Technology and patient adherence: Putting control of medication directly in patients’ hands

pharmafile | December 5, 2016 | Feature | Business Services, Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing |  apps, patient adherence, technology 

Ben Hargreaves looks at how apps and medical devices could reduce these figures by providing patients new ways of keeping track of their medication.

Hippocrates, from whom modern day medical still owes a debt, stated over 2,000 years ago that: “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate”. All this time later and the advice still holds some truth. Though we would no longer talk about making patients cooperate, instead speaking of patients adhering to medication, non-adherence remains an issue.

There are some very large figures floating around about the cost of patient non-adherence to medication: it costs the UK‘s NHS £300 million every year and, for the US, take that figure, convert it to dollars and add three more zeros on the end of it (for those of you who get vertigo from such dizzy figures, that’s $300 billion). The figures are mind-numbingly large.

To focus on these figures, however, is a trap that is too easy to fall into. There are underlying figures that are significantly more important and more worrying: in the European Union, non-adherence is estimated to cause 194,500 deaths each year, according to a NICE study. The ultimate beneficiaries of improving patient adherence are those who are taking the medication. However, it’s a thorny area. The area was previously referred to, and still commonly known as, patient compliance – with the insinuation that it is the fault of the patients themselves; they are not complying with those who know better.

The move away from this condescending attitude has been gradual and is exemplified by the move towards ‘patient centricity’ in recent years. Previously talked of as simply a new industry buzzword and looked at as a nuisance, perhaps because of the extra costs involved, the industry has now begun to accept that the shift is not a passing phase. Patient centricity actually opens up many new ways of interacting with patients, which can benefit both parties. When sums as large as those mentioned previously are involved, any incremental changes that encourage patients to adhere to medication is a win-win situation: for patients, it ensures that they have the best prediction against illness; for medical services, it stems losses and for the pharmaceutical industry, it improves success rates of medicines.

This is where technology can step in. It plays directly into patient centricity’s hands, quite literally. With 72% of people, according to PewResearch, using their smartphone to check for health information, there is clearly a desire by the public to have some degree of control over their own health. This is where technology, particularly smartphone apps and electronic devices, can help patients, or their relatives/helper, take control of their adherence and thereby their own health.

The issues facing patient adherence

Patient adherence is an issue and one that needs to be addressed. However, there is certainly not any one solution to the problem. Speaking to Pharmafocus, Richard Vautrey, deputy chair of the British Medical Association (BMA) and practising GP, identified that “we need to recognise that patients will respond in very different ways and as individuals. This is not an easy task and is one that we all need to have a role in to improve the situation. There isn’t one fix, there has to be a variety of approaches but, ultimately, it’s down to the individual patients to decide what they do and don’t do.” This is a very basic issue but one that needs to stand at the head of the argument about how to improve patient adherence; patients are people with individual reactions to medication and therefore any discussion of a solution to increase patient adherence must be recognised as one piece of a larger jigsaw, and not a single solution.

There are a number of reasons why patients do not adhere to medication and addressing all of them is an impossible task. It makes the most sense to identify the issues that can be solved and in the most efficient way. Common issues that seem to arise lie within communication: whether that’s complicated instruction for the use of the medication, unclear guidance on whether the drug is entirely safe or a lack of information about what can be expected from the drug. Richard Vautrey expressed his views on how this could be helped: “Having much clearer information for patients and provided in a consistent way. There is a need to have more time with patients, which often we, as consultants, don’t have and which we need to invest much more in. So that we can have longer consultation for unspoken anxieties to be identified and responded to by the clinician, at the time when decisions are being made regarding the patient’s treatment.”

Undoubtedly, spending longer with their clinician would improve patient adherence. A large part of taking and adhering to medication involves trusting the drug to do its job and having a clinician that possesses the time to talk patients through the treatment procedure would reinforce patient trust. Beyond this, according to NICE, an estimated £4bn of medicines used in the EU are not used correctly; clinicians having the time to make sure the patients understand every step of process, as well as correct dosages and timing is integral to correct adherence. EuroMedInfo reports that one of the primary reasons for patient adherence is how complicated the treatment regimen is, with adherence rates proportionate to how simple the regimen is. Longer consultation could then ensure that patients were clear on guidance before leaving the office.

