Patient Adherence and Human Nature

Jim O'Donoghue

It’s no secret that medication non-adherence represents an enormous challenge for the healthcare ecosystem: drugs manufacturers, payers and, of course, patients.

Previous studies have blamed non-adherence for around 125,000 deaths in the US and 194,500 in the EU each year, as well as hundreds of billions of dollars in costs to providers. Pharma companies are also losing out, to the tune of nearly $650 billion annually, in lost revenues - a level of leakage they can ill afford in the ever tighter financial environment all firms are operating in.

It’s estimated that less than 50% of patients with long-term conditions remain adherent to their recommended treatment. The question is: why? Why wouldn’t patients stick to a regime they know is in their long-term interests? To find the answer, we need to look to behavioral science to deconstruct the psychological foibles and barriers that make people act in ways that can seem irrational or self-defeating.

It may sound simple, but we need to remember that people are human beings first and foremost. No matter the cultural, legal or regulatory context, all humans follow fundamentally similar behavioral patterns. Following a diagnosis, every patient is on a personal emotional journey: they may be feeling frustration with their medication, fear of side effects, or “treatment fatigue” from perceived lack of progress. Equally, patients also have their own idiosyncratic set of beliefs, attitudes, routines and behaviors that are unique to them and determine how they respond to situations.

Patient support programs - the digital dimension

Armed with this insight, we can construct patient support programs (PSPs) that work with the grain of human nature and real-world behaviors.

Over the past 20 years, pharma has invested in developing PSPs, but they have been limited both in terms of efficiency and functionality. Generally call center-led programs, they are expensive to run, difficult to scale, lack the frequency and reach patients require, and are based on interventions at set intervals that are the same for every patient.

But digital technology has upended that paradigm. Patients now have access to a range of devices that provide continuous access to, and two-way exchange of, information. They enable increasing insight and engagement with our everyday routines and behaviors. What digital enhancements enable us to do is understand the patient context and provide the right support for them, in such a way that support can be personalized, relevant and context-aware.

Much more than a “nudge”

When designing support programs the aim is often to assist patients in forming healthy adherence habits around their treatment. This makes a lot of sense when research tells us that as much as 40% of our behavior on a given day is habitual. In other words, almost half of our day is effectively spent on autopilot.

There are over 200 behavioral biases, or “bottlenecks”, that affect how patients interact with a patient support program, and to overcome them, over 90 behavior change techniques that can help people build healthy habits and routines around their medication and treatment.

Typically, medication management apps leverage time-based reminders to “nudge” the patient when they’re due to take their medication, but these often don’t fit in with the patient’s lifestyle and so fail to stimulate longer-term habit formation. A more effective approach might employ a behavioral science technique called “conjunction reminders”. This involves asking the patient to link taking their medication to a routine that already exists in their day, such as having breakfast or brushing their teeth, and steadily reducing the frequency of reminders to allow a habit to form over time.

We can also leverage “social norms” to deliver more effective messages. As social creatures, we care deeply about what other people think. So comparing a patient’s behavior to that of their peers, highlighting that the patient is an outlier when not taking their medication as prescribed, or even suggesting that people they care about would disapprove of them missing a dose can all act as powerful motivators by appealing to deep human instinct.

This social aspect of medication adherence can be further reinforced by asking a patient to sign a behavioral contract with their clinician to take their medication as prescribed. We’re motivated to maintain a consistent image of ourselves and when we commit to an action, we’re much more likely to follow through. This is especially true if the commitment is shared with others, including family and friends.

For example, for the NHS in the UK, we developed a remote telemonitoring patient support program for patients with multiple comorbidities (COPD, diabetes, heart failure and stroke). The program was designed to educate and enable patients to build good routines around the management of their condition and to take daily measurement via a number of connected devices so they could be monitored and tracked by their care team.

With over 2m monitored patient days and 4.7m patient interactions, the patients on the program achieved 98% adherence to the care plan, having effectively established good habits and routines around the management of their condition. 

The data dilemma

Of course, the move towards digitally-enhanced PSPs underlines the critical importance of data protection and consent. The scandal engulfing Facebook serves as a salient reminder of the bear-traps that await data controllers when it comes to the sensitive handling of people’s personal information.

But that shouldn’t make us pessimistic. In this regard, healthcare has a major advantage over most other industries: the benefit we provide to patients is, essentially, longer life; more time with family and loved ones. And there’s good evidence to show that patients are motivated by altruism, with 94% of respondents to a 2014 PatientsLikeMe survey reporting a willingness to share their data if it helps others with the same condition.

Handled with respect, the unprecedented level of contextual data patients can share is creating the possibility of applying behavioral science at scale, to offer personalized support across patient populations on the management of their condition. This offers the opportunity not only of better outcomes for patients, but should also be seen as one of the most impactful tools we have to show value, improve the efficiency of program delivery and provide the real-world evidence base that payers increasingly expect.

Jim O’Donoghue is head of S3 Connected Health, headquartered in Dublin, Ireland.