Patient Compliance: Where does it fit into the management of patient relationships and why is it important?

From Left: Trevor Fitzpatrick -Parexel, Matthew Hunt -International SOS, Di Stafford -The Patient Practice and Steve Mackenzie-Lawrie - Vice-Chairman PM Society

Parexel kindly hosted the PM Society’s briefing meeting, held on Tuesday 29th April.  Although the country was battered by heavy rain and wind and the M25 was severely congested following a serious traffic accident which had closed the A3 an impressive 60 PM Society members turned turned out for the meeting at Parexel's offices in Uxbridge.  Their objective was to engage in an important discussion around the subject of patient compliance, and to discuss issues such as; how do you engage with patients? How does compliance impact on product marketing and sales and how do you create a successful patient support and compliance programme?

The first speaker was Di Stafford, Managing Director of The Patient Practice, a consultancy specialising in all aspects of patient marketing, communications and patient relationship management.  Prior to establishing The Patient Practice, Di Stafford was the Head of Patient Relationship Marketing at Pfizer UK, and part of the senior management team at PPP healthcare that established Access 24 (a medical call centre).

Di kicked off her presentation with the statement, ‘The Patients Are Coming’. This was in fact the title of a PM Society meeting that she had attended in October 2000.  At that meeting they had debated and discussed patient empowerment.  Would it actually happen?  Did it exist already?  What was going to happen in the future?  A mere eight years ago the industry was considering changes that they felt would happen not necessarily as a step change but more change by stealth.  But the changes have happened already, it is not a trend and it is not going away.

Reinforcing this, in January 2008 Gordon Brown unveiled his vision for the future of the NHS, “The NHS of the future will be more than a universal service - it will be a personal service too. It will not be the NHS of the passive patient – the NHS of the future will be one of patient power, patients engaged and taking greater control over their own health and their healthcare too.”

But what has caused such a massive attitudinal shift? One explanation is that we are now living in an age where the later Baby Boomers born in the early 1960s are approaching their mid to late 40s and they are beginning to present with early symptoms of chronic conditions like high cholesterol, hypertension, arthritis. However, unlike previous generations who had a passive relationship with their GP and were ‘just glad to be alive’ we are facing a new era of patients who are more demanding, more empowered and more challenging. 

This age group has grown up with a broader education and has embraced new technology, computers, the internet, mobile phones etc.  There are now numerous routes of information for the patient, they no longer rely on the information provided by their GP. An example of this is blogging.  Eight years ago blogging wasn’t something anyone considered and in fact the word was hardly known in the UK.  The idea that patients could get together on the internet to discuss conditions and treatments wasn’t even on the radar, but the impact this can now have on patient compliance can be huge. As a consequence we, the industry, need to begin to engage with patients more.

But why do we need to worry about compliance?  One answer to this is that the Pharma industry spends a lot of money on drug development and then sinks further investment into ensuring patients are prescribed these treatments but fails to provide the information and support they need to continue taking their medication. 

 

The gaps on the chart above represented by the red and blue arrows highlight lost volume. So with data like this it is clear why we, the Pharma industry care about this, but why should anyone else care?

The really important issue is that drugs don’t work in patients who don’t take them and they lose out on efficacy. This can then result in negative perceptions of efficacy and tolerability of products which can affect sales. As a result patients continue to suffer ill health, with perhaps reduced quality of life and life expectancy, and this can then lead to increased costs due to hospitalisation of patients with uncontrolled conditions.

So we understand from this the importance of compliance programmes on all stakeholders, and the need to educate and inform to try to ensure that patients take their medication as they should. At this point however, it is important to understand that noncompliance can happen for a variety of reasons and in some instances it may just be a patient asserting control and making their own decisions about what treatments they want to take.  In order to understand the situation we need to try and look at it from the patient’s perspective, and if we approach the issue in this way we will avoid the mistake of trying to solve the ‘corporation’s’ problem instead of filling the patient’s need.  We need to spend time understanding our patient groups:  How do they deal with treatment regimes?  How well do they comply?  What motivates them to comply (or otherwise)?

But we must remember that in fact non-compliance is simply a collective descriptor for a whole range of behaviours. While they may all be non-compliant, they are all non-compliant to different degrees and for different reasons: forgetfulness, denial, poorly informed, concerns about side effects, lack of concern about an asymptomatic condition, confusion or inconvenience.


 

According to a review of data it is possible to trace non-compliance back to one of EIGHT types of contributory factors, which clearly illustrates that when developing patient compliance programmes, one size does not fit all.  A one size fits all approach to patient communications will in fact just be a waste of resources.

The key to successful compliance programmes is to use patient segmentation to unlock medicine taking behaviour.  Once we understand what is happening to the patient and their current attitude we can begin to address the problem.  Issues can be simple forgetfulness (which typically accounts for 10-15%), or poor GP/Patient relationships which have a huge impact on compliance.  In many areas there is a huge drop off after 3 months, as patients start to feel better and consider themselves cured, or they just don’t go back for a repeat prescription because no one told them that they needed to .  If we can start to define some of these common attitudes amongst patient groups we can start to define compliance programmes.