Longer consultation definitely offer further options, not least because patients can have numerous conditions and circumstances in their life that require wider medical services for support. Research has found that the odds of patients suffering from depression are 1.76 times more likely to be non-adherent to medication. This is the complicated nature of understanding reasons why people do not adhere to medication – some reasons throw up needs within the patients for further help.

Another example of this are those who suffer from chronic conditions, a situation that is on the rise across the world as populations continue to increase in age. The World Health Organisation found that of the patients who suffered from chronic diseases, 50% did not take medication as prescribed and those drop further when applied to people living in ‘developing countries’ (China has a 43% adherence rate whilst in Gambia that stands at 27%). These are statistics that are difficult to improve on, as those that have chronic diseases know the effects of not managing their disease but must face a lifetime of taking medication whilst knowing that it will only manage symptoms. The constant need to take medication can then not be seen as providing relief but actually providing a constant reminder that they have a chronic condition.

Patients taking control of their own care

The key to stopping these underlying issues from getting in the way of patients maintaining their health and overall quality of life is to provide the patients with greater agency and involvement in their own treatment. One way of doing this is to make use of a technology that is already ubiquitous: the smartphone. According to Ofcom, there are currently around two billion owners of smartphones around the world, with apps being the popular method of accessing information, as TechCrunch reports that people spend 85% of their time on apps when using their smartphone.

The prevalence of app usage is then without question and therein resides the opportunity for medical services and the pharmaceutical industry to help patient’s stay adherent. Apps can function as a means of having a constant line of communication between patients and those responsible for their care; they can provide support to patients when having time with clinicians is sometimes not an option due to time or costing, though, it must be stressed, as a supplement and not a replacement for that time.

It is now widely recognised that there is a demand for these apps, as a 2015 article published in the Journal of Anaesthesiology Clinical Pharmacology reported that there are more than 20,000 mobile apps tied to healthcare, fitness, and medicine in existence, with numbers increasing since publication. One of the simplest methods by which apps can maintain adherence in patients is with apps that set up reminders. The simplicity of the idea means that this kind of app has developed many varieties, being set up by pharmaceutical, biotech and private companies alike.

Biogen, for example, has released an app for multiple sclerosis sufferers named MySidekick that helps patients keep track of their medication by letting them set up reminders. It can also track the mood of the patients, provides a list of questions that the patient can ask their doctor to manage their symptoms and a function that allows the user to send on confirmation that their medication has been taken to family members or caregivers. What cannot be denied is that the primary reason for developing the app was to ensure that patients remained adherent to Biogen’s particular medication, thereby safeguarding their own business.

However, there are numerous alternatives that now exist. One of the most prominent is MediSafe, which currently has 122,000 reviews on Google Play and an average rating of 4.5 out of 5. It is an app that was set up by two brothers, Mori and Rotem Shor, who state that their motivation for setting up the company occurred when their father accidently overdosed on insulin medication. The app’s primary function is to allow users to keep track of when they are taking their medication and, rather than one form of medication, it tracks multiple different medications – providing information about each and reminders of when they are due to be taken.

The only thing lacking from these examples is that their efficacy is kept hidden behind the owners of the app. There is no real impetus for them to reveal this data but there are studies that have examined how much easier patients find it to follow their medication regimen with reminders that can be provided from smartphones. According to the results of a 128,037-patient study, conducted by ResMed, sleep apnoea patients who use a self-management app in conjunction with positive airway pressure (PAP) showed an improvement of 16.9% in adherence to their medication. These may seem like small margins but if this could be transferred over to the amount of money that is lost worldwide on lack of adherence (with figures by Quintiles suggesting that total global healthcare costs account for 4.7% of expenditure), the sums would be enormous and patients would benefit in turn.

