Improving adherence of medication: a cornerstone of success
The challenge of ensuring treatment compliance has been appreciated since the time of Hippocrates. One of the famous quotes of Hippocrates says “keep watch also on the faults of the patients, which often make them lie about the taking of things prescribed”. The unassailable fact that medicines cannot be effective if the patient does not take them as prescribed is demonstrated daily in clinical practice as patients forget doses or refills, take extended “drug holidays,” and/or take medications only around physician visits (“white-coat compliance”) (Düsing R, et al 2001).
Treatment noncompliance is a long-standing problem for both doctor as well as patients. It has lately drawn an attention of the pharmaceutical industries as well due to its impact on pharmaceutical industry growth. Treatment compliance is important for optimum therapeutic outcome which improves patient’s quality of life. Noncompliance usually results in increased morbidity, treatment failures, exacerbation of disease, more frequent physician visits, increased hospitalizations and even death (increased mortality rates). Two common measures of compliance are adherence (sometimes used as a synonym for compliance) and persistence. Adherence refers to the proportion of pills taken within a specific time interval and persistence refers to the continuing use (in time) of the prescribed therapy.
According to World Health Organization (WHO), the term adherence may be defined as: the extent to which a person’s behavior (e.g. taking medication, following a diet and/or executing lifestyle changes) corresponds with agreed recommendations from a health care professional. Compliance for long-term treatment, such as lipid-lowering therapy, is influenced by biological factors, psychosocial factors, and regimen factors. It is important to identify patient lifestyles, mind-sets, or other factors that may compromise compliance. It may be possible for the physician to identify and resolve barriers to noncompliance through problem solving with the patient.
Low adherence is largely observed in long-term treatment when the treatment is complex or when the disease is asymptomatic (such as hypertension) (Leiva A, et al. 2010). During the asymptomatic phase of cardiovascular diseases, including hypertension and hypercholesterolemia, and other chronic disorders, many patients do not convinced of the need to take medications. A patient who experiences an adverse event early in treatment may not be convinced of a medication’s long-term safety. Those who start a statin and then experience a myocardial infarction (MI) may not be convinced of treatment efficacy (Benner JS, et al. 2002).
According to Haynes (Haynes RB. 2001), many patients are at risk for noncompliance because “the short-term disadvantages of following chronic disease therapy substantially outweigh the short-term benefits, and patients require persistent reminding of the long-term benefits to swing this unfavorable balance in a positive direction.”
Clinical trials to evaluate effect of treatment adherence on health outcomes
Numbers of clinical studies were conducted in various therapeutic areas to compare the desired health outcomes in treatment compliance versus treatment noncompliant patient groups.
A review done by Rhee MK, (Rhee MK, et al. 2005) for a study conducted to assess the influence of medication adherence on HbA1c in diabetic patients revealed the substantial improvements in HbA1c for the treatment compliant patients. Alfonso Leiva (Leiva A, et al. 2010) in his analysis of a study in hypertensive patients, conducted to access the effect of poor adherence to antihypertensive medications, concluded that in terms of relative risk reduction, an improvement in medication adherence could be as effective as the development of a new drug.
The association between cardioprotective medication adherence and mortality among patients with diabetes and IHD was evaluated in a randomized clinical trial. The evaluation concluded that, medication adherence is associated with improved outcomes among patients with diabetes and IHD. Quality improvement interventions are needed to increase medication adherence in order for patients to maximize the benefit of cardioprotective medications (Ho PM, et al. 2006).
In another systematic review done by J. A. Cramer (Cramer JA, et al. 2008) to evaluate the significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia, it was concluded that the poor compliance and persistence with cardiovascular and antidiabetic medication proved to be a significant problem.
