Patient Marketing Report: From A1C to Z

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Novo Nordisk's Bob Muha, Amy West and Martin Jernigan
Novo Nordisk's Bob Muha, Amy West and Martin Jernigan

Sites like Novo Nordisk's Cornerstones4Care are bringing full spectrum segmentation to the task of bolstering adherence and being there for the patient, reports Matthew Arnold

Patient POV—Three health activists discuss diabetes education efforts

Study: Adherence problems point to patient dialogue failure

The patient support site has become a standard element of the drug marketing armory—offering patients a mix of disease info, lifestyle tips, tools to manage their illness, maybe even a social, rewards or game element, all with the aim of helping patients stay on medication. For the most part, it's a simple matter of developing a patient profile—do disease sufferers skew Southern? Female? Middle-aged or elderly?—and tailoring your content to that audience.

But what to do when your patient population has more profiles than Facebook? Diabetes patients are as diverse as the nation is, and they come to treatment with a wide range of needs and degrees of awareness and acceptance. So when Novo Nordisk set out to build a patient relationship/adherence hub for its diabetes patients, the firm looked beyond the standard formula to target patients across its wide-ranging diabetes franchise, which includes human and modern insulins, delivery systems, oral anti-diabetics and GLP-1 med Victoza, with tailored information.

The company's Cornerstones4Care site uses a state-of-the-art screen to determine an individual patient's needs and meets them where they're at.

“We want to be able to talk to the person where they are in their treatment progression,” says Novo's Amy West, associate brand director, diabetes patient marketing. “It's based on how long they've been treated, what they're being treated with, their attitudes about how they're being treated. Somebody early in the disease state doesn't need to know all the options that are out there or what can happen down the road. They just need to know the basics up front. They're already overwhelmed and scared as it is, so let's not overload them with information, let's parcel it out in digestible ways. Then, as the disease progresses, if you're someone who's been treated for many years you don't need all those basic elements, you need to understand the longer-term impacts and other things you can do, like lifestyle adjustments. We want to be pulsing out information at the right time and at the right level of understanding.”

Novo Nordisk built the site with insights from its massive global Diabetes Attitudes, Wishes and Needs (DAWN) study, among other marketing research, in mind. Enrollee information is fed through a proprietary algorithm that gauges their likelihood of nonadherence to treatment. A sophisticated database “allows us to segment and profile all of the people that join our program so that we can have a two-way dialogue with them based on their individual needs,” says West. “Our messaging is not a one-size-fits-all approach. It's customized to the individual based on their needs, their attitudes, their preferences.”

Algorithmic thinking

The program's algorithm allows it to target the “model patient who just needs a little support, a pat on the back here and there or a bit more education” to stay adherent, says West. It is also sensitive to conversion opportunities, says Peter Newman, president of gcgConnect, Novo Nordisk's agency partner on Cornerstones4Care.

“The algorithm is able to determine the patient's therapeutic readiness to initiate therapy, determine if they're looking for a change in product, if they just need more help and support in adhering to the therapy they're on. That's a game changer,” says Newman. “Most manufacturers are taking a cookie cutter approach to segmentation. They'll look at whether a patient is on their therapy or if they're looking for information, and they'll send them a generic piece of mail or a couple of e-mails a couple times a year, or a co-pay opportunity. Just because they have a name on a list doesn't make it a relationship-marketing program. It's a marketing program, but it's not based on algorithmic thinking and on getting to a level of dialog with the patient or caregiver.”

It's a far cry from a product site, though.

“I refer to it as ‘lightly branded,'” says Bob Muha, senior director, CRM, at Novo, “and it's all patient driven. So if the patient identifies themselves as someone who's been on basal insulin for a period of time and they're looking to intensify their regimen, maybe get better control around mealtime, there's some…information around NovoLog, and if they're interested they can click through to NovoLog.com and get much more in-depth information to bring in and talk to their doctor with.”

