Posts tagged "prescription"

Ian handed me a fascinating article on ‘Should patients be paid for taking their medication?’. (He also said it was high time I wrote a blog. )The story described a trial where patients with mental illness were paid £15 for each fortnightly visit to their clinic where they were administered their depot.

My immediate answer was to say, of course they bloody shouldn’t be paid! Treatments are prescribed to make people feel better and help them function in the world, surely that is incentive enough?

Hold on, I thought – it’s plainly not enough. Poor compliance is a fact of mental healthcare. It’s easy to speculate on why these patients would avoid their medication. We need to ask about the conversations they are having with their HCPs. Are professionals helping patients reach an informed decision about treatments?

Well, at least one survey says not really. Here, 59% of patients taking an antipsychotic reported that other treatment options had not been discussed. Almost two thirds said that they hadn’t been given written information prior to starting their medication. And 46% said hey hadn’t been warned about its potential side effects.

The NHS and HCPs need to look at the way they are engaging with patients. How many have read the NICE guidance on patient adherence and choice, published in January? And how is the NHS supporting them in implementing change?

Of course, it’s not easy for anyone. The befuddling thing about informed choice is that patients can refuse medication, and the professional’s obligation is to respect this decision. But what if the individual is antisocial, or a danger to self or others? Why are we paying these guys, really – what are the savings down the line? To make a judgment on this pilot, we need to know more about these patients other than that they are poor compliers.

If the scheme sees the light, bitter laughter will accompany jokes about kids being paid to go to school and likewise to adults for behaving on a night out. No-one’s going to like the idea of a pay-for-peace society. Whatever happens, let’s hope these patients get something positive out of it.

Our ever loving ears hearken once more to the digital pitter patter of patient empowerment.  UCB Pharma have partnered with patientslikeme.com to bring an Epilepsy community to the site.

Patientslikeme.com is a privately owned initiative that encourages patients to post details about themselves. This real world, outcome-based data is shared with individuals and organisations who work to improve health outcomes, including pharmaceutical companies, research organizations, and non-profits.

30% of epilepsy patients are refractory to treatment, so this move is good news for patients, HCPs and even competing Pharma. Over 37,000 patients are already registered on the site as well as 3,000 caregivers. Any epilepsy community should include the voice of caregivers, as a significant proportion of epilepsy sufferers are elderly or have learning disabilities.

Patientslikeme.com doesn’t just collect data from patients, it provides quality information and allows them to blog and communicate with peers. It’s a site that really does seem to have patients’ interest at heart. That’s why we like it – and so congratulate UCB for being a part.

But it should be. Buried in amongst the papers this morning was the announcement from Sanofi-aventis of their intention to donate 100 million influenza vaccine doses to the developing world via the WHO. Well done Sanofi. See if you can find it on the BBC.

Sanofi-aventis to donate 100 million doses of pandemic influenza vaccine to WHO
Sanofi-aventis CEO Chris Viehbacher announced Wednesday that the company plans to make a donation of 100 million doses of influenza vaccine to the World Health Organization to help developing countries confront the influenza A (H1N1) pandemic. Speaking at the Pacific Health Summit, Viehbacher stated that “the future of our industry is linked to the healthcare solutions that will be found for emerging countries,” and added that the donation is being made in support of WHO Director-General Margaret Chan’s “call for common action to fight the pandemic.”

If you’re anything like me, you always read the Sunday magazine before the rest of the paper. Not that I don’t want to read about what’s going on the world, but most often, I only have 10 minutes to actually look at the Sunday papers!

A couple of Sundays ago, my eye was caught by the picture of Angelina Jolie on the front cover of the magazine. She’s beautiful – but more than that I thought there might be a picture of Brad Pitt inside. I was to be disappointed, but what I did find was an interesting – and disturbing – article on the “postcode lottery” pertaining to cancer treatments. I couldn’t believe this was still going on in that Primary Care Trusts (PCTs) have the authority to decide which drugs it will fund for patients in its area.

