By Xavier Tello
One of the most important [not so] hidden costs of therapeutics and health care, is patients’ lack of adherence to treatment.
According to several authors, including a review of the Cochrane Collaboration, the “desertion” index could go up to more than 50% of doses amongst patients.
“People who are prescribed self-administered medications typically take less than half the prescribed doses,” R.B. Haynes
While this problem has been addressed by scholars, physicians, health authorities and the Pharmaceutical Industry, it appears that neither an effective nor adequate solution exists. Worst of all, the proper diagnosis of this issue, has been established just a decade ago, at (almost) the same time that tougher regulatory, ethical and compliance codes have emerged, restricting the range of action of some instances like Industry-supported patient-groups or direct to patient initiatives.
As the demographical curve is directing towards a more elder population and epidemiological information indicates that chronic illnesses such as Diabetes and Cardiovascular disease, Cancer, Alzheimer, Depression, etc, will have a major impact in health and general economics; a big discussion is starting to emerge regarding the kind of interventional measures that have to be taken, as well as who has to take them, to improve patient compliance.
What should be done?
In an ideal world, all patients would follow their prescription ad integrum with no dose skipped or treatment dropout at all. However, there are motivations (some of them very strong) for patients to abandon their therapies.
These reasons, which are very well described, are:
Economical.- Patients who have no resources, insurance or healthcare system; or medications that are rather expensive.
Educational.- When patients don’t understand the implications of their disease and the importance of following an adequate treatment.
Technical.- Attributed to the medication itself. Difficult or unfriendly pharmacological forms like big or distasteful pills or painful injections; or complicated dosages like: five-times-a-day.
Cultural.- A phenomenon well identified in third world countries (like México), where challenging the physicians knowledge (or authority) happens frequently. In these scenarios, a lot of desertion occurs while patients look for friends or family “counseling”; and other forms of therapies emerge such as alternative medicine.
We are not mentioning religion here as a cause of low treatment adherence, as it should be detected by the physician while diagnosing and determining the best treatment option for the patient.
With these factors in mind, it would be obvious to think about addressing adequate countermeasures to avoid specific causes of treatment desertion.
In a 2007 paper published in the BMC Health Services Research (BMC Health Services Research 2007, 7:55) a team lead by Dr. Sandra van Dulmen, from the Netherlands Institute for Health Services Research, analyzed different forms of interventions towards a better adherence.
The first and perhaps more important conclusion, is that the most adequate interventions are effective in short term treatments, while efficacy of actions during chronic therapies has to be further investigated.
It is important to mention that there were different levels of efficacy while addressing to different types of intervention:
Technical Interventions, like modifying packaging characteristics or dosing prove to be very effective, but it has to be considered that benefits are better noted in patients complaining for these particular reasons.
“Behavioral” Interventions like reminders (newsletters, phone calls, or even personal paging) or rewards also were detected as very useful and cost-effective. Whereas these incentives have to be in kind (actual product rebates) or in cash (yes, cash…) has yet to be determined.
Educational Interventions are very difficult to evaluate, since there’s not an appropriate method of measuring the impact. If a patient doesn’t know or if he or she is simply not interested is always difficult issue to be solved.
Social support interventions proved to have the strongest relationship with adherence. Apparently, social or “common cause” bonding has really big implications when talking about changing treatment fulfillment attitudes, just like AA does to alcoholics.
Structural interventions, which are defined as specific programs created to “push” adherence within non-adherent patients could be as twice as effective as “general ones”.This programs could include specially trained nurses for administer treatment or at place of work programs.
Who has to be responsible for provide this interventions?
There has been lots of discussion regarding the actual implications of the involvement on these actions.
While it’s clear that something has to be done in order to improve adherence rates amongst patients, it’s more difficult to determine who has the moral / ethical authority to do so.
Governments could play an important role in this matter; however, it is inarguable that it implies a huge amount of resources in cash, headcount, logistics and informatics. In an age where a tough economical crisis is being faced worldwide, allocating resources to improve patient adherence will require in-depth pharmaco-economical studies.
Pharmaceutical Companies have traditionally embraced this quest, due to two obvious factors:
- The serious concern of their products not been associated with poor efficacy (due to treatment dropouts) and
- The economical benefits of doubling or multiplying the total number of units sold for each treatment-span.
The active intervention of the Biopharmaceutical Industry has been challenged by regulatory authorities, as it’s always seen as a proactive communication with and influence to the patient, in order to assure re-purchase of an specific brand.
The Financial Times published today an article about Roche been censored by UK’s Prescriptions Medicines Code of Practice auto-regulatory Authority, for giving ₤10 Toys-R-Us vouchers to persuade children of taking Pulmozime® to prevent pulmonary infections in cystic fibrosis cases.
At first sight, such a determination looks like nonsense; however the line that separates a real and plausible preoccupation for patient compliance from an open effort of pushing sales of a brand, is very thin.
With the recent outcome of the new PhRMA Code of ethics, a more difficult task is been faced: How to really help to improve patient compliance and adherence to treatment while moving within ethical limits.
Is patient education the only way?
Unfortunately our opinion is no. Although patient education looks fancy and could be the most regulatory / ethically correct, patient education is a difficult and rather risky subject.
First of all, a proper situational diagnosis has to be made. When someone (like a government health authority) addresses education as the only or most important factor around poor adherence; it is not recognizing that in many cases, other limitations exist such as the economical ones.
Economical constraints could not be an issue in Canada or Europe but in México and plenty of other countries, medicines are bought almost totally out of the pocket.
A recent poll conducted by Strategic Consulting within Mexican population, showed that 40% of patients abandoned their treatment because it was expensive, as 50% agreed that a “special price” or direct offer from the laboratory would put them back on track.
In the USA this phenomenon happens with people that only have basic coverage or not insurance at all.
As mentioned, patient groups seem to be a rather effective way to improve compliance, but someone with the appropriate resources should cover the costs of launching and properly operating them.
At this point, the only realistic means for correctly maintaining an effective patient compliance program should come from the Bio-pharmaceutical Industry.
More flexible and well-thought rules have to be designed in order to assure patients a better environment to maintain their medication regimes.
However, if these companies don’t understand well the responsibility that comes with a direct-communication to the patient, the whole intention of such a maneuver could be jeopardized and the reputation of the Sector would suffer more damage.