Where many patient support programs taper off after three or six months, Cornerstones4Care enrollees keep getting monthly e-newsletters and other communications from the program in perpetuity. Some have been getting the newsletters since the site went live two years ago, says West. Across the board, the program is seeing open rates as high as 55%-60%, and the website has clocked more than 500,000 visitors and 2 million page views. On average users spend approximately nine minutes per visit on the site. “That says to us that people know who we are, they find us of value and they're engaging with us.”

“If there is one challenge for healthcare overall, it's getting patients to own it,” says Martin Jernigan, VP, diabetes portfolio management, Novo Nordisk. “This means they must be aware of their medicines, why they are needed, and how/when to take them properly.” By providing information that's relevant and consumable for action, says Jernigan, “We've seen this program increase adherence for patients using [our] injectable medicines (insulins or GLP-1).”

Cornerstones4Care also offers a five-part e-book series that can be downloaded free at iTunes and other e-book sites. The firm is working on a “customizable lifestyle companion tool,” a Swiss Army Knife of an app incorporating a meal planner and calorie/carb counter powered by Calorie King, as well as exercise tools allowing users to track their caloric burn rates and build exercise plans from goals, and even calendars to support medical management. It will be hosted on the site this year and released as a free downloadable app next year. Novo Nordisk is also thinking of adding an instant chat function to the site—there's currently a phone line—and making it more mobile-friendly.

The program is promoted through banner ads on diabetes sites and search engine optimization, in doctor's offices and pharmacies. All of the firm's branded efforts in the category, including its Diabetes in a New Light campaign with Paula Deen for Victoza and FlexPen promotions featuring Charlie Kimball, funnel patients into ­Cornerstones4Care. Novo Nordisk has also worked with Wego Health and other networks to tap their patient communities. The company is weighing the pros, cons and cant's of building its own diabetes peer-to-peer networking site under the Cornerstones4Care banner, but concerns about reporting requirements and other, frequently ill-defined regulatory obligations are daunting, and the value-add isn't clear yet.

“Obviously, we know that patients are very engaged with other individuals who are dealing with the disease,” says West, “many times listening to them more than they're listening to their own care team. So we want to understand that space better—what can we do to support it in a positive way and not be intrusive? We want to do it right. We're doing a lot of research into how to do that and be credible but also be of value. We don't just want to do the bare minimum of what we're allowed to do. It doesn't add any value and it isn't going to change anybody's life in a positive way.”

A follow-on from an earlier Novo Nordisk site, Keeping Well With Diabetes, Cornerstones4Care launched in 2010 for patients with Type 2 diabetes, and information on Type 1 diabetes was added last year.

“From a patient perspective, they're almost two different disease states,” says Gina Gallagher, senior manager, patient marketing at Novo, “in that medications and motivations for lifestyle changes are so different across the two populations.”

The content on the site is organized around four “key pillars”—healthy eating, exercise, adherence and self-management, “which is really what this is all about,” according to West. “It's about giving the patient the information, the tools, the resources so that they're educated about the disease state, so that they feel empowered to take control, so that the disease no longer controls them.”

The aim is to touch patients at “Ah-hah moments,” turning points in the treatment continuum—moments when, says Gallagher, “they're ready and need to be talking about changing their diet or even moving on from an oral to an injectable product.”

A separate Novo Nordisk unbranded effort, “Ask. Screen. Know,” is aimed at general awareness-raising and promoting diabetes screening.

Closing the loop

The cystic fibrosis patient community is considerably smaller, more well-defined and close-knit compared to diabetes. Around 30,000 children and adults in the US have the genetic illness, making it a rare disease.

“They can't have physical interaction because of the potential spread of bacteria, so they can't meet in person…they can't have support groups,” says Shawn Michael, director, associated GI at Zenpep maker Aptalis. “There's really a sense of loneliness for these patients.”

