New insights into customer behavior fostered by the revolution in information technology are finally being applied to the age-old quandary of why most patients stop taking prescribed medications after a few months of therapy. This was a key conclusion of last month’s 11th annual Forum on Patient Adherence sponsored by Pharm Exec’s sister organization, the Center for Business Intelligence (CBI). The optimism of the more than 200 registered participants was reflected in what has become a regular feature of the Forum: the Strategic Patient Adherence Awards, which recognize excellence in adherence programs administered by drug manufacturers, PBM organizations, and—for the first time this year—employers.

“Our 2012 awards reflect the increasing capacity to leverage technology so that it can be tailored to the needs and motivations of the individual patient,” said judging panel member Robert Nauman, principal at BioPharma Advisors. “The insights follow—and the harvest is rich.” At a Forum discussion on the winning entries, all the judges noted that technology was enabling improvements in the design of programs, including the ability to reach out to more constituencies and to build coalitions, with a multiplier effect on results. Applicants are also doing better in addressing ROI, which is essential for maintaining support for these programs among senior management. “We call it the ‘why factor,’”  Larry Boress, CEO of the Midwest Business Group on Health, said during the panel debate.

PBM giant Medco—now Express Scripts, after a merger with its former rival approved earlier this spring—snagged the award in the managed care category for its Specialist Pharmacy Care model, which builds on a network of Therapeutic Resource Centers staffed by trained Specialist Pharmacists to provide members with customized information on their condition. This takes the form of periodic written materials, alerts, and, if necessary, direct contact by phone or in person.  The company applied its proprietary Health Action Plan software technology to develop individual profiles of member’s priority conditions, number of medications, gaps in treatment, and potential opportunities for cost savings through preventive care interventions. The network of Specialist Pharmacists has been trained to interpret this highly integrated data set and to make appropriate contacts with the member or his/her physician on ways to ensure medicines are taken for the duration of treatment.

To obtain the greatest benefits, the initiative is focused on 15 prevalent chronic care conditions that account for some 96 percent of Express Scripts total pharmacy spend. “Our company has enormous channels of data that we have synthesized into a tool directed to empowering the pharmacist as advocate for the patient,” Ellen Franzblau-Isaac, Director, Clinical Quality, told Pharm Exec. “Their access to this easily referenced data brings the pharmacist to another professional level, much higher than the norm. It has had a positive impact on member engagement as well as the job performance satisfaction of the employees who serve them.” Franzblau-Isaac relates that the toughest part of the program is classifying members within the 15 covered conditions, since it is often the case that members suffer from multiple chronic disorders.

Coming out tops in the employer category was Chicago-based Evive Health, which serves a varied industry client base with programs that apply insights from data to create personalized adherence communications that shape and change patient behavior, in a positive way. It was recognized for the breadth and variety of these communication programs—applied to a pool of nearly one million covered lives since 2008—in improving evidence-based care, including medication adherence, using new tools like the lessons from behavioral economics. “We have borrowed much of our engagement strategies from outside of healthcare,” relates CEO Peter Saravis. The main delivery channel is direct mail, but the messaging is cutting-edge. “Our goal is not simply to remind the patients about taking their medicine. We build beyond that with approaches designed to elicit a response and persuade them to reveal something about themselves that we can apply to good use later, this time emphasizing prevention and wellness extending beyond the simple act of taking the pill. It’s all about the right information, at the right time, and in the right way.” The judges were particularly impressed by Evive’s ability to document an average 15 to 28 percent increase in adherence over baseline in the populations covered by its sponsor programs.

Rounding out the winners was German-based drug manufacturer Boehringer Ingelheim, which applied the findings of a novel 2009 study on factors that lead patients to cycle off medications—The 11 Dimensions of Non-adherence—to create a highly focused, pharmacist-driven, patient-specific adherence program covering some 950 patients using prescribed B-I chronic use medications. The Patient Empowerment Program was built around a customized non-branded website, integrated with sophisticated pharmacy management software and offering easy access for participating patients. Patients start the process by completing an assessment, which generates an individual patient profile from the 11 dimensions of non-adherence. This profile provides an ongoing series of printed intervention tactics to share with patients when they fill or re-fill a prescription.