PCTs hold 80% of the total NHS budget. It is possible to challenge a PCT decision on drug funding – the patient has to demonstrate that he/she is an exceptional case, but this varies from PCT to PCT. I agree with Penny Wilson-Webb CE of the Rarer Cancers Forum that this is a “bizarre and demeaning process”. Imagine being forced to plead for your life by having to demonstrate that you are an exceptional case… what does an exceptional case look like? Is one life more valuable than another? Who decides?

It is astonishing that policies differ so much between parts of the country, and indeed, between neighbouring PCTs. But it’s not just postcodes that make this a lottery. The women featured in this article were middle class, educated; they had a voice. Who speaks for unempowered patients – those who don’t understand their choices, who have little support? A policy of one voice, one rule would solve this.

In April 2008, there was a “dramatic expansion of the patient choice initiative” in the NHS.  Patients referred to see a specialist can now choose their hospital (any that meets NHS standards). However, this doesn’t seem to cover cancer treatments. Why the lottery still?

I felt immensely for the individuals that have been affected by the decisions made by their PCTs. I also felt that doctors had in some way let down patients by not standing up to their PCTs, by not asking the difficult questions. I guess that no-one wants to put their head above the parapet and be seen to be causing a problem… or dare I say it, actually do what they believe to be right in the treatment of patients.

 So Obama has won, history made. But what a legacy Bush has left him with. Economic chaos and 2 wars to name just the obvious challenges he faces. Traditionally the healthcare industry is highly sceptical of Democratic nominees, but this election has been a little different. Donations to the Democrats are up 15%  and the industry seems more relaxed about Obama’s intentions than one would expect. Quite how things pan out is still anyone’s guess. How much focus can health get when there are such monumental issues facing the US economic and foreign policy programmes?

What is clear though is that drug prices will get severe scrutiny, generic drugs will feature heavily in both his and medicare’s planning and he wants an expansion in healthcare benefits to the uninsured. What he is also wedded to is investment in STEM (science, technology, engineering and mathematics). Over the last few years the US as a centre of innovation has been on the wane. Less graduates in science, less investment, less of everything. He has been clear that he wants greater investment in healthcare research, he is a firm believer in biological knowledge and stem and genetic research. These areas will be reinvigorated by his election and with his support the palate for cutting edge research may just be on the turn.

 What the real impact of all of this means is anyone’s guess, but if his mantra is true and “change is coming” I sincerely hope it reignites the exploration of life changing research.

It turns out that it’s a lot easier to peel a banana if you start from the ‘wrong’ end.

You don’t even have to use your teeth.

Here’s the thing: I know this. I’ve tried it. It’s true.

I still peel a banana the hard way. It feels like the right thing to do.

Convincing my friends of this change has been much harder than I thought.

Because it doesn’t feel like the right thing to do, it’ll be a tough thing to teach.

In the healthcare comms business, there are LOTS of bananas … things that people do because of convention, tradition, or simply “that’s just the way things are done.” For example, why is it that we have spent most of our time in Rx focusing on understanding the prescriber and not the uncompliant patient?  Why do ideas always have to be based on an a4 ad format.

The lesson for me is to consider everything we do. Are we making decisions because that’s just the way you’ve always done it? Or that’s the way all of our competitors are doing it? If so, you’re peeling the banana from the “right” end. Pick one of these things and, turn it around to see what happens.

Something seems to come over us when we write an ad brief, my planner friend reminded me this morning. It’s the way we do our best to cram everything about the product/condition/patient into one ad. We forget completely how we as consumers interact with ads; forget that below-the-line materials are on this earth only to communicate the underlying support for the product story.

I had a quick browse of OK! yesterday afternoon (dermatology research). The ads in there are graphic and simple. Their feel and message happened to me automatically, without conscious decision. Clarins just stepped right on in there. Bang, I was Gucci’d. But that’s a good thing. I didn’t have to waste time and delve into reams of body copy to know what it is these brands were trying to say to me. The same thing they were saying in their first, second, 500^th print ad. One-dimensional, loud and clear. Intent – a quick reminder of high-end status. (Plus a little eye candy for the logo lover.)

