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Central Nervous System

“Personalizing” adherence support with Patient Support Programs

  • Patient Support Programs (PSPs) are behavioral interventions designed to help patients with medication and therapy adherence.
  • PSPs increasingly incorporate digital components such as text messaging in order to reach the broadest patient population possible.
  • Digital interventions by nature lack a human element; “personalization” involves the application of behavioral science techniques to make interventions effective for patients.

Patient Support Programs are behavioral interventions for improving adherence

Non-adherence to therapies in neurological conditions is a significant issue, associated with worse clinical outcomes and increased healthcare utilization and costs.1 There are many factors involved, including complexity of medication regimens, depression, gender, and duration of disease that may lead to a patient being non-adherent,2,3 therefore, an individualized approach is required to address this issue.

The World Health Organization has identified medication non-adherence as a priority, preventable healthcare problem.4 Previous articles in this series discuss the role of patient decision-making and behavioral drivers in influencing treatment adherence. Different behavioral theories and frameworks exist that physicians and other healthcare providers can use to evaluate patients’ risk of non-adherence, including the Transtheoretical Model and Patient Activation Measure, among others.5–7

Interventions have also been developed to support patients in being comfortable with their treatment and correctly adhering to their therapy. Commonly called Patient Support Programs, or PSPs, these solutions can range from simple calendar pill boxes or pill blister packaging to organized programs based on behavioral science frameworks,4,8 and can either be provided directly by the physician’s office or via sponsored programs. Mobile health solutions (“mHealth”) provide an opportunity to improve health outcomes,4 given the prevalence of digital technology, with an estimated 95% of the global population living in areas covered by a mobile-cellular network.9 Initial reviews indicate that PSPs10 and mobile solutions4 can have a significant positive impact on adherence and other outcomes, such as patient quality of life. However, as discussed in previous articles, what is often missing from such programs is a personalized, evidence-based approach.11,12 Personalization techniques are already being used by successful technology companies like Amazon, which is leveraging artificial intelligence (AI) to anticipate customers’ needs and tailor recommendations.13 Similarly, digital solutions personalized using behavioral science methods represent a significant opportunity for improving adherence, and these concepts are fundamental to the latest PSPs.8

The latest personalization research builds on these behavioral models to enable patient profiling, an actionable, digitally compatible model of patient adherence.8

Patient Support Programs incorporate mobile health solutions to enable broad adherence support

The development of mobile technology over the last decade has made broad dissemination of medical and public health support both possible and cost-effective, with approximately a third of the world’s population estimated to own smartphones in 2017.9 Particularly in developing countries, simple text messaging interventions represent an important tool for reaching a broad patient population and alleviating the demands on physicians’ time,8 and are a common component of effective PSPs. mHealth solutions such as texts and SMS enable improved remote patient monitoring, patient communication and adherence support.14 Text messaging has already been used with positive results in behavior change communication such as appointment and medication reminders, health promotion such as smoking cessation, and community mobilization, and can positively influence adherence for chronic diseases.9 Furthermore, these solutions have the capacity to identify patients at risk of non-adherence.

Existing evidence of SMS messaging on improved adherence for chronic conditions is promising, but further research is required.15 The focus of these interventions is generally centered on reminders to address forgetfulness, which is only one facet of adherence. Educating patients is a major opportunity area that does not translate easily to digital interventions,16 which lack the personal dimension that occurs naturally in interactions between individuals. In order to optimize the patient’s experience and overall program effectiveness, digital PSPs must include a degree of personalization that can account for individual risk levels and behavioral drivers.8

Effective Patient Support Programs “personalize” digital solutions to the patient

The application of behavioral science theories to personalize adherence interventions and PSPs remains a significant opportunity area.11,12 Solutions customized to the individual patient according to his drivers and needs can enhance his experience and positively influence outcomes, as demonstrated by online retailers like Amazon.13 With respect to PSPs, there are some challenges to effective personalization:

  • Existing adherence models are not digitally compatible. Most behavioral science and adherence models lack the continuous and detailed mathematical principles that are the basis for AI and effective interaction with digital support programs.8 However, the latest personalization research builds on these models to enable patient profiling using questionnaires, resulting in an actionable, digitally compatible model of patient adherence.8
  • Self-reported data may have issues with inaccuracy. Personalization models administered in a digital setting may require self-reported data, which may be limited in terms of accuracy8,10