On the pharmacist side, a simple training module was designed to introduce the concept of the 11 dimensions and to demonstrate how to administer the program, from using the website to guidance on how to structure the discussion with patients. “Our goal from the start was to design a program that conforms to the workflow of the pharmacy—something that would complement their tasks, not compete with them,” Robert Belknap, Executive Director Trade Sales and Operations, told Pharm Exec. There is a perception that all a pharmacist does is point to “sign here” when you pick up a prescription. “This is an untrue depiction of a profession that wants to do more and has the skills and accessibility to get results from patients. Our program is designed to unlock the potential of the profession by making it easier for them to engage with the person on the other side of the counter.”

For its part, B-I has already unearthed a rich pool of data and insights from the program and is now considering how to “seed it” for a wider audience. “The template is literally something that everyone can own,” says Belknap. “There is no downside, as it represents a win for all—patient, payer, retailer, and manufacturer.”

No two patients are alike, but drug-makers may not consider how different a single patient’s perspective can be when viewed over time. A patient’s progress through disease management is a journey, and perceptions change over time. Changes in perceptions influence the meaning of “usability” and can have tremendous implications for how a drug delivery system supports the patient. To understand this concept better, consider two different points during the patient journey – a newly diagnosed patient and a patient further along with their condition – as examples of how different usage must influence the design of a drug’s delivery system.

The New Patient: Struggling to Adapt and Learn
Early on, patients who use delivery systems in their medical therapy struggle to cope with significant life disruptions. They often do not feel very well physically. Emotionally, they may be fluctuating between fear, anger and deep concern or depression. At the start of their disease management journey, these patients are asked to take on new responsibilities for their condition, learn new and sometimes difficult tasks, and become experts in managing parts of their disease, such as administering their own medication.

What does this mean for a drug company? Ease of use is a critical consideration; pharma should ensure that drug delivery requires as few steps as possible, guaranteeing that users can learn, remember and quickly master the process. Especially for the newly diagnosed, drug delivery devices need to provide clear, absolute confirmation that they were used properly, and that the medicine was successfully delivered. Any ambiguity heightens patient anxiety and will leave them questioning whether they received the proper dose. Such anxiety can lead to overdosing and create doubt that the device – and the drug – is trustworthy or effective, which quickly erodes adherence.

For a patient in an early stage, “ease of use” should translate to “ease of training.” With the rise of biologic therapies, patients rely on the support of healthcare practitioners and family to learn how to self-inject, for example, as they acclimate. Optimizing a drug for both self-administration and demonstration means manufacturers need to carefully consider how humans learn, and the differences between processing information by watching others, versus doing things ourselves. Failing to support these early stage requirements can lead patients to abandon therapies before they even have a chance to take hold.

Further Along: Staying Faithful
Later in the disease management journey, patients return to a more stable condition and reasonable quality of life. They have mastered their drug regimen and delivery system – but now the patient is more demanding of how the device supports quality of life. Reduced anxiety makes room for motivations based on convenience and the confidence that “I have this disease under control – at least for today.” As patients settle into this “new normal,” such attitudes can lead to skipped doses and lapses in adherence, often throttling the patient back to a state where the disease manifests itself more seriously.

At this point, the delivery system needs to not only continue to support efficiency with minimal steps, but also, and for different reasons, it must be designed based on convenience and lifestyle enhancement. Patient feedback must be considered differently and used to select a delivery design that encourages and incentivizes patients to remain adherent. For instance, compliance metrics, goal-oriented achievements or physiological measures might be tracked in order to encourage adherence, helping patients control their disease and improve their condition.

The Journey Determines Everything
Realizing that patients are on an ongoing journey is an important step in understanding the complexities behind how user-centered design can support adherence. Armed with this awareness, pharmaceutical companies are better enabled to select and develop safe, reliable and desirable drug delivery solutions.  These considerations can help to address the shifting nature of what usability means for any type of patient we may become, while traveling on our individual disease management journey.

Drug Usage by Demographic in 2011

Provisions in the Affordable Care Act (ACA) drove out-of-pocket costs down, while increasing drug spending among 19 to 25-year-olds in 2011, according to research published on Wednesday.

The decline observed in overall out-of-pocket spending last year was the “first on record,” and was “largely related to the introduction of the ‘donut-hole’ subsidy for Medicare Part D beneficiaries,” a highly-touted element of the ACA, according to the IMS Institute for Healthcare Informatics. While copays for commercial providers and Medicaid were flat (average commercial plan copays increased by $1.14, to $26.10 in 2011), seniors covered by Medicare Part D got the largest break, with average copays decreasing by $2.66 – from $25.97 in 2010, to $23.31 in 2011 – according to the report.

