PM360 JUNE 2010

ADHERENCE INSIGHTS

WHAT’S NEW AND WHAT WORKS

Barriers to adherence are more likely to correlate with patients’ perceptions, beliefs, and attitudes toward taking their medications rather than their age or income. Understanding each patient’s motivation is critical to marketers for creating effective adherence conversations.

By Brian Bertha

The Artful Science of Medication Adherence
As key stakeholders in improving healthcare outcomes, we are constantly seeking solutions to help patients overcome the challenges associated with medication adherence. Why? In the United States in 2009, nearly four billion new and renewed prescriptions were dispensed at a cost of $349 million. Yet in a National Community Pharmacists Association survey, 3 out of every 4 consumers reported they don’t always take their prescription medications as directed. The need to find the right approach to help people stay on track with their regimens has never been greater.

Traditionally, we’ve explored adherence strategies that take into account a patient’s demographic or ethnic group, since information about adherence trends within these groups can offer some insight into specific barriers and challenges. For example, we know that older adults might struggle with medication adherence because they are more likely to have chronic illnesses that require them to take a number of prescription medicines at once. On the other hand, younger patients might be hesitant to buy their medication because of the out-of-pocket costs.

However, research also shows that non-adherence affects males and females of all ages regardless of education and socioeconomic status. In fact, barriers to adherence are more likely to be correlated with patients’ perceptions, beliefs, and attitudes toward taking their medications rather than their age or income.

It’s therefore important that we look at patients as individuals—not just members of a particular demographic—when developing adherence strategies and solutions. Understand-ing each patient’s behaviors, attitudes, and beliefs is critical to creating effective conversations for marketers as well as clinicians. According to the New England Healthcare Institute, the odds that an adherence strategy will be successful are related to how well the strategy can identify the varying needs of individual patients and then match services accordingly.

At McKesson, we have created a multi-pronged approach that draws on both the scientific research available on patient adherence and one-on-one interactions between patients and healthcare providers. We believe that frequent, personalized interactions with patients create opportunities to reinforce messages about adherence and allow patients to take an active role in managing their own healthcare.

In essence, successful solutions combine an individual, personalized approach, while maximizing the most appropriate technologies and other data-based, scientific approaches available. This mixture of art and science allows us to maximize the impact of our solutions and ultimately improve adherence.

Tie in New Technologies
Thanks to interactive technologies, program sponsors now have many more ways to reach out to patients on an individual basis—for instance, via mobile phone text messages or automated voice technology. According to a recent study from PricewaterhouseCoopers Health Research Institute, consumers are open to alternate ways of accessing healthcare: About 50% of respondents said they would be willing to use telephone consultations or computer and Internet technology to access healthcare information, and more than 20% of respondents said they’d be willing to access care through their mobile devices.

Such communications could take many forms. Mobile phone messaging can offer reminders of when to take medication, such as a picture of the pill, to help patients who take multiple medications stay on schedule. Mobile phone messaging can also remind patients about medical appointments, helping to create a mobile messaging based support group that can send patients positive feedback and motivational messages from pharmacists and other members of their healthcare team.

We’ve leveraged mobile messaging, live phone calls from our trained call center representatives, and print-based communications to impact adherence. Using an automated IVR (interactive voice response) system, we’ve also taken our approach to adherence one step further through our Unclaimed Prescription Program. This platform recognizes patients who haven’t picked up their prescriptions at the pharmacy, triggers an outbound call that uncovers patients’ barriers, and provides a tailored message to help them overcome those barriers.

When creating solutions, it’s important to understand which technology might be most effective for the targeted patient groups. For instance, according to the journal Pediatrics, researchers at Mount Sinai Hospital in New York conducted a study showing that text messaging could significantly improve the rate of adherence among young liver transplant patients. However, in the same article, researchers reported that nearly a third of patients had to drop out of the study because they either lost their phone privileges or could no longer afford a cellphone. Understanding these nuances helps us to maximize the effectiveness of our solutions.

Consider Differences
Research suggests that patients not only vary in their health literacy and understanding of their disease but also their willingness and ability to adhere. This variability includes patients’ proclivity to persist in adherence over time. However, these issues can be mitigated somewhat by providing more one-on-one time with healthcare providers such as pharmacists.

Pharmacists can be trusted patient counselors and serve as an extension of current adherence programs where static technologies leave off. For instance, pharmacists can use identified patient insights to create an interactive, personal conversation that leads to increased understanding of their disease(s), the role and function of their medication(s), and the importance of adherence.

Recognize the Value of MI
Recently, compelling adherence insight has been derived from the pharmacy sector, where motivational interviewing (MI) has been successfully applied to impact adherence. Experts describe MI as directive, patient-centered counseling designed to motivate patients for change by helping them recognize and resolve the discrepancies among their behavior, personal goals, and values.

We use MI in our Pharmacy Intervention Program (PIP) to teach pharmacists about the benefits of artful intervention. Pharmacists are trained to deliver impactful five-minute counseling sessions with patients and adopt an empathetic approach during these interventions. For instance, they learn ways to be nonjudgmental and non-confrontational as well as how to use open questioning, which puts patients in the “driver’s seat.” The pharmacists are trained to listen for key words and phrases that signal that patients are accepting the adherence messages and then to help patients build a plan of action (for instance, quitting smoking).

Our data shows that PIP has improved adherence for our customers’ target patients. For example, pharmacies that counseled patients for a chronic obstructive pulmonary disease (COPD) therapy saw an average increase in refill rates of more than 44% through the 10th fill. And pharmacists who counseled patients for a 90-day smoking cessation therapy saw a nearly 30% increase in refill rates. Because of its success, this program is expanding to include other medications.

A Holistic Approach
Pharmaceutical companies are faced with a revenue growth rate that has dropped from 9.9% in 1997 to 1.3% in 2008. To address this drop in revenue, manufacturers need to shift toward a more holistic patient-centered approach that keeps patients more closely tethered to their brands, improves adherence, reduces “back end” medical costs, and improves patients’ quality of life.

Technologies, data, and people need to be leveraged throughout the continuum of care so the best mix of adherence “art and science” is truly achieved. By supporting medication adherence innovations, pharmaceutical companies will positively affect patient outcomes, rebuild trust among consumers, and be seen as strong partners in delivering effective healthcare.

REFERENCES

1. Wolters Kluwer Pharma Solutions, Source Pharmaceutical Audit Suite, National Trends Integrated, January–December 2009.
2. Take As Directed: A Prescription Not Followed. (2006, December 15). National Community Pharmacists Association. www.ncpanet.org/media/releases/2006/take_as_directed.php
3. Thinking Outside the Pillbox. (2009, August). New England Healthcare Institute. 1-18. 4. Jammed access: Widening the front door to healthcare. (2009, July). Pricewaterhouse- Coopers Health Research Institute. www.pwchealth.com/cgi-local/hregister.cgi?link=reg/ Jammed_access_ Widening_the_front_door_to_healthcare.pdf
4. Miloh, T., Annunziato, R., Arnon, R., Warshaw, J., Parkar, S., Suchy, F.J., Iyer, K & Kerkar, N. (2009, November). Improved Adherence and Outcomes for Pediatric Liver Transplant Recipients by Using Text Messaging. Pediatrics. 844-50.

Brian Bertha is SVP of McKesson Patient Relationship Solutions, McKesson U.S. Pharmaceutical. He is responsible for strategy, product development, and customer programs for manufacturers and payers to help patients achieve better outcomes.