We have all been guilty of it – starting something and then leaving it unfinished as we lost interest, got pulled away into other more pressing matters, or just simply forgot. When the object of our inattention is a Netflix series, a historical book or even a passion project at work, the result is a missed opportunity or perhaps a minor inconvenience. When it’s a medication for a disease like hypertension, TB or HIV/AIDS, the result can be increased cost of treatment, a worsening of the disease, and even death.
Medication non-adherence was reported in a 2017 story by The New York Times as an “out-of-control epidemic,” with staggering impact on public health. The numbers quoted in this and other studies speak for themselves:
- Non-adherence causes approximately 125,000 deaths and at least 10 percent of hospitalisations
- Up to $289 billion of cost to the healthcare system is incurred due to non-adherence
- Up to 30% of prescriptions are never filled and approximately 50% of medicines for chronic diseases are never taken as prescribed
Although this story was focused on the United States, a similar problem is seen worldwide, including in India. Non-adherence is a significant contributor to the rise of drug-resistant TB, a deadly form of the illness that affects about 100,000 Indians each year, representing about a quarter of the world’s burden, according to the WHO. A study in the Journal of Family Medicine and Primary Care on hypertension patients in Kerala found that 54% of the patients studied showed medium or low adherence to their medication.
With the tremendous loss of life and the financial burden on public health systems, it is imperative to tackle this issue on a war footing, and indeed, many programs are in place to do just that. These programs typically fall into a few categories:
1) Policy – improved health insurance, reduced costs, strengthened public health availability and delivery
2) Patient – engagement, awareness, support, counselling, access to reduced-cost medicines, access to health records, technology-driven and support, gamification, adherence reminders
3) Provider/system – Access to patient adherence data, pharmacist-driven education programs, case management
A study in the Annals of Internal Medicine found that many of these interventions, such as reduction in out-of-pocket costs and patient education with behavioural support, all improved adherence rates. It is this latter form of intervention that I will be diving into here. In the Indian context, “patient education with behavioural support” can translate into:
Better communication between the doctor and the patient
Improved access to quality healthcare information
Access to tools and people to help support the healing process, for example mobile apps, call centres with nutritionists, counsellors, etc.
Incentives to adhere to medication
All of these are important tools in the health system arsenal to improve adherence to medication. But it is one of the simplest tools – a daily reminder to take medication – that has proven to be extremely effective. Several studies have proven the impact of daily text-based reminders in terms of increasing adherence rates in diseases as diverse as asthma, malaria and coronary heart disease. At PharmaSecure®, we decided to apply this principle to TB adherence.
In a program supported by the Bill & Melinda Gates Foundation and USAID, we enrolled 1146 TB patients into a program with one objective: to test the impact of daily reminders on medicine non-adherence amongst TB patients. To measure adherence, we asked the patients to report a unique code on each daily dose of their medicine, the code having been applied before distributing the medicine into the market. This code served to uniquely identify each dose, and thus acted as a confirmation of a new dose being taken daily (see Fig. 1 below).
Fig. 1: Uniquely coded daily dose of TB medication
Four groups were created: an SMS reminder group (Group 1), an Automated Outbound call group (Group 2), a Voice Call group (Group 3), and a control group with no intervention (Group 4). We were curious to test if different interventions produced different rates of adherence.
The results are shown in Fig. 2 below.
Fig. 2: Results of TB Adherence Study by PharmaSecure®
As you can see, while there was no significant difference between the various intervention methods, having a daily reminder produced about a 30% increase in adherence rates versus no intervention. This shows the tremendous potential of such a program on some of the deadliest diseases we face in India and beyond.
To summarise, we face a particularly difficult problem here in medicine non-adherence, but the good news is that we have proven tools and methods at our disposal to tackle it. Given the infrastructure and financial challenges in a country like India, a daily reminder may just be the simple, cost-effective solution we need.
Pillbox Image courtesy QSEN Institute