Accomplishing Adherence: Highlights from a Conference

Yesterday, I attended eyeforpharma's Patient Adherence and Persistence Summit and eCommunications/Online Marketing conferences in Philadelphia, PA. While there I met the usual suspects and reconnected with some old friends.

Shire, Shire, Shire
People from Shire -- specifically the Vyvanse (for children with ADHD) marketing folks -- were there in force making at least 3 presentations. Recall that Mike Boken, Senior Product Director at Shire, spoke about creating synergy between PR and marketing at a previous conference I attended (see "J&J Blog, Shire PR: The Whole Story and Nothing But the Whole Story!").

I think the Shire people are out there laying the groundwork for Vyvanse, the new formulation of Adderall, which has lost patent protection. The big news is that Vyvanse will likely be approved for use by adults soon. We can expect, therefore, some interesting DTC advertising and PR focused on adult overachievers!

But, right now, the Shire folks at these conferences are focusing on ADHD in children because that's all they can talk about. Obviously, however, all their marketing and PR is directed at adult caregivers -- it's not ethical to promote directly to children.

In this post I will summarize a couple of presentations that focused on adherence. Tomorrow I will report on the eCommunications conference.

Adherence in the ADHD Market
David Baker, VP & General Manager of Shire's ADHD Business Unit, presented on "Best Practices for Fostering Adherence." He used the ADHD market as a case study.

First, how do you define adherence and why is it so important to "foster" it?

Baker suggested this definition of Adherence:

Adherence = Fulfillment + Compliance + Persistence

where Fulfillment refers to the filling of the very first script for a medication, Compliance means taking the medication as prescribed by the physician, and Persistence refers to the length of time you take the medication.

Poor persistence is the main culprit. Lack of persistence is a big problem for the pharmaceutical industry. James Chase, my friend and editor-in-chief of MM&M, once wrote "To say that tackling patient compliance and persistence poses a challenge to the pharmaceutical industry is like calling Tiger Woods a competent golfer or describing Katrina as a particularly bad storm. It is a gross understatement." (See "The Pursuit of Persistence".)

Persistence with ADHD medication -- like most other drugs that do not have a noticeable, immediate effect on lifestyle like Viagra -- is poor. Baker showed a persistence graph for, I suppose, Adderall, over a 10-month period. Starting with 98% of patients taking the medication, it ended with only 13%. It looked like this:

The drug industry simply does not understand why patients stop taking their medications although there are many theories. What Baker suggested is that marketers must first do the research in their market to find out why their patients are not compliant or stop taking their medication.

The ADHD market has its own particular barriers to persistence, which baker described in detail. I won't get into that detail here, but will save it for publication in a future issue of Pharma Marketing News.

Regarding solving the problem, Baker described Shire's SHINE program for ADHD support. Some of the features of SHINE, according the Vyvanse web site, include:

• Tips to improve focus, organization and behavior in your child
• Suggestions for working with your child's teachers
• Vyvanse Success Tracker
• Ideas for building and coaching your child's support team

It also includes multiple mailings -- especially during the first few months of treatment -- timed to key dropoff points. These mailings are customized according to age of patient, whether the patient was switched from another medication or is new to ADHD treatment, etc.

Baker explained why Shire focused on the patient in its effort to improve adherence. It seems obvious -- the patient is the one that exhibits the behavior. However, some people also lay the blame on the physician. According to a study of patient behavior reported in the June 2006 issue of MM&M, seventy-two percent of all patients who stopped taking their drugs lack confidence in their healthcare provider.

But Shire also had these reasons for focusing on the patient:

• better control of the message
• consumers are more willing to listen to 3rd parties about ADHD treatment

Baker didn't get into the role of 3rd parties such as celebrities in adherence messaging (for more on that see this post), but he did point out that the more control you have over the message, the lower will be your credibility. This little tidbit should be advice to pharma marketers, especially when they dive into the Web 2.0 arena.

"Forget forgetfulness" as a factor in adherence was one of Baker's main take-away points. Reminder programs alone have very little impact on adherence. Also, although Shire based a lot of its persistence messaging strategy on patient interviews, Baker warned attendees not to rely solely on what patients say are their reasons for non-persistence or non-compliance.

Reward Them -- Intermittently -- and They Shall Adhere!
Murat Kalayoglu, Director at HealthHonors, talked about "Crafting an Rx Adherence Program with Dynamic Intermittent Rewards." He actually paid homage to B.F. Skinner, the psychologist who invented the "operant conditioning chamber," aka the Skinner Box.

The classic Skinner Box experiment uses a pigeon, which gets rewarded with a food pellet every time it pecks the desired key (see left).

I remember the "The Dancing Chicken" exhibit in New York's Chinatown. Whenever I took a date to dinner in Chinatown, I took her to see the "Dancing Chicken." Hey, don't knock it. It was usually the highlight of my evening!

The chicken would "dance" whenever you dropped a quarter into the slot. Afterward, the pellet!

Only now, after listening to Kalayoglu, do I realize that the best way to improve patient adherence is to consider them "dancing chickens." Reward them and they shall comply!

NOTE: Kalayoglu actually suggested that we think of patients as kids and described the "Great Marshmallow Paradox" to make his point. I can't get into that level of detail here. Read about it in a future issue of Pharma Marketing News. Subscribe NOW so you don't miss it!

HealthHonors encourages patients enrolled in its program to call an 800 number every time they take their medication and earn points, which can be traded in for real life healthy goodies like discounts at Boscov's or wherever.

But...DO NOT reward then every time or else they will think they are entitled to a reward no matter what. Reward them "intermittently." Kalayoglu had some data to back up his claim that intermittent rewards sustain target behavior over time whereas continuous rewards show a dropoff in target behavior. Perhaps more important is the fact that giving fewer awards is cheaper!

No dancee, no rewardee!
In any case, unless HealthHonors installed a Big Brother spy cam in the patient's medicine chest, how would they know that the patient actually swallowed the pill?

OK. Enough. Time to take a shower and get to work!