Adherence Programs: What works?
What seperates successful adherence programs from unsuccessful ones?
In my last column I put together the "patient orientation quiz". Feedback has come from executives who point out that they have tried patient support and adherence programs but have had bad experiences and have therefore shied away from them. Two major sources of disappointment were:
- Lack of patients. Programs were launched with expectations of, say, 1000 patients and ended up with less than 100.
- Low impact. No appreciable effect was seen on the patients enrolled.
Yes, this happens. There have been a number of meta-studies of adherence programs and they tend to show that about 1/3 of programs are failures.
One reaction to this is to say "this whole new adherence thing doesn't work" and give up, which seems to often be the case. Another approach is to say "hang on, 2/3 do work, so what did we do wrong?"
Guess which of these reactions I suggest?
The first thing is to realize that you can have a very real impact on adherence. Here are just a few documented examples:
So what separates the successful programs from the unsuccessful programs?
First, it must be understood that to a large degree these meta-analyses only take into account patients enrolled. As such, they don't have much to say about lack of uptake.
On the other hand, those of us working in the adherence area all have our stories of undersubscribed programs, and we have, as a group, been learning about how to avoid this. As such, in terms of enlisting patients, here are a few main points:
- Counting on patients to enroll themselves is a bad idea. For one thing, they tend not to do it. For another, those who do enroll have a tendency to be naturally conscientious and therefore probably more likely to have been adherent anyway.
- The above point means that you are going to ask healthcare professionals (HCPs) to enroll patients. However, don't count on GPs, at least not in Europe. Most European GPs have their hands full and their pockets empty. Even with the best of intentions, they simply don't enroll that many patients.
- Specialists tend to be an all-or-nothing prospect and often, the difference is one of organization (and to a degree, specialty). If they work in hospitals that have a more comprehensive disease-management approach then they can be important proponants of a support program. If not, given their tendency to underestimate the problem, you can also run into difficulties with them.
- Nurses, on the other hand, tend to be much closer to these kinds of issues and can be excellent initiators.
- Pharmacists are the great unsung potential heroes of patient initiation in adherence programs. One one hand, they also tend not to have much time, but on the other hand, just as increasing adherence increases revenues for the pharma industry, it clearly has the same impact on them. Of course, their situation differs greatly from country to country.
Once you have your patients initiated, the net step is to get results. So what separates the failures from the successes?
- Some impact appears to be generated by very simply offering some patient eduaction at the point of dispensing, typically in pharmacy. A number of major players in the adherence world have focused exclusively on providing one-time information packets to patients at this point, and they do have a positive effect.
- However, meta-analyses show that this effect, while real, is relatively minor and tends to be short-lived. Ongoing communication is important and the highest-impact programs provide such support.
- And that support is customized. The more individualized the contact, the higher the impact. This is no surprise, just about every promotion to which you are subjected is customized as much as it can be (think Amazon.com). Adherence communications should be no exception.
- Reminding people to take their drugs or refill their prescription is only of minor help. Remember that only about 30% of non-adherence is due to forgetting. You need to convince them, and simple reminders don't do that.
- A number of programs have been designed to facilitate ongoing contact between physicians and patients and therefore address adherence. This sounds like a great idea, but in practice, the physicians in question have a distinct habit of shying away from these programs for the same reasons of time constraints that restrict their enrollment efforts. These programs can be traps: most physicians will say they find them interesting but they won't use them.
Do not make the error of assuming that text messaging programs are simple, that you only need to send a daily text reminder, or a refill text. It's true these can have an impact, but the real impact to be seen is with personalized text messaging programs designed to motivate and change behavior.
When you put this all together, text messaging becomes an extremely attractive channel for adherence programs. It is a low-cost way to provide regular, even daily communications to patients. It is not a coincidence that all of the programs cited at the start of this column use text messaging extensively.
However, do not make the error of assuming that text messaging programs are simple, that you only need to send a daily text reminder, or a refill text. It's true these can have an impact, but the real impact to be seen is with personalized text messaging programs designed to motivate and change behavior. These are driven by sophisticated customization algorithms and based on established models of patient behavior to deliver the right type of motivation to each patient.
Of course, text is just one channel. The very highest impact programs use multi-channel approaches that combine face-to-face elements, typically at treatment announcement or disbursement, coupled with informational resources, whether paper or digital, potentially follow-up phone calls as well as customized text messaging.
Never forget that on average, your expensive, hard-fought efforts to get new patients on your drug are delivering half of what they should be delivering. It's worth some effort and reflection to figure out how to put together a cohesive adherence approach to change this.
It sounds complicated, but it's certainly no more complicated than the multi-channel approaches you've been putting together for your sales force and frankly, it can have a much bigger impact - assuming it's based on a thorough understanding of the non-adherence phenomenon itself. Never forget that on average, your expensive, hard-fought efforts to get new patients on your drug are delivering half of what they should be delivering. It's worth some effort and reflection to figure out how to put together a cohesive adherence approach to change this, which we can discuss further in my next column.
Kevin Dolgin is an independent consultant and President of Observia, a French company providing patient compliance programs. Kevin is also Associate Professor of Marketing at the Sorbonne Graduate Business School.