Beyond the Norm

The mere presence of professional education and promotion or traditional direct-to-patient advertising doesn't necessarily mean that these messages reach patients—or that patients adhere to their doctors' advice. Adherence, especially to a daily medication's dosing schedule, is a complex problem with both practical and psychological aspects. It involves much more than merely "forgetting to take your medicine."

Pablo Przygoda

One obvious problem is a lack of appropriate patient communication. A recent meta-analysis by Dr. Prajesh Kothawala, published in Mayo Clinic Proceedings, looked at 24 studies of patient adherence to osteoporosis therapy. The findings? First, that one-third to one-half of all patients do not take their medication as directed; second, that nonadherence occurs soon after a patient starts taking the drug. And according to the National Council on Patient Information and Education, when the FDA conducted a patient phone survey in 2004, only 66 percent of those polled said they received instructions from their physicians about how often to take a new medication, and only 64 percent were told how much to take.

In other words, even though brand information may have been communicated to the healthcare professionals, it didn't necessarily reach the consumer. Even worse, if information is getting to consumers, they may not understand, remember, or act on it for a plethora of reasons (illness being just one).

These grim statistics contrast sharply with the success story of Actelion's Tracleer (bosentan) direct-to-patient (DTP) push. The Tracleer initiative goes beyond the conventional DTP program, and provides a potential model for other companies' efforts. Tracleer is an oral therapy for pulmonary arterial hypertension (PAH), a complex illness that isn't well understood by most physicians. Symptoms include fatigue, dizziness, fainting spells, edema, blue-tinted lips and skin, chest pain, and palpitations; sufferers may eventually become bedridden. There is no cure. But Tracleer can help manage PAH symptoms and delay disease progression. However, key barriers to adherence were identified after extensive patient market research.

Two stand out as major problems: Most patients who benefit from Tracleer do not experience symptomatic relief for two or three months, and all patients are required to get monthly blood tests due to safety requirements. As a result, patients may stop taking Tracleer within the first few weeks of treatment because they're not confident that it's right for them. Moreover, in certain cases, patients will never experience symptom relief, but may show clinical parameters of improvement or signs of delayed disease progression. In addition, patients' expectations are sometimes unrealistic, and frustration is a normal reaction. With only 30,000 patients being treated for PAH in the US, many likely feel alone with their disease and their treatment.

To address this specific patient persistency problem, Actelion implemented a DTP program that went beyond the traditional direct mail/newsletter approach to a concept of engaging patients. The result was a one-year, 18 percent increase in adherence for patients who joined the program at the time of prescription, compared to those who did not.

Actelion began by doing comprehensive market research that confirmed that patient expectations of immediate relief were indeed too high, and that setting more realistic expectations would increase adherence.

With this challenge identified, Actelion hired Roska Healthcare Advertising, a firm that specializes in relationship marketing, to help them develop and execute a DTP persistency program. Actelion also set objectives to:

• Help patients understand and manage their disease

• Set realistic expectations for patients

• Forge relationships with patients and foster their trust in both the product and the company

• Increase patients' commitment to therapy

The solution was the creation of Sure Steps, a DTP relationship marketing program that provides patients with personalized, one-on-one support. When Actelion launched this program near the end of 2006, it represented a relatively new approach to DTP communication, employing strategically planned outreach through multiple channels to engage patients on several fronts:

Physician-provided materials All support materials are provided to physicians so that they can discuss the program with patients from the moment Tracleer is first prescribed. Sure Steps includes patient-friendly brochures explaining the illness, the treatment, and the program itself along with easy-to-understand graphics and helpful disease-management tools.

Live support A special team of nurse counselors is available five days a week to answer questions, provide one-on-one support, and help patients work more effectively with their physicians.

Multiwave, tailored direct mail. With specific patient segments in mind, Sure Steps provides an ongoing series of direct mail that's targeted to all phases of treatment so that each patient receives timely and relevant information.

Patient-focused Web site The Tracleer Web site was redesigned so that 80 percent of the home page contains patient information, driving home the company's emphasis on patient support. The site encourages patients to enroll in the program online and access the company's complete line of support services.

In short, Sure Steps successfully incorporates the following nontraditional DTP approaches:

• All program aspects are fully integrated with the brand's professional marketing and sales efforts

• A "surround sound" effect is implemented to reach patients through numerous communication channels, with messages designed to increase receptivity and promote action

• Product promotion and registration materials work together to create a positive brand and program association

• Adherence is enhanced by capturing patients at the time of diagnosis —the main point of influence

Based on the amount and timing of contact, backed by the personalized support of the trained nurses and the program Web site, Sure Steps emphasizes the message that patients are not alone—and that realistic expectations about their therapy will ultimately aid in their effective treatment.

It is important to regularly survey patients to collect feedback and create new ways to update and improve DTP communications. For example, one main concern of Tracleer users was a lack of in-depth interaction with the relatively small cluster of PAH specialists. As a result, Actelion plans to add interactive webcasts to the Tracleer Web site, allowing patients to speak directly with specialists.

Pharmaceutical companies should consider whether nontraditional DTP approaches to improve adherence will benefit their brands. Once the tools are in place, they can be easily replicated or adapted to serve other brands or franchises with less setup cost. This personalized targeted approach to marketing may be what distinguishes one product from its competitors in the eyes of physicians and patients.

Pablo Przygoda is the patient initiatives product manager at Actelion US. He can be reached at pablo.przygoda@actelion.com