What Can We Do About Patient Non-Adherence?
It's been called "America's other drug problem” by the National Council on Patient Information and Education (NCPIE), “a worldwide problem of striking magnitude” by the World Health Organization, and by many, “a $300 billion problem.”
The problem, of course, is patient non-adherence (also referred by many as non-compliance), and we've all heard the statistics. Chief among them: how 50% or more of the estimated 3.8 billion prescriptions written every year are taken incorrectly or not at all. Yet, after decades of acknowledgement by governments, the medical, pharmaceutical and pharmacy communities, and a vast body of literature, the problem persists. So is it time to give up and accept that the human emotions, behaviors, and barriers that underpin non-adherence are simply too complex to be surmountable?
No! With a focus on the patient experience and behavioral economics, we can make an impact — and it starts with patient/provider communication, which remains at the epicenter of patient confidence and trust. Indeed, a meta-analysis in 2009 of more than 106 correlational studies performed by professors Kelly Haskard Zolnierek from Texas State University and M. Robin DiMatteo from the University of California, found that the odds of patient adherence are 2.16 times higher if a physician communicates effectively. And a comprehensive study funded by Pfizer in 2008, The Glaucoma Adherence and Persistency Study (GAPS), determined that there was a direct link between beliefs and behaviors, and that those beliefs were most significantly impacted by the degree of urgency and clarity imparted at the initial diagnosis.
It's intuitive that those unsettling moments at the time of an initial diagnosis are when the physician-patient relationship may be most formative, and how the experience in its entirety can ultimately shape the belief systems, attitudes, and behaviors that ultimately determine a patient's adherence proclivity.
Which is why the clearest path to impacting non-adherence just may be the simple task of making adherence “screening” more routine.
THE 'ADHERENCE DIAGNOSIS'
Patient self-reporting tools such as the Morisky 8-Item Medication Adherence Questionnaire (MAQ), Medication Adherence Rating Scale (MARS), and Self-Efficacy For Appropriate Medication Use Scale (SEAMS) have attempted to provide physicians with much-needed insight. The problem, of course, is that administering questionnaires like these is burdensome on most physician practices, which already struggle to keep up with the mountain of paperwork.
Instead, consider that physicians are trained to be detectives…that is, to ask their patients a series of questions that, when combined with medical history and physical examination, enable them to determine what disease or condition is responsible for the symptoms being exhibited. Many, if not most, doctors fail, however, to use these same techniques upon follow-up visits to determine if their patients have been adherent, or not.
In fact, my casual conversations with physicians on this topic have revealed something startling: an acknowledgement that they're awful at predicting non-adherence. Indeed, a 2011 study by Televox, a self-described engagement communications company, reported that only one in four providers believe it's their job to keep patients on track between office visits.
That's where the idea of an “adherence diagnosis” comes in. Why not create a structured and standardized series of non-confrontational, non-judgmental questions that can help doctors determine if their patients have been taking their medication as prescribed and have, at their disposal, resources (developed by medical marketers to be “patient friendly”) to assist those who are not. These can run the gamut from manufacturer copay assistance programs, reminder tools, or recommendations for how to enlist caregivers.
Think how transformational it would be if the concept of an adherence diagnosis were to become institutionalized, perhaps through mandatory CME programs? The mere fact that the medical community was focused on non-adherence would be a coup unto itself.
THE PEAK END RULE
Much is being written nowadays on how behavioral economics can be applied to non-adherence strategies, and rightly so: after all, what can be more predictably irrational (as in the title of the book by Dan Ariely that popularized the topic) than someone who we know will stop taking their medicine despite the risk of having a heart attack, going blind, or even death?
Of the many theories, or specifically heuristics, that explain the psychology behind consumer/patient choices and behavior that apply to non-adherence, the one that intrigues me most is called the peak end rule. Simply stated, it suggests that experiences are not judged by their entirety, but rather how they felt at its most intense point, or peak. If you apply this behavioral logic to the GAPS study, not only is the degree of urgency parted at the initial diagnosis critical, so too are the messages and instructions at the conclusion of that experience.
It would behoove doctors, hospital staff, or pharmacists, therefore, to help boil it all down for their patients at the conclusion of an engagement:
- Here's what you should remember most
- Here's how to take what you're being prescribed
- Here's what to do before even thinking about stopping your treatment
Simple tools such as in-office posters or follow up emails can help “stoke” the conversation—by reminding the patient to ask for those three takeaways if they weren't volunteered before leaving the office. Doing so will crystalize for the patient what they need to do and why and create a peak-end experience that can serve as a “shield” against indecision, misinformation, conflict temptation, etc.
THE BOTTOM LINE
It's shocking that a consortium of pharmaceutical companies at the very least, or multiple players in the health delivery ecosystem ideally, haven't formed a coalition/cooperative to address non-adherence as a public service. If they did, I'd be first in line to pitch a chance to take a crack at developing a PSA.
Meanwhile, the epic problem of non-adherence persists. New “marketing” approaches and technologies such as “smart pills,” ingestible sensors, pillcaps, gamification, rewards, and reminder apps provide intriguing solutions. Until the time when they can be operationalized to scale, however, there are ample opportunities make real inroads improving something far more basic: patient communication.
Rich Feldman is principal and managing partner at Source.