The Missing Link: A Digitized Dx for Patient Behavior
In order to increase the effectiveness of adherence interventions, we need to take into account the fact that human beings are not always rational.
Life has changed over these past 100 years more than it has changed in any century in human history. The average life expectancy in the United States in 1900 was 49-years-old. Today, at age 49, a person is still young, vibrant, and not even nearing retirement.
Why is that? Part of the answer is in better hygiene and sanitation, but much of it is thanks to advances in medicine—including antibiotics, vaccines, and better diagnostic and surgical techniques.
However, advances in lifespan have started to flatten and the average lifespan has even decreased in the United States the past few years. Furthermore, long life has not always equated to a healthy life, as the prevalence of long-term chronic diseases has increased enormously. All of this is despite a continuous flow of new drugs.
Why don’t these new treatments translate to continued improvements in health? Why, for example, have rates of glucose control in type 2 diabetes remained relatively stable over the past decade despite a veritable plethora of new drugs that have been clinically proven to help?
Why, despite the increasingly effective and terrifically expensive treatments available, have overall health results stagnated in most countries? Is there some other variable at play that has not been sufficiently addressed? Of course there is (or you wouldn’t be reading an article that asks these questions)—the missing variable is behavior.
On the level of public health, it is clear that all the time we were benefitting from better medicines, we were adopting behaviors that were bad for our health. We started eating worse, exercising less, and succumbing to stress and isolation. True, we learned to smoke less, but even that is a long and painful process and one that isn’t over.
And when we do end up with chronic disease, we don’t take all that wonderful modern medicine, not by a longshot. In fact, approximately half of all drugs prescribed are not taken, leading the World Health Organization (WHO) to proclaim that improving the efficacy of adherence interventions may do more to improve overall population health than any specific medical treatment.
This often leads to the conclusion that education is necessary. People must not be sufficiently aware of the impact of their behavior. Of course, education is necessary, both for patients and for health care professionals, who inevitably underestimate the problem.
However, relying only on education assumes that human beings are rational. It assumes that people only need to be better informed in order to make the right decisions. But if we were rational, we wouldn’t need signs at the zoo warning us not to try to pet lions or at the park telling people not to sit on spiked fences.
In order to increase the effectiveness of adherence interventions, as suggested by the WHO, we need to take into account the fact that we humans are not always rational. We do not behave like perfect Cartesian thinking machines—even in the presence of perfect information we make irrational decisions.
The groundbreaking psychologist, Daniel Kahneman, PhD, won a Nobel Prize because he investigated our irrationality and founded modern behavioral science. His work, along with the research of others, allow us to better predict exactly how irrational factors influence our decision-making process, combining with rational factors to drive our behavior. Using behavioral science, we can begin to categorize exactly which irrational processes will drive people toward behavior that is detrimental to their health.
Modern medicine is effective because it is based on an understanding of the mechanisms within our bodies that lead to disease. Understanding these mechanisms allows for accurate diagnosis, which can then be followed by treatment designed to work in the context these same mechanisms.
Exactly the same thing must be done to address the issue of behavior. Each of us has very real concerns and attitudes about our health. Some of which are born of circumstance, others of rational thought processes, and others yet of the irrational processes that make us human. If we want to address behavior, then the patient’s behavioral drivers must be diagnosed and the proper support provided.
Yet to a large degree, the medical system does not allow for this at all, only the clinical diagnosis and treatment process is taught, applied, and delivered. The behavioral diagnosis and treatment process must take place if ever we expect to increase the efficacy of adherence interventions.
How can this be done? In quite the same way clinical diagnosis and treatment is done—via the scientific method. Diagnosis and support tools must be developed and tested. The good news is that this is already taking place.
A number of excellent tools have been developed over the last 15 years that help to understand the risks of non-adherence, some of which explore some of the drivers behind these behavioral risks. Likewise, interventions have been studied to address the issue, many of which have generated excellent results.
We believe that the next step is going to be to enhance the digitalization of these efforts. Nothing can currently replace human interaction and clearly, the most effective behavioral “nudge” will be via person to person (P2P) interactions. The first of these, of course, is with the treating physician.
Physicians, as well as nurses, pharmacists, and other health care professionals, must be provided with time-efficient tools to help make behavioral diagnoses, and they must be educated about the importance and means of using them; however, this is far from enough.
A typical patient with type 2 diabetes who has been prescribed an oral medication might spend an hour a year actually interacting with health care professionals. It is during the other 8759 hours, though, that the patient will decide whether or not to adhere to medication every day when that medication has to be taken.
It is then that the health care professional’s recommendations have to be present in the patient’s mind and it is then that the patient needs motivation. Relying on memories of a 10 minute discussion with a physician or a 2 minute discussion with a pharmacist 3 months before is not sufficient.
Digital interventions can be extremely effective in helping the patient to adapt adherent behavior. Apps, SMS programs, email alerts, and other automated communication methods have been proven to be efficient if used correctly. The most effective programs tie different communications channels together into a coherent whole, based on the specific needs and profile of the patient, combining P2P interactions with virtual-to-person interactions.
The core of such a program is the behavioral diagnostic tool. For example, at Observia, we have developed SPUR, a digitally administered behavioral diagnostic based on a brief interactive questionnaire that can accurately predict attitudes and behavioral drivers, while allowing the patient to compare their own attitudes with those of others.
Through its interactive features, this tool and the feedback it provides has proven to be extremely well appreciated by patients, while allowing digital programs to be adjusted to correspond to the patient’s needs and attitudes. Tools such as SPUR can create a profile for each patient, allowing engagement planning algorithms to select appropriate content with the right frequency using the right channels for each and every patient.
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Gone are the days of behavioral segmentation, no longer must each patient be considered a “1, 2, 3, or 4,” or an “enthusiast” as opposed to a “denier.” We are all far more complex than that and each individual patient needs to have a customized program. Even the tone of individual content elements can be adjusted to correspond to a patient’s mindset, delivering regular messages with information, coaching, and associated “nudges” as needed, and providing regular reports to health care professionals as desired.
Digital patient support programs such as this can be quite simple, ranging from a single app or an SMS engine to a fully holistic program tying in websites, connected devices, telephone centers, apps, and doctor, nurse and pharmacist portals into the system. Such programs can be far more cost-effective, allocating expensive resources to the patients who need them and ensuring both content and tone are appropriate to every patient.
Hippocrates warned, “Keep watch also on the faults of the patients, which often make them lie about the taking of things prescribed.”
Patients haven’t changed much over the past 2000 years or so, but the tools available to help them change their behavior most certainly have. So let’s use them and not just assume that our patients are going to make rational decisions without our help.