patients, their needs and how the healthcare system can encourage and support behaviour that leads to the best outcomes. The whole ecosystem around health and care needs to work in synchronicity – it’s all very disconnected for patients, and this can have a detrimental impact on adherence. Pharma can help join the dots by providing useful information for patients and services that influence adherence.”
Behavioural economics
Pharma is increasingly focusing on the patient experience. Most current approaches to non-adherence are reactive, but as patient-centricity matures, proactive strategies will emerge. Certainly, companies need to consider adherence far earlier. “If pharma wants to inspire desirable behaviours, it needs to start thinking about those behaviours at all stages along the patient journey,” says Di Adams, partner at Hall and Partners. “For example, even before initiation, your goals might be around disrupting complacency. Later, at initiation, different objectives apply – you may wish to create involvement by making sure patients are asking the right questions and getting the right information for their condition. Further down the line, when they’re on therapy, you might consider different ways of promoting engagement. You have to look at things from a humanistic, social and contextual level and understand that there are lots of factors impacting individuals’ decisions, and they’re constantly evolving. That’s why it’s important to be agile. Your concordance strategy cannot remain the same at every stage of the patient journey. Success depends upon developing behavioural insights and establishing what they mean – so you can identify triggers and build support programmes that help change those behaviours.
“Ultimately, patients are people and don’t always make sensible decisions or act in their own best interests. Decisions are often unconscious or emotional and may be influenced by the behaviours of those around us. It’s no surprise, therefore, that behavioural economics is increasingly recognised as a framework that helps explain why people do what they do – and acts as a conduit to encourage better behaviour in patients taking medicines. Our recent study of patients with type 2 diabetes shows how behavioural economics could be used to trigger positive changes in behaviour. 70% of patients showed improved concordance with their medication as a result of an intervention based on behavioural economic frameworks.”
Measuring adherence
As the industry grapples with new patient-focused initiatives to tackle non-adherence, reliable metrics are essential. “You can’t understand patient adherence nor manage it if you cannot measure it,” says Bernard Vrijens.
Information and insight lies at this heart of the challenge and, with digital innovation, the focus on patient experience and developments in behavioural change techniques, the tools to tackle medication adherence is evolving. But is pharma ready to evolve with it?
“Pharma is good at developing smart innovations that are singularly focused on curing disease, but there are other aspects that support the well-being of patients that companies should be looking at,” says Elisa del Galdo. “The industry should perhaps consider looking at the problem from the outside-in, and work harder to understand the perspectives of all other stakeholders. The only way to understand how you can support patients and HCPs in the long journey from pre-diagnosis through to cure is to be able to see it from their perspective – and use those insights to develop the tools and services to help them.”
The importance of collaboration cannot be underestimated. “Concordance is about understanding patients at an early stage and understanding the myriad of influences at play – both conscious and unconscious, societal, humanistic, emotional and rational. It’s only by understanding these influences that we can leverage them to our advantage,” says Di Adams. “The aim is to help patients take their treatments appropriately. It’s worth remembering that, whatever our approach, behaviour is always at the heart of it.”
It’s time to model behaviour.