Did you know that about 50% of patients who suffer from chronic illnesses and undergo long-term treatment fail to adhere to the medication regime prescribed by their caregivers? Poor medication adherence evades optimum clinical benefit to the patient, increasing the risk of hospitalization and escalating the cost of healthcare treatments. In the United States alone, an estimated 125,000 patients die each year due to treatment failures tied to nonadherence, 10% of hospitalizations are caused by nonadherence, and although estimates vary, a minimum of USD 100 billion is spent annually towards preventable healthcare costs.
What is the medication adherence problem?
Medication nonadherence is a complex problem that stems from several factors including the healthcare system, disease-related conditions, therapy-related factors, socioeconomic status, and the patients themselves. According to the World Health Organization (WHO), treatment adherence is defined as the extent to which a person’s behavior — taking medication, following a diet, and/or executing lifestyle changes — corresponds to the recommendations from a healthcare provider.
At the same time, the WHO projects that chronic diseases will account for three-quarters of worldwide deaths in 2020. As the healthcare industry strives for cost-effective value-based solutions, effective interventions to increase medication adherence are imperative.
What are the major factors leading to nonadherence?
The most studied patient-related factors are gender, age, family support received, mental comorbidities, and memory capacity. Among these factors, age and memory capacity seem to play significant roles, since forgetful and older patients are least compliant. Often patients fail to clearly understand the prescription issued by their provider. However, although patient behavior is considered as a major determinant of adherence, the onus is often not on the patient alone.
Disease-related conditions like the complexity of the treatment, duration of treatment, and severity of the disease also play a role in adherence. Greater numbers of medications and higher dosing frequency per day often trigger noncompliance in patients. Physician-related factors include lack of effective communication, failure to ensure the patient understands the prescription, and the inability to dissuade fears around side effects or to demonstrate the benefits of long-term medication use.
Factors related to healthcare systems — for instance, limited access to care, the price of medication, and a lack of health information technology — also influence adherence. For example, a higher socioeconomic status and ample social support promote adherence, while belonging to an ethnic minority negatively impacts adherence.
How do we record nonadherence?
Assessing nonadherence is fundamental to providing effective interventions to increase adherence. Adherence, which is usually measured over a period of time and expressed as a percentage of the drug taken in relation to what was recommended, can be monitored by directly measuring the drug or its metabolites in the patient’s bodily fluids. This measurement will, however, differ between individuals due to varying drug metabolism rates and interactions with other medications and the food ingested. Some drugs may be removed from the body readily before the assessment can be made, making this a rather inconsistent and unreliable method. Directly monitoring the patient’s medicine intake by the healthcare provider is another method that, while seemingly reliable, is not feasible unless the patient is under observation in a hospital setting.
Thus, indirect methods like counting the number of pills taken, analyzing electronic records (read as prescriptions filled), and relying on self-reports by patients are often used. However, these methods also come with certain limitations. For instance, a decrease in the number of pills does not necessarily demonstrate the patient’s compliance. Similarly, a prescription filled does not guarantee that the patient takes the medication as prescribed. Patient self-reports are not reliable either, and often result in overestimation of adherence.
Thus, more reliable electronic monitoring systems using smart technologies may provide a solution.
Can smart approaches provide a solution?
Never before have we been more connected, with smart technologies being used to navigate our roads, drive our cars, monitor our home safety, clean our rooms, and aid in surgeries. Not surprisingly, recent years have also witnessed the use of smart technologies in increasing medication adherence.
Mobile apps like Medisafe are user-friendly, remind patients to take their medications on time, warn about interactions with other medications, send notifications to other family members when a pill is missed, and help communicate with the doctor. There are several players including Dosecast, PatientPartner, My Pillbox, and others that compete against each other. A recent review that studied whether they really help has shown that these apps are indeed effective in increasing adherence, and the authors of the review recommend the personalization of an app for better results.
Automated and fully connected pill dispensers have recently hit the market. The following table provides a comparison between a few commercial brands (RxPense, Spencer, Karie, Hero, Livi and Philips).
Notably, Karie is a smart medication management tool especially designed for seniors that offers a simple, easy-to-use technology. When plugged into a power outlet, it connects to the cellular data network via a SIM and in turn connects to the pharmacy, loads the prescription, alerts the patient to take the prescribed medication, and also messages the caregiver when a dose is missed.
Companies like Proteus Digital Health haven taken adherence tracking a step further, through smart pills with ingestible digital sensors that can conveniently track medication adherence. The patient’s data can also be sent to the healthcare provider to adjust the treatment schedule as needed.
Propeller Health, a player in the field of respiratory care medication, provides a digital solution through sensors attached to the patient’s inhaler paired to a mobile app for tracking usage. Used by patients in the United States, Europe, and Asia, this this technology has demonstrated a 58% improvement in medication adherence.
Even for the tech-averse elderly, companies like Cardinal Health provide smart solutions through products like Dispill based on smart packaging of pills. The blister packs can hold up to a months’ daily doses with clear, personalized instructions printed on the labels.
CuePath provides a similar innovation, where the scheduled medication is prepackaged by a pharmacist and personally curated for the patient. Additionally, a family member can monitor the usage through a connected app and track the patient’s adherence.
The future?
It is still uncertain whether these smart technologies will substantially improve patient behavior and help them better adhere to their medications. As pointed out by a large evaluation study, digitalization and even financial incentives may not suffice to increase patient adherence. In this example, a high-tech digitally connected pill bottle, an alert when the medicine was skipped, and even a cash reward for taking the medicine failed to coax the patients to take their medicine on time. Thus, while smart technologies are a step in the right direction, even more efficacious methods may be required to fully address the problem of nonadherence.
One answer may be for the big players to join hands and provide a consolidated solution to medication adherence, similar to the agreement on smart home systems that recently made headlines, in order to fully integrate these innovative technologies into the existing healthcare ecosystem and ensure a smooth experience for all parties involved — patients, caregivers, healthcare providers, and payers.
