Hooked on Medication Adherence?

Posted by Kevin Coiley from Ogilvy CommonHealth Worldwide — North America on August 2, 2018


Nonadherence: A Heart-Breaking Story

A study on medication adherence in heart attack and atherosclerotic patients by Aetna, Ferrer, and Icahn School of Medicine found some troubling news. At least 50% of patients are not adequately taking prescribed medications within two years of a cardiovascular event. This study also found that fully adherent patients not only experienced significantly better outcomes but lower overall healthcare costs than partially compliant and noncompliant patients as well.


Some solutions have been implemented in the attempts to curb nonadherence, such as the Appointment Based Medication Synchronization (ABMS) patient engagement system. Have you ever received a message from your pharmacist asking you if you want to reach out to your doctor for a refill? This is an example of what the ABMS system is. The ABMS increased communication and interaction between patients and physicians/pharmacists, sent reminders to patients, reviewed medicine orders, and much more. Overall, this engagement system increased patient adherence to their medications by a whopping 2.57 times and decreased the likelihood of patients to discontinue therapies by 21% in ABMS enrollees compared to controls. The ABMS is a good example of how engagement systems can be applied to the healthcare industry to increase patient medication adherence.


Getting Patients Hooked on Medication Adherence

After seeing the success of the ABMS engagement system, it is important to explore other channels of creating strong engagement systems to solve the problem of patient nonadherence to medication. One engagement strategy that looks promising is the Hook Model. Why? The Hook Model uses behavioral science to create a more authentic, engaging form of motivation. This motivation is more engaging than the ABMS system’s external motivation as it elicits a deep-seated desire to engage with a product or service.


Developed by Nir Eyal, it is a cyclical feedback loop that has been shown to boost engagement through encouraging repetitive user behavior. Each completed loop is called a hook cycle and each cycle consists of four phases: Trigger, Action, Variable Reward, and Investment. Let’s look at each of these phases through the lens of me, a new user, joining Instagram:


I was triggered to download the app when I noticed my friends were on a pre-existing social media platform, in this case Instagram.


Once triggered I took action, posting content to Instagram. My first post was a selfie at the beach.


I received variable rewards in the form of likes and comments.


I got a lot of likes, but I wanted more. Since then, I’ve invested in improving my content by researching online, using more filters, and taking more pictures in the hopes of getting a better response from my followers.


Applying the Hook Model

With the Hook Model now in our behavioral science toolkit, we can go back to the problem at hand. Researchers from Aetna’s study claim poor motivation due to lack of knowledge and low self-management skills are major barriers for adherence to heart disease treatments. With patient barriers in mind, let’s look at what a mobile health application via smartphone would look like by creating a plan for each of the four phases:


Patients will be triggered through an educational notification system. To place a higher value on medication adherence, notifications will provide brief, educational content on the importance of adherence. Content can include information on the economic and wellness benefits of correctly adhering to medication along with the consequences of nonadherence. This accomplishes the goal of educating patients and places a value on adherence by creating deep-seated motivation through transforming a trigger from external to internal. How? The notifications start off as external reminders until their educational messages intrinsically motivate users by creating awareness of the benefits of adherence and consequences of nonadherence, therefore giving adherence value.


Once triggered, patients will take action by performing tasks that increase self-management skills. This could be pressing a big button that says you adhered, checking boxes of the medications you took, or anything else that involves managing medications.


A loot-box system will reward patients for self-managing. Once an act is performed, patients receive a key that can open a reward box. Patients choose from one of three boxes and receive a random prize, such as coupons or a discount on their next medication purchase. Without this variable reward system, patients will have no desire to reuse the app.


In the aim of fostering long-term engagement, users will invest time and loyalty in exchange for a higher rate of receiving loot rewards. Daily log-in systems are great for this phase. Heart attack patients will receive an extra key for every three consecutive days they have used the app. Patients ultimately use the app to improve their health, but creating another reason to log in every day strengthens habitual use.


Who Needs to Care?

Potential solutions like the Hook Model are important, as nonadherence is prevalent enough to affect many of our loved ones. Sadly, only about 50% of patients in developed countries treat their chronic diseases according to the instruction. With only half of patients in developed countries adhering to their medication, there’s a high chance someone you know isn’t properly adhering to their medication. What does this mean for them? Nonadherent individuals cause 10-20% of hospital and nursing home admissions per year, meaning their health is more at risk. Not only is their health more at risk but the damage nonadherence does to their wallet is just as bad, with research finding nonadherence to cost nearly $10,000 in additional spending per individual. Intrinsic motivation models are a potential treatment for ending the symptoms of medication nonadherence.