What Gets Measured Gets Done.

Do the KPIs on pharma's dashboard include adherence, a key indicator of patient centricity and is it time for a standard measure?



What gets measured gets done. We've all heard this, and it's been proven over and over again. Why is it true? Largely because by measuring something repeatedly, we can no longer ignore it. We have to take it seriously.

The other side of the coin, though, is that if you don't regularly measure something it becomes very easy not to take it seriously. This is why just about any quality management initiative begins with measures of quality KPIs. Otherwise, it's just too easy to talk about quality without making any fundamental changes.

Industry has always understood the importance of quality: look at magazine ads from 1890 and you'll see that they all talk about quality. However, it took the total quality management (TQM) revolution, with its tenet "what gets measured gets done" to affect real change. Up until then, everyone talked about quality, but there were very few big companies that systematically provided the levels of quality that were achieved after William Deming's ideas and the six sigma approach became widespread. Centuries ago, (at least it seems that way), I used to work at American Express, and we went through a comprehensive TQM initiative. I'll never forget that the first year or so was all about simply determining KPIs, measuring them, and then providing that information to everyone. Almost like magic, attitudes - and results - started to change.

What does this have to do with patient centricity? I believe that right now, we are at the point where everyone in pharma is talking about patient centricity... which is good! However, what does pharma measure?

What are the KPIs on pharma management's dashboard? Pharma pays close attention to share price, which is important for any public company. This tells you how you're doing with investors, who are key stakeholders. Pharma also closely follows market share, which is important for any company - it tells you how you're doing with prescribers, and to a certain degree with payers, who are key stakeholders. Most pharma companies also measure employee turnover, and satisfaction, which are key indicators about your employees - again, crucial stakeholders. And now that we are becoming patient-centric... i.e. patients are at the center of everything we do, obviously we are closely measuring... what again?

Clearly, pharma must have some key measure of how patients are reacting to and using drugs. Pharma must measure this closely, coherently, and regularly. Just as everyone follows their stock price, their market share, their turnover, everyone should be following some basic, accepted patient use measures. But this is not the case.

Adherence is the obvious measure. Are patients actually taking your drugs as they are prescribed? Do you know? "Yes!" you'll respond. "We did a study on that in the US, or in France, or in Japan", or wherever. And yes, pharma has started to look. I assume, therefore, that you track this regularly; that you know how your adherence breaks down; that you know adherence rates in different countries and pathologies; how adherence differs across age bands, regionally; how you compare to your competitors; how your patient support programs affect adherence... and that this is not a mish-mash of unconnected ad hoc research studies, but a regular measurement, a KPI that is built into every brand plan. If not, frankly, you have a long way to go.

Luckily, this is all possible. It's more or less easy but it's possible, and in the vast majority of countries and pathologies, it's probably easier than you think. The first step, though, is to figure out what to measure.

Trying to compare adherence is a nightmare. If you look at systematic reviews of adherence within pathologies, and even within given patient groups, you can find wildly different numbers. One systematic review of TNF-α inhibitors found measured adherence rates ranging from 27% to 97%. A review of adherence in Parkinson's disease ranged from 33% to 85%. How can you reach any conclusions when even RCTs are giving such disparate results?

The answer is to use the same measure. There are many, many different ways to measure adherence, and many different ways to calculate the measures. Pharma has to decide on a standard. We strongly suggest that the standard (at least for about 80% of pharmaceutical products) be population MPR.

Medication Possession Ratio (MPR) is widely used as an adherence measure. It is simply the amount of drug in the possession of a patient over a given period divided by the amount required for treatment over that period. To calculate an individual's MPR for a once-a-day pill, for example, I would look at how many pills were dispensed to that patient over the course of a year (we suggest a year) divided by 365. If the patient was in possession of 182 pills over the course of the year then his or her MPR is 0.5.

Of course, I don't know how many the patient actually consumed, but there are many studies that closely link MPR to consumption and clinical outcomes, particularly on a population basis. And from the point of view of financial calculations, we are taking into account the fact that the drugs were sold. For a population of patients, we look at how much of the drug would have been required to treat everyone who began the period as a patient with how much of the drug they actually received over that period.

What are the advantages of MPR? First, it is far, far easier to get data than for consumption measures. Secondly, it can be broken down into persistence and compliance. Persistence measures how many patients remained on treatment over the course of the year while compliance measures what proportion of prescribed drugs were possessed by persistent patients. Roughly speaking, MPR = Persistence x Compliance. It's a little more complicated than that, but it works.

We've started to analyse some major products in some major European markets using this breakdown and the results are fascinating. First, there are significant differences in adherence between products - serious differences, even when products are competing in the same class, with the same dosing regimen and the same general profiles. Second, differences in MPR can be driven by very different mechanisms between products, some with higher persistence, some with higher compliance. Third, numbers can be very different across age bands, genders, even regions. Understanding these differences can lead to very different conclusions about how to best support patients, or even how to present products to prescribers. And all of this is driven by data that is available for most products in most major markets... data you might already have.

Furthermore, a coherent 4-step process (the "4P" approach) can be standardized, used around the industry, and allows for clear, insightful, regular measurement of adherence and its drivers. We'll talk about this in the next column.


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