Bridgewater, NJ-based Aptalis, together with McCann, created Live2Thrive, an unbranded site which aims to connect sufferers in a place where they can get medical info. For the time being, interaction is limited to video patient testimonials that must undergo legal, medical and regulatory review before being posted, but the firm is exploring the possibility of live communication between patients. Step one is to build a community around the site, which offers patients financial assistance through Aptalis's co-pay program, free vitamins and supplements and a rewards program through which patients can win health-related gadgets. Members can win points through viewing educational content or for filling their prescriptions on a monthly basis.

“It's a unique area,” says Michael, “because these patients, even though they don't have the direct interaction, they're much more educated than most disease states we've worked in, and they're always looking for new information.”

Even in a disease state like CF, segmentation is key. Live2Thrive's content varies by age and stage of the disease.

“Obviously, the tone we're speaking to them in changes as they age, but also, the disease progresses and the kind of support they need changes over time,” says Marcia Goddard, EVP, creative director at Aptalis' agency partner on Live2Thrive, McCann Torre Lazur.

The goal, says Michaels, is to ultimately be able to share that data on prescriptions filled and educational content viewed with physicians, social workers and dieticians in CF clinics which would otherwise see the patient only four times per year.

“Yes, we're trying to reach out to patients directly from a marketing and a patient education standpoint, but looping in those healthcare providers is really the end goal,” says Michael.

“Social media is a disruptive technology,” says Wendy White, founder and president of Siren Interactive, an RM firm focused on the rare disease space. “It allows people to engage in new and different ways and presents both challenges and opportunities.  Right now, there's transparency of company pipelines, which means that a lot of the patients in the disease space we work in know exactly what's in the pipelines. They have very empowered and educated patients and families and of course, there's a global use of social media and everybody's sharing info across country lines. So it's particularly messy and organic and global and fluid, and it's allowing this fracturing of the advocacy landscape. There's an opportunity for brands to step in and, if they do it the right way, to be the aggregator of information and bring all these different factions together using social media.”

Programs like Live2Thrive and Connect4Care are focused on patients, but they give reps something to talk about besides the same old data.

 “It's also another speaking point for reps,” says Erika Heigef, director of health education at agency HealthEd. “When they're going in to talk with physicians and healthcare teams around their product, they can also talk about patient support, and that's a huge value-add. Doctors have little time with patients. So physicians almost see it as an extension of their healthcare services because one, they're prescribing this medication, but they're also offering support and education they may not be able to offer if they only have 15 minutes with the patient.” Plus, it's a morale-booster for the field force.

“In a disease state like [CF], the sales force is really motivated to be able to provide this to the community, and because it's meaningful, there's such a higher level of involvement than there is in just doing a sample drop,” says Tatiana Lyons, SVP, director of client services at McCann Torre Lazur.

Says Stephen Wray, CEO of relationship marketing agency Cadient: “Marketers should be asking themselves: Is the consumer attempting to obtain condition information prior to a doctor visit? Are they considering their treatment options following a diagnosis? Or are they seeking support as a user of the brand? Those are three different experiences in three different contexts, and the user should be  able to get to the most relevant information with relative ease. And today we should be able to design an experience across channels and platforms that meets those needs. Digital certainly provides us with a greater latitude of options to accomplish that.”

PATIENT POV

Three health activists (below, from left, Scott Benner, Sysy Morales and Kate Cornell) were assembled by Wego Health to represent the patient perspective, and asked for their opinions of Cornerstones4Care and other diabetes education efforts.Click here to see what the panelists have to say about the abundance of diabetes education online, and here to get the their specific feedback on the Cornerstones4Care program

With an overabundance of online health information competing for patients' attention, it can be hard to break through and be heard, especially in a crowded category like diabetes.

Why is it that a pharma company can spend a ton promoting its website, only to see a blog gain more web traffic? “It tends to be ignored if it's direct from pharma to us,” says Sysy Morales, a patient with type 1 diabetes who blogs at thegirlsguidetodiabetes.com.

Panelists say their preferred avenues for diabetes education start with blogs, followed by mainstream social media, online patient hubs and forums, pharma-backed product or disease-information sites, and lastly websites of non-profit health centers or organizations.

