6th September, 2024
Table of Contents
According to the World Health Organization (WHO), adherence is ‘the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes – corresponds with agreed recommendations from a healthcare provider.’
Patients’ adherence to prescribed treatments can positively influence their illness’ long-term outcomes and prognosis. Conversely, non-adherence can lead to repeated hospitalization incidents or physician consultations, lower quality of life, medication waste, and increased healthcare costs. In most cases, non-adherence may lead to disease progression.
Low adherence is a leading problem worldwide, especially in patients with chronic diseases that require long-term management, such as diabetes mellitus, hypertension, cardiovascular disease, and cancer in low-and middle-income countries (LMICs), adherence among patients suffering from chronic diseases averages about 50 percent, with even lower numbers reported in developing countries.
Barriers to adherence to treatment
Various factors contribute to non-adherence, broadly divided into five domains or dimensions, as defined by WHO: socio-economic, health system or systemic, therapy-related, condition—or illness-related, and patient-related. “Socio-economic factors, such as the high cost of medications, lack of social support, and living far away from hospitals are some of the key challenges patients face, which can contribute to low adherence in patients. These are further compounded by other factors that may be unique to specific illnesses or individual circumstances in different regions,” says Dr Joseph Saba, the Chief Executive Officer and Co-Founder of Axios International.
Let’s look at cardiovascular disease (CVD) as an example. The leading cause of morbidity and mortality globally, CVD accounts for about 17 million (30 percent) deaths annually and is expected to increase to over 23.3 million by 2030. Although the CVD epidemic has begun to recede in some high-income countries (HICs), CVD mortality rates in LMICs continue to rise to about 300 to 600 CVD deaths per 100,000 population every year. A key factor driving these rates is sub-optimal adherence to medications for the prevention and treatment of CVD. Adherence to CVD medications in emerging economies is challenged primarily by limited health resources, socioeconomic barriers, and inequities in access to healthcare.
Dr Navin Sukilan, consultant cardiologist from Subang Jaya Medical Centre (SJMC) in Malaysia, says, “Adherence is a big issue in hypertensive patients. In younger patients who are pre-hypertensive or in Stage 1 of hypertension, we usually prescribe lifestyle modifications and regular monitoring of blood pressure. However, patients who present with Stage 3 hypertension or blood pressure reading of more than 160, have a higher risk of organ damage and complications such as heart attack or stroke, where we prescribe medications immediately."
“To control their blood pressure effectively, hypertensive patients must take a few different medicines over a prolonged period. The increased pill burden is a significant challenge in medicine adherence. Other factors include low tolerance to side effects of the medicines and misinformation. They often obtain false information regarding the adverse effects of taking certain medicines for the long term through social media and chat apps such as WhatsApp, despite scientific data proving otherwise. Even highly educated working professionals believe these messages make adherence to medication even more challenging,” adds Dr Navin.
Improving medication adherence
One American study found that if patients took their drugs as directed, it could avoid up to 23 percent of nursing home admissions, 10 percent of hospital admissions, physician visits, diagnostic tests, and unnecessary treatments.
Although interventions to improve medication adherence have been introduced in high-income countries for patients with CVD, a 2021 study found that they are still at a nascent stage in LMICs. Strategies such as patient education, medication regimen management, fixed-dose combination medications, consultation with clinical pharmacists, and team-based care have been shown to have some success, but due to their cost, may be unsuitable for the health systems of many LMICs.
“Fixed-dose combinations have recently become available to hypertensive patients in Malaysia. These medicines consolidate two or three drugs into just one pill, which reduces the number of medicines patients must consume and improves adherence. However, the drug is available only in limited supplies outside of private hospitals here and is quite expensive, which impacts the ability of some patients to stay on long-term treatment. When a patient visits a government clinic or hospital for follow-ups and refills, they are usually unable to obtain the fixed-dose combination and have no choice but to revert to their former three-pill treatment regimen,” explains Dr Navin.
