Reaching beyond adherence

The language surrounding adherence is a prime example of the issue's importance, but also its potential for causing confusion.

It is true that pharma companies often talk about 'adherence', but they largely report the easier to measure 'persistence'. Healthcare institutions, meanwhile, commonly refer to 'compliance', 'concordance' or 'shared decision-making' - and in the latter's case improved adherence is but one of its intended results.

The multiple definitions also bring with them the risk of misaligned objectives and, consequently, outcomes. The picture is further clouded at a global level by the different rates at which countries move from a traditional directive, paternalistic approach to healthcare delivery to one based more on partnership between patients and their healthcare professionals.

Conscious and unconscious patient behaviour
Adherence itself normally relates to prescribed medication, and measures how closely patients follow their prescribed duration of dosing (persistence), as well as the dose's required frequency and timing.

An individual's non-adherent behaviour can be either conscious or unconscious. Unconscious non-adherence, forgetting to take a medication for example, can be addressed by relatively simple interventions like text reminders. In contrast, at a conscious level non-adherent behaviour is driven by an individual's deep-seated psychological beliefs about his illness and/or its management.

To address individuals' beliefs, and therefore challenge their conscious non-adherent behaviour, more complex and personalised interventions may need to be developed. But achieving this level of personalisation is a challenge that really requires pharmaceutical companies to respond with deeper levels of engagement than they perhaps do at present.

Engaging the influencers
To achieve true patient engagement companies also need to engage those who influence patients. There is, therefore, a need to understand and address not only patients' beliefs and behaviours, but also those of their healthcare professionals (HCPs) and the carers, such as family or friends, who help support them.

But embracing the concept of patient engagement requires  pharmaceutical and healthcare companies to develop new skills and competencies. It is only by doing so that they can address their own internal organisational beliefs and behaviours in order to develop and deliver effective solutions.

Looking at the wider healthcare picture
GPs and specialist physicians traditionally have limited time with the patient, during which their focus is mainly on diagnosis or referral. They therefore have limited opportunities to impart the information and knowledge needed by patients to achieve true concordance. Even those that try to engage patients in a share decision-making approach often have to manage their own beliefs about how this should sit alongside delivering evidence-based medicine.

In contrast, pharmacists and nurses are often able to take a broader viewpoint and can be more receptive when it comes to delivering patient education. Tools and interventions that involve these HCPs are often well received - not only by them, but also by the patients and carers they support.

Ultimately achieving true engagement will only become more important as healthcare systems move away from focusing on acute conditions and step ever-further into an era of chronic condition management. As this shift progresses patients are being asked to take on more responsibility for the self-management of their condition - not least because by doing so they help contain rising healthcare costs.

Achieving patient and HCP engagement in the management of chronic conditions may mean looking at a whole healthcare system redesign, which can seem unachievable at first sight. It certainly is a significant task, but reducing the system to its component parts will help you understand the various touch-points within it, and it is then that solutions can be developed and successfully implemented.

In order to help drive this culture change towards such a patient-centric approach, measuring the changes in beliefs and behaviours that are needed is key. GPs, other HCPs and payers have to be able to see improvements in outcomes from their engagement with, and endorsement of, patient-centred interventions.

Consequently, the pressure is on for pharmaceutical and healthcare companies to demonstrate how changes in investment to focus on new approaches and services can add true value.