Clare Howard, deputy chief pharmaceutical officer at NHS England led a prestigious line up at the ABPI Patient Adherence Meeting on 19 June 2013, in London. Over 60 APBI members heard the latest research on patient behaviour relating to medicines and were presented with opportunities for pharma to help in improving adherence.
"When medicines are used properly, with the right patient, the right drug, the right time and the right use, we will see the value of the medicine extracted," explained Kevin Blakemore, Regional Partnership Manager, ABPI in his opening comments.
Clare Howard picked up this theme, saying: "From drug development onwards, pharma should be thinking about how the patient will take the medicine – how difficult will that be."
The NHS spends 13-14 billion pounds on medicines in the UK, yet NICE reports that 30-50 per cent of patients do not take their drugs as intended and UK literature suggests that five to eight per cent of hospital admissions are due to preventable adverse effects of medicines.
We must start engaging with patients on how they take medicines and ask 'what would help you to get optimal benefit?'
Medicines waste is estimated to cost primary care around £300 million, of which £150,000 is thought preventable.
Clare Howard highlighted how you rarely achieve the 'Holy Grail' of 80 per cent adherence with a patient. She said: "Our default position currently is that patients will take medicine as prescribed. Perhaps we should assume they won't, because the evidence tells us that they won't take the meds as intended. So what can we do to support the patient to take the meds appropriately?"
Of patients prescribed a new medicine, the data suggest that around 30 per cent will be non-adherent at 10 days. Further, 61 per cent of patients say that they do not have all the information they need or are experiencing problems.
There is a body of evidence to show why everyone involved in healthcare provision needs to improve and how and Clare Howard identified three big opportunities for change:
- We must start engaging with patients on how they take medicines and ask 'what would help you to get optimal benefit'
- NHS needs to engage with the pharma industry in medicines optimisation, particularly around waste and outcomes, otherwise the results in clinical trials will never be reflected in the real world
- IT is critical in all of this and a move to electronic prescribing in hospital and EPS 2 (Electronic Prescription Service) in the community.
She concluded with a quote for Sven Olof Karlsson: "You can't take two steps over a gap" and challenged: "A leap of faith is required. It is a brave new world and requires all of us to be brave and step out of the comfort zone and it is for the likes of us to try and embark on and fix some of these issues."
During the Q&A session, Clare Howard added: "There is a lot concentrated on the prescriber to get the drug selected, but the need is all the way along and each of us has a part to play in both initial adherence and sustaining adherence over 20 years. The longer term is important too."
There was a suggestion from a delegate to treat the issue of patient adherence as a product launch, to overcome cross-silo barriers to progress in medicines optimisation by identifying the real advocates who work together across HCPS.
John Wienman, Professor of Psychology as Applied to Medicine, King's College London showed that adherence is not just an issue in medicines. He cited examples of speech therapy for children aged one to five, where 70 per cent of parents are non-adherent in supporting the homework given to support progress. He explained that non-adherence is the norm, it is not just about medicines but about individuals trying to make sense of what is happening and integrate chances into their life.
Five Core Beliefs Relating to Illness
These patient perceptions influence adherence
- Identity – being associated with an illness 'label'
- Causal beliefs – why they have the health problem
- Timeline – perceived duration and profile of the disease
- Consequences – how bad they think the condition will be for them and its impact
- Cure and control – what they can do to influence their disease outcome and how others can help
Prof Wienman identified two key types of non-adherence – intentional and unintentional.
For the intentional, there is a need to understand what it is that causes the problem for the individual and then intervention may be tailored to take account of this.
In unintentional non-adherence reasons may include
- Poor HCP/ patient communications
- Low patient satisfaction and/ or recall
- Problems in planning/ executive function in the context of a general population where around 25 per cent of people may not be great at this
- Financial or other barriers – 'which medicine should I drop, because I can't afford the charges?'
'Oh I forget' covers a multitude of possibilities, explained Prof Weinman. Broadly non-adherence occurs when either the patient doesn't make sense to a patient, for example because it is treating asymptomatic long term illness, or perhaps the patient may have major concerns or issues.
The key beliefs that influence adherence are patients' perceptions of their illness and perceptions around their treatment. There are five components of illness perception that are global – whether you are in the developed or developing world – and they help provide some understanding that can be a starting point in the adherence story.
Individuals evaluate the need for treatment in light of how they are thinking about their illness. Prof Weinman described how he has worked with colleagues to develop a way of assessing how patients think about their treatment.
He summarised how patient beliefs about illness and treatment influence adherence and have an internal logic. They are influenced by symptoms and may different from the medical view; and may be based on mistaken beliefs or premises. Importantly, they may not be disclosed in a consultation and they are not set in stone and can be changed.
"That is where the hope lies in this area," said Prof Weinman. "Beliefs in many contexts are remarkably changeable. If you work with patients and give them a different way of thinking about their illness or treatment many can say 'oh, I see, that makes a lot more sense'. That they are not set in stone and are changeable gives us a really important direction ahead."
Graham Davies, Professor of Clinical Pharmacy and Therapeutics, King's College London opened with an anecdote that highlighted how patients become adept at using and misusing information. He recalled a story back in the days of the anti-coagulant clinic where he overheard one patient say to another:
"How are you getting on with the warfarin?"
