Examining the Impact of COVID on Adherence and the Path Forward

One of the major concerns during the early days of the pandemic was how it would impact patients’ ability to access their medications, and hence comply with their prescribed therapy. Now that we are more than a year removed from the start of the pandemic, we can actually look at whether these fears came to fruition.

In one study published by PLOS One in April 2021, researchers examined data from Symphony Health to see whether patients had sufficient Days of Supply (DOS) of their medication dispensed to cover a given month for six different drugs: buprenorphine/naloxone (oral film and tablets for addiction), tacrolimus (immunosuppressant), norgestrel-ethinyl estradiol (hormonal contraceptive), dexmethylphenidate HCL (stimulant for ADHD), escitalopram oxalate (SSRI for depression), and haloperidol (antipsychotic).

Overall, they found 543.7 million prescription drug claims were approved in March 2020, more than in any previous month, as patients likely stocked up early. But there was a steep decline in subsequent months, with August 2020 showing a 12.05% drop in DOS compared with August 2019. However, while discontinuation increased for norgestrel-ethinyl estradiol (0.62%), dexmethylphenidate HCL (2.84%), escitalopram oxalate (0.57%), and haloperidol (1.49%), it actually decreased for tacrolimus (0.15%) and buprenorphine/naloxone (0.59%). The researchers hypothesized this difference could be because both of those drugs tend to have more physician oversight.

But one thing the drug classes had in common—with haloperidol being the lone exception—new patients taking the medication decreased each month on average once COVID began as compared to pre-COVID: dexmethylphenidate HCL dropped 45.8%, escitalopram oxalate (17.6%), buprenorphine/naloxone therapy (18.8%), and norgestrel-ethinyl estradiol (21.4%). Besides the decline in new patients and increasing discontinuation rates, the researchers also found that many existing patients filled their prescriptions for chronic medications during the early months of the pandemic.

In his own observations, Stephen Jones, Senior Director of Advanced Analytics, RxAnte, noticed at the population level that adherence to chronic medications for diseases such as type 2 diabetes, hypertension, and hypercholesterolemia did not appear to have been significantly impacted, positively or negatively, in 2020 compared to prior years.

“Many forces are at play which could influence this near net zero effect, now and into the foreseeable future,” Jones explains. “Many pharmacies quickly pivoted to mail-order and other forms of direct delivery to service customers. Psychologically, people may have been more concerned about their health and thus taken more safeguards to prevent non-compliance. Also, medication adherence improvement programs rely very heavily on member engagement. It is possible that with more people staying at home post-pandemic, outreach engagement rates may increase simply because members are more available to talk with adherence counselors and/or receive automated refill reminders.”

Determining Areas in Need of Addressing

Even if COVID had a “near net zero” effect on adherence to chronic medications, the pandemic did highlight pre-existing health disparities: people at a greater risk of severe illness and hospitalization from COVID-19 include older people, people from racial and ethnic minority groups, people with a disability, and those on low incomes or living in deprived areas. As Vanessa Cooper, PhD, CPsychol, Principal, Sprout Health Solutions, explains, people in these groups may be most in need of adherence programs.

“Digital solutions could help to reduce health inequalities by increasing the reach of adherence support and providing a means of tailoring content to the needs of individuals,” Dr. Cooper says. “However, poorly designed digital adherence solutions could have the unintended consequence of increasing health inequalities through further exclusion of those who could benefit most. The meaningful involvement of members of the target population in the development of adherence solutions through a co-design process can increase their relevance, usability, and acceptability, and facilitate their adoption and sustained engagement.”

Iyiola Obayomi, Practice Lead, Marketing Analytics, Ogilvy Health, says that when designing adherence solutions, brands need to also conduct research that covers both adherent and non-adherent patients, caregivers, physicians, and social workers to best determine the reasons behind nonadherence, which can be multi-faceted and vary by treatment. For example, reasons can include drug-specific factors (e.g., side effects, treatment regimen burden); individual personalities; or social determinant of health (SDOH) factors (e.g., lack of affordability, low levels of treatment understanding, and racial inequality).

“Brands can analyze Electronic Health Records (EHR) data sets because most EHR systems include fields for capturing and updating these SDOH data sets,” Obayomi adds. “The outcomes of these empirical data can be validated further with research and interviews and help gain insights to aid in the design of both broad and targeted solutions. They can also be used when designing experiments for appropriate educational programs, patient support, and access tools.  Once companies identify these drivers, personalized non-discriminatory decision rules are now implementable in EHR systems as medication algorithms to help prescribers as they determine the right drugs or patient support based on the patient profiles.”

The one issue with that, according to Obayomi, is that SDOH data fields are often not filled out in EHR systems—sometimes at rates lower than 10%. But the hope is that the continued shift to value-based care will motivate more HCPs to fill those SDOH fields.

How to Help Patients Right Now

In the meantime, to deal with the long list of potential SDOH factors impacting adherence, Shelby Foote, PhD, Head of Behavioral Science, Quio, suggests companies focus on ways to maintain constants, stability, and structures for their patients. To start, companies should consider two things: Can we quickly identify vulnerable patient populations? Do we have a communication method to assess their clinical and environmental situation?

“Once we do this, we can start working to reestablish constants such as leveraging telemedicine to maintain appointments and creating human touch points for monitoring questions and concerns,” Dr. Foote says. “We can reestablish stability by providing education, coping mechanisms, and community resources; and we can reestablish structure by providing up-to-date information on where and how patients can get their meds refilled or how they can speak with their care team to help get back into a routine with their medications.”

Lynn Nezin, PhD, SVP, Brand Strategy, Calcium, who points out that script abandonment can reach as high as 140 million prescriptions per year, says that encouraging adherence ideally begins before issuing the prescription.

“Effective adherence to drug regimens requires a restructuring of the clinical interaction to create an atmosphere of ‘preherence.’ This would provide an environment in which patient barriers are recognized and pre-emptively addressed through shared decision-making,” Dr. Nezin explains. “Ultimately, adherence needs to be an active decision by the patient and align with the intentions of the prescriber.”


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