May 2008
	Patient Adherence: Information, Motivation and Aggravation – A Self-Ethnographic Portrait In previous presentations and articles, I have frequently commented that patient adherence, i.e., the combination of behaviors involving staying on chronic medications and not abandoning them without doctors’ advice, and compliance, i.e. taking the medication as instructed, is finally gaining the attention it deserves in the pharmaceutical industry. Battling it out to be drug of choice for new-start patients on a chronic medication makes little sense in an era when only half the patients you win are on the drug within six months of initiation of therapy, especially since we are attempting to milk every dollar we can out of the limited number of new products being introduced each year. Reports of previous studies we have conducted, you will recall, indicate that the major drivers for patient adherence can be classified as information, motivation and aggravation. Sadly, the industry has focused primarily on information, believing that if we bomb patients with enough information about a product and/or the disease it is intended to treat, they will respond with adherence. This is the line of reasoning that causes the industry to mount patient compliance programs, like hypertension newsletters that patients ignore in droves, reporting that they really don’t need to understand hypertension in any great depth, are irritated to be reminded on a regular basis that they are ill, and may be embarrassed if a family member encounters a document for a patient concerning a condition they did not know another family member had. In brief, swamping a patient with information will not engender adherence. Motivation, or rather the lack thereof, is, on the other hand, the member of the triad most likely to moderate whether or not a patient adheres with his/her program of chronic medication, since people are not prone to continue to spend time and money, both of which are required for compliance, if they do not understand the value proposition of the medication they are being told to take. And since physicians often do a poor job of explaining to patients why they must take a medication, especially for chronic, silent illnesses like hypertension, this can lead to significant amounts of loss in patient adherence. The problem here is that it is time consuming and not necessarily very easy for a physician to communicate the value proposition to the patient, and efforts on the part of pharmaceutical companies to help, while contributory, have been far from totally successful. Unless, for example, a patient’s father has died of a heart attack at an early age, it is difficult to make real to the patient the concept of cardiovascular risk and that something can be done about it by taking pills such as lipid-lowering agents and antihypertensives. The third piece of the nonadherence apocalypse, aggravation, is often given short shrift but can in fact be one of the most effective and efficient areas to manipulate. Moreover, if not paid attention to, it can also swiftly do in an adherence regimen. Let me give you an ethnographic example from my own experience. I have two houses. My main residence is right outside Philadelphia and serves as my major base of operation for working in the pharmaceutical industry that surrounds it. My other residence, an oceanfront condominium on Jupiter Island in Florida, is my winter retreat to which I hasten when I can’t stand it being 9 degrees in Philadelphia anymore. What, you might reasonably ask, do my real estate holdings have to do with pharmaceutical marketing, marketing research and aggravation as a blocker to patient adherence and thus to pharmaceutical company profitability? Lots. Last year, during one of my visits to Florida, I needed to renew a prescription I have taken for years. Since there is no national database of prescriptions, the Florida pharmacy needed to call my pharmacy in Pennsylvania to have the prescription transferred. When I returned to Pennsylvania and once again needed a monthly script renewal, I found out from my local pharmacy that once a prescription has been transferred, it was impossible to recapture, thus requiring me to call my physician to get a new script written. This year was even goofier. I called the pharmacy in Florida to get the prescription refilled. Since they still had the prescription that had been transferred, I anticipated no difficulty. I went to the “convenient” drive-through window to pick up the prescription, only to be told that they did not have the medication. Let me name names and tell you that this was a CVS, one of the largest pharmacy chains in the United States, with a store on every street corner in Florida. Let me also tell you that if I had needed soda, milk, laundry detergent or a beach chair, they could have readily met my needs. But drugs in a drugstore, no dice. I should also mention that the product I was seeking is one of the most frequently prescribed in the United States, not some orphan drug. Nonetheless, they didn’t have it, and I was told that a message to that effect had been left on my voice mail at home. Of course it had not. I was then reassured that the medication would be available the next day. When I called to ensure it was indeed available, I was told that they had forwarded the prescription (without my permission) to another chain. When I surfaced at that store, I was told that all they had was the brand, not the generic covered by my insurance plan, and that I would have to pay cash — $225, more specifically — rather than the $0 it would have cost me had they had the generic. The plot thickens. The next time, the new pharmacy that now held my prescription captive told me that they still did not have the generic. One of their other branches, several miles farther from my house, did, and I was instructed to proceed there. Again I went to the “convenient” drive-through window, this time to be told that while they indeed had the product for me, none of my insurance information had been forwarded with the prescription. I was literally told to drive in circles around the building, rather than wait in the drive-through, until they worked out the matter on the phone. Fast forward 15 minutes and I was told that I would need to bring in my insurance cards. A return trip to the pharmacy required yet another 30 minutes or so of negotiation and interpretation until the insurance coverage was approved. Bored yet? I certainly was, having consumed about four hours trying to get 30 pills. And why, we ask, do patients give up on taking their medications? Rest assured that had I not needed this medication, I might well have given up. So what does this have to do with pharmaceutical marketing and marketing research? Quite simply, I have come to believe that rather than beating our brains out with product specific compliance programs, it would be much more straightforward to research what aggravations patients experience in getting their medications and eliminating them. Making it easier for patients to get and use their medications should be a key goal, and we should not have to go through hours of grief to lay our hands on 30 pills. Interestingly, in the window of the pharmacy at which I received such wonderful service were several signs advertising what could be potential solutions to some of the aggravations. One of them offered free home delivery, while another offered pre-fills (an arrangement in which the pharmacist refills the prescription without a specific request from the patient, and then notifies the patient that it is ready to be picked up). Mail service pharmacies, which not only provide larger supplies of pills (typically 90 versus 30) but also deliver to the patient’s home and do so automatically, can also contribute here, especially if the billing is handled for, or made simple for, the patient. The more drugs a patient is taking, obviously, the more important such considerations turn out to be. In summary, I strongly believe that one of the most important contributions we as pharmaceutical marketing researchers can make, interestingly enough both to the health of the patients who use our products and to the profitability of the companies we serve, is to thoroughly research aggravations that our patients face overall and by segment (e.g., for some patients the co-pay for a medication is an aggravation, and for some it is not), and help our companies develop ways to eliminate them. Amazingly little thoughtful work has been done in this area domestically, let alone globally, and it is about time we turn our attention to this important effort. Richard B. Vanderveer, Ph.D. Group Chief Executive Officer GfK U.S. Healthcare Companies