The ease with which companies can connect to their patients through apps and thereby increase adherence opens up possibilities outside of the sphere of reducing costs and helping patients to manage their regimen. There is the possibility to increase patient adherence in clinical trials: an area where patient numbers often either struggle to keep up with the study or with their medication. Novartis, for example, are currently introducing smartphone apps to ‘coach’ patients through the process in three to five clinical trials to judge the impact on patient adherence. Commenting on this development, Joris Van Dam, a strategic projects leader in pharmaceutical development at Novartis, stated: “Where we’re going to start is having an app on your phone that asks you if you had adhered [to a study medication] twice a day…It can remind you of an upcoming visit, help you prepare, and if you have a question it can connect you to your coach.”

In the UK, with the NHS suffering from a serious financial issues, this has provided an even greater urgency to the issue and one of the results has been a turn to technology – not always successfully, it should be added. There is a plan to relaunch the 2013-2015 health app library that featured apps assessed by the NHS. While a new app, Echo, launched on 15 November, will see patients using the app to be able to scan barcodes of medications and automatically re-order their prescription once approved by their GP. It will be interesting to see how much impact this approach takes and it will surely be of interest to other countries around the world as governments look to reduce the cost, both in lives and in money, of patient adherence.

Thinking outside the pill box with technology

The potential to improve patient adherence cannot lie solely on apps; there has to be numerous approaches to the problem in the aim of small, incremental changes adding to bigger results. Generally, technology has the potential to have an impact on a patient’s adherence in a way that a smartphone may miss. A physical device could perhaps be more intuitive to people who are not as au fait with smartphone technology; this is particularly true when it comes age demographics. Individuals who are above 65 years of age are less likely to own a smartphone, with only 30% possessing a smartphone compared with the 86% of those aged between 16-29, according to PewResearch. So, a device that can be operated much like familiar devices have potential to aid.

One such example is EllieGrid, which is advertised as a ‘smart pill box’ and won Takeda funding for its design on 28 September. It has a very similar functional design to an ordinary pill box – with separate compartments for different pills. It is an example of technology that would change little in functional design but the technology behind it could help to ensure adherence. The way the pill box functions is that it tracks medicine usage, alerting the users when a dosage is required and is able to notify any linked in users, via a smartphone app, when a medication has been taken. This means that the patient is helped to remember when and what medication to take and caregivers can then be notified if the patient is being adherent. It’s a system that combines functionality with technology, potentially improving adherence whilst encouraging more individuals to become involved in a patient’s adherence.

Another device that has featured in the news recently that has potential to improve adherence is Medtronic’s MiniMed670G, dubbed the ‘artificial pancreas’. The device constantly measures the blood sugar levels of the individual and then delivers the exact amount of insulin that is needed. It removes the potential for the example that inspired the development of MediSafe, where patients are able to accidently dose themselves with too much or too little insulin. The device has been approved by the FDA and is currently undergoing real world tests but could see some of the weight of adhering to medication lifted from the patients’ hands.

“Treating patients as partners”

We must place as many tools in the patients’ hands as possible; it is then their choice whether they stay adherent or not, possessive of the knowledge they need. There is a temptation to believe that, with many different means of contacting a patient, attacking them with SMS messages, email reminders, communication apps and phone calls that we can ensure levels of adherence are raised through reminders. As has been discussed, this method won’t work if the patient is expressly not taking their medication because to do so is a constant reminder of their condition. Richard Vautrey, speaking upon the possibilities of technology, stressed this concern: “I think there’s potential but we need to be careful not to be bombarding patients with messaging, in case they find them intrusive. I think we need to be careful in treating patients as partners rather than expecting to do as they’re told and respect them in their decisions they make in adherence to treatments and medications they take.”

What seems to be the most persuasive method is to provide the patients with a full awareness of the range of options that they have on hand to help them to adhere to medication. This comes back to the repeated refrain explored in this piece that communication is the key, of which apps and electronic devices are simply another tool in an expanding armoury. Though the use medical devices, apps and technology is still in its infancy, in regard to a patient-centred approach, it is inevitable that technology will continue to develop and become an ever more important part of both patients’ care and their lives in general.