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In part 3 of our discussion on patient adherence, Dermatology Times editorial adviser Elaine Siegfried, M.D., continues the discussion with Steven Feldman, M.D., on assessing adherence and intervening to encourage the best possible treatment outcomes. They review a method for developing patient accountability, clinical trial results versus real life, and whole health system incentives for focusing more research in this area. Dr. Feldman is a professor of dermatology at the Wake Forest University School of Medicine, Winston-Salem, N.C.
Listen to the discussion.n part 3 of our discussion on patient adherence, Dermatology Times editorial adviser Elaine Siegfried, M.D. continues the discussion with Steven Feldman, M.D., on assessing adherence and intervening to encourage the best possible treatment outcomes. They review a method for developing patient accountability, clinical trial results versus real life, and whole health system incentives for focusing more research in this area. Dr. Feldman is a professor of dermatology at the Wake Forest University School of Medicine, Winston-Salem, N.C.
Dr. Siegfried: What is Causa Research?
Dr. Feldman: Causa is a Wake Forest spin off. It comes out of what I’ve learned from treating patients with scalp psoriasis. This condition has taught me so much about adherence, because scalp psoriasis is the mother of all compliance problems. In treating patients with this condition, I found that getting patients to use the medicine was possible if I only asked them to do it for a few days. First, I found that if I brought people back in three days after starting treatment they’d get well. Then, I found if I gave just them my cell phone number and had them call me in three days they did well. So, I thought we could might be able to have them fill out an online survey shortly after starting treatment as a way to get them to feel like they were reporting, being watched over, and well-cared for.
I liken this project to piano lessons. Kids take piano lessons once a week and at the end of eight to 12 weeks, they have a recital. The recital sounds fabulous because they practiced each week. If the piano teacher told the kids that it would be more efficient to skip the weekly piano lessons and for each child to practice every day leading up to a recital in eight or 12 weeks, the recital would sound miserable because kids wouldn’t start practicing until three days before the recital. The weekly piano visits force the kids to practice. They practice right before each lesson.
In the clinical studies on which drugs are approved, they bring the patients back at weeks one, two, four, six, eight and 12 and those return visits force patients to use the medicine. But doctors, like a crazy piano teacher, say, “OK, here’s the medicine, see you in eight to 12 weeks.” There’s nothing that assures accountability.
This is an online attempt at creating accountability. We studied this by randomizing kids with acne into two groups: one group was given the medicine and told to come back in six to 12 weeks; the second group was given the medicine and told to come back in six to 12 weeks but they were also given a weekly survey to fill out on how well the medicine was working. The group that received the weekly Internet surveys used the medicine about three times as often. The compliance rate went from 30 percent with standard of care to around 85 percent to 90 percent with the surveys.[i]
Wake Forest has applied for a patent for this and has spun-off Causa Research as a way to commercialize this for doctors or health systems that want to help patients have better outcomes. A drug company that wants to improve its refill rates could do this. In theory, I think it should work not just in dermatology. If a hospital didn’t want the patient who had a heart attack or congestive heart failure to be readmitted, you have to get them to take their medications. A simple and easy way to do it would be to send them a survey once a week asking how well is the medicine working; how many times did you take it this week; are you having any problems with it? Patients are going to take their medicines much better knowing that those surveys are going to come and that they’re going to be reporting the results.
Dr. Siegfried: Are there any other types of data that you’re collecting in your office that look at interventions and how they’re impacting adherence.
Dr. Feldman: With Causa Research and our Internet surveys, we’re at our local university enrolling teenagers with ADHD (attention deficit and hyperactivity disorder) and depression to see if we can improve their use of medication. We’re also in our pharmacy here at the medical center looking to see if we can improve adherence to medicines for depression, hypertension and diabetes.
Dr. Siegfried: Do you have any ideas about models to incentivize the healthcare industry to support or turn more focus to adherence?
Dr. Feldman: I’m glad you pointed out that adherence is so critical to getting people well. After we make the right diagnosis and prescribe the right treatment, then it’s all about adherence. When I was in medical school, we had Goodman and Gilman’s pharmacology textbook. It told you everything you could want to know about drugs but I don’t remember it mentioning adherence once. I used to joke with Steve Wolverton about the fact that his book, “Comprehensive Dermatologic Drug Therapy,” didn’t have a chapter on adherence (it does now). It’s something that we haven’t been thinking about nearly as much as we should be.
With respect to the models to incentivize the healthcare industry, I look at this a little differently. The No. 1 factor that drives me in medicine is the joy that I get out of getting patients well. I can’t believe that isn’t the No. 1 factor that drives every other dermatologist. I feel fabulous when I take a kid with atopic dermatitis who’s scratching and itching and has already seen other doctors but hasn’t gotten well, and with a few adherence tricks, I get them clear. That affects me far more than my bank account. I don’t think money is what drives physicians to enjoy work the way they do. There was a study published that said that 90 percent of physicians would not recommend medicine as a career.[ii] We asked the same question to dermatologists and 90 percent of them said they would recommend dermatology.[iii] It is a joy and a pleasure.
Just the way we spend time on CME to understand the diseases we’re seeing and to stay up-to-date on treatments, I think dermatologists will find themselves highly incentivized to incorporate strategies for adherence.
That said, I mentioned that hospitals get dinged for their readmission rates, and so they are actively interested in seeing patients use their medicine better after discharge. Insurance plans get scored on their covered lives’ adherence to treatment as measured by pharmacy records and so they’re incentivized. You don’t have to incentivize drug companies and pharmacies, because they only get paid when patients buy the drugs and so they’re interested in adherence. Adherence is the one thing that I think all the players in the health care system can get behind trying to improve.
Dr. Siegfried: You mentioned Goodman and Gilman and Dr. Wolverton’s tome. Are you aware of any FDA (Food and Drug Administration) requirements that incorporate adherence or take adherence into account in any way during the drug development process?
Dr. Feldman: There are good ways of assessing patients’ adherence to treatments. One of my research colleagues here at Wake Forest mentioned a company, which sold medicine bottle caps containing computer chips that record the day and time the patients take the medicine. However, in clinical trials, they include patient diaries, they count pills - which is totally unreliable because patients chuck the stuff in the toilet - but to some extent the clinical trial is giving you somewhat of a real life sensor. If the clinical trial controlled adherence too much then you wouldn’t find out what things are like in real life. So if you do put those caps on containers for FDA studies and you show the FDA the data on the drug with the additional data that patients weren’t really using it, I don’t think they would know how to interpret that. So my sense is that neither the companies nor the FDA, at this point, really want detailed adherence data in those clinical trials.
Dr. Siegfried: It’s difficult to interpret, but as you mentioned, clinical trials are a best-case scenario, because of more frequent visits and medication use monitoring. Although as your classic microchip study showed that even in a best possible case scenario, adherence is not great and probably worse for topicals than for pills, so that’s an area that definitely needs more understanding.
Dr. Feldman: When I was a first-year dermatology resident, I remember that the chair of our department at the time, Dr. Wheeler at the University of North Carolina, Chapel Hill, told us - and I’ve heard other dermatologists say they were taught the same thing - that “when new drugs are approved, use them fast before they stop working.” In the clinical trials, these drugs work great and then in the real life they don’t work so well, and I think it’s because of all those factors in the trials that lead to better adherence.
[i] Yentzer BA, Wood AA, Sagransky MJ, et al. Arch Dermatol. 2011 Oct;147(10):1223-1224
More in this series on medication adherence