By Nick Barnes, Vice President, Healthcare and Life Sciences, UK and Ireland, Salesforce
It’s a $300 billion dollar problem and yet it sounds like a very simple problem. But it’s one that has dogged medicine and medical research for centuries: How do you ensure that patients, whether under treatment or taking part in clinical trials, take the drugs they’re supposed to, when they’re told to, and in the right amounts? The gap between a medical professional’s instructions and what the patient (or research subject) actually does is called ‘The Adherence Gap’. And that gap affects patient outcomes, skews research results, and can, ultimately cost lives.
The renowned Surgeon General of the United States, Dr. C. Everett Koop, the physician who did more than any other to, as the New York Times put it in its obituary, ‘change public attitudes to smoking and save millions of lives,’ had a pithy way of summing up the underlying problem that a lack of adherence to a medication regimen caused: “Drugs don’t work in patients who don’t take them.”[1] He made that statement at a symposium called ‘Improving Medication Compliance,’ in 1985. It seems that little has changed since then. Perhaps it’s just human nature to seek out medication, be told how and when to take it, and then end up forgetting, misunderstanding or just plain slacking.
There is hope of a solution. Not a panacea, but at least a way of achieving significant improvements in how to foster adherence through a better patient journey. And it comes from technology. Of course, that’s an overused claim, but the rise of what I like to call, Patient Relationship Management (PRM) is the key to bridging the Adherence Gap. It is a simple reframing of CRM, Customer Relationship Management. Instead of trying to foster sales and brand relationships, the same technology which underpins CRM can deliver beneficial outcomes when it becomes PRM. And that’s because the word ‘relationship’ is the key to solving this age-old conundrum. Perhaps not completely, but enough to improve both patient journeys and outcomes (which is the whole point of both medical practice and research) and enable a broader, more diverse population to get the care they need for the right cost to healthcare providers and pharmaceutical companies.
Research paper after research paper shows that adherence is vital. One paper put the problem starkly; “Low adherence is associated with adverse outcomes, hospitalisation and increased mortality. It is therefore a source of avoidable patient harm, as well as increased healthcare costs and reduced cost-effectiveness of medicines.”[2] That highlights a big problem: the millions (billions!) that are poured into medical and drug research can be wasted if adherence is either low or muddled. The only way to ensure that patients do what they need to do is to create a relationship that’s based on clarity of information and communication as well as trust. And it must be a relationship that is both ongoing and granular. That means it spans the time from consultation to optimal outcome and isn’t just based on a lot of information up-front, a couple of contacts in the middle, and (if the patient is lucky) a brief follow-up at the end. It needs to be a dialogue which can respond to changing situations and attitudes as well as tracking adherence closely without, of course, being intrusive.
The statistics around adherence are stubbornly problematic. The 2021 paper from which I just quoted showed that “Approximately 30% to 50% of patients with long-term conditions are estimated to be non-adherent to their medication.” Researchers have struggled to understand how to improve adherence. One study in Spain showed that when pharmacists contacted patients to understand their adherence to a range of medical regimens, and then used that data to provide ongoing advice, adherence improved by over 50%. That’s not surprising. The success of the intervention only highlighted the problem that most healthcare organisations face: the resources needed to achieve the same level of constant contact with patients aren’t available generally. Healthcare providers don’t have the staff or the time to deliver numerous human interventions on a regular basis.
The Adherence Gap is especially prevalent in populations that are poorer, less educated, and more diverse. That’s another complicating factor and is, again, a stubborn one. A 2014 review of research into the issue found that “…belonging to an ethnic minority, unemployment and cost for the patient for their medications showed consistently a negative effect on adherence which indicates that there is a social gradient.”[3] Another study, conducted in the US amongst Black adults with hypertension, found that more regular contact by medical professionals greatly improved adherence to regimens. The report concluded that “Patient‐clinician communication and involvement… are important predictors of optimal adherence to antihypertensive medication and should be targeted for improving adherence in this population.”[4]
Accenture found that the effects of the Adherence Gap extend all the way from research into new drugs and therapies through to patient outcomes at all levels of society and across a wide range of circumstances, including the use of medical devices and uptake of vaccines like Flu and Covid. And it results in increased costs within healthcare organisations as well as across society even when provision models differ (insurance based and state funded). Pharmaceutical companies rely on a pipeline of new drugs and therapies and that depends on clinical trials.
