Improving patient adherence in cardiovascular medicine – a new approach

Thursday, 12 March 2015

Pharma rightly places a great deal of emphasis on the research and development of new medicines. However, substantial gains can also be made by improving adherence to existing treatments. Indeed, non-adherence is not only associated with worse outcomes, it can often dominate risk – sometimes by an order of magnitude more than any other factor.1

Logically, one might think that adherence would be less of an issue for those of us who work with medicines designed to prevent major cardiovascular (CV) events. Surely someone whose life is in danger will take their pills every day? Not so. Indeed, non-adherence with CV medications was recently described as “pandemic”.1

Nonetheless, as in most disease areas, adherence remains a great challenge. Despite ever increasing focus and investment, the Pharma industry is still grappling with the best way to improve adherence.

Adherence interventions are often ineffective

A recent Cochrane review analysed interventions designed to enhance patient adherence to medications across a range of disease areas.2It examined 182 randomised controlled trials (RCTs) – and found only five that reported improvements in both adherence and clinical outcomes. Many of the interventions employed were considered too complex to be effective, and many of the studies were underpowered to detect improvements in outcomes.

Summarising their work, the authors stated that: “Low adherence with medications is a ubiquitous problem, found with self-administered treatments for all medical conditions. Without considering what has been studied across disease conditions, researchers will find themselves with inadequate knowledge of what does not work, and will be unable to avoid repeating the painful lessons of adherence research to date. Rather, we need to begin with interventions that have shown some promise, or at least have not been tested with repeatedly negative results.”2

Improving the effectiveness of adherence interventions

There are two clear messages from the Cochrane review for our CV adherence programmes here at AstraZeneca:

Message 1: Follow the science – We need to start from a solid understanding of the underlying reasons behind the behaviour we are trying to change and the interventions that have proven effective. Then we can robustly measure the impact of these initiatives and build on those that demonstrate promise.

Several systematic reviews have been published that examine the factors that drive non-adherence and which of those might be modifiable, specifically to cardiovascular medicines. This is a great starting point for our understanding, which is then enhanced by real world evidence, both from sources such as registries and our own adherence initiatives around the world. This evidence base provides us a framework for better understanding the challenges each patient faces and helps to guide the development of future initiatives.

We have developed various adherence initiatives around the world that have been well received by patients and clinicians. However, as anyone who has worked in adherence knows, it can be difficult to really measure the impact. Recognising this, AstraZeneca has committed to several RCTs to assess the effectiveness of our adherence programmes at the highest level of scrutiny. These trials will not only measure medication adherence, but also other factors important in reducing further CV risk, such as quality of life. We look forward to publishing the findings of the AstraZeneca-led SUPPORT, eMocial and OneHeart studies and other insights in due course.

But this isn’t just about us, which leads me nicely onto my next point.

Message 2: We will not solve this by ourselves – Non-adherence is not a pharma problem, it is a problem for the wider healthcare community and as such everyone is looking at the challenge through their own lens. Working together, we can harness these different understandings and introduce expertise in associated disciplines, such as behavioural change and technology to develop more successful, scalable solutions.

We are already partnering with a number of groups in the healthcare system from leading providers, patient groups, academia and industry peers, to insurers and technology companies. The increasing use of consumer technology and the growth of wearable devices provides new opportunities to develop simple, scalable adherence programmes that can be tailored to the individual patient – and that ultimately improve outcomes.

Our Intelligent Pharma division perhaps best embodies both of these principles. Intelligent Pharma combines an evidence-based approach, behavioural science and novel device technology to transform treatment outcomes across a number of diseases, not just cardiovascular. Working with partners is central to this to understand the problem and develop a solution that is truly valued by patients to help manage their disease, monitor their condition and ultimately achieve better health outcomes.

The future is brighter than ever for improving adherence to treatment but there is much work to do. We welcome any the opportunity to further our understanding and capabilities so if you’re interested in discussing any aspect of CV adherence with us, respond to this blog post via the comment box below. Alternatively, do come and talk to us at the Annual Scientific Session of the American College of Cardiology in San Diego, USA (14–16 March 2015).

I look forward to speaking to you!

References:

1. Kolandaivelu et al. (2014). Non-adherence to cardiovascular medications. Eur Heart J 35:3267-76.Nieuwlaat et al. (2014).
2. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 11:CD000011.