The benefits of PSPs and personalization may be illustrated in the following example of a patient with epilepsy at a clinic for a regular checkup. By asking a few behavioral science-based questions, the treating physician understands that her patient is not managing his therapy regimen properly and is not taking his medication as directed. The physician also learns that her patient does not see himself as being responsible for managing his epilepsy to prevent seizures, e.g. he has low “activation”. The physician recommends that the patient enroll in their local epilepsy foundation support program to learn more about the importance of adherence to prescribed routines and treatment to avoid seizures. With the patient’s consent, she sends an SMS message to enroll the patient in the 90-day program and immediately gives him some printed educational materials. The patient receives an enrollment call from a specialist a few days later, who asks the patient some select questions, including behavioral questions. The answers automatically generate a digital profile for the patient and determine the type and timing of support to be provided. During the program, the patient receives regular SMS messages with coaching and information on managing his treatment, as well as telephone counseling. He develops a better understanding of his role in preventing seizures, including adherence to his treatment.

Patient Support Programs are important tools for physicians to support their patients

There is no replacement for the education, advice and support provided by physicians to their patients on any clinical topic, including adherence; however, significant opportunities exist to enhance these communications using behavioral science theories, extending the impact of the physician into the patient’s daily life.4,8 Physicians can improve their interactions with methods covered in this series to assess their patients’ risk of non-adherence and provide targeted support.8 Furthermore, digital adherence solutions and PSPs can enhance these efforts while alleviating the burden for physicians and creating value for patients. They do this by providing important educational resources and additional support.8 Personalization of digital tools and “nudge” techniques is fundamental for acceptance by patients and thus their effectiveness.8 Physicians are uniquely positioned to educate patients on the benefits of PSPs and personalization.8 The final article in this series will consider in more detail the different strategies employed by PSPs, the benefits to patients and the impact on adherence.

References

  1. World Health Organization. Neurological Disorders: Public Health Challenges. 2006. Available at: https://www.who.int/mental_health/publications/neurological_disorders
  2. Straka I, et al. Adherence to Pharmacotherapy in Patients With Parkinson’s Disease Taking Three and More Daily Doses of Medication. Frontiers in Neurology 2019;10:799.
  3. Ferrari CMM, et al. Factors associated with treatment non-adherence in patients with epilepsy in Brazil. Seizure 2013;22:384–9.
  4. Gandapur Y, et al. The role of mHealth for improving medication adherence in patients with cardiovascular disease: a systematic review. Eur Heart J Qual Care Clin Outcomes 2016;2(4):237–44.
  5. Ajzen I. “From intentions to actions: A theory of planned behavior.” In: J. Kuhl & J. Beckmann, Eds. Action Control. Berlin, Heidelberg: Springer Berlin Heidelberg, pp. 11–39.
  6. Gipson P and King C. Health Behavior Theories and Research: Implications for Suicidal Individuals’ Treatment Linkage and Adherence. Cogn Behav Pract 2012;19(2):209–17.
  7. Hibbard JH, et al. Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Serv Res 2004;39:1005–26.
  8. Dolgin K. The SPUR Model: A Framework for Considering Patient Behavior. Patient Prefer Adherence 2020;14:97–105.
  9. Iribarren S, et al. Scoping Review and Evaluation of SMS/text Messaging Platforms for mHealth Projects or Clinical Interventions. Int J Med Inform 2017;101:28–40.
  10. Ganguli A, et al. The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review. Patient Prefer Adherence 2016;10:711–25.
  11. Van den Bemt BJF, et al. Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert Review of Clinical Immunology 2012;8(4):337–51.
  12. Michie S, et al. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science 2011;6:42.
  13. Arora S. Recommendation Engines: How Amazon and Netflix Are Winning the Personalization Battle. 2016. Available at: www.martechadvisor.com/articles/customer-experience-2/recommendation-engines-how-amazon-and-netflix-are-winning-the-personalization-battle [Accessed March. 2021].
  14. Meister S, et al. Digital health and digital biomarkers – enabling value chains on health data.
  15. Marcolino MS, et al. The Impact of mHealth Interventions: Systematic Review of Systematic Reviews. JMIR Mhealth Uhealth 2018;6(1):e23.
  16. Treskes RW, et al. Implementation of smart technology to improve medication adherence in patients with cardiovascular disease: is it effective? Expert Review of Medical Devices 2018;15(2):119–26.