Accenture’s figures show that a staggering 85% of trials don’t start on time because of a lack of patients, not just because they aren’t willing to join, but they don’t even know they can take part. When they do, 30% drop out before the end of the trial which means that 19% trials end before they can achieve any significant (and valuable) results. That’s estimated to cost the sector over $800 billion in terms of lost long-term value. Similar problems afflict the treatment of chronic conditions. Accenture found that fully half of the patients studied did not adhere to their medication / therapeutic regimens. That results in a loss of value of $300 billion.
The same report revealed that, post-Covid, patients are becoming more demanding of their healthcare providers. They expect better patient services to help them adhere to and benefit from their regimens. But the increased pressure of all healthcare providers caused by not only the pandemic, but also the resulting problems across supply chains and global political instability, has created a perfect storm of pressure which, if not addressed, will only make the situation worse.
Relationships are what count. That isn’t news to the profession. Evidence from numerous studies prove it. As one summary put it, “The interpersonal dynamics of the physician–patient relationship play an important role in determining a variety of patient outcomes including patient adherence to their treatment recommendations. Patients who feel that their physicians communicate well with them and actively encourage them to be involved in their own care tend to be more motivated to adhere.”[5] The operative word in that quote is ‘feel’; when you believe that you are in a dialogue with your healthcare professional, you are more likely to work harder to keep up with your medication or therapeutics because, by not doing so, you’ll be letting down another human being.
So, the ability to achieve a single view of each patient and create a dynamic relationship is clearly important in not only closing the Adherence Gap but also improving healthcare services across the board. Unlocking the power of the data medical professionals already have and augmenting it with additional, often real-time, data is how healthcare can benefit from existing CRM technologies and techniques.
Many pundits and commentators, both medical and non-medical, have been waxing lyrical about the power of technology to improve patient journeys and reduce the cost of care (to patients, insurers, and the state) through digital means. The stories usually revolve around devices that remind people to take their pills or encourage exercise. Digital connectivity that enables healthcare providers to track patients and keep an eye on their wellbeing (with consent and protected privacy of course) is also touted as the answer to adherence problems.
But the problem is that brave new medical world isn’t rolling out fast enough. Accenture found that, despite significant investment in patient services, only 20% of patients are aware of what’s on offer, and those that do avail themselves of them feel that they aren’t supported enough. In other words, to quote Accenture, “they want to hear more… about how they can manage their conditions better.” What people want are patient journeys which provide timely advice and guidance as well as medication and therapy. It’s about enabling the physician and/or healthcare provider to engage with patients on a personal level about the medication or therapy they need. Encounters that can then take into account patients’ personal situations, including both emotional and financial issues which can have a direct effect on their wellbeing.
That’s why the word ‘relationship’ is so important. It’s not just ‘take this pill at this time and take it again four hours later’; it’s got to be ‘take your medication and by the way, how are you doing?’ The problem is that that takes time and effort. Time and effort that’s in short supply across all healthcare situations. You only have to track the news about the National Health Service in the UK to understand the pressures on the profession.
PRM isn’t a cure for the Adherence Gap, but it can make a real difference. Adapting CRM and the powers of what’s usually called ‘the marketing cloud’ in my business is very easy to do. The ‘cloud’ is neutral as is the technology. Feed in the data and you can both create and track patient journeys focused on improving care and patient outcomes. The point is to achieve regular, patient-centric, very human communications which adapt to each patient’s needs and changing circumstances.
That’s one of the best ways in which we can close the Adherence Gap. It’s how medical professionals can deliver the education and understanding which empowers patients as well as ensures that they understand the importance of following their regimen. It enables healthcare providers to remind patients (many of whom will have problems with memory anyway) to take their medication or use their devices. It’s how patients can feel supported throughout their journey through the healthcare system and their individual treatment. PRM enables better and more timely reviews of the regimen, and can include telemedicine opportunities to schedule consultations without the need for patients or their physicians to take time out travelling.
Importantly, the technology allows us to adapt to the different needs of diverse groups in society and focus help where it’s needed most. By making better use of data, we can overcome the problem Surgeon General Koop so vividly summarised: let’s make sure the drug and therapeutic regimens work because patients take them how and when they’re supposed to.
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[1] https://www.nytimes.com/2013/02/26/us/c-everett-koop-forceful-surgeon-general-dies-at-96.html
[2] https://qualitysafety.bmj.com/content/31/2/83
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323150/
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483480/
[5] https://pubmed.ncbi.nlm.nih.gov/18360559/