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Listen to the Doctor

In 2003, the WHO indicated that "increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments" (1). In light of this recommendation, particularly at a time when outpatient services are becoming the preferred option and patients are being encouraged to take more responsibility, any solution that can improve adherence to treatment will be welcome.

Global Phenomenon

Following a medical prescription to the letter is a well-known problem for patients taking several medicines at once or who are on regular medical treatment. It is estimated that in developed countries, one patient in two with a chronic disease fails to follow their treatment correctly by simply forgetting, taking their medication late, or other reasons. It can be hard to keep track even when taking a simple treatment for just a week. Yet observance – or adherence – to treatment is essential, since it contributes to the success of a medicine or, conversely, can be a source of complications such as non-improvement, healing or even death, if it is not taken correctly.

Observance is attracting a significant amount of attention from health stakeholders, who are aware of the major public health issue it represents. Their aim is to mobilise the authorities and communicate more broadly with the general public to improve the effectiveness of the measures taken to address the problem. Some people in France are even going as far as asking for observance to become a major national cause (2).

Intricacies of Treatment

The idea of treatment observance or compliance is defined by a particular patient following the prescription given to them by their doctor, whether this relates to:

● Dosage
● Number of daily, weekly or monthly doses
● Times at which to take the medication
● Duration of treatment
● Associated recommendations (such as hygiene or dietary rules)

The problems associated with failure to comply with treatment – or non-observance – are seen wherever the patient administers their own medication, very often regardless of the type of illness and the quality and/or accessibility of the healthcare system.

There are several reasons for nonobservance, which are useful to identify and share with patients to raise awareness of the issue:

● Lack of symptoms
● Simple forgetfulness
● Too many medicines to take at once
● The patient’s psychological condition (for example, associated depression)
● Lack of patient involvement due to being uninformed about their illness, its risks and consequences
● Fear of side effects
● Intolerance of the treatment
● Fatigue

Non-observance is not without its consequences, which can include problems such as:

● Reducing treatment efficacy
● Overdosing, either directly by taking too much, or because of the patient trying to compensate for a treatment they believe is ineffective by increasing the prescribed doses
● Interactions or reactions that make the patient ill

Studying Patient Behaviour

Non-observance therefore represents a therapeutic failure, causing the patient’s health to deteriorate rather than improve. This is coupled with a heavy price to pay for the national health system, as a study conducted by IMS Health France and Cerde de Réflexion de l’Industrie Pharmaceutique shows (2,3). The study was carried out in France and focused on six chronic conditions, which represent a quarter of spending on drugs and carry a long-term risk of serious complications:

● High blood pressure
● Asthma
● Type 2 diabetes
● Osteoporosis
● Heart failure
● High cholesterol

Treatment observance was recorded longitudinally for a 12-month period, anonymously and in real-life conditions, for around 170,000 patients beginning their course of treatment using a specially designed tool (LifeLink Treatment Dynamics database).

The results of the study showed that only 40% of the group adhered to their treatment. Just 13% of asthma patients followed their treatment correctly, followed by patients with heart failure (36%), type 2 diabetes (37%), high blood pressure (40%), high cholesterol (44%) and osteoporosis (52%).

Non-observance generates very high avoidable costs caused by complications. The study calculated only the direct cost of the most significant complication for each condition:

● Stroke for high blood pressure
● Coronary disease for type 2 diabetes
● Severe myocardial infarction for high cholesterol
● Pulmonary oedema for heart failure
● Osteoporotic fractures for osteoporosis
● Acute severe asthma for asthmatics

In the case of high blood pressure, the direct cost of strokes alone represents €4.4 billion a year. The total potential savings for the six conditions studied could be €9.3 billion in just one year. Not to mention patients’ suffering, lives disabled by disease and the indirect costs to society linked to people taking time off sick or not being in employment. The results can only support the initiatives already launched to improve observance.

Multiple Solutions


Several educational and technical solutions can contribute to better treatment observance, starting with therapeutic education. This consists of a range of information, advice and learning activities designed to enable the patient to develop skills and attitudes that will help them live as well as possible with their disease and treatment.

Therapeutic education is aimed essentially at patients suffering from chronic diseases, such as diabetes, asthma, ischemic heart failure, heart failure and chronic kidney failure, but also short-term illnesses, such as disease episodes that require prolonged anti-coagulant or analgesic treatment. While the conditions concerned are often asymptomatic apart from their initial presentation, they need patients to adhere closely to various monitoring and treatment methods on a daily basis (such as taking medication, following a diet, monitoring their own biological parameters, and so on) in order to prevent any complications arising.

‘Proximology’ is a new area of research, which focuses on the study of relationships between the patient and their friends and family. It is a multidisciplinary approach that stands at the crossroads of medicine, psychology and physiology, and focuses on the people around sick or dependent patients.

In addition, each of the partners in the tripartite ‘doctor-patient-pharmacist’ relationship needs to feel involved and committed, particularly given that the current lack of coordination in care and multiple prescriptions make the task more complicated for everyone.

● The doctor issuing the prescription must educate their patient, by explaining the purpose of the treatment and the reasons for prescribed doses. They need to make the patient aware of the importance of correct observance
● The patient must be willing to ask any questions that are of concern to them. In general terms, patients who understand the purpose of their treatment and are aware of the side effects are more likely to adhere to it
● The pharmacist is the person who physically hands the treatment over to the patient. They provide information and pharmaceutical education and have to check that the patient has understood what they have been told, in addition to knowing how to administer their treatment. It is therefore the pharmacist’s role to guide and help their customer with observance

Different solutions are deployed from a technical point of view to help the patient adhere to their treatment and avoid the risk of confusion, forgetting or taking a medicine twice.

● From the medicine’s point of view, manufacturers are working on both inner and outer packaging to make it easier to use various formulations. Preparing the right doses also improves observance
● On the tool’s side, the pill dispenser is now recommended by health professionals as a major aid to observance. The combination of electronics and plastic – the plastronics already widely used in the automotive industry – offers multiple solutions, such as an alarm to indicate when a dose should be taken, the box unlocking at the right time, or feeding information back to a third party to confirm that the patient has taken their medication
● At the same time, smartphone apps are being used to remind the patient when it is time to take their medication, renew their prescription, archive prescriptions and the calendar of appointments, switch on medicine cabinets with a light in response to an alert on the phone, and so on
● Connected pill dispensers undergoing clinical trials are generating data that could also be used to adjust treatment based on observance, to administer the ideal dose required to achieve the best possible result

Next Big Thing


Health stakeholders involved in observance are well aware of the multiple benefits associated with adherence to treatment and regularly develop new formulations and educational and technological solutions.

The development of the internet of things and the technologies associated with it to produce smarter and more effective packaging – benefiting both patients and health stakeholders – will undoubtedly bring new innovations in the near future.

References
1. Sabaté E, Adherence to long-term therapies: Evidence for action, 2003. Visit: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
2. Visit: www.imshealth.com
3. Visit: www.cnam-paysdelaloire.fr

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Originally recruited as Stiplastics’ Sales Director, Jérôme Empereur is now the Chairman. French company Stiplastics has been designing, developing, manufacturing and marketing technical products and innovative devices using injection-moulded plastics, particularly medical devices, for 30 years. Before joining Stiplastics, Jérôme was Packaging Product Manager at Wittman Battenfeld France.
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