Adherence thoughts

Dr. Golub co-wrote a review paper on adherence with antidepressant meds for Wyeth Neuroscience.

In addition, I worked on an very interesting and challenging initiative where we were asked to “think through” what would be required to integrate an adherence program into a Phase III clinical trial of a BPH/ED drug….specifically we were asked to consider what might increase (1) the odds of the adherence program working and (2) the likelihood of proving, in the context of a clinical trial, that our adherence program improved outcomes over “drug+no adherence program.” This was especially difficult since patients in clinical trials tend to get much closer follow-up/care than patients in the real world, so their adherence tends to be better. I thought about the challenges of adherence a lot when I was practicing medicine, and have observed my own behavior pretty closely with respect to why I do or don’t take rx meds as precscribed.

The bottom line, to me, and to the many authors and researchers who have studied the problem of adherence (including the World Health Organization, which published a monograph on the topic 7 or 8 years ago—further indicting the worldwide nature of the challenge)…the bottom line is that the psychological and characterologic traits that lead to poor adherence run pretty deep in the psyche. At least in those segments du-jour from whom adherence is always a challenge. And so the accumulated data indicates that most efforts to date designed to improve adherence for asymptomatic conditions like HTN and high cholesterol, are not really generating adequate motivation, which is why their results are usually pretty minimal.

So we could try the multichannel approach (phone, SMS, print, web-based support). But it is expensive, and rarely moves the needle more than a few percentage points, if that many. Why? Because such programs do not get at the deep-rooted reasons for non-compliance with rx therapy for asymptomatic conditions.

The psychologist Abraham Maslow wrote about what motivates us, and after our needs for food, shelter (and I think he may have included love and sex in that first tier) the next important set of motivators can be characterized as security, affiliation, and self-esteem. This model has been cited in the medical/pscyhololgical literature in a number of different ways.

Security, in operational terms in our society, often boils down to money. Monetary rewards for compliance (for patients) or for doctors (for doing a better job teaching/coaching/ensuring adherence) might work. This could be outright financial rewards or discounts and coupons of some type. Affiliation—as operationalized for this type of effort—often boils down to feeling like you are part of some meaningful group. And self-esteem can be provided through feedback and reinforcement that boost the ego.

Certainly the US government has shown that they believe monetary rewards are the best motivator for MDs and are building cash incentives (through Medicare payments) into their plan to get more doctors to use eprescribing.

Is there is a way to make doctors feel like they are part of a special group by virtue of participation in this program. (IE, select 1/3 of the doctors in each large medical group to include in the initial pilot program? Might be a way to light a fire under doctors to get them to embrace this new effort. Memos and emails and reminders and pamphlets from group medical practice administrations are often greeted negatively /skeptically by MDs.

Also we need to think about the motivating factors from the large medical practice director’s perspective. What usually motivates them is lower per unit cost per pill from pharma. Generally, though, we need to remember that it is challenging to get large institutions of any kind to embrace any new program unless they took are persuaded that there is money/profit/better margins that will somehow emerge from the program. Also, even when they are convinced, they usually need help figuring out the logistics of implementation.

As for patients, the segmentation specialists tell us that certain people will always be compliant, while others (the majority) have all sorts of reasons for non-compliance/adherence. In the interests of changing the behavior of those notoriously recalcitrant groups, can we offer them something more than the standard multichannel reminder/support/encouragement/education program. Like something/anything they genuinely want and need. Seems bizarre when you think about it (in some ways) but perhaps people are better motivated by getting material stuff they want than in the IDEA that they will have a lower likelihood of something terrible like a heart attack or heart failure or a stroke 1 or 5 or 20 years down the line. By “stuff” I don’t mean a vinyl pouch they can wear around their waste, but something/anything, that they might want, say on a monthly basis.

We need to break new ground in this field. Because insanity is, as you know, doing the same thing over and over and expecting a different result.