The dip in copay costs for seniors didn’t translate into an increase in volume for chronic or acute medications, however; in fact, patients 65-years and older reduced their drug usage by 3.1%. Prescription use among the same group declined in 2010 as well, by 2.7%, but the last two years represent an inflection from prior years, when “seniors’ usage of medicines grew on average at 4%,” the report found. College-aged patients (19-24 years old), on the other hand, were the only age group to increase their drug usage, by a modest 2%. That increase “coincides with the first full year of implementation of the provision of the ACA allowing under-26-year-olds to stay on their parents’ health insurance,” according to the report.

Michael Kleinrock, director of research development at the institute, said on a call with reporters that patients over 65 years old are foregoing the medications they use the most. Drug usage for hypertension, the most common disease among this population, decreased more than any other class of drugs. “This correlates strongly with the economy…seniors are on a fixed income, and costs [of living] are rising,” said Kleinrock on the call. Kleinrock called the development a “tipping point,” adding that seniors are resetting their expectations around how often, and under what circumstances, they will visit a doctor.

Per capita figures adjusted for currency changes showed a 0.5% growth in total drug spending in 2011 – to $320 billion. Other fun facts from the report include:

• New York state had far and away the largest growth in per capita retail prescription usage at 5.6%, bucking the national trend. Volume rates fell in 41 states.
• Visits to the ER increased by 7.4%, while doctor’s office visits decreased by 4.7%, from 2010 to 2011, a “possible result of continued high levels of uninsured patients associated with long-term unemployment,” according to the report.
• Copay card usage increased in 2011, but only by 1.4%. Still, patients used copay cards or vouchers for only 3.8% of dispensed brand prescriptions last year. The average copay card subsidy provided by drug manufacturers grew by 20%, from $19.34 in 2010, to $24.28 in 2011.
• Spending on new brand drugs – products approved in the last 24 months – was $12.2 billion, up from $8.5 billion in 2010.
• 34 new molecular entities (NMEs) launched in 2011, the most in “at least 10 years,” according to the report
• Key blockbusters that expired in 2011: Pfizer’s Lipitor, GSK’s Advair Diskus, Lilly’s Zyprexa, and J&J’s Levaquin and Concerta.
• Hydrocodone, an opioid for pain, was once again the most dispensed drug last year, at 136.7 million prescriptions.
• Among therapeutic classes, anti-depressants were dispensed most often, at 264 million prescriptions in 2011.

If the Supreme Court decides in favor of the Affordable Care Act, particularly the mandate to buy insurance, the spate of newly insured patients would likely curb the rise in emergency room admissions, and could also turn around the decrease in office visits, which are “the lowest-cost medical interventions,” according to the report.

Amidst yellow sandstone arches and California Mission Revival architecture, The Medicine 2.0 +Stanford Summit (otherwise known as the Fourth World Congress on Social Media and Web 2.0 in Health Medicine) set out on a three day journey to challenge its diverse audience to break down silos and expand beyond traditional boundaries. From a focus on research findings and scientific data to dialogue around the future of science, medicine and emerging technology, innovators and thought leaders congregated from around the globe at the state-of the-art Stanford venue, Li Ka Shing Center for Learning & Knowledge. Through the congress, Stanford extended an invitation for open scientific inquiries into the pursuit of teaching, learning, and research, in alignment with its motto. ¹

The energy in the room was contagious starting with the unique conference badges that featured personal QR codes (eliminating the need for business cards), lively twitter feed and building of a #med2 community (over 5,000 tweets!), to the theatrical presentations that conveyed unconventional solutions to healthcare issues. From theory to practice–patients, healthcare professionals, academics and executives discussed and debated concepts such as participatory medicine, patient self management, behavioral change, decision making, the quantified self, communities of practice, social networking, gamification, personalized healthcare, and innovation in medical education. There were so many interesting points made at Med2.0, but I’ve captured a few highlights below:

Abraham Verghese, MD eloquently walked us through the bedside ritual of examining the patient as a critical but threatened skill that is the foundation to the patient-physician relationship. He explained the potential of displacing the patient during the digital age and reliance on technology during the clinical encounter —with more emphasis placed on patient data, rather than the person being treated.