Another side of the coin
Tripod of the healthcare system has been equally balanced on three legs, i.e. patient, healthcare provider (physician), and pharmaceutical company. Treatment adherence is the combine responsibility of patient, healthcare provider and a pharmaceutical company. The most common reasons for treatment noncompliance are always linked with patient’s forgetfulness (“forgetting to take medication”), or unwillingness to take medicine (e.g. due to unpleasant flavor/ taste). Among three legs of health system tripod (patient, physician, and pharmaceutical company), the patient is always a first one to be blamed for the noncompliance issue. But there is always another side for every coin. Sometimes inability of the physician to convince the importance of treatment adherence to the patient and improper follow-up also contributes as a major cause for noncompliance. Pharmaceutical company may play a vital role in this regard. Systematic education program to the healthcare provider and a use of appropriate technology as a treatment reminder can help to improve treatment adherence by the patient.
Treatment noncompliance: Pharmaceutical marketing perspective
The treatment noncompliance not only affects the health outcome, but it also has a great impact on marketing strategy and profitability of the pharmaceutical company. Indian pharmaceutical industry is the fasted growing and most competitive industry. It is now the third largest in the world in terms of volume and stands 14th in terms of value. According to the All India Organisation of Chemists and Druggists (AIOCD), the pharmaceuticals industry in India will grow by over 100 percent over the next two years. As per AIOCD estimations, the pharmaceutical industry is currently growing at the rate of 12 percent, but this will accelerate soon (IBEF NEWS July 2010).
However, the actual picture of the pharmaceutical industry growth may not be such smooth and without hurdle. Treatment noncompliance is the major hurdle in this growth, since it has a direct negative impact on it. Treatment noncompliance and premature medication discontinuation seems like a missed opportunity to sale the essential pharmacotherapy to the patient and has resulted in decreasing or even negative returns on investment in both pharmaceutical product development and marketing. According to Cutting Edge Information (Year 2006), patient non-adherence to prescription medications costs the pharmaceutical industry more than $30 billion in lost revenues. Each year, noncompliance with effective medication regimens costs the US healthcare system at least $100 billion, including indirect costs in terms of lost productivity (Oldridge NB, 2001, Berg JS, 1993).
Companies who implement strategies to increase adherence and persistence with their products can better face the numerous challenges in today’s competitive pharmaceutical market and increase their share of profits. Patient adherence programs not only make sound business sense for products’ bottom lines, but they also help bolster the pharmaceutical industry’s image by illustrating companies’ social responsibility.
The practical solution: Pharmakeez ways!
Objective based strategies are required to improve patient adherence. Proper communication with patient regarding the goals and priorities of the treatment and continuous monitoring of treatment adherence are two important parts of this strategy. The certain minimal steps can be taken by most clinicians, including spending a few seconds each visit discussing adherence and maintaining scheduled follow-up visits.
The proper use of the technology to deal with treatment noncompliance may be a confident step towards desired health outcomes. PHARMAKEEZ which aims to provide an end-to-end solution to all the requirements of a pharmaceutical industry, has come up with a simple and novel concept of as how to improve patient adherence with a unique ‘PILL REMINDER SERVICE’. This unique software includes two way SMS system and web based application for medicine pill reminder.
Dr. Amit Dang, Entrepreneur, PHARMAKEEZ states that, “The power of text messages (SMS) and a clutch of health applications on the mobile is changing the healthscape of India and other countries across the globe by establishing a personalized communication with patients and monitoring their health progress”. An American survey shows that 40% of the respondents don’t mind paying for an SMS reminder service as it is personalized. Patients can be managed with timely reminders about need to take pills and tests—either via SMSes or emails. India has over 652 million mobile phone subscriptions. Worldwide, the number is 4 billion. Every mobile phone has at least a facility to send and receive text messages. “This SMS service is already in use in India to remind people about their glucose monitoring, fertile days of the month or dosage” he says. “The same technology has been used by Pharmakeez to solve the emerging problem of treatment compliance. This newly developed ‘PILL REMINDER SERVICE’ by Pharmakeez is the hopeful step towards improved patient health, and thereby expanded societal benefit and pharmaceutical profitability” he added.
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Rhee MK, Slocum W, Ziemer DC, Culler SD, et al., The Diabetes EDUCATOR, Volume 31, Number 2, March/April 2005:240-250.