How do you solve a problem like non-adherence?

Elisa del Galdo | 18th 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.

The drugs don’t work – factors of non-adherence

Although patients know that the medications prescribed are effective at curing or controlling their medical conditions and diseases, depending on the therapeutic area, the percentage of patients who do not adhere to their treatment can range from 25% to 78%. This behaviour can drastically reduce the efficacy of treatment, which in turn leads to increased medical emergencies, increased morbidity and, in the worst case scenario, death. There are many factors that influence a patient’s ability to follow their treatment as prescribed. Just the fact that there are many different reasons, and that a single patient can be dealing with a combination of factors that influence their behaviour, makes the identification of a single solution to non-adherence almost impossible. The known factors that affect adherence can be derived from:

  • the attributes of the patient
  • issues with healthcare practitioners (HCPs), and the healthcare system
  • issues with pharma products e.g., side effects or mode of administration

More specific reasons for non-adherence can include:

  • low health literacy
  • poor patient-HCP relationship
  • lack of communication or continuity of care
  • having an asymptomatic chronic disease
  • physical impairments
  • co-morbidities and poly- pharmacy
  • treatment complexity and length
  • side effects
  • lack of emotional or social support

It’s obvious from this long list why a ‘one-size fits all’ solution is not possible.

 

Several factors have a direct influence on adherence

A major concern for healthcare practitioners is the lack of time they get to spend with patients so they can properly communicate to patients what to expect with regard to their condition, treatment options, potential adverse effects from medication, and any issues surrounding poly-pharmacy or co-morbidity. For the patient, this type of information can be difficult to fully digest. The information is not always presented in a way that is understandable, and there usually is a great deal of it presented at a time when the patient may be under high levels of stress.

Patients also often need to cope not only with masses of information, but also conflicting information from multiple HCPs. This can result in patients not having a full understanding of their condition, how their treatment works, or the importance of adherence. Ultimately, patients want to be well, however, for many patients this requires education and behaviour support to ensure that not only do they understand the importance of adherence, but also have the tools to tackle any barriers that they face. A simple solution would be providing a patient more time with their HCP, but this is unlikely to be achievable within current healthcare systems.

Lack of information around non-adherence can impact behaviour

For common prescriptions such as antibiotics, it has been assumed that the importance of adherence is recognised, so instructions may not be as prescriptive, informative or persuasive as they should be. For a patient to be told, “ensure you complete the entire course” is not enough, especially if a patient’s symptoms disappear and they believe they are cured.

Even when a patient adheres to their treatment, taking their mediation in the correct dose and on time, behaviour such as consuming alcohol while taking certain antibiotics can contribute to poor efficacy by causing a reduction or delay in the effect of the treatment, in addition to some unpleasant side effects. Understanding the effect on the patient (and the greater population) of not completing the treatment as prescribed could provide both the rational and emotional reasons for adherence.

The impact of long term conditions

Another contributing factor is the actual condition from which the patient suffers. Advances in healthcare have evolved in a relatively short amount of time. This means that many of the conditions that previously lead to mortality are now classified as chronic conditions whose treatment is long term and often complex. Typically, complex and long term treatment regimens contribute greatly to non-adherence statistics. The complexity and length of a treatment, and understanding where a treatment may be controlling a condition as opposed to curing, can influence a patient’s ability to adhere – especially when the results are not immediately obvious.

Influencing the patient’s behaviour

The healthcare system can also influence patients’ ability to adhere to their treatment regime. Ensuring that the information provided to patients is appropriate and addresses the issues that concern the patient, written at a level that is informative, yet digestible by someone without a medical background. This will allow the patient to become more knowledgeable about their prescribed treatment, and more confident in self-administering, resulting in them being fully engaged with their treatment.

Poor adherence is costly for the wider healthcare system, as prolonged or unsuccessful treatments can lead to secondary issues, such as increased morbidity in patients and a need for greater levels of care, as well as the potential for emergency or institutional care. This ultimately leads to an increased cost in care and a greater financial burden on the healthcare system, and the patient or their carer.

An opportunity for Pharma

Pharma also want to see their products being used successfully to control chronic conditions and treat diseases. Supporting patients to adhere to their treatment regime with relevant and suitable information, products, tools, or services that address patients’ barriers can lead to better outcomes. Providing additional services can not only support the patient, but will also help the HCP in their efforts to elicit adherence behaviour and better outcomes.

Services that go ‘beyond the pill’ can help patients to not only remember to take their medication, but also help them to understand their treatment at times when an HCP may not be available. Well-designed services can provide the motivation and behavioural change to make adherence easier and create a habit that elicits adherence behaviour. In order to do this, services, tools and products must focus on addressing the causes or problems that lead to non-adherence – not just the symptoms.

Additionally, we see pharma products that can increase adherence by addressing some of the barriers or pain points that patients experience. Drugs that can be taken once a month as opposed to every day, or that can be done at home (as opposed to a long and sometimes difficult visits to a clinic), can be beneficial for adherence, and ultimately patient outcomes.

Not adhering to treatment is costly for the patient, the healthcare system, and pharmaceutical companies. In order to effectively address the issues that cause non-adherence, the content – patient attributes, therapeutic area, the healthcare system, the treatment and the relationship with HCPs – must be taken into account. Solutions must be tailored to the context of the patient.

No matter how effective a treatment, patients must take it for it to work as intended by their physician.

Read the second instalment in the adherence series by Elisa del Galdo here.

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