“Nobody's diabetes is the same, so getting direction about it is almost impossible,” says Scott Benner, who cares for a daughter with type 1 diabetes and speaks to other parents via the blog ardensday.com. “But when you hear somebody who starts telling a story that sounds similar to yours, you feel a connection…and then that person seems like a viable option to learn from.”

To be sure, blogs, Twitter and Facebook represent someone's opinions or ideas. Individuals should research a topic themselves, bounce information off a healthcare provider, and look at a variety of sources to glean what works best for them, panel members say.

Adds Kate Cornell, who has type 2 diabetes and blogs at kates-sweet-success.blogspot.com, sometimes “support” is the best form of education. She mentions the “You Can Do This” project, an online initiative run by diabetes advocates that gives people a chance to tell their stories by posting videos. “I learn most from reading other people's blogs,” she says.

Not that bloggers are the pinnacles of altruism; many can be self-promotional. But an opportunity is there “to feel comfortable enough to at least find out more about it,” says Benner. “When it comes directly from the corporate side, there's an anticipation that it's being done for business reasons.”

When they do get involved, how can industry appear sincere? “Once [individuals] start something on their own and find a connection with pharma… it's easier to trust it,” says Benner.

Consider grassroots project the Diabetes Hands Foundation, which was founded by Manny Hernandez, himself a person living with diabetes, who has gone on to partner with such pharma companies as Roche and Sanofi, to deliver education and support.

That model is one way to garner legitimacy in the community. “[Companies are] going to have to brand backwards if they want a piece of this,” says Benner.

Another approach is the industry-funded program that's led by patients. Morales volunteers for an unbranded educational effort called A1C Champions, a Sanofi-backed initiative in which people living with diabetes lead informational workshops for groups of sufferers.

To be successful, educational campaigns must also reach more people than those with a Twitter handle or Facebook page. They “have to find a way to get past this virtual wall and get out to the people who really need the help,” says Benner. “Those of us that are this tech savvy could go find the information on their own. I have the opportunity to speak to people who aren't connected like this, and they struggle...They're fighting against basic concepts, because nobody has the right information for them.”

Adds Cornell, “Sometimes those of us who are online a lot kind of live in a bubble and tend to forget there are thousands and thousands of people out there who are not online and, based on my experience when I was diagnosed, I got nothing. There's a complete lack of educational information on the ground. For a program to be successful, it needs to be available in a variety of different places and in a variety of different ways.”

Ironically, one of the places where patients complain of a lack of education is right in the endocrinologist's office. “Pharma companies have such an easy pipeline through their sales reps to make these kinds of things more visible to people, but…no one has ever once mentioned anything that I've seen online to me in my doctor's office, and my daughter goes to one of the more prestigious children's hospitals on the East Coast,” says Benner.

Walmart, where people often go to save on diabetes supplies, would be a good conduit to reach people who, say, need information on access programs. “You have to go find them; they're not going to be able to find you,” Benner says.

Since diabetes manifests uniquely from patient to patient, an educational site that tries to cater to a wide swath of patients and caregivers is an ambitious undertaking. But that's what Novo Nordisk's online support site CornerStones4Care tries to do. Billed as a one-stop source, it offers information about diabetes and Novo treatment options and delivery systems, as well as a program of tailored dialogue for enrollees.

Cornell, the only one of the three who had seen it, thinks the site succeeds in that regard. “I like the way it lets you target what you're looking for based on what type of diabetes you have, or whether you're newly diagnosed or have been at it for a while,” she says. “As someone who was diagnosed seven years ago, I don't want to wade through all of the basics. I want to go straight to something I'm looking for.”

This aspect resonates with Morales as well. In her experience as a health coach, “the number-one thing people think they'll enjoy getting is someone meeting them…wherever they are in their journey. It's a lot more appealing for people to have some type of customization.”

Indications are that the program is helping people: it's garnered open rates as high as 60%. The site has seen more than half a million visitors, and two million page views, with patients spending an average of nine minutes perusing the material.

There are some pitfalls to trying to speak to both the type 1 and type 2 audiences, though. “On the type 1 side,” says Benner, “there's a lot of disappointment throughout the community that there's not a better understanding between the two different diseases.”

With type 2 making up about 90% of the cases globally, “If you're trying to service people when they're coming in, you might not want them coming in from the type 1 side feeling like this is a website that's really focused toward the greater number of people.”

Patients also suggested that the site's plethora of white space, preference for models vs. real patients, and de-identified format (as opposed to the blog approach of reading someone's personal daily ­experience), could stand some improvement. Morales suggests throwing some real people with diabetes into the mix. “Our presence might make it a more friendly kind of atmosphere.”

 

Adherence problems point to patient dialogue failure

A study looking at adherence to statins shows a surprising rationale behind the astonishing number of patients who go off medication.

Nearly two-thirds (62%) of the 10,100 non-adherent US statin users surveyed by Livalo makers Eli Lilly and Kowa said they'd quit taking their meds because of side effects, while 17% cited cost, 12% efficacy, 8% “other” and 6% “I don't know/can't remember.” Past studies have indicated that nearly three-quarters of new statin users stop therapy by the end of their first year.

Part of the problem is the asymptomatic nature of the disease, says Lisa Garman, associate marketing director at the Japanese pharma Kowa's US headquarters in Montgomery, AL. “For the most part,” she notes, “until you've had an event like a heart attack, you don't feel a lot of symptoms to make you feel like you need to be on a medication.”

Another factor Garman cites is the high rate of co-morbidity in hypercholesterolemia patients, over half of whom suffer from other chronic conditions requiring medication. “When you consider that 75% of all drugs are metabolized through this one particular pathway in the liver, you're just upping your odds for a drug-drug, interaction-related side effect,” she says, noting that these patients are on an average of three medications. Only 38% said they were worried about potential drug interactions.

Kowa and Lilly developed the survey, dubbed USAGE (Understanding Statin Use in America and Gaps in Education), with the National Lipid Association. They trumpeted the results of the survey with a roll-out featuring John O'Hurley (pictured) of Seinfeld and Dancing With the Stars fame, who was diagnosed with high cholesterol five years ago.

The survey didn't go too far into what specific side effects prompted patients to go off their meds, though it did ask about myalgia, the muscle aches and pains some users experience. But patient concerns about side effects and statins belie another problem, says Judy Spann of the National Lipid Association—poor patient-physician communication. “It really illuminated the need to discuss side effects with patients, because they don't always understand side effects very well, or sometimes there's the possibility of a placebo effect, where they think they're experiencing side effects when they're not and stop taking a medication they really need.” Alarmingly, 34% of those who stopped taking their statins said they did so without consulting their doctor.

 

To improve that dialogue around side effects and drug interactions, the survey site, statinusage.com, hosts a medication tracker with a twist—it's organized by physician, so different doctors can see what others have prescribed the patient.

There's also a patient discussion guide and resources aimed at improving patient understanding of the importance of lipid-level measures. Survey respondents were more likely to remember their pant size from high school (64%) than their most recent cholesterol level (46%). Three out of four female respondents could not remember their initial LDL-C readings, and more than half could not recall their most recent LDL-C levels.

The survey showed that patients primarily look to physicians for health info, but it also revealed another weak link in the dialogue. “One of the things we found interesting was the number of patients on statin therapy that rely on their pharmacist to identify those drug-drug interactions,” says Lilly's Tina Gaines, communications manager for cardiovascular.

“It illustrates the need to further integrate the entire healthcare system so that the pharmacist, the NP, the physician are working together as a multidisciplinary team, not segmented,” says NLA's Spann, “that they're aware of what each patient is taking so that when they're writing a new prescription or filling prescriptions, they have a good sense of how that's going to affect the patient's overall health.”

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