Doubling Down on Drug Adherence

Inconsistent adherence to prescribed medications results in clinical and financial implications for all stakeholders, including patients, prescribers, payers, and the overall healthcare system. For patients managing certain chronic conditions, such as diabetes, rheumatoid arthritis, and many types of cancer, failure to stay on therapy makes it harder for these individuals to manage their symptoms and slow their disease progression. For patients managing other conditions, such as hypertension, high cholesterol, and cardiovascular disease, which often present no symptoms on a day-to-day basis, failure to consistently take their treatments as prescribed increases the patient’s risk of experiencing acute medical emergencies, hospitalizations, or even death that may have been prevented.

Payers end up shouldering the cost of hospitalizations, emergency room visits, and other medical and therapeutic interventions that could have been prevented by consistent adherence to the prescribed medication regimen. Meanwhile, poor adherence among large patient groups over long time periods also dilutes and confuses the real-world evidence (RWE) that life sciences companies develop to help articulate the therapy’s overall safety and efficacy profile. Mixed clinical signals coming from real-world patient experiences can damage not only the brand reputation among prescribers and patients but, importantly, can undermine the pharma company’s bargaining power when it comes to the data-driven negotiations they engage in with drug-pricing and formulary-placement decision-makers.

Meanwhile, as the Inflation Reduction Act (IRA) is likely to create pricing pressure for many branded therapeutics, “it’s more important than ever for drug companies to double down on adherence-related initiatives,” says Kim Plesnarski, VP, market access and patient services solutions for Syneos Health. “Successful interventions that are able to keep patients on therapy help to close the valve on related revenue losses.”

Potholes and speed bumps impede the patient’s journey

A.J. Triano, EVP, customer experience practice, for Syneos Health Communications, notes that it's a "different mountain to climb" when patients don't necessarily feel the impact of their disease on a day-to-day basis. In such cases, it's still vital for these individuals to remain adherent to potentially costly and complex drug regimens in efforts to prevent the occurrence of some abstract problem in the future.

“Unlike cancer patients who typically acknowledge the crucial role of medication in their survival, patients managing long-term chronic conditions with fewer symptoms may feel healthy and not perceive the imminent threat from their disease,” adds Andrew Hourani, founder and CEO of EveryDose. “As a result, they may underestimate the importance of their medications, creating an environment that is prone to non-adherence.”

In the US, roughly half of medications are not taken as prescribed by physicians.¹ This non-adherence leads to preventable healthcare costs, hospitalizations and deaths that cost more than $500 billion (roughly 16% of the total) in U.S. healthcare costs each year.²

The tendency for any given patient to fail when it comes to taking their drug as prescribed cannot be blamed on forgetfulness alone. Rather, a number of factors are at play. These factors include:

• Fear of discomfort (such as from self-injection) or potential side effects
• High out-of-pocket costs
• Misunderstanding related to the importance of taking medications as prescribed
• Complexity of the drug regimen or self-administration routines
• Lack of tangible symptoms
• Mistrust of healthcare providers (HCPs) or healthcare systems
• Anxiety and depression

Developing a holistic view of the patient experience

According to John Doyle, DrPh, group VP at Exponent and adjunct assistant professor at Columbia University’s Mailman School of Public Health, the adherence concept has been around for quite some time—along with the resources that are used to help address it—but these tools could use improvement.

“The entire adherence challenge has been ripe for re-examination, because many of the early tools have been around for a while, achieving only moderate benefits,” he says. “Version 1.0 of adherence support really focused on tactical tools to provide one-way push reminders. There’s still room for that strategy, but we’ve all learned that that’s not enough.”

He notes that Version 2.0 of adherence support is pursuing a much broader set of goals. “Today, the focus is on driving improved adherence through better upstream engagement by educating patients about the disease and about managing the medication," explains Doyle, noting especially the implications of the disease's progression, the role the therapy plays, and helping patients understand the complex drug-administration requirements and potential side effects. “The next generation of adherence support also catalyzes downstream engagement to track and analyze clinical, humanistic, economic, and even social outcomes.”