Jennifer Aaker, PhD delivered a brilliant keynote that demonstrated the impact of social media saving lives through storytelling, collaboration, and enabling the wider community to quickly act. The story began with 2 Indian men with AML in search of bone marrow matches and ended with 20,000 South Asians registering as a result of a powerful awareness and social media campaign. Attendees had the opportunity to have their cheeks swabbed and sign up for the Be The Match Registry during the break in the corridors.

The eclectic BJ Fogg, PhD shared his behavior change model which shows that three elements must converge at the same moment for a behavior to occur: B = MAT (Behavior = Motivation x Ability x Trigger).

Susannah Fox gave the closing keynote on the impact of “peer to peer healthcare” where patients are seeking and sharing health advice online. Roadblocks included pockets of offline patients, patients not motivated to engage in their healthcare, silo tools/communities, and lack of awareness of resources. Opportunities included leveraging the power of online caregivers, engagement prompted by life changing diagnoses/events, rise of mobile adoption, and emerging focus of technology that bridges silos and allows data flow. The beacons of change in these efforts include patient, clinician, and technology leaders.

There was a major focus on patient self management platforms in chronic diseases, the Quantified Self and use of digital devices to collect real-time quantifiable patient data, decision support tools to make informed choices, and gaming to change behavior by rewarding patients for meeting health related goals. With all the data being collected, the question is how do you give back the data to patients, synthesize, and set context in a way they can understand?

The use of technology as a catalyst in healthcare improvement was prevalent.  From the use of social media and mobile health tools by physicians to communicate and improve clinical workflow to the use of virtual community platforms by patients to share experiences, understand options and obtain social support–It was clear that patients and healthcare professionals are embracing the impact of technology—although not necessarily at the same pace. Patient online usage to share and obtain healthcare information is on the rise; however a research abstract (764) demonstrating physician attitudes towards social media for their own professional education and knowledge sharing showed that usage and intent to use is fairly low. Plagued with social media privacy concerns and associated risks, traditional modes of learning, and lack of clear guidance and policies—physician usage is growing at a snail’s pace in comparison.

There was a spotlight on the e-patients, of which 23 received scholarships to attend the conference. Each had a compelling story to tell regarding their personal but at times unfavorable experiences with the healthcare system and how they made informed medical decisions by becoming more empowered and engaged in their healthcare. These real life interactions crystallized key themes conveyed throughout the conference.

Larry Chu, MD was the skilled conductor of this colorful performance, which set the bar high for future Med2.0 conferences. We were each given the opportunity to challenge both established and new orthodoxies in healthcare, infuse innovation and creativity into potential solutions, and explore collaborations among the diverse Med2.0 community to make things happen!

Planning for the 2012 Med2.0 Congress is underway to be held September 15-16^th at Harvard Medical School. Stanford will also debut MedicineX in 2012 focused on the intersection of emerging technology and the future of medicine.

¹ Die Luft der Freiheit Weht-unofficial Stanford Motto, Ulrich von hutten, 16^th century

Sarah Krüg is executive director at Cancer101, a patient organization. She was previously Global Education Director in the Medical Education Group at Pfizer

Pharm Exec’s sister conference organization, CBI, sponsored its 10th annual Patient Adherence Forum in April to highlight current trends in industry compliance and adherence programs — where companies reach out to help an increasingly skittish community of patients take their pills. A key feature of the conference is the grant of the Strategic Patient Adherence Awards (SPA) to recognize companies doing breakthrough work to promote the compliance agenda.

The competition aims to recognize successful programs that measurably increase patients’ compliance to their prescription medication regimen, devised and implemented by bio or pharmaceutical companies, pharmacies, health systems, payer groups, employers, agencies, or vendors.

To be eligible, a program must have been implemented prior to February 1, 2010, and campaigns must have been produced, printed, or aired and had response results tabulated between January 1, 2010 and December 30, 2010.

