We asked four authorities to tell us what’s new and what works in reinforcing patients’ adherence to therapy.
- What is the most unexpected patient behavioral dynamic you’ve encountered?
- What is the most unexpectedly effective adherence-promotion tool?
- How do you measure program effectiveness?
- What is the most successful provider-centered strategy?
- What is the most successful patient-centered strategy?
reflect those of their affiliated companies or organizations.
Vernon Schabert, PhD
Senior Principal, IMS Consulting HEOR, IMS Health
We used to see that patient out-of-pocket share had a measurable, but small, effect on patient adherence. Most of the literature supporting this was published before three- and four-tier formularies established $50+ co-pays for non-preferred products. We are seeing early evidence that patients with such large co-pays decide against using a medication at the first pharmacy pickup. Those patients are not measured in adherence studies that require an initial medication fill.
The most effective adherence promotion tool is perspective-taking. Not by the patients, but by the intervention designers. I’m constantly surprised by how many interventions are implemented without any evidence that patients were asked why they had trouble taking the drug of interest. Interventions that meet patients stated challenges and needs will be far more effective than one-size-fits-all solutions.
Most program-effectiveness evaluations focus solely on how often patient X took drug Y. You’ll learn more about your intervention’s value if you correlate adherence with measures of: one, which component(s) patients actually used; two, patients’ stated commitment and ability to stick with treatment; and three, the clinical outcome that the treatment is supposed to improve.
Programs fail unless they use both provider and patient strategies. Patients won’t even think about investing effort in behavior changes unless their physicians and pharmacists have shown sincere belief in their value. But providers are not there each time their patients make the decision to use one more pill, injection, drop, ointment, or patch. Each dose and each medication fill is an opportunity for patients to re-evaluate whether they’re getting value from their effort. Don’t you want to be reinforcing value with the patient at each of these moments?
Shera Gruen, MPH
Director/Team Leader, US Adherence Team Pfizer
About half of all patients do not take their medications as directed, leading to serious health consequences and avoidable costs.1 There are numerous reasons why patients may be non-adherent, including lack of symptom improvement, anticipated side effects, cost or forgetfulness. While these more straightforward explanations are true for some, it is not that simple for others. Pfizer recently conducted some qualitative market research with patients to better understand some of the underlying attitudes and beliefs that may contribute to non-adherence. It was surprising to learn from this research that many patients actually choose not to take their medication for a variety of reasons. Some may not accept that they have a condition. Others believe that needing medication represents a loss of control or a weakness. They may not want to depend on medication, think that it is for old or sick people (and may not see themselves in that way), or are concerned about causing long-term bodily harm.2 A multi-disciplinary approach is needed to address these complex issues, including patient support and coordinated action from health care professionals, researchers, health plans, pharmaceutical companies, employers and policymakers.
Effective communication between providers and patients is critical to helping patients start and stay on therapy. The provider needs to ensure that the patient understands his or her condition, the reasons for taking the medication, how it should be taken, possible side effects to anticipate, and suggestions for how to effectively manage them. Pfizer supports multiple programs that enlist providers to support medication adherence. One example is the My Heartwise Great Starts Program, which providers can use to help their patients get off to a good start when managing their cholesterol over the long term. It was designed specifically for medical groups, because they expressed the need for more educational tools they could provide to their patients. This program has demonstrated a statistically significant increase in the number of patients who report taking their medication regularly as directed.3 Pfizer also offers behavioral interventions that consist of live counseling with a pharmacist, which are very effective and highly personalized.
In addition to offering differentiated medicines that provide clinical benefits, Pfizer is investing heavily in patient behavioral support and educational programs to help patients understand and manage their conditions as well as to help them stay on therapy.
Pfizer’s Get Quit program for smoking cessation treatment Chantix is an interactive, highly customized program, designed to address specific challenges with being able to quit smoking. Upon signing up, patients answer questions about how they like to receive information, why they smoke, when they smoke, and their reasons for quitting. The program provides them with customized messages and activities, specifically designed to help them quit. They also receive support from a Mayo Clinic-certified tobacco treatment specialist who counsels them on how to overcome the challenges of quitting.
1. Roebuck et al, Health Affairs, Jan 2011 2. Pfizer data on file, 2011 3. Self-reported. Harris Interactive Market Research Readout April 2010: The data reported are based on the responses of 120 patients who completed all three waves of the study. While 125 completed the pre-wave survey, 5 did not complete the phone follow-up waves notwithstanding numerous call attempts.
Andrew M. Peterson, PharmD, PhD
Dean, Mayes College of Healthcare Business and Policy University of the Sciences
Over the years, I have encountered a number of different tips, tricks and tools to improve medication adherence. Recently, the trend toward tailored information and feedback to patients is the most intriguing and most likely to make the biggest impact on adherence. A common way to measure the success of an adherence program is refill rates; but that is fraught with trouble because so many other factors influence adherence. Better measures of a program’s success are enrollment and participation by patients and providers. If it is easy to use, and the users find value in the program (i.e., improved adherence or communication), then they will continue to participate.
The most successful adherence programs promote the concept of maintaining good health through a variety of channels at key points when a patient makes a decision to take a medication:
• At the provider’s office when the prescription is first issued;
• At the pharmacy when the patient picks up the prescription; and
• At home when the patient decides to take the medication as scheduled.
So, information about medication adherence needs to be tailored and targeted to the individuals involved in the decision making at each of these points. Currently, the most successful programs engage health care practitioners, such as pharmacists and nurses, who provide tailored information to patients based on interviews and past history. However, I see technology as a strong platform for gathering patient specific information and developing a tailored information product, be it a video or a simple pamphlet, which will enhance a patient’s medication adherence. Using this platform, and tailoring it on a regular basis, will help keep the patient engaged with the program and improve adherence.
Richard G. Stefanacci, DO, MGH, MBA, AGFS, CMD
Chief Medical Officer Promidian Consulting
As a physician, I had been trained to make the right diagnosis and then write for the correct treatment plan. As a chief medical officer for health plans, I thought access to medications was the critical link in achieving outcomes. Recently, I have witnessed that, even with those components in place, one can’t forget patient issues.
Consider what happened with one patient a few weeks ago: as the health plan, we provided comprehensive medication access—including delivery —with no copayments, for all necessary medications. Of course, we assumed that, with this level of medication access, that our patient was in fact taking her medications. That assumption was incorrect.
When our patient failed to meet some expected outcomes from therapy, a home visit helped uncover what was really happening. She was not taking her meds as prescribed…but she did continue to fill the prescription. Why? She liked the color and shape of the tablets—a design feature important in her macaroni art projects. For several reasons, she had stopped taking her meds, but didn’t tell her team because she still wanted them as art supplies.
The key point is that the patient can’t be left out of any adherence plan. Even when assisted by advanced technology—such as bedside dispensing devices or smart phone apps that remind patients when it’s time to take a medication—treatments can fail if the patients fail to appreciate how important adherence itself is to their outcomes. The most successful are patient-specific and (because adherence declines over time) include both initial and ongoing patient education. Unfortunately, I’ve seen millions of dollars wasted on “nice” boxed resources that never leave their wrappings because they don’t fit with the patients’ behavior or the providers’ practice flow.