Medicines adherence – the missing piece in the puzzle of effective patient care
Jue, 17 Nov 2011 03:00
The social and monetary costs of non-adherence to prescribed medication has been a discussion topic among healthcare providers, funders, academics and other industry stakeholders for quite some time. Despite this, improvement has been slow in coming with many players unwilling to take the lead. However, an increasing focus on the underlying causes of non-adherence could be the key to resolving this concerning and complex problem.
Non-adherence is a global issue. World Health Organisation data shows 50 percent of patients do not take their medications as prescribed, leading to stretched hospital resources, reduced efficacy of medications, and poorer long-term patient health outcomes.
In the US, non-adherence generated an estimated $300 billion in avoidable medical spending during 2009. In Europe, non-adherence is a contributing factor in an estimated 200,000 deaths each year, and costs the economy €125 billion. 1
Healthcare funders determined to optimise their spending are taking notice. Payment systems that reward manufacturers and distributors purely for the supply of medicines, rather than on the value they provide, are being reconsidered. In the future, payment is increasingly likely to become performance-linked and, as a result, the pharmaceutical industry will need to find ways to ensure the drug efficacy levels achieved in clinical trials are matched in the real world. An effective adherence programme, that delivers outcomes, is likely to become a vital part of the total offering.
The UK National Health Service (NHS) now has adherence on its radar. The New Medicine Service, designed to improve adherence amongst patients with long term illnesses, is one example of this – and with initial funding of £110 million over two years, it provides a significant opportunity to improve patient health outcomes. 2
To make the most of those opportunities, interventions must target the underlying causes of non-adherence. Research carried out by health psychologists working in the area of behavioural change, suggests the strongest predictors of non-adherence are:
- Concerns about the treatment (fear of side effects)
- Beliefs about the illness (cause and timeline)
- Cost of therapy
- Perceived need for the medicine, and perceived drug efficacy. 3
Professor John Weinman, Head of Health Psychology at Kings College London’s Institute of Psychiatry, cites research suggesting that 70 percent of non-adherence is intentional. In other words, non-adherence to medication is not simply a matter of forgetfulness, which might be remedied by a generic reminder or similar traditional type of intervention; rather, it is a product of the individual patient’s health literacy, symptom experience, social support, coping skills, belief systems, and other social and cultural factors.
Successfully overcoming these barriers to effective treatment requires interventions that target the individual’s behavioural drivers. To succeed and positively influence behaviours, these interventions need to be based in sound, evidence based principles. To be commercially viable, they need to be scalable, and easily adaptable to deal with a variety of cultural norms. Converting this theory into practice is no easy feat outside of a clinical trial setting, and requires a full understanding of the intentional drivers of non-adherence.
An effective adherence programme, therefore, must not only meet ethical, legal and regulatory obligations, including pharmacovigilance requirements, it needs to incorporate a sound understanding of what motivates the patient, and of the most effective ways for individual patients to share and receive information.
Sophisticated psychological modelling helps explain the behaviour of the individual patient – and those explanations allow support programmes to be personalised. The message; what we say and how relevant it is to the patient, is of higher importance than the channel with which that message is delivered. Certainly media channels (e.g. email, SMS, phone) are important in ensuring a programme is well received and patient burden is minimized e.g. the support programme fits into the patient’s lifestyle allowing for more timely and convenient consumption.
The discipline of health psychology has developed research tools that have been validated across multiple disease states at being effective in predicting non-adherence and in developing interventions to improve adherence to treatment.
The Beliefs about Medication Questionnaire is one of these tools. Patients are asked to rate how strongly they agree or disagree with statements relating to their health and to their prescribed medication using a 5-point Likert scale (1=Strongly Disagree, 2=Disagree, 3=Uncertain, 4=Agree, 5=Strongly Agree). Their answers enable the reliable identification of beliefs that are predictive of non-adherence, and the development of an intervention that encourages the patient to base their beliefs on sound information, rather than anecdote, and an informed understanding of the importance of following the prescribed course of treatment. 4
What patient support can be given?