Strategies such as cognitive-behavioral therapies and electronic pill monitoring with text messages, automated refill tracking of in-patient electronic records or email alerts to a provider for missed refills, although widely used in HICs, have not been sufficiently adapted for use in LMICs, often due to cost limitations. Reminders to take medication via phone calls, text messages, Short Message Services (SMS), or in-phone calendars were some of the most common adherence interventions in LMICs. The study also found that reminders were more effective when they were personalized or interactive rather than generic.
“Improving adherence is a complex issue that involves different factors and multiple stakeholders. While we, as physicians, should take certain proactive steps to remind patients or reiterate the importance of adhering to their treatments, it is usually factors such as the high cost of medication and limited availability of less costly options that would ultimately determine if the patient continued to adhere to their treatment. This is especially true in managing chronic conditions such as hypertension and cardiovascular disease, which require long-term management,” says Dr Navin.
Importance of personalized adherence solutions
Thanks to decades of work by researchers worldwide, adherence is now understood and addressed as a behavioral issue that requires more than consistent reminders. Much of that research supports the theory that behavior is mediated by cognition, where knowledge of a person's condition, treatment, and attitude affects their actions. Cognitive-behavioral theories recognize knowledge alone as insufficient to produce behavioral change. A person’s perception, motivation, skills, and social environment influence behavioral change.
As a result, adherence programs and apps must prompt patients to take their medication and promote well-being through goal setting and tracking. Ideally, they should also consider their patients' needs and barriers to adherence. This allows for more tailored support to meet the needs of individual patients.
Patient Support Programs (PSPs), such as those provided by Axios International, benefit from approaching adherence as a behavioral issue and play a key role in providing 360-degree support to patients to maximize their health outcomes.
“Adherence is rooted in creating an environment where patients can cope with their disease throughout their treatment journey. At Axios International, we believe there is no ‘one size fits all’ when it comes to designing access solutions. Every patient’s journey is unique, so to help patients stay on treatment, we must utilize a multi-layered approach to effectively address the five dimensions of adherence through a versatile approach with a broad range of Maximized Adherence Solutions,” explains Dr. Saba.
“The PSPs we manage are designed to create an integrated ecosystem of care and treatment. Using our proprietary Patient Needs Assessment Tool (PNAT), we identify the risk factors that may lead patients to discontinue their treatment and tailor programs to best meet those unique requirements. By adopting an evidence-based approach, PNAT customizes services for each patient, thereby maximizing adherence to treatment, engagement, and program cost-efficiency,” adds Dr. Saba.
Our partnered-access programs yield improved medical outcomes and reduce the burden on hospitals and healthcare professionals by following through with patients outside the hospital environment. Through the programs we manage, we also foster trust with patients and their caregivers, thus ensuring sustained program outcomes. PNAT is currently used in five countries, including the UAE, Kuwait, Kingdom of Saudi Arabia, Iraq, and Egypt, for disease areas such as Dermatology, Rheumatology, Immunology, Neuroscience, Asthma, Cardiology, and Oncology.
Using digital to support adherence
In recent years, many positive advances have been made in developing digital support programs that facilitate stronger adherence to treatment.
Axios’ digital health ecosystem, Axios+, intuitive tools to enhance the patient experience and medical outcomes while facilitating the delivery of Axios-managed Patient Access Programs (PAPs and PSPs). Axios+ offers intuitive tools to enhance the patient experience and medical outcomes while facilitating the delivery of Axios-managed Patient Access Programs (PAPs and PSPs). The MyPatients app helps physicians stay in touch with their patients, allowing them to check their progress in a personalized way to help them stay on treatment and get the most out of their medication. To improve patients' medical outcomes, barriers to treatment adherence must be considered as seriously as patients’ ability to afford treatment. To encourage and sustain behavior that leads to medication adherence, patient’s personal needs and motivations to use digital tools must be considered and incorporated into the design and implementation of healthcare solutions.
