In an age where medication adherence apps are the contemporary equivalent of ‘a pill for every ill’, a fresh approach is desperately needed to break through the oversaturated market.

There are a number of reasons why medicines aren’t taken as directed, from cost to fear of side effects to forgetfulness, and a growing number of smart technologies are now attempting to change the way healthcare systems, pharmacies and patients themselves tackle the issue of patients failing to stick to prescribed medication regimens.

Adherence failure is a serious problem that not only affects the patient but also the healthcare system, and, despite the vast health and economic benefits of taking medicines correctly, remains a pressing – yet entirely preventable – public health burden.

Highlighting the vast scope of the problem, a study published by The National Centre for Biotechnology Information found in 2018 that between 25% and 50% of patients worldwide do not take their medications as recommended. In the US alone, suboptimal adherence has been linked with 125,000 deaths, 10% of hospitalisations and costs of up to $289 billion annually.

Elsewhere, the UK’s Department of Health estimates that the overall cost of wasted medicines to the NHS is more than £300 million each year, with around £110 million worth of medicine returned to pharmacies and £90 million worth of unused prescriptions being stored in homes, partly due to non-compliance.

However, the solution lies within the problem. The last thing patients who are already overwhelmed by having to keep up with daily treatment routines need is multiple apps to keep track of, meaning that we need to go back to the root of the cause – human behaviour.

Positive Reinforcement

A study conducted by Boots UK, University College London and Columbia Business School in the US found positive reinforcement to be an effective way of encouraging patients to remember to take their medication. The researchers tested different behavioural ‘nudges’, or subtle changes to the patient’s environment, to determine the best ways of boosting compliance.

The ‘nudge theory’ proposes indirect suggestion as a means of influencing the behaviour and decision-making of the patient. As part of the study, pharmacists asked patients to sign a sticker committing themselves to completing their medication, which was affixed to their medication packaging. Those who signed their name to a sticker that included a message warning of the adverse consequences of non-adherence to his or her own health were found to be significantly more likely to adhere to their medication than other patients, including those who signed stickers warning of the potential financial costs to society.

Other avenues also being explored include digital ingestion tracking systems, such as Abilify MyCite, which was launched in 2018 and contains an ingestible sensor that aims to help patients keep tabs on their medication.

The technology, which is currently only approved in the US for the treatment of schizophrenia and bipolar disorder, is used along with a wearable patch and a mobile application. Once ingested, the technology within the pill sends a wireless signal to the patch, which then transmits information to the app and a companion web portal.

Tone of Voice

However, research published in the Risk Management and Healthcare Policy journal suggests that providers and clinicians can be the connectors between patients and external factors influencing non-adherence, highlighting that human interaction can be more effective than a technological solution. So much so, that poor communication was found to result in a 19% higher risk of patients skipping medications.

A company that has already tapped into a similar line of thinking is Danish pharma giant Novo Nordisk. Speaking at this year’s eyeforpharma conference in Barcelona, Spain, the group said the message it was getting from patients was ‘we don’t want any more apps’. In response, it went on to develop another app, but one with a different approach, that integrates “behavioural science as the starting point to build something relevant to the patient, because it recognises the whole person and not just the disease they are suffering from.”

The app is designed to be a user-friendly, undemanding platform that uses a chat bot interface, reflecting a real-life conversation to enhance patient-centricity and adherence in what can be a complex environment. The interaction aims to deter patients with diabetes from giving up on their medication by surpassing the complexity of most apps, and providing support at the most basic level.

“If you look at the uptake of pharma sponsored apps, the adoption rate is really low. If we figure out how to make good, relevant and usable software, then I am sure people with diabetes would use it,” said Herluf Nis Thomsen, Novo’s global product lead on Ozempic.

“Pharma in general is new to this area, but we have ambitions, and now digital opportunities, and if we manage to bring the people living with diabetes into this equation as the starting point and all the way through then I am confident that this will drive better adherence.”

To put things into perspective, when the launch of the app was first initiated there were already 318,000 health apps and 50,000 diabetes related apps available to the public, all aimed at the same demographic and all preaching the same benefits as each other.

What now?

To understand the future of patient adherence it must be broken down into two parts – both the setting in which it will happen and the technology involved need to be addressed, explains Herluf.

“Diabetes medicine is definitely advancing into much more convenient and safer compounds – pushing the boundaries of medication frequency from daily to weekly treatments; safer drugs with less hypos, and with these advances comes a good starting point for better adherence on its own. But, recent years have also seen pharma moving into services around the products in areas that are not traditionally a core business, like behavioural science for example. We also see more and more tech companies moving into the healthcare, wellness and health services space; major players but also loads of start-ups, patient entrepreneurs, apps, etc.”

Herluf believes that going forward there will be more collaboration and partnership between traditional pharma companies and the new-to-health care tech groups “as health- related digital technologies are maturing, diabetes drugs become more commoditised, and patients are becoming more vocal on treatment options.”

There is uncertainty, however, that artificial intelligence (AI), blockchain or any other particular technology is going to revolutionise patient services or solve adherence. “We tend to focus more on the technological advances and capabilities rather than the habits we would like to see changed”, a path which has led the industry down a less personal approach to non-adherence, he said.

“Ultimately these changes are only going to happen if we have the right foundation of trust, empathy, convenience, and a better alternative to existing practices that are appealing to the individual. I do think tech will increasingly become an enabler to more and more advanced services that increase compliance and adherence. And, I think the successful technologies will be like the perfect waiter, you don’t see them, but they provide you with exactly what you need at the exact time you need it.”

If we, as a society, want to have more control over medicine adherence, we need to return to the root of the problem as opposed to focusing on advancing tech and foregoing patient interaction. Ultimately, there’s only so far an app will get you if the patient doesn’t feel supported and cared for.