Inside View: Adherence Centered Therapy Design (ACTD)

With U.S. healthcare costs rapidly approaching 20% of GDP, there is an increasing demand for healthcare innovators to bend the healthcare cost curve downward by developing therapies that simultaneously improve health outcomes and drive down costs.

While there are many areas that hold potential for improving healthcare value, I believe the most compelling innovations in therapies are driven by an increased focus on improving patient adherence through Adherence Centered Therapy Design (ACTD).

The Patient Adherence Dilemma

Nearly 2,500 years ago, Hippocrates warned physicians to beware of patients who “lie about the taking of things prescribed,” bluntly noting that because of their failure to comply with unpleasant instructions from their doctor, “they sometimes die.”.

Medical treatments have made incredible progress since Hippocrates, but patient compliance (which is now more politely and accurately referred to as “adherence”) has continued to be a major hindrance to the efficacy of treatments, particularly for chronic diseases.

While studies over the last several decades vary in their criteria for declaring adherence, most findings show stagnation in adherence, with average estimates of adherence rates hovering around 50%.

Many aspects of adherence can be difficult to quantify, but non-adherence is estimated to account for more than 10% of hospital admissions, 100,000 deaths annually, and additional preventable medical expenses in the hundreds of billions of dollars annually in the U.S. alone.

If general non-adherence to established medical advice is included, its costs are likely several times higher, even ignoring indirect costs like reduced productivity. In that sense, non-adherence is healthcare’s multi-trillion dollar problem.

Reconceptualizing Adherence

As research continued to show the extent of adherence-related treatment issues through the end of the 20th century, particularly for chronic diseases, there was a focus on improving patient adherence at the provider level.

After studies found that over 40% of patients couldn’t correctly explain what their doctor expected from them even 10 minutes after receiving instructions, the responsibility for increasing patient adherence to therapies was pushed to the very end of the healthcare chain: the individual physician and patient. Doctors and pharmacists were expected to communicate more effectively and simplify prescription practices in order to improve patient adherence.

In its 2005 report on adherence, the World Health Organization (WHO) recognized that this one-dimensional approach is not sufficient to solve the problem of non-adherence by itself. As part of the report, they officially re-defined adherence as “the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” and suggested a systems approach to the problem.

The WHO recognized that while adherence is strongly affected by healthcare providers and patient interactions, decisions in other areas of the healthcare ecosystem have a significant effect on adherence.

In particular, I believe we have reached a point where those creating and marketing treatments (whether pharmaceutical or otherwise) can make significant impacts on patient adherence rates through savvy therapy design choices. More effective treatments don't always require medical breakthroughs. Very often, the effectiveness of an existing therapy can be significantly improved simply through innovations that improve patient adherence.

Adherence Centered Therapy Design (ACTD)

Adherence Centered Therapy Design (ACTD) starts with an understanding of the patient who will be tasked with implementing the therapy on a daily basis. This means understanding that very basic tasks for a healthcare professional might be extremely difficult for some patients.

For example, a sweeping 2003 U.S. study on adult literacy found that 35% of U.S. adults lacked the health literacy to perform even intermediate health literacy tasks like:

• Determining a healthy weight using a BMI chart
• Determining medication timing relative to meals using a prescription drug label
• Identifying three substances that may interact with an over-the counter drug based on its label

It also means understanding the most common causes behind patient non-adherence. Studies have found that about half of all non-adherence is intentional. For intentional non-adherence, the high cost of treatment, perceived side effects, and perceived lack of effectiveness are the primary drivers. For unintentional non-adherence, the most common causes are forgetfulness and an incorrect understanding of how to implement the therapy.

There are many ways therapy designers can innovate to more effectively address these causes, but four of the most promising and broadly applicable are:

• Limiting required behavior changes
• Increasing accountability potential
• Gamifying therapy plans
• Creating more patient friendly delivery modes

Limit Behavior Change

Fewer, smaller, and simpler changes typically see greater adherence. For example, a single prescribed medicine, dosed once per day sees an average adherence of 80% per day. Each added daily dose or added medicine decreases adherence by roughly 10% (leveling off after 3 or 4 medicines). Because of this, combining medicines into single pills and creating medicines that are still effective with missed doses have been effective design shifts.

Similarly, tying therapies to existing routines is a powerful way to limit behavior change. For example, Allerdent is a toothpaste that provides allergy immunotherapy in toothpaste form. Because it’s part of an established routine (toothbrushing), it has higher adherence rates than traditional forms of allergy immunotherapy in the form of subcutaneous injections (shots).

Increase Accountability

One of the issues with treating chronic conditions is that it can sometimes be hard for patients to see immediate results from adherence or non-adherence. Providers can increase accountability by asking direct questions to the patient about adherence, but the most ideal scenario is to identify or create clear markers that will track patient adherence.

Prescription tracking, blood test results, and specific symptom checks are all traditional markers, and wearable technology is further increasing this kind tracking mobility. From self-monitoring pills to wireless blood pressure or breathing monitors the technology now exists to track patient data (and by extension adherence to a variety of therapies) in real time. The challenge for innovators is to apply the available technology to existing therapies in a way that promotes accountability.

Gamify

Gamification is a slightly different strategy than most design approaches related to adherence. Rather than removing barriers, gamification relies on increasing motivation. By turning adherence into a challenge and offering “rewards” or recognition of success, gamification can make a therapy “sticky” (a nice word for addictive). From the well-known Fitbit challenges to more niche tools like Bayer’s Nintendo DS-compatible DIDGET (blood glucose management), gamification is a promising technique for increasing adherence, at least early in a therapy regimen to build habits.

Develop New Delivery Modes

Finally, for certain therapies, changing the delivery method can significantly increase adherence. For example, replacing oral delivery with a patch or an implant reduces or removes the need for patients’ to remember to take a pill. Delivering a flu vaccine through nasal spray rather than via shots reduces barriers for patients who fear or dislike shots.

Even small changes, like a more user-friendly single-hand, pump action dispenser for a lotion based product or a more ergonomic flossing device can increase adherence by making the user’s experience faster and more pleasant.

Adherence Drives Better Outcomes

Regardless of the strategies used to increase adherence, therapy designers must include therapy adherence as a major factor in evaluating the overall effectiveness of a new therapy. Further, real-world adherence challenges should be primary considerations very early in any therapy design process. When properly implemented, this kind of adherence centered design thinking drives innovation, improves health outcomes, reduces needless non-adherence related costs, and increases the overall healthcare value provided by the therapy.