Traditionally, the clinician has been the patient’s primary source of support and on-going care. However, the modern reality is that Primary Care Trusts are struggling to keep up with supporting these patients. Patients nowadays want more information, yet consultation times are increasingly truncated. In many cases it is simply not possible for clinicians to fully explain why the prescribed treatment is required, let alone discuss how it works, or provide sufficient follow-up observation and support.
Clinicians practicing in other European nations are facing similar pressures. In Germany, workloads are such that the average consultation lasts for less than eight minutes – leaving patients seeking alternative sources for information and support. 5
Public health systems cannot support extended consultation times; instead, patients must be given the tools to better self-manage their illnesses, with education and support delivered in ways that reflect the individual patient’s needs and preferences.
Nursing calls, customized health magazines, brochures and information sheets, SMS and email campaigns are the most common channels used to communicate with patients during their treatment journeys.
But emerging digital channels, otherwise known as digital interventions, have real scope to make a difference in the future. These include; smart mobile applications, social media and interactive presence solutions. Although these interventions are certainly growing in popularity and are seemingly quite successful, it is important to note that these new interventions are still largely untested in the market when compared with more traditional channels.
Websites that equip patients with engaging health information are important for improving self-management and enhancing patient treatment outcomes. An example of this is the award winning ThisWayUp website, specifically designed to assist patients who have been prescribed Merck Serono's growth hormone treatment from their healthcare professional. Through a password protected secure website, patients are offered support online – enabling them to better self-manage their condition.
Nursing support – building a sense of community
Nursing support is invaluable to a patient’s care. Elizabeth Akinwumi is a Qualified Nurse who supports and provides advice for a variety of patients. She currently works with Atlantis Healthcare (an Adherence solutions business) as a Senior Nurse Advisor. According to her, each patient support programme she works on is different – tailored to the disease state and the unique needs of each patient.
“Patients want to know they are talking to a qualified health professional who not only has knowledge about their disease but understands the social, psychological and emotional implications of their disease.”
“There’s a certain rapport you build with patients over the phone that encourages open dialogue, where patients feel like they are really being listened to as well as supported. And it is through this dialogue that a patient reveals factors that may affect their ability to comply with their prescribed health regime.”
Elizabeth shares the following quotes from patients who were involved in the “Embrace” patient support programme - initiated and funded by Servier, specifically for patients prescribed their treatment for Osteoporosis.
- “Thank you I never realised I had to leave a 2 hour gap either side of taking the medication.”
- “No one tells you these things when you get your prescription.”
- “It’s wonderful to know there are people out there that care!”
- “I found the mailings very useful and informative!”
- “I never really had a clue what it did “until you explained”!”
- “I never thought about taking it in the middle of the night when I get up!”
- “I found the recipes wonderful in the mailings.” 6
Through support hotlines, and scheduled follow-up calls to patients, Nurses play a vital role in helping patients remain adherent throughout their treatment journeys’.
Personalised approach to patient support
A study recently published in the British Journal of Health Psychology shows the difference a personalised support programme can make to improving medication adherence rates. The study was initiated to address the common issue of non-adherence to preventative asthma medication. 25 percent of asthma patients have poor disease control; this is strongly associated with non-adherence to treatment, which has been shown to be as high as 50 percent. The economic impact of non-adherence is significant, with uncontrolled asthma patients costing £381 per year vs. £108 for controlled.
The study set out to identify whether sending patients with asthma a series of text messages designed to change their beliefs about their illness and treatment would improve adherence with preventer inhaler medication. Adherence rates were captured via patient self-report and ‘smartinhaler’ data.
A number of previous studies have highlighted the relationship between people’s beliefs about the nature of asthma and their adherence to preventer inhaler medication. This study targeted five illness perceptions: short timeline (no symptoms = no asthma), low personal control, low symptoms, high symptoms, and poor understanding; and two medication beliefs: low necessity and high concerns. A bank of 166 messages designed to counter these seven beliefs – all of which had previously been found to be associated with non-adherence to preventer medication – was prepared ahead of the study. Participants received tailored text messages based on their responses to a questionnaire assessing their individual illness perceptions.