Importantly, today’s adherence-related tools are increasingly designed to provide two-way communication, rather than just the static “push” reminders of yesteryear. When adherence-support tools are designed to be more interactive, drug companies can collect insights actively, for instance, through regular questionnaires for users, or passively, such as through data collected by wearable health devices or sensors that monitor blood glucose levels or blood pressure on the go, for example. Companies can then use the data-driven insights to tailor the support and outreach and inform ongoing improvement.

“Some patients may respond better to digital or self-service interactions versus more traditional human coaching, and these same patients may have different attitudes toward rewards or peer interventions,” says Scott Snyder, EVERSANA’s chief digital officer. “Understanding the behavioral profile of each patient is just as critical as their clinical profile to combat non-adherence, so using predictive analytics and behavioral segmentation programs can be critical to determine the best intervention strategy for each individual.”

In one recent example, EVERSANA used its proprietary ACTICS artificial intelligence (AI)-driven platform to tailor adherence outreach for an oral anticoagulant from the patient services hub to serve up customized messages to specific patient segments based on real-world data (RWD). The model leveraged RWD related to claims, demographic information, prescription drug costs, and total cost of care.

“Using predictive analytics, we were able to help drive a 50% increase in adherence while reducing the cost of a hub program by nearly 40% over a three-month period for a cohort of nearly 1,000 patients,” says Snyder. “This shows the significant impact of personalizing adherence programs by focusing on the whole patient experience [including their behavioral profile].”

However, too often, efforts to assess the patient experience are overlooked. “Pharma companies should be reaching out directly to patients and physicians, asking, ‘Tell me about how and why the experience of using my product and dealing with this disease are difficult,’” says Triano. “These two questions need to get asked more often when developing adherence-support interventions."

He adds that while it's not always possible to measure the impact, this type of qualitative input can help to establish a growth roadmap for a brand and inform direct, just-in-time messaging to improve patient engagement and adherence to therapy.

“Mining your own call center data will provide a really good jump on this process of gathering up such qualitative insights from users of your product,’” adds Plesnarski.

Meanwhile, to drive patient engagement with support tools or a program, patients often resonate with anecdotes and motivational insights from those in the same position. “After the initial trial, patients want to confirm that their own experience matches the promise of the promotional claims and the experience of other patients," says Triano. "A well-timed testimonial or case study can provide a make-or-break moment to cement adoption and motivate long-term adherence.”

Understanding patient behavior—and then changing it

The hub concept has grown in popularity in recent years, giving patients and providers a centralized, one-stop access to a range of high-touch and high-tech support programs to help patients get on and stay on therapy. “For instance, a patient who is struggling with cost or affordability concerns may require patient services support to help navigate to the best reimbursement options available, while at the same time, a patient that stops experiencing symptoms needs more educational or awareness-focused experiences on the risks of stopping their therapy regimen,” explains Snyder.

However, from a brand perspective, involving multiple vendors or partners to provide different parts of the offering can create tremendous operational burden to ensure they are seamlessly bridging all of the connections, according to Syneos Health's Plesnarski. “Brands should strive toward simplification and streamlining, reducing the number of separate partners and vendors involved," he says. "The more partnerships and bolt-on program elements you have, the harder it can be to pivot in the face of new information or changing market dynamics.”

Harnessing technology advances

Experts believe today's digital adherence-support tools have markedly improved, with more customization and better integration with electronic health record (EHR) systems and care plans. In turn, as Doyle points out, this enables stronger networking of the various components in the overall tool. For example, integration of wearable devices with a patient’s EHR can result in a more comprehensive conversation with the individual's doctors and earlier interventions where needed.

“Finding out why a particular patient is non-adherent and then working with the patient to overcome that specific barrier is critical,” adds Hourani. However, he notes that historically, such an approach was a costly and labor-intensive undertaking, as it required live communication between a care provider and the patient.

EveryDose, according to Hourani, uses a conversational AI via a feature its calls Maxwell to help uncover patients’ unique barriers to adherence and deliver a more personalized intervention. The AI engages with patients to reveal potential issues that can then be relayed to care teams through a clinical portal.

