Personalization of adherence support with Patient Support Programs (PSPs): the advent of the digital era

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PSPs are behavioral interventions for improving adherence 

Patient Support Programs, or PSPs, can range from simple calendar pill boxes or pill blister packaging, to organized programs based on behavioral science frameworks.^1,2 They can either be provided directly by the physician’s office or via sponsored programs. They are designed to support patients in being comfortable with their treatment and correctly adhering to their therapy. They can provide daily support when the patient needs it, whereas the physician may only physically see their patient from time to time.

PSPs are increasingly digital in nature 

Mobile health solutions (“mHealth”) are increasingly included in PSPs, with an estimated 95% of the global population now living in areas covered by a mobile-cellular network.³  Initial reviews indicate that PSPs⁴ and mobile solutions¹ can have a significant positive impact on adherence and other outcomes, such as patient quality of life. However, what is often missing from such programs is a personalized, evidence-based approach.^5,6  

Personalization techniques are already being used by successful technology companies like Amazon, which is leveraging artificial intelligence (AI) to anticipate customers’ needs and tailor recommendations.⁷  

Web portals have the potential to increase patient health understanding and shared decision-making. They can be used for hosting e-visits and telemedicine, viewing test results, and ordering prescription re-fills.^8,9  

Similarly, digital solutions personalized using behavioral-science methods represent a significant opportunity for improving adherence.² 

Incorporating mobile-health solutions into PSPs to enable broad adherence support

The development of mobile technology over the last decade has made broad dissemination of medical and public health support both possible and cost-effective, with mobile phone subscriptions estimated at 7 billion globally.³ Simple text-messaging interventions represent an important tool for reaching a broad patient population and alleviating the demands on physicians’ time,² particularly in developing countries, and are a common component of effective PSPs. mHealth solutions, such as texts and SMS, enable improved remote patient monitoring, patient communication and adherence support.¹⁰ Text messaging has already been used with positive results as a tool to support changes in behavior, including appointment and medication reminders, health promotions such as smoking cessation, and community mobilization; these can positively influence adherence for chronic diseases.³  

Existing evidence of SMS messaging on improved adherence in treatment of cardiovascular disease remains promising but inconclusive.^11,12 In a review of seven trials of patients with cardiovascular disease, six of the trials found a beneficial effect of interventions with text messaging; however, more evidence in larger trials is needed to confirm this.¹¹ The focus of these interventions is generally centered on reminders to address forgetfulness, which is only one element of adherence. Educating patients is a major opportunity area that does not translate easily to digital interventions,¹³ which lack the advantages of face-to-face interactions. In order to optimize the patient’s experience and overall program effectiveness, digital PSPs must include a degree of personalization that can account for individual risk levels and behavioral drivers.² 

Effective PSPs “personalize” digital solutions to individual patients 

The application of behavioral-science theories to personalize adherence interventions and PSPs remains a significant opportunity area.^5,6 Solutions customized to the individual patient according to their needs and beliefs can enhance their experience and positively influence outcomes.² However, there are some challenges to effective personalization in the context of PSPs: 

• Existing adherence models are not digitally compatible. Most behavioral science and adherence models lack the continuous and detailed mathematical principles that are the basis for AI and effective interaction with digital support programs.² However, the latest personalization research builds on these models to enable patient profiling using questionnaires, resulting in an actionable, digitally compatible model of patient adherence² 
• Self-reported data may have issues with inaccuracy. Personalization models administered in a digital setting may require self-reported data, which may be limited in terms of accuracy^2,4 

An example interaction utilizing a PSP 

A  hypertension patient is at a clinic for a regular checkup.  

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The physician asks behavioral science-based questions, establishing that their patient is not taking their medication as directed, managing their diet and salt intake properly, and does not see themselves as responsible for managing their condition. 

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The physician recommends enrolment in a support program for the patient to learn more about their condition and the importance of lifestyle modification and adherence to treatment, sending an SMS to do this (with the patient’s consent). They also provide some printed educational materials 

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A few days later, the patient receives an enrolment call from a specialist, who asks them questions to determine the type and timing of support that the patient needs. 

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The patient receives regular SMS messages with dietary support and information about hypertension, as well as telephone counseling 

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The patient develops a better understanding of hypertension and the importance of adherence

PSPs are important tools for physicians to support their patients 

There is no replacement for the education, advice and support provided by physicians to their patients on any clinical topic, including adherence; however, significant opportunities exist to enhance these communications using behavioral-science theories, allowing the physician to influence the patient’s daily life.^1,2 Physicians can use these theories to assess their patients’ risk of non-adherence and provide targeted support.²  

Furthermore, digital-adherence solutions and PSPs can enhance these efforts while alleviating the burden for physicians and creating value for patients.  They do this by providing important educational resources and additional support.² Personalization of digital tools can enhance initiatives designed to support patients and help them modify their behavior.² Physicians can educate patients on the benefits of PSPs and help with personalization of a patients’ care plan.²

References: 
1. Gandapur Y, et al. The role of mHealth for improving medication adherence in patients with cardiovascular disease: a systematic review. Eur Heart H Qual Care Clin Outcomes 2016;2(4):237–44. 
2. Dolgin K. The SPUR Model: A Framework for Considering Patient Behavior. Patient Prefer Adherence 2020;14:97–105. 
3. Iribarren SJ, et al. Scoping review and evaluation of SMS/text messaging platforms for mHealth projects or clinical interventions. Int J Med Inform 2017;101:28–40. 
4. Ganguli A, et al. The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review. Patient Prefer Adherence 2016;10:711–25. 
5. Van den Bemt BJF, et al. Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert Rev Clin Immunol 2012;8(4):337–51. 
6. Michie M, et al. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42. 
7. Arora S (Martech Advisor). “Recommendation Engines: How Amazon and Netflix are Winning the Personalization Battle”. Available at: https://www.martechadvisor.com/articles/customer-experience-2/recommendation-engines-how-amazon-and-netflix-are-winning-the-personalization-battle/ [Accessed Jan 21, 2020]. 
8. Graetz I, et al. Association of Mobile Patient Portal Access With Diabetes Medication Adherence and Glycemic Levels Among Adults With Diabetes. JAMA Network Open 202;3(2):e1921429. 
9. Ferdinand KC, et al. Improving Medication Adherence in Cardiometabolic Disease: Practical and Regulatory Implications. J Am Coll Cardiol 2017;69(4):437–51. 
10. Meister S, et al. Digital health and digital biomarkers – enabling value chains on health data. Current Directions in Biomedical Engineering 2016;2(1):577–81. 
11. Adler AJ, et al. Mobile phone text messaging to improve medication adherence in secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2017;4(4):CD011851. 
12. Palmer MJ, et al. Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults. Cochrane Database Syst Rev 2018;6(6):CD012675. 
13. Treskes RW, et al. Implementation of smart technology to improve medication adherence: is it effective? Expert Rev Med Devices 2018;15(2):119–26.