Improving patient compliance with low-cost wireless technologies
According to Datamonitor, patient non-adherence costs the pharmaceutical industry in excess of $30 billion a year.
By on Oct 11, 2006According to Datamonitor, patient non-adherence costs the pharmaceutical industry in excess of $30 billion a year. In the US statin market alone, non-adherence in a single year adds up to an estimated $3.9 billion in lost revenues for the industry.
Improving patient compliance, even slightly, can have significant impacts on revenues for drug makers, expenses for third party payers and outcomes for patients. For a $1 billion product, a 5% increase in patient adherence can reap $30-40 million in revenue.
According to Jane Martin, a respiratory therapist and founder of pulmonary patient support programs in Michigan, the most successful patient compliance interventions come down to patient education made so simple and convincingly logical, that there is little reason for a patient not follow the prescribed instructions.
In Martin's case, she identified the areas of development, chemistry, engineering, user-friendly product design, and distribution as all being vital components in the success of inhaled pulmonary medications for her COPD patients. But she encourages the pharmaceutical industry to work on methods of integrating technology with the human element to improve the level of adherence.
You have to impact the patient's behavior as well as educate them about the relative benefits of the medication suggests Robert Nauman, Principal at BioPharma Advisors. Patients need consistent information reinforcement to change their behavior. Relevant content is the key to the adoption of positive behaviors.
As outlined in previous eyeforpharma articles ( www.eyeforpharma.com/search.asp?news=45652 ), the following behaviors have been identified as some of the top reasons for patient non-adherence:
simply forgetting (65%);
concerns about the drugs themselves (45%);
and feeling the drug is unnecessary (43%).
Phil Cohen of Mobile Reach Media believes wireless technologies offer just the kind of simplicity Martin and Nauman advocate, while providing a quick and effective solution to the three leading reasons for non-compliance.
Cell phones are a user friendly, yet multi-faceted technology that allow those concerned with patient adherence to identify non-compliant patients, determine the key issues hindering their adherence, and respond in an effective, timely and simple manner.
Cohen says that although wireless technologies, like SMS, have been around for a few years now, wireless carriers have made the technology nearly impossible to execute effectively for the purpose of improving adherence. But that's all changing, he says, as carriers want more volume of transactions on their networks, prices are falling and richer media driven content is being made available to subscribers.
Cohen believes the timing and fit are ripe for wireless technologies to help pharmaceutical companies, healthcare providers, insurers, and governments initiate programs that improve patient compliance.
Applying wireless technologies to improve patient adherence
According to a recent World Health Organization report on patient compliance, studies consistently find significant cost-savings and increases in the effectiveness of health interventions that are attributable to low-cost interventions for improving adherence. In many cases investments in improving adherence are fully repaid with savings in health care utilization and, in other instances, the improvement in health outcomes fully justifies the investment.
Pharmas investing in patient compliance initiatives stand to benefit to the tune of tens of millions of dollars per project, while those who are not, risk leaving hundreds of millions of dollars on the table across their portfolios.
Solving adherence problems really shouldn'st require rocket science.'s Issues hindering adherence are usually not technical matters, but are related to cognitive behavior A solution begins with effectively identifying and understanding the trouble spots's from the patient's perspective in order to be able to selectively apply a relevant solution.
For patients that simply forget to take their medication - the leading reason for non-compliance - an effective wireless solution can be used to detect non-adherence and to intercede with an increase in relevant information. Treatment regimen reminders and relevant content delivered in a timely manner (i.e. when their dose is getting late and may be missed) provide a significant improvement over education alone. That additional information helps patients questioning the efficacy of their treatments at a time when they may begin to drop off's their medication. A timed communication protocol, in which patients are encouraged to look for both the subtle and overreaching signs of their progress helps reinforce the need to stay on the medication as prescribed by their physician.
Patients also may become non-adherent in response to concerns about drug side effects (45%). Cohen suggests a simple, interactive wireless communication can be used to both detect and instantly respond to side effects. Such communication, he says, will either generate a level of comfort among patients that some side effects are normal's or initiate a response by appropriate medical staff for instances of adverse side effects, driving increased awareness of the issue in both cases.