We know that behaviours affecting compliance tend to be entrenched in the first three months, so as an industry we need to have programmes in place that support the patient from the outset. There are a whole range of tools available to us from pill boxes, reminders, SMS texts, and indeed the product packaging which is often a really underdeveloped resource in terms of patient compliance. Understanding the patient will enable us to use these appropriately. In addition it is important to focus on the patient in their social setting so we mustn’t forget the important role friends and family also play in treatment compliance.

In summary, there is no such thing as the ‘average patient’, and understanding patient’s attitudes and perceptions is key.  Whilst there are some key patient types for compliance across different conditions, the specific condition suffered can significantly influence attitudes towards compliance.  It is vital that we aim for an integrated, multi-channel, communication approach for maximum results.


The second speaker of the evening, Matthew Hunt is currently the European Patient Support Services Director for International SOS.  International SOS is world leader in the provision of Patient Support Programmes working with the world’s top ten pharmaceutical companies.  Matthew has been actively involved in the design, implementation and management of patient support and compliance programmes over the last four years.

He began his presentation by explaining that before we can start looking at the issue of compliance, we need to be aware that clinical governance is an important part of a compliance programme because it is essentially about patients and patient safety. So we need to be mindful of this in all our activities.  In addition we need to be aware about data privacy and protection.  If we are working on these types of programmes where we are interacting with patients we will be collecting data along the way and as such we need to be aware of regulations and ensure we ourselves are compliant.

Compliance is a complex issue and one that industry shares with the NHS.  An estimated 50% of medicines for chronic conditions are not taken as prescribed.  The consequence of this is ill health and reduced quality of life, reduced life expectance, avoidable healthcare cost and economic loss to society.  At PCT level they have started to address the issue of compliance themselves but there are areas where they will need help from industry.  It will also be interesting to see how in the future NICE will review treatments with compliance programmes attached vs. those without. 

As touched on by Di Stafford in the first talk, issues affecting compliance are wide ranging: real side effects, fear of side effects, inconvenient dosing, belief that treatment isn’t helping, belief that treatment is no longer needed, forgetfulness, cost, distrust of doctors and medicines. It therefore makes sense that a compliance programme is more effective if it evaluates the reasons why a patient is not compliant and then seeks to address them. 

Non compliance is a key issue for doctors because they know they will see that patient again, it could be a high demand patient that blames the GP for lack of efficacy.  But another issue or potential barrier we face is that doctors generally believe that THEIR patients are adherent, and are usually in disbelief of survey data that says otherwise.

There is a disparity in perception of doctor-patient relations.  Doctors are vital for the provision of instructions for taking the medication, discussing side effects and allaying concerns, engaging patients in conversation to find out what they think of the treatment plan and their ability to following the treatment plan.  But there is a difference, between what doctors think they do and what they actually do.

 

So what is the impact on both patients and the brand? We know that 33% of patients take a drug holiday of at least one month, 20% switch to another therapy and that 27% of those who stop will do so in the first six months.

When designing a compliance programme getting a patient to take a pill is just one element.  It is actually important to consider the family picture and build programmes that address the wider potential issues.  An example of this is in hypertension.  We could get a patient to take their drug at the right time etc but if they are still eating badly and leading an unhealthy lifestyle the drug may not work effectively anyway.  Family and friends are an untapped resource in terms of helping to build the patient picture and we need to find ways to reach them.  And it is research, like this that will be vital to support a compliance programme and ensure that we get Healthcare professionals (HCPs) on board.

Another important consideration is that a good compliance programme should keep the prescriber informed throughout the patient journey.  The doctor needs to know the reasons why a patient has compliance issues, or what the trigger was for good compliance.  This will help them with future patients.  In addition peers are most effective in influencing each other, with anecdotal evidence which can be much more effective than anything a sales rep says.  
The challenge will be finding ways to improve contact with patients to get this valuable feedback.  As an industry we need to find ways to collapse the distance between brand teams and the patient.

When developing compliance programmes there are three key steps that should be addressed:

1. Quantify your brand’s adherence profile
2. Look at what is influencing patient behaviours
3. Design appropriate interventions which meet patient needs and have realistic expectations.

It is also critical to look at the key objectives for each group:

• Patient
  • Improve levels of knowledge within the patient group
  • Support patients with changes to their daily routine
  • Support patients throughout their treatment journey
• Healthcare Providers
  • Improve the communication and support to their patients
  • Contribute to ‘Good Medicine’ by improving compliance
  • Improve relationship with the brand
• Brand
  • Improve product performance through improved compliance
  • Generate enhanced insight into patient behaviour
  • Build stronger relationships with prescribers through tangible support for the patient base.

There are a wide variety of tools available for us to use to implement programmes: inbound medical helplines, outbound call schedules, websites, direct mail, SMS/IVR schedules or on-site nursing support.  In addition we need to consider the important role of the pharmacist who are crucial and will take on more responsibility. Whatever we choose good research will help us flesh out the key messages and strategy and Good Medicine has to be at its heart.

The critical success factors of a compliance programme are:

• Programmes must be genuinely designed to improve healthcare standards for patients and healthcare
• Programmes must ensure patient safety and data security
• Programmes must not be designed as product marketing programmes, and must be designed only for pre-prescribed patients
• Registration onto the programme must be optional, simple and compelling
• Sales teams must understand the significance of the programme.

Once we have conducted the research, defined out objectives and developed a compliance programme the final hurdle will be to ensure sufficient training and help is given to the sales force to enable them to sell the intangible benefits of such a programme.

Held on: 29/04/2008