This year’s winners are:

• Best Branded Program: Lori-Jean Manness of Merck Canada, for the Merck/RxCanada Januvia program
• Scientific Pursuit of Excellence: Abhijit Gadkari of Merck US on behalf of Colleen McHorney
• Innovation – Suzanne Clough of WellDoc
• Best Employee Participation Program:  Laura Del Guerra of MAHCP’s Take Control Program
• Best Managed Care Program: Kelley Green of Kaiser Permanente

“I look for programs that use research, evidence, and science to drive design. I look for programs that operate at the patient level. Adherence is about people’s behavior and choices, which are terribly complex and not logical or rational. It’s personal. We quip that education alone does not improve adherence and that’s why. I also look for programs that are more subtle and affect behavior through the subconscious because that’s what drives our daily behavior,” says Steve Basiago, veteran judge and VP of trade relations at Walgreens.

“The biggest challenge is to address adherence as a long-term proposition. Chronic medications taken for a short period of time only add cost to the healthcare system without tangible benefit to health. Chronic medications when taken consistently over a longer time are more likely to provide health benefit and hopefully, reduce overall healthcare cost,” he continues.

“We often focus our attention on patients starting therapy because that’s a critical decision-making phase for them. But we still see significant discontinuation as time goes on. Instead of programs getting one extra prescription per year, how about getting an extra year of persistence?”

Finally, when asked what pharma can do to promote improved compliance, Basiago says, “My best advice is to get the funding of adherence out from under the brand marketing budget. Too often, brand marketers don’t understand adherence but are tasked with funding it as part of the brand strategy. They’re driven by and measured by new patient acquisition and not patient retention. They ration dollars and often under-fund adherence. The most successful companies have created an adherence leader, which helps with understanding. The really successful companies have funded adherence through Finance directly as an overall company priority.”

All three drugs are atypical antipsychotics indicated for schizophrenia, and had US launches in late 2009 (Saphris), early 2010 (Fenapt) and February of this year (Latuda). Latuda, however, appears to be gaining favor with at least some psychiatrists, due in part to successful interactions with sales reps.

When asked about the most important part of a Latuda sales call, and the brand’s greatest advantage, “metabolic profile was frequently singled-out” by survey respondents, according to David Rittenhouse, manager, analytic services, at DTW Marketing Research. “In addition, unaided message recall showed that [Latuda’s] reps are pushing two unique aspects of the product in their overall message, when compared to the competition: metabolic profile [cited by 45% of respondents] and once-daily dosing [24% or respondents], both of which are topics that can help improve patient compliance,” said Rittenhouse.

Among surveyed psychiatrists that attended a dinner meeting for Latuda (28% of respondents), almost half rated the information given at the dinner as “extremely useful,” or a five on a one-to-five Likert scale. Eighty-six percent gave the dinner information a rating of four or five, the top two scores. “This shows the influence that in-person discussions can have and still have, even if it’s not necessarily one-to-one,” said Rittenhouse. Too few psychiatrists had recently received an invitation for an e-detail on Latuda to analyze their perceptions of face-to-face detailing versus online detailing, Rittenhouse said.

Billed as the first Chinese product development partnership (PDP), the Global Health R&D Center of China (GHRC) hopes to discover and develop new treatments for tuberculosis (TB) and other diseases by collaborating with pharmaceutical companies, the Chinese government, academic institutions and other groups, according to a statement.

The GHRC was created through a partnership between The International Scientific Exchange Foundation of China (ISEFC), a translational sciences group, and the TB Alliance, a not-for-profit organization focused on developing new and better TB medications.

Mel Spigelman, president and CEO of the TB Alliance, said in an email that pharmaceutical companies stand to gain from sharing resources, such as intellectual property, with the GHRC. “The GHRC will offer companies financial and world-class discovery and clinical development resources to advance compounds for neglected diseases that they otherwise may not be able to [develop] on their own,” said Spigelman. “In addition, companies will establish strong working relationships with key discovery, regulatory, and clinical resources in the fastest-growing pharmaceutical market in the world.”

The TB Alliance has drug development partnerships with AstraZeneca, Bayer, GSK, Novartis, Sanofi-Aventis, and Tibotec, and is currently managing three drug candidates in clinical trials, according to organization’s website. Spigelman declined to specify which compounds the TB Alliance itself will contribute to the GHRC.

“The vision of the GHRC is to focus on translational medicine for public health and bridge the innovation gap that currently exists into new treatments and cures,” said Geng Jianyue, secretary-general assistant of the ISEFC, in a statement. In China alone, some 1.3 million people develop active TB annually, and 150,000 die from the disease each year, according to the TB Alliance.