Consider this example: If Maxwell notices a discrepancy between a patient’s adherence to a statin and its adherence to other prescribed medications, it will automatically initiate a chat with the patient via conversational AI. “In just a few back-and-forth exchanges, we are able to determine that the patient is having severe leg cramps when taking their statin and has responded by skipping doses,” says Hourani. “We notify the prescribing physician, prompting them to work with the patient to find alternative therapies.”

Another important finding, according to Hourani, is that engagement with the EveryDose app has been the highest with older patients, thanks to what he says are simpler features and an easier-to-understand layout. “Specifically, Medicare patients have been engaging at a rate three times higher than our median user,” notes Hourani. “This disproves the common misconception that Medicare patients don’t engage with technology.”

Addressing adherence challenges in OTC

Traditionally, over-the-counter (OTC) medications have not received as much attention when it comes to organized efforts to keep patients on therapy. However, the OTC smoking-cessation space is unique in that users of nicotine-replacement products are typically not patients under the care of a physician. Rather, they are consumers who have made a conscientious decision to reduce or quit smoking to improve their health outcomes and seek out an OTC drug that can help. Nonetheless, even when a consumer has decided to quit smoking, a mosaic of factors still undermines that individual’s adherence to therapy—yet few programs exist to help consumers using nicotine-replacement products to stay on therapy, and there has not been much innovation in new product development over the past two decades, notes says Ashish Girotra, head of marketing for the consumer care business of Dr. Reddy’s Laboratories.

Dr. Reddy’s, which acquired the Habitrol nicotine-replacement product line from Novartis in 2014, recently conducted a longitudinal study of patients to gain a deeper understanding of when, where, and why people reach for their tobacco, in an effort to more effectively support their objectives when it comes to reducing or eliminating their tobacco use. “The findings were very telling,” says Girotra. “Our study found that cigarettes solve at least 11 different needs that spread over physical, social, emotional, and psychological realms. For some people, it satisfies hand-to-mouth habits or an oral fixation; for others, it’s deeply connected to their feelings of social or psychological well-being.”

According to Girotra, the Habitrol timed-release transdermal patch requires a 12-week commitment, as the nicotine-replacement patches work by successively stepping down to a new set of patches with a lower dosage every four weeks, and despite the simplicity of the design, he notes that adherence challenges are “shockingly pervasive.”

In fact, the company recently partnered with CVS to study how many people moved successfully through all three stages of the Habitrol patch, and the study found that only 7% of users made it all the way through—in part because reliance on the nicotine-replacement patch alone does not address the other 11 needs that smokers battle with when they are attempting to quit.

To close that gap, the Habitrol brand has introduced an eight-week version of the product and it has been well received, says Girotra. The company has also piloted an app called AIMI by Habitrol. Launched in 2022, the tool provides gamification to engage users, educational and motivational content, reminders, and easy product re-ordering (to receive the next set of patches days before the current set runs out). To date, the app has only had a “soft launch,” and Dr. Reddy's is currently working on version three to incorporate some of the findings learned from early user experience; it is also partnering with other digital therapeutic companies to help users overcome the range of social, emotional, and psychological hurdles that make it difficult to quit smoking.

Girotra adds that Dr. Reddy’s will likely become involved in the diabetes and metabolic market in the next half of the decade as generic products start entering the space. Thus, he says: “There’s a big opportunity for us to leverage the experience we’ve gained from our Habitrol adherence efforts in terms of digital tools, patient education, behavioral issues, and more to address the multifaceted social, emotional, and behavioral factors that are at work in that sector, too.”

References

1. Phillion, M. The Impact of Cost on Medication Adherence. Patient Safety & Quality Healthcare. May 9, 2022. https://www.psqh.com/analysis/the-impact-of-cost-on-medication-adherence/#:~:text=This%20non%2Dadherence%20leads%20to,U.S.%20healthcare%20spend%20every%20year

2. Watanabe, J.H.; McInnis, T.; Hirsch, J.D. Cost of Prescription Drug-Related Morbidity and Mortality. Ann. Pharmacother. 2008. 52 (9), 829–837. https://pubmed.ncbi.nlm.nih.gov/29577766/