At the end of the 18 week study period, the authors found those study participants receiving the text messages viewed had an increased perception of: their asthma as a chronic condition; the degree of personal control they had over their asthma; and their need for preventer medication.
As these findings would imply, the intervention group also recorded adherence rates around 10 percent higher than the control group – and a significantly higher achievement of 80 percent plus adherence levels. The research concluded that if targeted SMS messages are used to communicate with Asthma patients, adherent behaviour will increase for the long term. Even nine months after the SMS messages ceased, the majority of people who took part in this were found to have continued adherence. 7
Turning theory into practice
Ultimately, everybody in healthcare – pharmaceutical companies, healthcare funders, providers and patients – want the same thing: improved health outcomes. However, every stakeholder may have slightly different objectives for an adherence solution.
For the pharmaceutical industry it may be improved adherence to treatment. For the healthcare professional it might be enabling the patient to better self-manage and understand their condition enhancing clinical outcomes. For the patient it might be emotional support or advice about how to minimize the side effects they are experiencing – in turn giving them a greater sense of control over their condition.
Adherence regulatory considerations
Looking at the wider industry, the Patient Information Forum is in place to raise the standard of consumer health information; the member organisations range from Not For Profit, to NHS organisations and commercial companies. Through their guidelines, they ensure health information professionals can be successful in communicating effectively with patients.
But pharmaceutical companies and regulatory agencies may also need to consider re-evaluating their systems and processes if they are to get the maximum benefit from medication adherence programmes. Legislation currently in place across much of Europe prevents reference to patient support programmes in packaging. Many of the protocols governing communication with patients need to enable informed patient dialogue that is at the heart of the dynamic, patient-specific model of adherence programmes.
We need to ask if current regulatory policies are benefiting patients, and work to build better mutual understanding between adherence programme providers, pharmaceutical companies, regulatory authorities and other stakeholders. All of whom are trying to achieve the same objective: better health outcomes for patients. We need to consider the benefits of acting to improve adherence – and the costs of inaction.
In other markets, such as Australia, there is more scope to support patients by providing extra health information within medication packaging. Consumer Medicines Information (CMI) guidelines are designed to provide patients with important facts before, during and after taking medication by working closely with pharmacists to deliver this information. This organisation is government funded.
There have also been adherence programmes successfully run in Australia where enrolment forms have been permitted within medication packaging – giving more patients access to support. An example of this is the Verve patient support programme, designed for Breast Cancer patients’ prescribed hormonal medication. According to a paper from the Southern Cross University in Australia, this support programme delivered excellent results; 6 months after interventions ceased 91% of surveyed patients self-reported to be 100% compliant to their prescribed medication. 8
While developments in health psychology and communications technology are allowing significant advancements to be made in adherence solutions and patient support, the success of these will be limited if they are not readily available to patients. A rethink on how to lower the barriers of entry to these programmes needs to be undertaken with wide consultation, so patient adherence to treatment can be improved and better outcomes achieved.
By Kate Reid - Managing Director, Atlantis Healthcare UK
1. Cap Gemini (2011). Patient Adherence, the next frontier in patient care.
2. In Pharmacy (2011). New Medicine Service in Pharmacy Contract. Retrieved from
3. The Boston Consulting Group (2003). The Hidden Epidemic. Finding a cure for unfilled prescriptions and missed doses.
4. Horne, R., Weinman, J. & Hankins, M. (1999). The Beliefs about Medicines Questionnaire: The development and evaluation of a new method for assessing the cognitive representation of medication. Psychology and Health, 14, 1-24.
5. Arztreport Barmer GEK. (2010)
6. Atlantis Healthcare (2011). “Embrace” patient quotes.
7. Petrie, K., Perry, K., Broadbent, E., Weinman, J. (2011). A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. British Journal of Health Psychology.
8. Southern Cross (2008). Breast care nurses’ attitudes towards adherence and patient information – a new approach to patient management.