Google any chronic or serious condition and you’ll find a clinical paper describing how non-adherence to treatment remains a significant problem; from cardiovascular to respiratory, diabetes to osteoporosis, all the major long-term conditions seem to suffer the same fate.
In response, pharmaceutical companies have developed all sorts of approaches designed to alleviate the problem – yet despite the efforts, we still haven’t shifted the needle from the oft-quoted WHO statistic that 50% of medicines aren’t taken as prescribed. And as the number of people with co-morbidities grows in line with an ageing population, the cost of non-adherence is only likely to increase unless we do something about it. But what? It’s the million dollar question.
It’s easy to conclude that the industry doesn’t do enough to tackle the issue. Critics claim that pharma’s approach to adherence is simply an attempt to increase ROI and that the well-peddled notion of patient-centricity is merely a lip-service. That’s unfair. Yet perhaps companies don’t do enough to build adherence into their long-term commercialisation strategies? There’s a huge focus on R&D and getting a drug prescribed – but perhaps too many companies just walk away when the first script is written and don’t pay enough attention to how their drug performs in the real world? That’s harsh, but is it wholly unfair? Who knows. What we do know, however, is that despite an increasingly engaged audience empowered by digital technology, and widespread industry investment in tools to support patients, the incidence of non-adherence remains stuck where it was in the 90s. Things can only get better.
So where do we go from here? There’s growing consensus that the old approaches to non-adherence have failed and that industry needs to rethink its strategies. Here, with the help of some industry thought-leaders with experience and expertise in managing adherence programmes, are three distinct views on how the sector can drive better results.
It’s all about behaviours
Behavioural economics is gaining a lot of traction in the adherence space. But are we getting it right? Natalie Seebeck, senior consultant, Blue Latitude Health, thinks there’s work to be done. “Pharmaceutical companies are perhaps becoming frustrated that their adherence programmes are not delivering the results that they want. However, I’m not sure that, as an industry, we always listen to to the right people or understand the right mechanisms of change to actually help with adherence.
“We need to think of the patient as a person – a person that exists not only in a healthcare system but in a wider societal ecosystem too. There are fundamental reasons why people don’t take their medicines, and it’s rarely as simple as them needing a reminder or being told what to do. You can’t make patients do anything. We have to empower people to become more engaged and help them make their own choices. Patients should be encouraged to come up with their own techniques to manage adherence. For instance, if a person needs to be reminded to do something, don’t give them a reminder system, get them to think of their own mechanism; a post-it note in the bathroom, an alarm clock or their partner. We shouldn’t force solutions on people.”
So where do you start? “Primarily you have to understand your end users,” says Natalie. “It’s about understanding the ‘necessity beliefs’ and ‘concern beliefs’ and making sure that the necessities are higher than the concerns. It’s been shown in multiple trials that those beliefs are predictive of adherence. But we can’t just focus on adherence; the person sits in a whole system of society, so we need to support them from that perspective. We need to understand their lifestyle, their family and how they communicate with their doctors.”
But are we pinning the whole burden of adherence on patients? Commentators argue that it can sometimes feel like there’s a blame game going on; ‘my patient isn’t adherent so I’m going to develop an adherence programme to fix them’. That’s the wrong approach.
“It’s much wider than that,” says Natalie. “We need to start by understanding patients but then build out to include everyone else that’s involved in supporting that patient, in particular HCPs. Only then can we start to develop the right approach. Too often patient support programmes are developed by agencies that are great at writing content, but are not quite so good at focusing on the right content in the right tone of voice. Health literacy is a massive part of the problem. Data shows that around 50% of UK people have limited health literacy and find the information they’re given too complex. In the US it’s even higher. Research suggests that when you have low literacy and high long-term conditions you’re more likely to be non-adherent. We need to focus on improving health literacy.”
It’s a complex problem and greater investment alone is not the only way forward
Improve HCP engagement
Pharma may also need to work harder to bring HCPs more actively into the adherence discussion.
