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Digestive Health

Patient Support Programs: personalized digital adherence support

  • Combining measures and survey tools with objective measures can help to characterize patient health behaviors, with the potential to increase adherence

What are PSPs?

Patient Support Programs are specifically designed to help patients in understanding their condition and taking medications directly. They can range from simple interventions such as the provision of pill boxes, to more complex solutions, for example organized programs with their roots in behavioral science theory.1,2 Whereas healthcare professionals may only have time-limited and occasional contact with their patients, these tools are designed to be available to patients as needed, or on a daily basis.

Some PSPs are purely informative, providing practical information on disease and drug management. These could either be printed materials or supplied digitally.3 It has been shown that, in isolation, the impact of these programs may be limited and insufficient. Other PSPs are purely behavioral, for example nurse-assisted patient programs.3 Research has shown that combination programs that use elements of both strategies may be superior to using one or the other alone, with complex, multi-modal educational interventions having a greater influence on patient health behaviors.3,4 A careful mix of the two may be the most effective way to improve adherence.

Structural barriers to effective treatment in cirrhosis include medication complexity and limited adherence. Tested interventions in this setting include provider-driven patient education, intensive case management including medication blister packs, and smartphone applications.5

Digital PSPs and mobile health solutions

Digital tools, including mobile applications or text messaging, are increasingly popular as more and more of the global population have access to mobile phones. In 2017, it was estimated that seven billion people (95% of the global population) were resident in an area that was covered by a mobile-cellular network.6 Text messaging interventions are popular since they can be used by people without smartphones, are convenient and relatively inexpensive, which may give them increased utility in developing countries,6 but more sophisticated mobile apps such as chatbots are also available.7

Text messaging has been demonstrated as an effective tool in behavior change, including appointment and medications reminders, helping people to stop smoking and enabling community mobilization.6 A study found that pediatric patients following liver transplantation were better adherent to therapy and had reduced rejection episodes when they (or their caregiver, whichever was the primary medication administrator) received text message reminders.8

Web portals may help patients to understand their condition and medications (additionally showing test results and allowing patients to re-order prescriptions), and provide a platform for shared decision making by hosting ‘e-visits’.9,10

However, these tools may lack the advantages of face-to-face interactions, including for educational purposes. It is therefore important that digital PSPs are personalized to individual patients, and tailored to their risk levels and behavioral drivers.2

Personalization of PSPs in adherence

Using behavioral science theories may assist in enhancing patient experiences and lead to better outcomes. However, there are some challenges to personalizing PSPs:

  • Existing adherence models do not lend themselves well to digital applications. They are not generally suitable for feeding into AI and digital support programs, as they are basic and are not rooted in detailed mathematical principles. However, recent research is helping to enable patient profiling using questionnaires, which can lead to patient adherence tools that are digitally compatible2
  • Digital tools may require self-reported data, which is subject to mis-reporting by patients, either willful or not2,11

Screening questionnaires are available to assist in personalization. The SPUR (Social, Psychological, Usage, Rational) framework is a profiling tool that produces detailed quantitative outputs describing the risk of non-adherence of a particular patient and what is driving these risk factors.2

Developments in behavioral sciences have led to a greater understanding of patient decision- making processes, thereby determining appropriate ‘nudges’ on the basis of their behavioral profiles.2 Digital technologies based on this increased knowledge can lead to enhanced patient experience.2,7

An example tool might be a ‘chat-bot’ with a virtual patient coach, available at all times via the patient’s smartphone, tablet or computer that helps them to manage their disease and treatment.12 This kind of tool has the potential to improve communication between physicians and their patients, and allow for doctors to review medication adherence remotely.7 These are a relatively recent innovation in the healthcare function, and their effectiveness and acceptability is yet to be fully determined. However, they present an opportunity for the physician to positively influence the daily lives of their patients.7

An example PSP for patients with pancreatic insufficiency

Smartphone apps are available that help patients with chronic conditions such as PEI. The doctor may encourage their patient to try a few of these and select one that they feel comfortable using. Suitable apps would allow the patient to track their medication requirements (as well as symptoms and lab results, for example) and share the information with their doctor and family members supporting them.13

Other practical tools in PERT self-management may differ depending on the age of the patient; for example, PERT could be taped to foods in a school lunchbox, but adults may require more education on identifying the fat content of their meals and snacks, with support in dosing strategies and label reading.14

PSPs have an important role in the physician-patient relationship

Whilst PSPs are not capable of or designed to replace the education, advice or support that physicians provide to their patients on any topic, including adherence, they provide opportunities to influence the daily lives of their patients, providing targeted educational resources and support. They can be used to personalize patients’ care plans and help them modify their behavior.1,2

References

  1. Gandapur Y, Kianoush S, Kelli HM, et al. The role of mHealth for improving medication adherence in patients with cardiovascular disease: A systematic review. EurHear J -QualCareClinOutcomes. 2016;2(4):237–244.
  2. Dolgin K. The SPUR model: A framework for considering patient behavior. PatientPreferAdherence. 2020;14:97–105.
  3. Burudpakdee C, Khan ZM, Gala S, Nanavaty M, Kaura S. Impact of patient programs on adherence and persistence in inflammatory and immunologic diseases: A meta- analysis. Patient PreferAdherence. 2015;9:435–448.
  4. Hayward KL, Weersink RA. Improving Medication‐Related Outcomes in Chronic Liver Disease. HepatolCommun. 2020;4(11):1562–1577.
  5. Thomson MJ, Lok AS, Tapper EB. Optimizing medication management for patients with cirrhosis: Evidence-based strategies and their outcomes. Liver Int. 2018;38(11):1882–1890.
  6. Iribarren SJ, Brown W, Giguere R, et al. Scoping review and evaluation of SMS/text messaging platforms for mHealth projects or clinical interventions. Int J MedInform. 2017;101:28-40.
  7. Nadarzynski T, Miles O, Cowie A, Ridge D. Acceptability of artificial intelligence (AI)- led chatbot services in healthcare: A mixed-methods study. Digit Heal. 2019;5:2055207619871808.
  8. Miloh T, Annunziato R, Arnon R, et al. Improved adherence and outcomes for pediatric liver transplant recipients by using text messaging. Pediatrics. 2009;124(5):e844-3850.
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