Adherence to medications is key to good outcomes in chronic illness. Yet studies indicate no real breakthroughs in achieving better adherence. In all the major conditions where adherence is critical, e.g. control of blood pressure in diabetics, prevention of asthma attacks, anti-platelet and hypolipidemic therapy post myocardial infarction, and adherence rates are dismal.
Given the significance of adherence to individual patients, health care providers, governments, employers, insurers and pharma it is surprising that so little work is focused on this critical aspect of medicines related outcomes. Cost-effective solutions are urgently needed. The potential for mobile technologies to lead to breakthroughs in promoting significant improvement in adherence seems obvious. Encouraging examples are emerging, yet much more needs to be done.
In their excellent paper on adherence in the NEJM in 2005, Osterberg and Blaschke recalled the challenge of Surgeon General Dr. C. Everett Koop, who noted “Drugs don’t work in patients who don’t take them”. They constructed a framework helpful for guiding research and development into improving adherence. A decade later, much has been said but little in the way of durable and cost-effective approaches to enhancing adherence have emerged. Real innovation is needed. The gains possible in population and individual health outcomes are astounding.
What if individual patients or those organizations who insure them for health costs, purchased health outcomes, not the actual medicine? Medicines prices are set based on incremental cost-effectiveness in many markets around the globe. The product is purchased to achieve the outcome e.g. prevention of stroke or MI in the case of anti platelet medicines. Prices could be adjusted up or down based on achievement or not of the forecast effect size in the population. Risks and benefits could be shared by the stakeholders – patients (premiums adjustments), payers/purchasers (refunds, economic benefits from superior outcomes), pharma (higher prices for greater than predicted effects) and health care providers (bonuses for adherence outcomes). Big Data would be needed to collect post marketing data. With all stakeholders with ‘skin in the game’ linked directly to adherence, true innovation in perhaps the greatest challenge in drug therapy will likely emerge.
1. Osterberg L, Blaschke T Adherence to Medication N Engl J Med 2005;353:487-97.
2. Cutler DM, Everett W. Thinking Outside the Pillbox — Medication Adherence as a Priority for Health Care Reform N Eng J Med 2010: 362:1553-1555
3. Psaty BM, Breckenridge AM Mini-Sentinel and Regulatory Science — Big Data Rendered Fit and Functional N Engl J Med 2014; 370:2165-2167
Richard Day is Professor of Clinical Pharmacology at UNSW and St Vincent’s Hospital Sydney. He has a clinical practice in Clinical Pharmacology and Toxicology, and Rheumatology. He has particular interests in promoting the quality of use of medicines. He was a Director and President of the DIA (2009-11). He is the senior academic for the Masters in Medical Science in Drug Development in the Faculty of Medicine at UNSW. His research focuses upon the pharmacotherapy of gout, diabetes, infectious and psychotic diseases. He also researches methods of enhancing the safe use of medicines using electronic medication management and decision support tools.