The third key impediment to compliance feeling like the prescribed medicine is unnecessary also can be addressed with wireless intervention. Self-efficacy ratings collected in real-time with the aid of wireless compliance technologies may more accurately document a patient's true attitudes about the effectiveness and perceived side effects of the prescribed drug than recollections collected on a paper questionnaire at a later time are able to capture. In addition, incremental reporting offers opportunities for educational interventions that reassure patients that the effects they are feeling (or not) are normal or desirable with a given drug and to reinforce the importance of adhering to the prescribed drug and dosing protocol.
Wireless technology makes sense as an educational tool because its messages are, by definition, short and to the point. In a world where we are constantly bombarded with messages from various media, wireless messaging can often hit the spot's in a quick and effective manner. Furthermore, the wireless device today, is a medium that often gets priority treatment; cell phone calls rarely go unanswered, and short messages, are almost always retrieved right away, because it can be done without significant interruption to other activities.
Overcoming inertia with the voice of a health leader's
If industry experts say that 50% of all prescriptions are never consumed and 20% of all new drug prescriptions are never filled the first time, there is clearly a need for tools that will help patients overcome the initial inertia of beginning their treatments and understanding the relevant benefits of that action, says Cohen. There is an obvious need to keep the patient's initial enthusiasm from the visit with their physician alive until they have actually filled the prescription and initialized an established routine of behavior that will bring about positive change.
Even though one's personal healthcare should be the most primal concern, there is evidence all around us that we behave to the contrary. One need only look at the number of smokers in the world or the level of consumption of unhealthy foods for anecdotal evidence that people are not taking action.
Sometimes all people need is a reminder from the right authority's with some rationale as to why it is important to them to take the medication as prescribed.
According to the UK Medicines Partnership project, people are more likely to adhere if they believe that their doctor, nurse, physician assistant or pharmacist cares whether or not they stick with the plan. Studies show that people who receive explanations from a concerned doctor are more satisfied with the help they receive and like the doctor more. And the more they like the doctor, the better they follow a treatment plan.
In the case of prescription non-compliance, the physician as a health leader's and influencer can be largely represented by an automated, wireless service with a simple message reminding patients what they must do to get healthy.
Nauman cites a pilot project done several years ago were a vaccine company was losing 85% of its patients before their second dose. Through cellular technology, physicians were given a microsite to register patients and enroll them in a reminder program. The results showed that 70% of the patients who were on the program came back for their second dose as a result of the reminder program.
Being able to reach patients at critical times, no matter where they are, and involving other parties to intervene directly with the patient in real-time when there is an identified risk of non-adherence may yield increased effectiveness and adherence.
Through the looking glass
A successful patient compliance program might begin, for example, with patients being encouraged (at the time a prescription is initially written) to participate in a proven adherence method to increase their chances of success, suggests Cohen. By getting communication started right away and by alerting a wireless adherence service provider quickly, the patient can be guided by educational messaging even before they start their medication.
Once a wireless adherence service is activated on a patient's mobile device, if non-adherence is detected, an automated reminder to comply can be delivered. If the reminder is not heeded, Cohen says, a friend, family member or even a willing physician can be automatically notified in real-time and may intervene with the patient. This is particularly true of parents with teenagers or young adults who may be on medication while at school.
If a patient's family, friends or other key influencers are playing the primary role in maintaining adherence, the physician may only receive periodic, aggregated patient activity notices as a secondary line of defense in adherence monitoring, Cohen points out. This gives doctors complete discretion, he says, as to whether their involvement is required, how much time they might want to invest and if office staff should intervene to investigate what is causing non-adherence with individual patients.
After a while, Cohen says, patients may stop using the adherence system altogether when good habits are established or may simply find it is not right's for them. Others may choose to change the key intervener for their service to friends and family. But the bottom line, he says, is patients should be allowed to opt out if they choose to do so to preserve patient satisfaction.
Most patients, however, will cognitively recognize the value and appreciate the intervention, Cohen says. Despite the significant impact wireless programs can have on improving patient compliance, however, an overall adherence solution should incorporate other adherence tools and efforts, each targeting specific patients, but combining to be greater than the sum of the parts.
Whose responsibility?
It can be argued that those who stand to gain the most financially should be the ones to invest the time and effort into ensuring patient adherence, Cohen says. But he warns patients are less likely to feel comfortable that it is in their best interests to remain compliant if they are being urged to do so by those with an obvious financial incentive to see them do so indefinitely.