Chris Edmonds, managing director, emotive, thinks this is essential if we’re to shift the needle of non-adherence. “Although a lot of good work is being done by all of us in understanding the individual, building programmes that fit better into their lives and nudge them towards greater adherence, nothing yet is making a real dent in the problem of low adherence. It’s my belief that the single biggest reason for that is a lack of engagement in adherence by healthcare professionals. Typically, doctors don’t see adherence as their problem; their role, they believe, is to diagnose, treat and monitor patients. More often than not there’s an assumption that patients will simply follow their instructions. The evidence shows they don’t. These are behaviours that, as an industry, we must try harder to change.
“One approach would be for pharma to make adherence more of an integral part of the product they sell. Rather than solely focus on messages around safety and efficacy, and even cost, there’s a strong argument that companies should be clear in emphasizing that the product alone won’t deliver optimal outcomes unless patients adhere to it – and that HCPs’ role in encouraging patients to participate in adherence programmes will be crucial in driving optimal outcomes.”
Pharma is certainly trying hard to address the problem. “There are lots of adherence programmes being developed and substantial investment being made. But it’s a complex problem and greater investment alone is not the only way forward,” says Chris. “Undoubtedly, technology is the future of adherence – there is so much more we can do than is possible with paper-based tools and phone calls. But on its own it’s not enough. What is required is the will of pharma companies to make adherence part of what they sell, rather than its programmes becoming almost an afterthought.”
Engagement with HCPs will therefore need to change. “From the very first point that we explain the benefits of a product to a prescriber, we should also be sharing the importance of the adherence programme and showing how it works. Furthermore, adherence programmes need to be more than simply education – they need to include tools that provide ongoing support for the patient but also capture patient-reported outcomes data that feeds back to the HCP. This becomes a circular loop so that the next time the patient goes to see the doctor, there’s already information that shows the journey the patient has been on, rather than just a discussion about what they’ve suffered in the past few days. This can only improve health outcomes. What’s more, by wrapping the product and the programme together, pharma is providing added value and demonstrating that the solution is more than just the drug.”
There are fundamental reasons people don’t take their medicines, and it’s rarely as simple as needing a reminder or being told what to do
Make medicine fun!
Finally, it may be time for a fundamental rethink around the language of adherence, to drive a more positive experience for patients as they engage with their treatments. Is it time to make medicine fun? Dan Weaden, head of strategy, Havas Lynx, thinks it might be. “One of the most interesting aspects of the adherence challenge is the important distinction between intentional and unintentional non-adherence. Research shows that 70% of non-adherence is actually intentional. That’s a huge number of people who are consciously choosing not to take their medicines – and much of that is due their attitudes, beliefs and relationships with their condition and treatment. Despite this, a lot of the tools and technologies being developed to support adherence focus on the 30% of people who just ‘forget’ to take their meds. There’s so much more to it than that.
“Technology can certainly make a difference. For instance, bioelectronic medicine – an emerging technology – raises the prospect of implants being used to treat chronic conditions without the need for pills or injections. Such innovation may eventually remove the problem of non-adherence altogether, but while we await the revolution, there’s a here-and-now problem that we’re struggling to resolve. And no amount of reminder tools and apps are going to influence those patients who intentionally choose not to take their medicines.”
So what do we do? “We know we need to do more to understand and respond to individual behaviours. But perhaps we also need a fundamental reframing of what adherence means,” says Dan. “So much of the language around it has negative connotations; adherence, concordance, persistence, compliance. We’re basically asking: ‘How do we get people to take our drugs?’ We need to flip the concept and work out how we make our drugs fit patients’ lifestyles. Our challenge is to make medicine fun. It’s an abstract concept, but with intentional non-adherence at 70%, we need make taking medicines less of a negative experience and show the benefits of treatment. Whilst not being flippant about serious conditions, we must understand that more fun equals more patient engagement, relevance and ownership.
“There are great examples of this; the Chemo Hero campaign has used superhero branding to show children the rewards of treatment; Sleepio has introduced cartoons and personalisation to approach CBT; Bayer is using video games to encourage diabetic children to take regular blood tests; Lily is collaborating with Disney to empower families with diabetes. These innovative approaches show how improving the brand experience can make engaging with medicines more interesting – and flip the negative connotations of adherence. The wider challenge is how we can translate those learning so that they can be applied across other areas and patient demographics. If we can do more to make taking medicine a more positive experience, we might finally start to move in the right direction.”