PharmExec sat down with Colleen A. McHorney, PhD, former Senior Scientist at Merck’s U.S. Outcomes Research to review her long record of scientific research on adherence in advance of her retirement last month. McHorney highlights the cyclical nature of engagement on adherence programs, technology’s inherent inadequacies, the need to study the provider as well as the patient, and the importance of effective communication practices for providers when prescribing medications.
PE: Prescriptions for a Healthier America is a new coalition of government, industry, and patient groups formed to address the problem of medication adherence and to develop sound strategies for intervention. Do you believe it’s going to be an effective collaboration?
CM: It isn’t going to hurt. There have been similar calls to action in the past. NCPIE, the National Center for Patient Information and Education, published Enhancing Medicines Adherence: A National Action Plan in 2007, but I’m not sure how much it rallied sustained national attention. The National Consumer League also has their Script Your Future national campaign, running since 2011, which is slated to expire next year. We tend to have these cycles of heightened interest in adherence and then it goes away or something else replaces it. Success for these interventions really depends upon how well they are able to mobilize diverse stakeholders and interest groups behind a clear and cogent reform agenda.
PE: Today we see a focus on improvements in technology to drive increased adherence. Do you believe that, for instance, dosing reminder apps and flashing pill bottles will be game-changers?
CM: Personally, as a scientist and as a patient myself, I do not think they will. I’ve spoken to over 2,000 patients in my career in the past six years, and very few people want to get a text message every day saying, “Take your medication.” People who have problems remembering are going to appreciate that, but I estimate from Merck’s research, as well as others, that only 20% of non-adherence is due
to forgetfulness. The other 80% consists of people making intentional decisions about their medications. You can text people all they want and have sirens go off on their pill bottle caps, but unless the patient feels that they need a medication and they don’t have concerns about taking it, I don’t think technology is going to make the inroads its advocates claim.
PE: A lot of companies are funding and conducting their own studies on adherence, whether it be for particular disease states, demographic differences, or looking at behavioral economic factors. Based on your long record of expertise on adherence, do you believe that more information will solve the problem?
CM: In the past 40 years, some 40,000 articles have been published on medication adherence. At this point, I doubt more information is going to solve the problem. However, more targeted and theoretically-driven information may have an impact. The research I led at Merck went a long way towards elucidating some of the key drivers of non-adherence. Now it’s about meeting patients’ informational needs. Knowledge is necessary, but it’s not sufficient. Repeating the same studies on demographics and diagnoses will not get us anywhere. What’s going to move the needle is figuring out how and what to effectively message to patients about their medications. How do we communicate to patients exactly what they want to know about their medications in a way that will resonate with them and lay the foundation for their autonomous commitment to therapy? How do we incent providers to spend more than a handful of seconds discussing the rationale for and importance of the medication?
PE: What are the hot trends in research on adherence? If you were to remain in industry, what would your adherence agenda consist of in the next two years?
CM: I would do basic research to document the fact that patients have different adherence patterns for different medications to continue to underscore the fact that there is no such thing as an “adherent personality” (which many providers erroneously believe). I’m also working on a manuscript now which is documenting the extent of non-adherence at first fill of the prescription, where approximately 25% of patients are gone in the first 30 days. They don’t come back for their second fill.
I also have a passion for studying adherence at the physician level. Roughly 95% of all studies on adherence have focused on the patient. We need to start focusing on dyads (i.e., the relationship between provider and patient), and we need to start focusing on providers. One thing I’ve always wanted to do is aggregate patient-level adherence data up to the physician level and document that there are some physicians who have lots of high adhering patients and some physicians who have lots of low adhering patients. Believe it or not, there have been only two studies conducted on inter-physician variability and adherence rates. We need to understand the attributes of those providers and practices that have higher than average adherence rates. In 40 years of adherence research, we’ve almost completely ignored the role of the physician in medication adherence? it’s the next logical step for researchers to take.