The figures are striking. In England, the overall NHS drug spend has increased by 8% between 2015 and 2016, reaching £16.8bn. Yet, more than one in five patients don’t take their medications, resulting in £300m wasted annually. Rates of adherence are especially low among patients with chronic conditions such as COPD (33%), schizophrenia (52%) and asthma (67%).
Dimitrios Georgiopoulos, medical director and chief scientific officer at Novartis UK, told PME: “Poor adherence to prescribed treatment[s] is an ongoing challenge and the consequences are not only poor clinical outcomes but also unnecessary and avoidable healthcare costs.”
He explained: “All medicines go through a rigorous development and regulatory process to understand their effectiveness, potential side effects and optimised dosage. If adherence is not maintained there is a definite risk of losing the efficacy of the medicine.”
The consequences for patients range from poor symptom control and associated life quality to increased co-morbidity and mortality. A joint study by the University of Nottingham, UK, and Kaohsiung Medical University, Taiwan, suggests for example that in breast cancer, non-adherence to adjuvant hormonal therapy increases all-cause mortality risk by 45%, compared with adherence. In earlier research, the likelihood of dying prematurely for patients with epilepsy who did not take their medicines was threefold that of patients who did.
Adding to this is the economic impact that non-adherence has on health systems and society, due to wasted prescription medications, increased healthcare service utilisation and work absenteeism-related productivity losses.
As Dimitrios notes: “The NHS is under huge financial pressure and is being challenged to become more efficient. Improving patient adherence… is one way of improving this efficiency as there is decreased spending on hospitalisations, re-admissions, disease progression and complications.”
Indeed, the latest available figures, from an analysis of economic models by the York Health Economics Consortium and the School of Pharmacy, University of London, indicate that increasing medication adherence to 80% in just five disease areas – asthma, type 2 diabetes, coronary heart disease, hypertension and schizophrenia – would generate cost-savings in excess of £500m a year.
Globally, avoidable costs associated with non-adherence amount to $269bn, according to a report by the IMS Institute of Healthcare Informatics. That is 57% of the world’s total spending associated with inadequate medicine use, and 4.6% of the global total health expenditure (THE).
Empowering patients through technology
John Parker, director of operation, UK & Ireland, at Omnicell, told PME that tapping into mobile health (mHealth) technology is one way pharmaceutical companies can help improve medication adherence. This has the added effect, he notes, of “enhancing the quality of the relationship between patients and prescribers, which may further encourage medicine-taking behaviours”.
The industry has already taken steps in this direction. Examples include the development of smart packaging, pills and pill organisers that can communicate with Wi-Fi-enabled smartphones and computer tablets to remind patients to take their medicines, or alert healthcare professionals if doses are missed.
Pharmaceutical companies have also been manufacturing mHealth apps for the remote monitoring of biometric data and disease-specific symptoms, particularly for patients with cardiovascular, metabolic and respiratory chronic conditions. While these don’t improve medicine-taking behaviour, they can “engage patients in monitoring their condition and… becom[ing] more involved with their care, which then has a knock-on effect on improving adherence rates”, said Novartis’ Dimitrios.
Studies have provided some interesting insights in this regard. For example, in a recent randomised clinical trial comparing usual care with a smartphone app for blood glucose monitoring in patients with type 2 diabetes, the latter was associated with significantly greater medication adherence – 39.0% vs 12.8%.
Other research, published in the Journal of the American Pharmacists Association, found that, as a result of having patients take pills containing ingestible sensors, community pharmacists on the Isle of Wight were able to identify those with uncontrolled hypertension due to medication non-adherence, and the information helped improved compliance.
However, the existing evidence is too limited and inconsistent. Last year, an American team from the University of Washington, Seattle, conducted a systematic review of studies assessing the efficacy of digital health solutions in improving chronic disease management. They reported in the Journal of Medical Internet Research that only 56% of reviewed randomised controlled trials “demonstrated significant effects on adherence, and less than half (40%) on clinical outcomes”.
On this point, Omnicell’s John notes that “it is important for pharmaceutical companies to produce evidence that technology improves adherence and consequently health outcomes, especially as they move into a much more payment-by-results environment”. However, he acknowledged that conducting large-scale clinical trials to demonstrate statistically significant and clinically relevant benefits can be expensive and time consuming.
Unlocking the potential of big data
Another important point to consider is that the real value of digital solutions for adherence lies in the ability of the industry and healthcare stakeholders to share, analyse and interpret the enormous amount of data that is gathered. This is because integrated big data analytics can reveal trends in drug usage and patient behaviours and preferences, which in turn can assist in developing patient-centred adherence interventions that are tailored to individual needs, and therefore more likely to work.
A 2016 Best Practices LLC survey of leading drug manufacturers including Genentech Baxter BioScience, GlaxoSmithKline, Boehringer Ingelheim and Teva Pharmaceutical Industries revealed that 40% already have a dedicated big data group. Another 30-40% said they expect to increase their data capabilities by 2018.
Collaboration is key
But technology alone is unlikely to spell the end of non-adherence. According to John, the key to truly addressing the problem is more collaboration between healthcare stakeholders and pharmaceutical companies in helping patients understand why they need to take their medication, which ultimately empowers them to be active partners in their own care.
Supporting this view, Dimitrios said: “Doctors and industry should start by assessing the health literacy from the patient perspective and creating an educational plan customised to each patient… a patient should [be able] to understand the reasons for the medication, proper dose, timing and duration to reinforce the importance of adherence.”
In this regard, companies like AstraZeneca, Merck, Novartis and Shire have developed self-management education programmes for patients, which also promote information sharing and interaction with pharmacists, providers and other healthcare stakeholders. Among other things, these offer online information resources, reminder phone calls and ongoing reinforcement, as well as incentives such as discounts for following medication regimes. Drug manufacturers have reported improved medication adherence and multifold increases in drug sales following the implementation of such initiatives.
Some pharmaceutical companies are providing homecare programmes involving nurses administering medications directly to patients in their homes and uploading the information into digital portals, which clinicians can access for monitoring and feedback. Increasingly, key players in the industry are also working with the NHS on the implementation of outcome-based models, by targeting factors that include medication adherence, which contribute to achieving positive clinical results.
Barriers and solutions
There are, however, significant barriers to the implementation of interventions for adherence. One of these is “the difficulty to coordinate efforts across multidisciplinary teams that include consultants, nurses, clinical commissioning group (CCG) representatives, as well as industry [representatives]”, said Mr Georgiopoulos. Plus, there is the time needed to implement such programmes and the ageing IT system of our NHS to consider.
According to John, further barriers include the high cost and slow adoption of digital solutions aimed at promoting medicine-taking behaviours. Of note in this regard are the findings of a survey of hospital healthcare professionals by Imperial College London. It found that, although 90% of surveyed doctors regularly use mHealth apps, only a few recommend them to their patients.
“To overcome these barriers all parties involved have to first understand the implications of non-adherence”, said Dimitrios. “There needs to be wider acceptance of the important role the industry can have in educating doctors, nurses, commissioners, patients and carers. We need to support the build-up of digital infrastructure that would allow collation of data from different sources… [and] to have an even stronger collaboration between the NHS and the pharmaceutical industry… Only through an ongoing collaboration will we succeed in improving optimal use of evidence-based treatment and adherence to medicines.”
