New forces at play
At a minimum, an effective company strategy on adherence begins with an understanding of the trends that are raising the profile
of drug adherence programs in the overall continuum of healthcare. One is the growing influence of government, where legislative
and regulatory changes are spawning new research initiatives that will create incentives for those who administer, finance,
deliver and receive services designed to raise adherence rates among patients.
Adherence is an embedded feature of the Obama Administration's Affordable Care Act (ACA), which sees this as a valuable tool
in containing future medicines costs by enhancing the outcomes that keep people well and less reliant on expensive acute care
interventions. New delivery mechanisms like episode of care are premised on the idea that adherence will keep the cost of
other health services down and thus help providers meet their budgetary targets.
The ACA is committed to more federal support in analyzing the effectiveness of novel interventions that keep patients on medicine.
As part of its research agenda, the Patient-Centered Outcomes Research Institute (PCORI) is funding a study at Boston's Brigham
and Women's Hospital to identify factors and test ways to increase primary adherence (i.e., the patient's initial fill of
a medication). This two-year study will develop and implement a decision support tool on hypertension designed to reframe
the prescribing event from the perspective of the patient and create a more collaborative discussion with the physician and
pharmacist—one that the patient will feel compelled to act on. The tool will be made available to patient advocacy groups,
physicians, and pharmacist organizations.
The federal government is also reaching out to create partnerships with stakeholder groups, which is in itself a sea change
from its traditional approach of going it alone. In fact, everyone is seeking partners in confronting the adherence challenge.
The latest example of a coalition-based strategy is Prescriptions for a Healthier America, led by a strong supporter of the
ACA, the Council for Affordable Health Care Coverage. Other organizations on its roster include the National Consumers League,
the Healthcare Leadership Council, CVS/Caremark, AstraZeneca, National Pharmaceutical Council, Pharmaceutical Care Management
Association, PhRMA, and the US Chamber of Commerce. In banding together to highlight the issue, the coalition hopes to raise
awareness among Congress and state legislatures to enact regulations that build adherence into clinical guidelines and treatment
plans. Each member has endorsed five key public policy imperatives: care coordination; comprehensive medication management,
both across a broad range of practices, including physicians, pharmacists, and nurses; instituting health information technology
to improve the flow of information and to address gaps in care; communication and educational outreach to patients; and sponsorship
of field research.
Technology: promise or pitfall?
Another force shaping the adherence challenge is the onset of a host of new technology solutions, the cumulative effect of
which is the enhanced capability these platforms give to influence behavior and educate patients directly, without the intervention
of traditional gate-keepers like the physician. Hardware and software tools are making headway, with mobile showing the most
Of the hundreds of mobile health apps and associated gadgetry designed for smartphones, those that help the most appear to
be those with dosing reminders. For example, MediSafe is the first cloud-synced software of its kind to offer reminders with
a corresponding image of the pill itself, thanks to a feature that can scan the barcode of the drug's packaging. The app,
available for both Android and iOS, allows trusted family and friends to view their loved ones' adherence to their daily regimens.
More recently, the Israel-based developer added an interface with physicians to send them data on the user's adherence rates
to all their meds.
Vitality Inc.'s GlowCaps replace the typical pill bottle cap as a visual and auditory aid for distracted elderly patients—lighting
up and playing music every time the user has a dose scheduled. They are also integrated with smartphones to ping the user's
mobile device simultaneously. GlowPacks, a more recent iteration of Vitality's smart packaging, applies the same illuminant
concept in a pouch to accommodate blister packs, injectables, and other non-pill medications. Both communicate via AT&T's
wireless network, and GlowCaps are now being sold through CVS pharmacy outlets. The caps are also being tested in randomized
control settings by Duke, Harvard Medical School, various pharmacies, and pharmaceutical companies all measuring the impact
they have on different patient populations.
Proteus Digital Health's approach to understanding adherence has set some mouths watering in the clinical research setting.
Its ingestible sensors, powered like that of a potato-battery, send signals to a Bluetooth-enabled device to monitor data
on when the patient doses and more. Proteus has whetted the appetite of Oracle Health Care, as indicated by their investment
of a "relatively small" undisclosed sum in the company. In using the sensors to measure ingestion rates, dosing times, and
body response to a pill, Oracle hopes to use Proteus' product to generate valuable insight in incorporating them into drug
Another technology gaining traction is gamification—engaging the patient by incorporating the act of medication-taking into
the design of a game. One game making headlines is the cancer-themed "Re-Mission 2," which expands on a previous product that
held bragging rights to a study that it improved adherence rates in adolescent and young adult cancer patients, as published
in the medical journal Pediatrics in 2008.
Significantly, the value of all these new and emerging technologies is not substantiated by large bodies of research. The
research that does exist fails to test large enough samples to draw relevant conclusions. It raises methodological concerns;
such as measuring downloads of apps rather than actual usage.