"Ok, the alcohol is an issue; I can't take the warfarin…"
"It's very easy," said the first patient. "Stop taking the warfarin, drink and start again three days before the clinic."
The system is not geared up to giving the right information. This patient didn't have sufficient information to use the medicine safely. The other aspect was what happens in between clinics, when seeing the pharmacist or GP?
He posed the question: "So how do we improve how community pharmacists consult and make appropriate changes in secondary care."
One experience in which he has been involved in South London looked at patients with diabetes and consulted multidisciplinary healthcare professionals and patient groups. They identified a set of themes including:
- Identifying concerns and facilitating goal setting
- Risk Assessment using trigger drugs
- Supporting diagnostics (also issues around screening)
Some patients also commented that doctor doesn't have time to talk, neither does the nurse but that the community pharmacists is a very good source of information about this, when a patient is proactive about asking.
Ideally he explained that the role of the pharmacist might encompass:
- Raising awareness of common beliefs about illness and treatment held by patients
Enhance consultation skills
- Provide systematic approach
- Examples of good behaviours
- Develop a proactive versus reactive approach - where people are normalising this behaviour as part of routine care.
He also talked about a screening tool in hepatitis C, which has been piloted and works. This provides useful information relating to the individual patients' beliefs and perceptual barriers to adherence. Prof Davies claimed that the challenge now is to extend the use of the document to other healthcare professionals so that there is multidisciplinary understanding of the relevant issues.
At the Q&A session interested discussion was had around industry investment in patient adherence and how there is a collective advantage in going 'above brand' even though achieving this may prove more of a challenge.
Pharmacists may have a huge role in this and the new contract may help in achieving it. Prof Davies commented: "We used to make products, now we supply them. It is about the professional maturing and it is relatively new as a discipline. What has not come alongside that is a structure and a process of work and encouraging the community pharmacist to be more patient-centred."
Opportunities were identified for pharma in training up the workforce so that their advice to patients is fully up to date, but information must be aligned across all healthcare professionals. There is no one easy answer. No 'tick here' and I have done my adherence work, but rather a series of opportunities to look at how adherence costs/ benefits the patient and in the context of behaviours as well as delivery systems and how this in turn may improve patient outcomes.
Chris Boulton, Director Marketing and Medicines Access, AstraZeneca UK gave insight into the OneHeart programme by AstraZeneca. He commented: "We should be proud of our brands; the onus is on us to find common ground in partnership with the NHS." OneHeart is an initiative in acute coronary syndrome designed to improve medicines adherence to oral antiplatelet therapy in accordance with current guidelines and to provide holistic support for acute coronary syndrome patients. Patients who do not adhere have twice the mortality rate within 12 months – problem for the patient but also a cost for the NHS. Personalised support has been the key in the OneHeart intervention programme tailoring a mix of a range of materials to the individual.
A randomised controlled trial running alongside the initiative will measure its impact. From a company perspective, they have a brand with NICE approval and so there is a business argument, but patient outcomes are the primary driver.
Interesting discussion centred around how companies may put forward proposals for patient-outcome focused initiatives like this, with transparency in the business agenda and individual healthcare professionals may not believe that patients need it. There is still a need to build trust through transparency and ensure that the physician can really see clearly how the patient will benefit.
Andy Carter, Director of Strategy, Atlantis Healthcare set out the commercial argument for patient support programmes. He described how the one constant in the past 10-15 years of NHS change has been issues with patient adherence. At its most detrimental, this can impact on a healthcare professional's view of a product, when the patient does not use it properly but the doctor has no idea of this and simply thinks it doesn't work. Cochrane acknowledges that effective ways to help people follow medical treatments could have far larger effects on health than any treatment itself and perhaps now with the ABPI, Royal Pharmaceutical Society and others pushing the patient adherence agenda the time is right. Even so, said Andy Carter, the evidence is not compelling, so can we actually justify them and deliver ROI?
Effective ways to help people follow medical treatments could have far larger effects on health than any treatment itself.
He cited evidence from of a survey of specialist physicians where 61 per cent said that the availability of a patient support programme would likely impact on their choice of treatment. He also gave an example of an effective campaign in macular degeneration that has run for five years due to its positive commercial impact. Key in any intervention is to look at the most prominent beliefs and drivers for a condition and to develop a strategy that empowers the patient to take control. Patient support programmes must be valued by patients and recognised by healthcare professionals and in certain cases this may also provide an opportunity to differentiate a product from its competitors.
"These things are not necessarily easy," warned Andy Carter. "People have run programmes in the past that have not worked, but hopefully now within the mix there is some understanding about why. If you can hone in on these, I hope you can see that it is possible," he concluded.
During the Q&A, Andy acknowledged that AMD as a therapy area has high cost treatments and could bear the investment in patient support programmes. He was clear that there are opportunities for less intensive programmes at lower costs which might still improve patient outcomes and benefit pharma. He suggested it is a question of cutting the cloth accordingly.
Kevin Blakemore rounded up the session by pointing to the ABPI Regional Interest Groups which were recently set up to bring together industry in a non-competing environment to explore opportunities for working with the NHS. These may have opportunities to contribute to the debate.
Additionally, the PM Society Patient Engagement Interest Group was recently set up to examine the potential for industry to add real value in ensuring patients are included in decisions, strategies and policies which shape their healthcare.