In a recent presentation to attendees at eyeforpharma’s Patient Compliance Europe 2008 conference, Bernard Vrijens, chief scientist with Aardex Group, dispelled what he calls the five myths of patient adherence and along the way delivered an engaging and insightful “how to” guide to tackling the challenges of patient adherence.
Myth #1
The first myth, Vrijens says, is that caregivers assure adequate adherence.
There is a vast difference, he explains, between daily “effectiveness” and the efficacy seen in clinical trials. The problem of adherence in daily practice is a real and significant one that is not alleviated by the presence of caregivers and that has real health outcomes consequences. For example, one study among the many featured regularly in the popular press, he says, revealed that 12% of emergency room visits are the result of medication problems.
Myth #2
Vrijens says the second myth is that the circumstances of clinical trials assure satisfactory adherence.
First, he says, it is important to understand the definition of adherence. There are three steps for the patient: acceptance of a disease diagnosis, execution of the dosing regimen and for some patients a discontinuation of their medication. Across this continuum, Vrijens says, there are three elements or definitions of importance: persistence, which is how long a patient takes a prescribed medication; the quality of execution, which is how well a patient follows the prescribed dosing regimen while he is still engaged; and adherence or compliance, which covers all of the steps – or the whole picture.
“So, if you have a problem with compliance/adherence, it could be that a patient didn’t accept the treatment, they didn’t execute the dosing regimen well, they stopped taking the medication too early, or a combination of any of these three,” he says.
In a hypertension case study, Vrijens says, after about one year 50% of patients had quite the therapy, while 8-10% stayed on the medication but had shortfalls in adherence on a daily basis due to poor execution of the dosing regimen.
“Those two components are very different – how long and how well both affect adherence, but how you might address these hurdles will be completely different,” Vrijens says. “The conclusion from the hypertension case study is that it is important to develop drugs that have a long ‘forgiveness’ (sustain their pharmacological action long enough) to cope with the common mistakes in dosing made by patients. But it also is important to realize that half of the patients quit therapy early and will need effective management to help them to comply.”
Myth #3
The third myth is that adherence can be expressed as a percentage of prescribed doses, or even worse, as a dichotomy, says Vrijens.
When people talk about adherence they often say a patient is 80% adherent, but that really doesn’t tell the story, he says. One patient may have taken the drug perfectly to begin with, but stopped taking it too early, while another may have missed a lot of evening doses. Another may take “drug holidays,” but take the drug well when they take it. Yet another may decide after a while to take their morning dose, but not the evening one. All of the patients, however, could be classified as 80% adherent.
“To say they are 80% adherent means nothing without knowing what they really did - the clinical consequences of their patterns,” he says. “It’s especially important when you’re trying to build an intervention. You certainly wouldn’t want to give the same message to all of these patients.”
Myth #4
Vrijens says the fourth myth is that patient adherence improvement programs can rely solely on motivating.
In a 1992 academic paper, McKinney and colleagues outlined three strategies for adherence, Vrijens says. Enabling, which are strategies to equip patients to be adherent; consequences, which are strategies aimed at outcomes; and stimulants, which are strategies intended to prompt pill taking.
Vrijens says that although some enabling strategies help, they don’t always work or aren’t always enough. Consequence strategies, he explains, are helpful if outcomes are positive, for instance blood pressure is heading in the right direction with therapy.
“What if they are negative, though?” he asks. “A patient may quit a therapy too early if outcomes are not going in the right direction. You really need multiple steps for successful intervention, including understanding a patient’s history – for instance, whether they like doctors, are receptive to taking medications, and whether is it their first medication or their tenth – and the barriers and motivations that are specific to their situation.”
But because it’s difficult to monitor when barriers occur and when to give motivation, working on execution is often the most effective strategy, Vrijens says.
“What can be measured, can be managed,” he says. “You need a realistic and accurate measurement of day-to-day execution and dosing regimens, which is achieved through Measurement Guided Medication Management (MGMM).”
Vrijens says this kind of data, when given to a pharmacist for intervention has yielded 15% improvements in adherence after a year, for example.
“Adherence interventions need MGMM to know what kind of deviations the patient is making, how well intervention has worked and when intervention needs to be reapplied,” he says. “This lets you pinpoint specific problems with an individual patient and tailor the intervention to their situation.”
Myth #5
The fifth myth, Vrijens says, is that electronic monitoring is expensive.
He argues it’s more of a value than a cost. It’s important to break the downward spiral, he says.
“With poor adherence and persistence, everyone – patients, payers and the industry loses,” Vrijens says. “With robust adherence and long persistence everyone wins.”
There are, he explains, three types of patients: new patients, those in the midst of treatment and those who have stopped treatment. Currently, to increase sales, the pharmaceutical industry focuses on targeting new patients, but very few address what other industries call “churn” – those customers who drop off or are in danger of doing so.
The cost of addressing patient compliance doesn’t really seem as expensive when it is put in a sales and marketing context, he implies. When the cost of retaining a patient likely to be lost to poor compliance is compared to the cost of acquiring new patients, the value is clear, he says.
Author: Lisa Roner, editor, eyeforpharma
