Are the adherence solutions we’re currently testing too simple for a highly complex problem?
If solving the issue of medication adherence were easy, it would have been fixed years ago. The fact there’s still a way to go underlines just how complex a problem it is. Many articles on adherence echo this point.
Adherence – A Complex Problem
Take for example the reasons, causes, factors, or barriers that underlie non-adherence (I’ll just call them “reasons” from here on). There are over 60 sites on the Web that deal with this topic. The fullest single list can be found on page 13 of this report. It offers 55 different reasons organized under five categories:
- Social and economic
- Health care system
Once an individual is identified as non-adherent to his or her medications, the next step should be to carry out a differential diagnosis – to determine which of the 55 reasons apply for this particular patient. Maybe not so simple?
But wait, a person may often have multiple reasons for non-adherence (an individual “reason-set”). And these reasons may change over time (see page XIV of this report and page 12 of this report). Now the complexities begin to mount up.
Lastly, one more complication must be added in. An individual patient’s reason-set is typically unique (see page 21 of this report). And reason-sets for non-adherence may differ widely from one person to the next.
At the end of the day, there’s no simple ‘one-size-fits-all’ solution to improving medication adherence. Because as a senior director for Aetna commented in a recent interview:
“[There’s] not just one thing that keeps a group of patients or even one patient from taking their medications as prescribed.”
Are Current Approaches to Improving Adherence Too Simple?
Many studies have assessed the effectiveness of different approaches to improve adherence. For example, the authors of a review in Annals of Internal Medicine found 758 publications that addressed this topic. Interestingly, 685 of these articles were excluded from the final review based on not meeting pre-set review criteria (eg, geography, study design, and bias). Perhaps this – at least in part – may be a comment on the general quality of adherence studies?
The remaining studies reported on 36 different ways that adherence might be improved. The majority of these were single-component approaches. That is to say they examined just one single intervention type.
Of the 36 approaches reviewed, less than 10% (3/36) looked at multi-component approaches.
Let’s take a moment to think about this finding in the context of two earlier statements:
- There are around 55 possible reasons for non-adherence
- An individual patient may have multiple reasons for non-adherence
Is it possible that current approaches are looking at the adherence issue through the wrong lens? That present approaches are too simple? Adherence presents as a complex problem, for which singular, standalone solutions are ill-suited. Instead, the search should be for multi-component answers.
The authors of a review in Advanced Therapeutics had the right idea when they said:
“Multifaceted interventions that target specific barriers to adherence are most effective …”
Combinations of Solutions Are Needed to Improve Adherence
In a continuation his interview, the senior Aetna director commented that it’s necessary, “to find the combination of solutions that work best.” This goal of identifying multifaceted solutions to non-adherence – potentially coordinated through multidisciplinary care teams – is widely echoed by other experts in the field.
Defining multi-component solutions tailored to specific reasons for non-adherence will require changes to current approaches and thinking.
Looking to the future, I strongly feel that greater emphasis on multifaceted solutions must surely become the norm when addressing the adherence problem.
Would you agree?
I’d love to hear your thoughts and views on the best ways to put together effective, multi-component solutions?