1. 1 Patient Compliance, Adherence, and Persistence Tim R. Garde Managing Partner The Star Group May 20, 2008

2. 2 // Definitions Patient Compliance – general term for the extent to which patients follow their physicians’ directions with medications Adherence – used to define appropriateness of use, typically calculated as a proportion of prescribed doses that are actually taken as prescribed (i.e., a fraction) Persistence – a measure of duration, in terms of days, months, or years Patient Compliance, Adherence, and Persistence

3. 3 // Target Audiences Patients…… improving health and quality of life Caregivers Health Care Providers – Physicians and Pharmacists Payors Healthcare System Patient Compliance, Adherence, and Persistence

4. 4 // The Facts * 60% of physician visits result in a pharmacy prescription 50% of patients fail to have initial prescriptions filled 20% of patients comply 30% of patients fail to refill their prescriptions 30-50% decline after 1 st or 2 nd refill Patient Compliance, Adherence, and Persistence *Various Commercially Available Sources, 2007-2008

5. 5 // The Facts * Low adherence can cost an extra $2,000 a year per patient in extra physician visits alone $177 billion in medical bills and lost productivity due t poor medication adherence The poor are the least compliant…the healthiest are the most compliant Patient Compliance, Adherence, and Persistence *Various Commercially Available Sources, 2007-2008

6. 6 //Rates and Possible Consequences of Non-Adherence * ConditionNon-Adherence RateConsequence Epilepsy30-50%Relapse Arthritis55-70%Pain Hypertension40%Hospitalization Diabetes40-50%Loss of Control Asthma20%In-patient Visits Alcoholism48-56%Relapse Anticoagulants30%Bleeding Estrogen RT57%Osteoporosis Patient Compliance, Adherence, and Persistence *Source: GlaxoSmithKline 2008

7. 7 // Why Patients Do Not Comply * Forget Do not understand or misinterpret instructions Obstacles (i.e., difficulty in swallowing, opening bottle) Adverse side effects / lack of understanding or confidence in drug safety Cost / lack of insurance coverage Patient Compliance, Adherence, and Persistence *Source: Alliance Healthcare Information, Inc., 2008

8. 8 // Why Patients Do Not Comply * Feel better Deny illness Do not believe drug will help Do not care about getting better Worry about becoming resistant to the drug or think the dug is not working because they do not feel different Patient Compliance, Adherence, and Persistence *Source: Alliance Healthcare Information, Inc., 2008

9. 9 // Critical Success Factors To Overcoming Non-Adherence Patient education is key > it is about changing behavior > the more educated patients are about a particular disease, the more wiling they are to adapt their behavior and motivation Pharmaceutical company call center nurses > treating patients like people! Better and more accurate databases > allow pharmaceutical companies to analyze what’s been prescribed and compare to what is already filled Patient Compliance, Adherence, and Persistence

10. 10 // Critical Success Factors To Overcoming Non-Adherence Improve the communication chain among physicians, pharmacists, payors > minimize the misunderstandings, inconsistencies > understand the barriers and motivators > set reasonable expectations Leverage the pharmacist as a highly influential source of contact > relevance – why it is important to stay on therapy > repetition – takes 2 to 5 messages or communications to change or modify behavior > comfort level – patients are comfortable with and trust their pharmacists Patient Compliance, Adherence, and Persistence

11. 11 // Patient Relationship Management At the point of pharmacy, patients are thinking about their health > pharmacist can answer questions Education materials need to focus on questions patients should ask a physician or pharmacist > critical for patient retention Need to improve the “one size fits all” strategy within a specific indication > Set expectations for specific disease state and patient populations (Alzheimer’s Disease) Patient Compliance, Adherence, and Persistence

12. 12 // Must do a better job of aligning risk-reward scenarios > patients need an accurate understanding of the risks and benefits of the mediation or therapy > physicians, pharmacists, and payers need to communicate these facts > “Here is the risk if you do not take it, here is the reward if you do” Need to better understand why patients do not comply and why they do comply…it is about behavior > the reasons why a patient chooses not to take his/her medication anymore may be different than the reasons why a patient chooses to take half the dose or than the reasons why they just forget Patient Compliance, Adherence, and Persistence // Patient Relationship Management

13. 13 The motivation for taking prescriptions is personal Patient Compliance, Adherence, and Persistence

14. 14 // What Motivates Patients To Be Compliant….Changing Behavior * Counseling by physicians and pharmacists Pill boxes Email alerts / electronic reminders Alarm devices Phone calls Patient Compliance, Adherence, and Persistence Sources: The Star Group Medical Monitor™ 2007, Available Data

15. 15 // What Motivates Patients To Be Compliant….Changing Behavior * Web sites / SEO Discount coupons Educational materials Personal health records / online diaries Patient Compliance, Adherence, and Persistence *Sources: The Star Group Medical Monitor™ 2007, Available Data

16. 16 // Measuring Success Actual change in prescription volume Need to consider integrated programs that work together Utilize surveys with all audiences – test vs. control groups Use retail pharmacy and DTC communications Patient Compliance, Adherence, and Persistence

17. 17 // Measuring Success Utilize data from patient advocacy groups, public and private payors Physician time is limited – leverage the pharmacist Give the physician a reason to address adherence (i.e., quality performance criteria) Patient starter kits, samples……ability to capture names Funding….spend wisely Patient Compliance, Adherence, and Persistence

18. 18 // Measuring Success Utilize these multiple vehicles supported by pharmaceutical companies and payers > Letters > Newsletters……including from 3 rd parties > DVDs > Email > Websites / Social networking / Blogs > Patient assistance programs > Onsite physician and pharmacy consulting Patient Compliance, Adherence, and Persistence

19. 19 // Measuring Success * 2-10% improvements in compliance are good – do not expect 50% range 1% increase in patient loyalty = 10% cost reduction The success probability of selling to a new patient is only 5-20%, while the success probability of selling to an existing patient is 60-70% Patient Compliance, Adherence, and Persistence *Sources: Bain & Co., 2008, Marketing Metrics, 2008

20. 20 // What Must Pharmaceutical Companies Do * Evaluate underlying specific causes for patient non-compliance with their brands to guide effective program implementation Address barriers to successful program implementation with all audiences – patients, physicians, pharmacists, payers Understand the return on investment for specific activities…be willing to analyze program results and refine as necessary Patient Compliance, Adherence, and Persistence *Source: Pharmaceutical Executive, March 2008

21. 21 Questions? Patient Compliance, Adherence, and Persistence