How do you solve a problem like non-adherence? (Part II)

Elisa del Galdo | 28^th May 2015

Recent research from the World Health Organisation and the Mayo Clinic on the impact of (and influences on) a patient’s ability to adhere to their treatment regime has shown that an astounding amount of patients do not follow or complete their treatment as prescribed.

In part one of this series, Elisa del Galdo looked at the complex factors around patient non-adherence. In the final instalment, she examines additional barriers to adherence as well as the patient persona most likely to not adhere to their treatment plan.

Efficacy data doesn't tell the whole story

Efficacy in drugs is demonstrated via tightly controlled and monitored clinical trials. In the real world, the same drugs may not be as effective; not because they no longer work, but because patients very often do not take their treatments as prescribed. Research by the NIH has shown that 25%-78% of patients do not adhere to their prescribed treatment. For Pharma, addressing the issue of non-adherence is complex.

Ideally, healthcare professionals (HCPs) will take a more holistic approach when deciding on a treatment for their patient, rather than relying on efficacy data. However, some key questions are raised in the process of choosing the treatment:

• How is the treatment decision made? Is it physician led or is it a collaborative decision with the patient?
• What attributes make one treatment more attractive to a patient than another?
• Is the physician fully aware of the patient’s potential barriers to adherence, and have they incorporated the patient’s potential issues with adherence into their prescribing decisions?
• Is the patient fully aware of the idiosyncrasies of the treatment, and how non-adherence can affect its success?
• Do services or support mechanisms exist to ensure the patient has the best possible chance to adhere?

Factors of non-adherence: real-world scenarios

There are many variables to consider; some of the information available to a patient might be conflicting, which causes further confusion when making a decision about the best treatment option. For example, drugs that show superior efficacy in clinical trials, where adherence is tightly controlled, may not show the same level of efficacy in a situation where the patient has the majority of the responsibility for adherence. The HCP has to determine whether this is due to non-adherence, or to an underlying effect in a real-world scenario. This could include:

• length of treatment
• complexity of the treatment
• mode of administration
• side effects
• patient’s health literacy and living conditions
• the existence of a patient’s support unit (family, friends and carers)
• the patients relationship with their HCP and ease of access

Solutions to address a complex set of needs

The solution isn't just about communicating the benefits of adherence – most physicians will understand and completely agree that adherence is vital, as without it, achieving the desired outcomes for your patients is incredibly difficult; patients tend to echo this sentiment.

A ‘one size fits all’ approach will be ineffective at targeting all the factors that influence each patient. Providing additional services, guidance, advice, and tools to influence and support the desired behaviour, which is likely to require a change of habits or behaviour change, will help to ensure patients understand:

• their condition and the treatment options available
• the idiosyncrasies of the treatment and any side effects they may experience
• how best to handle any side effects
• efficacy and persistence expectations
• mode of administration and its importance
• the difference between cure and control
• options for addressing the ‘pain points’ and barriers to adherence that they may experience

By going ‘beyond the pill’ with the support of Pharma, the healthcare system, and HCPs, an environment and tools can be created for the patient that will help them overcome the barriers to adherence they experience, and result in better outcomes.

Patient personas and journeys

During our research with oncology and diabetes patients, we documented the patient journey in a number of stages from pre-diagnosis of their condition to diagnosis and treatment, followed by either remission, recovery or a maintenance phase. Throughout this journey, patients all followed a similar path, until they got to the final stage – recovery/maintenance. It seemed to be at this point that patients split into three different personas:

The advocate – these patients are highly knowledgeable on most aspects of their condition and the treatment options available. They tend to become advocates, or what we refer to as a Patient Key Opinion Leaders (PKOLs) and often influence other patients via support groups or even creating charities.

The self-concerned – these patients are similar to the advocates in their knowledge, however they tend to focus this knowledge on their own wellbeing (and the benefit it has for their family members) rather than for a community of similar patients.

The unengaged – these patients find it difficult to engage with their HCPs and their treatment. They have not gained enough understanding of their condition or treatment to move past their rationalisation of non-adherence.

Although we can’t predict the percentages of patients in each group, based on other research in the field and our experience at Blue Latitude Health, it is the unengaged who are most likely to represent the 50% of the patient population that does not adhere to their treatment regime. In contrast, the advocate is likely to be a very small percentage, perhaps less than 5%.

Designing services for the unengaged

The approach is two-fold:

• Firstly, as researchers and designers, we need to understand patients’ barriers to adherence and how to motivate them to improve their adherence in their specific context.
• Secondly, with this insight, we can then design solutions (content, services, apps, and products) that overcome or lessen the impact of these identified barriers, whilst incorporating relevant content and mechanisms to support the desired behaviour.

Only by clearly understanding the patient’s barriers to adherence to their treatment will we be able to create solutions that truly work within the context in which the patient exists. Ultimately, pharma companies want their product to be successful in treatment, and to be the most prescribed. HCPs are focused on treating their patients for the best possible outcomes, and patients want to be well. With the design and delivery of research-based, insight-driven innovative solutions, the best possible outcomes can be achieved.  

Download the full sized sketchnote of the three patient personas below: