Joseph C. Kvedar, MD, Director, Center for Connected Health, Partners HealthCare System, Inc.
Adherence to medical care plans is really about behavior change, which makes it difficult to successfully implement and value.
According to a now infamous WHO report, adherence to care plan for chronic illnesses, worldwide, is about 50%. This is a sweeping statistic with a great deal of caveat underneath and, after a more careful look, appears even worse. This has led some to suggest that the single most important way to improve disease management is to make sure that patients accurately take the medications they are prescribed.
But, the concept of adherence is really much broader, extending to the behavior changes required for adherence to a complete care plan. Considering how technology can play a part in improving this broader definition of adherence, we should consider three areas: reminders, motivation and education.
At the Center for Connected Health, we envision adherence to be a critical component of care delivery, such that it represents one of three components to our Connected Health platform (the others being monitoring and communications).
Why is adherence so abysmal?
First, let’s be candid: physicians have only the most elementary knowledge of how much patients really take our advice – and prescriptions – seriously. This is most likely related to another important component of the connected health platform, communication. Without a foundation of trust and confidence in a physician, a prescription could be seen as merely a hollow attempt to give the patient some value for their visit and quickly move them along. Our experience with focus groups of patients with hypertension and diabetes reveals remarkable variability in how much they consider the doctor a real authority and trust his/her advice.
Then there are the complex internal struggles patients wrestle with regarding their health, illness, issues of control and fears of death, to further test the doctor’s best-practice management versus patient adherence. (I owe much of my thinking in this analysis to my friend and colleague, Michael Barrett, who is a critical thinker and has spent much time pondering why individuals are not adherent to the care plans we as physicians prescribe.)
Mike has borrowed from economic theory of risk to explain the well-known phenomenon about risky behaviors and subsequent ill health effects. I think his analysis says a lot about the challenge of adherence. Ideally, we’d like the relationship between tangible gains and psychological gains – and losses – to be linear. E.g., for each pound lost, we’d like the perceived health benefit and motivation to be equally appealing. Unfortunately, dieting doesn’t work that way.
Likewise, the first pound regained after a weight loss is disappointing, but after we’ve gained 10 lbs, the 11th makes less of an impression. These non-linear relationships between tangible gains and losses and psychological gains and losses create significant challenges for adherence and especially persistence.
Of course there are the more mundane reasons for lack of adherence as well, including forgetting to take medication and inability to afford medication.
How can technology help?
There are real opportunities to use technologies to solve this vexing problem and we’re just scratching the surface today. Consider that in our heart failure telemonitoring program with Partners HomeCare and Mass General Hospital, the number one comment that patients make is that they are motivated and comforted by the fact that a nurse will call if their monitored vital signs are out of range. Patients admit that this virtual oversight motivates them to limit salt intake and thus better self manage their disease.
In another study underway at the Center, a ‘smart’ pill bottle signals a glowing globe (that sits on a patient’s desk or counter at home) to turn color when a patient takes his medication. This is not only a great reminder for the patient, but is also a tool to involve the whole family in care management. And think of the possibilities for using mobile phone technologies (games, mp3 downloads, or more minutes) to both remind and motivate those growing numbers of obese youth to be more active.
But just in case you’ve been saying, ‘This is easy,’ the technologies on the market today are immature and in many cases unreliable.
How can we extract value?
Along with the uphill battle we face in patient psychology, a growing mistrust of health care providers, simple forgetfulness and the current technology challenges, probably the biggest barrier to fixing the adherence problem is that no one seems to want to own it, financially. High co-pays for prescription drugs serve as a financial inhibitor to improved adherence. We’re starting from a position somewhere south of neutral!
Some forward thinking employers have taken the first step (for more on this see “The Asheville Project”) by removing co-pays for medications for strategic patients with chronic conditions. It should be no surprise that, in this model, even though the pharmacy cost increases, the total cost of care decreases. Yet, there is no real dialogue in the policy sphere on adherence, its importance and the questions that are on every adherence advocate’s lips, “Who will pay and how do we build the business case?” So much more can and should be done.
Adherence presents enormous opportunity and challenge. We are all hardwired as individuals to be less adherent over time. Patients are spending less and less time with their providers, so are less likely to believe in our advice. Patients are busier than ever, so more likely to forget to take their medication. The technologies that exist are not yet mature. And no one has figured out the business model yet. Sounds like a great space for entrepreneurs to enter!!
Joseph C. Kvedar, MD
Director, Center for Connected Health
Partners HealthCare System, Inc.
www.connected-health.org
During the second half of the twentieth century, the physician-patient relationship has evolved towards shared decision making. The patient is respected as an autonomous agent with a right to hold views, to make choices, and to take actions based on personal values and beliefs. Patients have been increasingly entitled to weigh the benefits and risks of alternative treatments, including the alternative of no treatment, and to select the alternative that best promotes their own values.
But when a physician faces requests for services, such as contraception or abortion, which could raise a conflict for the physician, what should he do? Physicians do not have to provide medical services in opposition to their personal beliefs. Though, it's the patient's choice. It is acceptable to have a nonjudgmental discussion with a patient regarding her need for the service, and to ensure that the patient understands alternative forms of therapy. However, it is never appropriate to proselytize. While the physician may decline to provide the requested service, the patient must be treated as a respected, autonomous individual. Where appropriate, the patient should be provided with resources about how to obtain the desired service.
Posted by: doctors-4u | January 27, 2008 at 06:27 AM