Physicians, pharmacists and family members hold the most sway over encouraging adherence, because they have, presumably, already earned the trust of the patient. The challenge is to create a reliable system that allows these influencers to be involved in increasing health benefits to patients, while encroaching only minimally on their limited available time to do so.
Programs need to be devised and coordinated at the level of the drug manufacturers and retailers, which manage and encourage physician involvement in this vital role, Cohen says. But doctors must be duly compensated for increased time spent on adherence efforts with patients and for results achieved.
At least in the beginning, Cohen suggests, the pharmaceutical industry should foot the bill for compliance programs, since they have the most to lose financially from patient non-adherence. But ultimately, he says, early successes and lobbying power can be used to convince retailers, insurers and governments to contribute, as all will gain from better patient compliance.
In fact, a recent study sponsored by GlaxoSmithKline found that in the state of Ohio, one in five patients do not take their medications as recommended, adding $700 million a year to healthcare costs statewide.
The bottom line for pharma: Compliance pays
Wireless solutions will likely be effective among only a sub-population of all patients in any given group. With 65-70% penetration of cell phones in the greater population, not everyone can participate. And among those that do participate, some attrition can be expected during the initial period of a program.
However, if a solution is cost effective and does a good job of increasing adherence among those who do participate, the net effect can be significant.
For example, Cohen says, maybe only 15% of a given patient population would be willing to participate in a wireless adherence program. And perhaps only 75% of those already have a phone, leaving 11% able to participate. If patient attrition from the program reached as high as 50% for various reasons during the first months of the program, only 6.5% from the initial 15% that showed interest in the program would remain.
But if the adherence rate among the remaining 6.5% could be increased from the average 40% rate commonly achieved to 85% with the program, net adherence rates among the entire group of patients ever written a prescription for the drug in question could be boosted by 2.5%.
If the drug in question costs $80/month, for example, a pharma company's product generating 2 million prescriptions annually could reap increased annual revenues of $48 million. In addition, patients's health would be improved and insurers would avoid additional expenses due to hospitalizations, surgeries or other protracted healthcare interventions.
In the above scenario, if a typical wireless adherence service costs $5 per patient per month, a return on investment from 300-600% can be achieved. That compares quite favorably with typical average returns on direct to consumer advertising (200%), traditional in-office details by sales representatives (172%) and e-detailing (248%).
Moving forward
According to the IFPMA's director general Harvey Bale, the industry's role should go beyond the traditional one of bringing the medicines to the market. Industry, he says, also has a necessary role in helping to inform patients about their products. This should be in such a way, Bale suggests, that broader and increased knowledge and understanding can support the patient's relation to, and dialogue with, the prescribing doctor and the other health professionals involved, such as nurses and pharmacists, in following the prescribed treatment to achieve the best outcome for both the patient and the health care system.
In many scenarios, wireless technologies can efficiently and cost-effectively improve patient adherence, but Cohen says the industry faces a few challenges moving forward. Pharmas, in conjunction with technology providers, must:
Understand where improvements can be made within the confines of governmental regulations
Choose technology that can enable the desired levels of adherence improvement in a flexible and cost effective manner
Prove increased adherence, leading to exceptional ROI
Validate ease of use among patients
Understand that different situations call for different wireless technologies and deploy the easiest technologies and maintain ease of use among patients
The most logical place to begin as a proof of concept, Cohen suggests, is with high value drugs (blockbuster or semi-blockbuster products) taken at low dosage frequencies (e.g. 1-4 times per month) and carrying a fairly high price (i.e. $60+/month). But significant returns on investment in wireless adherence programs promise to make the technology a must have for many products in pharma's portfolios.
Phil Cohen is the president of Mobile Reach Media Inc., a Toronto-based company specializing in wireless adherence and communication tools for the pharmaceutical industry. Phil can be reached at (416) 934-5565 or pcohen@echoalert.net.
Robert Nauman is Principal at BioPharma Advisors Network, a consultancy community. Rob can be reached at (919) 372-1658 or rnauman@MyBPA.net.
eyeforpharma's 3rd Annual Patient Compliance, Adherence and Education Congress USA is being held November 30-December 1 in Philadelphia. For more information or to register, visit www.eyeforpharma.com/pcusa06 .