A recent World Health Organization (WHO) report found that only a 10% of the multidrug-resistant tuberculosis (MDR-TB) cases identified globally received treatment in 2009. The WHO report called multidrug-resistant and extensively drug-resistant tuberculosis a global epidemic, and TB in general kills almost 2 million people each year, according to the TB Alliance. The announcement of the GHRC coincides with World TB Day, which is celebrated on March 24 each year, to commemorate Robert Koch’s discovery of TB bacillus, the cause of the disease.

While access to treatment remains a major problem in many of the 27 countries most burdened with MDR-TB, the treatments themselves, many over forty years old, present further difficulties, since first-line drugs like isoniazid, ethambutol, pyrazinamide and rifampin require a six to nine month regimen. Failure to adhere to a treatment regimen can result in drug resistant strains of TB, which require second-line drugs, many with severe side effects.

In addition to developing new TB treatments and addressing other public health diseases in China, the GHRC will also develop compounds for the rest of the developing world, according to Spigelman. “Global development programs will likely be partnered with disease-specific PDPs or with global pharmaceutical companies, who will then work with GHRC to register the compounds throughout the world,” he said.

Jacky Law

There can be few areas of research that are as extensive and as inconclusive as that which seeks to understand why patients don’t follow doctors’ orders. According to an April 2008 IMS Health analysis of the Medline database, at that point no fewer than 25,000 articles had been published in English on the subject since 1996.

Research continues to proliferate if only because pharma has realised that in the absence of new drugs, it pays to ensure patients refill scrips of their old ones. That and the fact adherence to treatment usually improves outcomes.
For all this research, however, very little is known. Estimates of what noncompliance costs healthcare services differ widely, for example, from $70 billion to $300 billion a year in the US, highlighting such massive differences in assumptions and methodologies to render the figures virtually meaningless. And the picture is no clearer in the UK, with the National Institute for Health and Clinical Excellence (NICE) stating in the most general of terms that “it is thought that between a third and a half of all medicines prescribed for long-term conditions are not taken as recommended.”1

AlignMap.com, a website devoted to “supporting the patient’s implementation of optimal treatment,” confirms the only thing anyone knows for sure, which is  that “noncompliance is massive and widespread regardless of the disorder, the nature of the treatment, the cultural or ethnic background of the patient, the personality of the clinician, the cost of the treatment, or any other studied factor.”2

It is also pervasive when the stakes are high, as was shown in a study that found 58 percent of glaucoma patients are noncompliant even when told this could result in blindness. Indeed, the study found 42 percent of patients who had already lost sight in one eye continued to defy doctor’s orders.3

Not to be defeated, most pharma companies have embarked on a range of programmes to challenge, cajole and coax patients to take their medicines properly (see sidebar). Many now use digital technologies to send out reminders to mobile phones; others have packaging solutions whereby a message is sent back to the doctor each time a patient opens a pill container; others still are investing in iPhone applications to improve disease management by making it easier for patients to remember to take their medicine, monitor their sugar levels, track injection sites and so on.

Then there is plain old bribery. According to a new report from FirstWord,4 Novartis has indicated it is working on a project with telecommunication companies that rewards patients with free talk time if they can demonstrate they have taken their medication as indicated.

Source: AlignMap.com

But for all this effort, my personal suspicion is that companies are simply not hearing what patients are saying, which is that they need reminders, information, free talk time and so on, in the same way they need perfect health. They don’t.  Most people on medication have lived to whatever age they are being overweight, having raised sugar levels, excess cholesterol and, in a million other ways, less than perfect health. They adjust their lifestyles and expectations to deal with imperfect health in ways that are meaningful to them. Medicines are part of their lifestyles and adjustments are made in an effort to understand and retain some control of what is happening to them.

It doesn’t help that denial of being ill or of needing drugs is also prevalent. It is well known that patients regularly overestimate their rate of compliance, perhaps in the same way they underestimate how much they eat or smoke. They may want perfect health, but drugs, being only one factor in that outcome and a complex one at that, are easily toyed with. Why that should be is the real question pharma should be asking itself.

Jacky Law

References
1. NICE guidance: ‘Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence’ (CG76).
2. http://alignmap.com/noncompliance-fact-fiction/prevalence/
3. Ibid.
4 ‘Digital technologies to boost patient compliance’, FirstWord, October 2010.