06.21.16 By Sanofi Le Hub
Sanofi’s Patient Centricity Unit is working to develop innovative programs that promote patient engagement and empowerment in chronic condition management, built as part or whole-person patient centered healthcare strategies.
One of the world’s leading experts on patient centricity and the use of Behavioral Science in healthcare is Dr Hayden Bosworth, Professor of Medicine, Psychiatry and Nursing at Duke University, and Associate Director of the Center for Health Services Research in Primary Care at the Durham Veterans Affairs Medical Center, USA. He is also Adjunct Professor in the Department of Health Policy and Management at the University of North Carolina, Chapel Hill.
Sanofi Le Hub sat down with Dr Bosworth to talk about how behavior change and patient empowerment can help improve health outcomes across a wide range of chronic conditions.
Behavioral Science is the systematic analysis and investigation of human behavior. With reference to health, we’re talking about how human behavior can affect medication adherence, physical activity, diet, smoking and alcohol consumption, to name just a few areas.
Behavior is a fundamental component of the way we manage our health and lifestyle. If you take cardiovascular disease – hyperlipidemia, diabetes, hypertension etc. – behavior is estimated to explain about 80% of cardiovascular events. When it comes to heart attacks and strokes, behavior can explain up to 75% of these events. We see similar statistics with oncology and other fields of medicine.
The challenge for us is to change these behaviors through what we call positive-negative reinforcement, and to eventually create new habits that positively impact patient’s ability for self-management. For example, we are all taught to brush our teeth in the morning and at night. As a result, most people brush their teeth – it’s a habit; it’s something they do without thinking about. With medication adherence, we initiate change so that patients remember their medication just as they remember to brush their teeth.
Behavioral Science is the core of patient empowerment. What we’re seeing is also a movement towards Population Health Science, which includes Behavioral Science, but it puts it in a context. By that I mean that an individual isn’t just an individual but there’s a larger network: family, community, health care system and policy. Population Health Science tries to use all these factors to influence behavior and empower patients as individuals.
For adherence, we look at why individuals don’t take their medication and apply solutions to instigate positive change. In this process, you really can’t use logic. If a person who has been treated for breast cancer is prescribed a medication that’s proven to be effective, then why after 5 years have 50% of people stopped taking it?
We need to peel it back and look at the Behavioral Science behind the decision to stop taking the medication. You may find issues with motivation, confidence, affordability, side effects, etc., which can be addressed with the right knowledge and support.
The underlying issue for adherence is that we need to address risks and benefits – you can’t expect someone to agree to take cholesterol medication for the next 30 years without understanding the risks and the benefits and weighing those. If we ask someone how confident they are about their ability to take their medication as prescribed and they say 7 or less, we know they’re going to fail to adhere. Using Behavioral Science, we can identify this risk and provide support to help the patient to adhere.
Many interventions can be used across fields. For example, we are using mobile health at the moment for a study based on kidney disease, whereby case managers provide reminders, education and reinforcement over the phone once a month. We are also using pharmacists to provide phone support.
These are effective, simple interventions that don’t require a lot of resources – just a phone and some time. They also improve access to healthcare. For a person with a low income, taking time off work to go to a GP is a big deal. If that support can be offered over the phone, then it’s quicker and more convenient for the patient, and it’s cheaper for a nurse or pharmacist to provide that service than for a GP.
We need to be aware that behaviors changes over time – we can initiate people to start medication, but we need to check in periodically and not wait until there’s a problem. All too often we look at things from a negative reinforcement perspective – you have high blood pressure, I need to give you a hypertension medication. But if someone’s engaging and we’re not giving them positive reinforcement, at some point they will stop taking their medication. They want to know that they’re doing well and that we know they’re doing well.
That means we also need to motivate HCPs to commit to a long-term plan, to share responsibility, make information available, reinforce that information and adapt the message as the patient’s behavior changes.
We also need to align our healthcare systems to support a more integrated way of working. For example, we need to link up our prescriber and pharmacy data – doctors might prescribe a medication but they don’t know if the prescription has been filled. We need more visibility of a problem like non-adherence before it occurs.
This is where we come back to Population Health Science. What happens is that we look at Big Data and we put people into categories that relate to their health. That’s the first level of Population Health. The second level is that once a population is segmented, we need to look at our data and tailor programs so that we are soliciting, reinforcing and changing our information in line with the needs of that particular patient.
Personalized interventions in the context of population health should be more cost effective as we would be using resources in a more efficient way.
This is where we can use mobile technology to solicit ongoing, real time information about patients and this can be adapted over time. Mobile health makes it possible to gather information and scale interventions over a large population.
If we look at adherence, it’s estimate that in the US alone between $100-250 billon is wasted each year in non-adherence. We can use Population Health Science to help address this by adopting programs that can be amended across the system to treat groups with specific concerns.
For example, there are as many as 100 reasons why people do not take their medication. However, in practice, we know there are really about 6-8 main reasons: lack of motivation, lack of understanding about risk/benefits, lack of understanding about side effects, cost, forgetfulness etc. We can structure a program that allows us to screen for these possible responses, and then to provide those patients with information that specifically addresses their individual concerns.
Often it’s a matter of helping the patient understand what to expect and how to manage side effects, for example. It’s very simple but it’s easy to get it wrong if you’re not tailoring information to the specific side effect the patient is having.
To the patient, the care comes across as being personalized, but when we are putting these programs together, it’s really about research – it’s about anticipating responses and having the necessary support available to address those responses.
This can all be standardized; it’s a matter of finding out what a person knows, where their knowledge gaps are and offering information to fit those gaps. The platform can be text, email, voice recognition – it doesn’t matter as long as it’s tailored to the individual.
This allows us to use step-level care so we can allocate resources more efficiently across the entire healthcare system to where they are needed most. If a patient is taking their medication, we can track this for positive reinforcement and intervene when necessary. Not everyone needs to see their doctor at the same time for the same reasons, so we should see fewer wasted resources and more tailored care.
I could also add family and friends because we’re talking about treating the patient as a whole person in terms of both chronic illness and preventative care.
Support doesn’t have to be in a clinic with a GP – in many cases, nurses and pharmacists are actually more qualified and better trained to offer these services than GPs or specialists. It’s also more cost-effective for the healthcare system.
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