In the 10+ years since the WHO’s “Evidence for Action” report, little real-world progress in adherence has been achieved. We’re drowning in information, but struggle to convert it into practical solutions. Here are some thoughts on how to cut through all the adherence clutter.
More of the Same?
No one doubts that adherence is a complex issue to solve. After all, over 50 reasons for non-adherence have been described and I’d guess 50+ types of intervention have been tested. That’s more than 2,500 combination options. Surely more than most HCPs can confidently master or comfortably handle, given their hectic daily schedules. And these could quite easily be conservative numbers!
Just last week an article in MedScape asked the question: “Why Are So Many Patients Noncompliant?” The complexities underlying this simple question are best illustrated by the length of the answer ‒ more than 4,750 words! The article concluded that despite over 40,000 studies the state of adherence knowledge has advanced to a level of only “compliance 1.5”.
Which provokes the question: is sheer information overload ‒ or at least making sense of it ‒ impeding progress? If so, then how do we best move forward? Will it be through more of the same? Or is it time for some lateral thinking? Something that will help relieve the current adherence clutter.
Most data on adherence has been created through a ‘top-down’ approach. Specific, promising interventions have been identified and then tested for impact in relevant patient groups. The diversity of patient reasons for non-adherence, multiplied by variety of intervention types, multiplied again by different chronic diseases, and multiplied further by different methodologies have created the wealth of data at our disposal.
Unfortunately it has been difficult to cross-compare study findings (see here and here). So it’s hard for HCPs to figure out which interventions are most worthy of use? Or in which situations their use is most valuable?
HCPs must also work out how to include adherence discussions into their hectic, over-worked, over-stressed, everyday schedule. Something that could be the biggest barrier of all; and which seems barely addressed in current adherence literature.
Overcoming these levels of adherence clutter requires a fresh approach; one that turns current thinking on its head.
What’s needed is a ‘bottom-up’ approach to improving adherence. What do I mean by ‘bottom-up’? Well, instead of starting with myriad reasons and possible interventions, let’s start with an ‘ideal’ HCP-patient interaction. For example: what are the desirable intervention qualities an HCP wants? And what is desirable from a patient standpoint?
Yes, I acknowledge this is out-of-synch with the notion that adherence should be tailored to an individual patient’s needs. However tailoring requires HCPs to fully define patients’ reasons for non-adherence and then carefully match interventions to reasons. Can most HCPs really do this, based on current knowledge levels? And even if they did, would most HCPs have the time or inclination to do it on a regular basis?
In the real world, let’s assume HCPs want patients to adhere better to their treatment recommendations. However, they need to break through the adherence clutter to do this effectively. On the patient side, the high levels of unintentional non-adherence reported suggest that lack of motivation to adhere is potentially a widespread issue. Also ‒ as a sidebar ‒ if overall patient motivation is improved, then other interventions would likely be more effective.
3 Factors That Can Make a Difference
So here are my proposals for 3 factors that can cut through the adherence clutter:
- Simplicity & Relevance ‒ For HCPs, interventions must be easily implementable and not too time-consuming. They also should offer the potential to achieve above-average improvements in adherence levels. Here I might suggest 20% or higher increases in adherence. I’d defer to more informed sources on this one though!
- Broad Applicability ‒ This may or may not be a tough one. The ideal would be to have one primary intervention that worked for many different patients (ie, independent of non-adherence reasons and across different disease states). Does such an intervention exist? Well maybe it might; but more about that another time.
- Patient-Centricity ‒ A perspective that HCPs are increasingly encouraged to adopt. In terms of adherence, regular and persistent questioning of patients to confirm a >80% tablet taking rate is one area of focus. Where adherence is poor, determining the patient’s motivation level towards regular tablet taking is a second ‒ potentially more important focus. One that needs to be properly addressed before any other intervention type can be expected to be effective.
I’ll develop these thoughts further in later blogs.
In the meantime, comments on the idea of adherence clutter would be welcomed!