We’d hardly dream of addressing healthcare professionals this way, because we seem to feel we need a myriad of reasons to excuse ourselves. The disease area needs innovating, here’s why, here’s how we help, here’s the whole deal in microscopic detail. Certainly, HCPs need this information – but a brand ad just can’t and shouldn’t carry all of it. Instead, we must communicate quickly the offer/ position in the one elegant wrapper of a creative idea or perhaps like Gucci, a proud identity. To keep our messages simple we can use a separate, successive approach – that’s why we often roll things out in campaigns.

However, healthcare is a major area of research and advancement and that’s why drugs and services are constantly turning over. Research shows that a small amount of inner detail is appreciated by HCPs, so we have room for a couple of clear sentences in our work. OK, our clients are not Gucci, but we can still learn from such brands. Manufacturing processes kept to the label, leather ageing techniques communicated in store, deals kept to a business-to-business environment, and endorsement happens via PR. The ad is left to communicate the feel of the brand as simply and elegantly as possible. Isn’t what really sticks in our heads the stuff we don’t have to think about too much?

To build upon this and make it relevant to our proposition here at Hive. Using the ad to communicate an element of the story, and the whole mix to contribute to a bigger idea which exists outside and above that of the ad concept seems to us to be a better way, and should provide not just a brand feel but a story and richness that contributes to a truer more in depth relationship.

Any healthcare industry observer knows that today’s patients participate more actively in decisions affecting their health than ever before. This is facilitated by a less stigmatised approach to personal health, and by the internet as the ‘premier’ source of healthcare opinion and information.

Aside from some downsides (see previous posts) , most of us see knowledge-empowerment as a promising impact on health outcomes. However, it’s unfortunate that EU citizens are restricted to gaining information online peer to peer (via discussion forums) or from company sites in unrestricted markets, such as the US. This information rarely represents local indications or local market conditions. As a result the patient reviews information that is not always relevant to them, with products that are not always available in their market.

The European pharmaceutical industry has become an outsider to this information exchange. They are legally liable for the products they produce, but prevented from providing a regulated information source to the concerned consumer.

Isn’t it about time that Pharma be recognised as important contributors to health information alongside healthcare professionals, patient groups and regulatory bodies?

The recent European Federation of Pharmaceutical Industries and Associations (EFPIA) call on policy makers to improve access of citizens to medical information seems sensible and long overdue.

The EFPIA have proposed 4 main information categories to clarify the discussion. Firstly, pro-active information, which is provided unsolicited to the public, should be limited to general information on diseases, e.g. covering awareness, prevention etc. but not mentioning specific medicines. Secondly, reference information, covering diseases and medicines, which is sought by patients as in a library, e.g. through the internet. Thirdly, reactive information on medicines in response to enquires received from patients. And finally, support information supplied to support compliance with a prescribed medicine.

The European Commission is also in the process of reviewing the current practice with regard to information to patients on medicines and plans to announce its findings in October 2008.

The European Commission fully supports that better information available to patients can contribute to achieving better health conditions, a more efficient use of resources and better adherence to treatments. And has further concerns over inequalities of information provision across EU members, and the lack of quality standards. In addition to this it also recognises that Member States authorities may not be in a position to fully address patients’ needs in terms of the substance of information and the access via different means.

It would appear that the EFPIA and the European Commission are on the right track and we could expect to see at least a recommendation of harmonisation across member states.

In the mean time consumers of medicines in the EU remain exposed to inaccurate information and at potential risk to their health.

A Cambridge University academic is leading a call to dispense with medical jargon in favour of everyday language. Dr Melinda Lyons claims in the Lancet that patients can get dangerously confused by unfamiliar and similar-sounding terms (intra vs inter; hypo vs hyper), particularly in stressful and noisy situations.

This is something to be grateful for, because it’s more proof that healthcare is becoming more patient-focused. While not without its challenges, communication built on the needs and expectations of the end user is clearly the way forward. Dr Lyons’ work, and the fact her research featured in the morning Metro, reminds us that everyone has a stake and a growing interest in what happens in the healthcare world.

But it also reminds us that people aren’t the same. Words that are necessary to one person may patronise another. At Hive we play our part by first understanding who the end user is. Only then can we get the dialogue right between that person and the person looking after them. We do this by letting the HCP know more about who’s in front of them.

It’s a subtle thing, joining the dots between different mentalities and creating proper engagement, but it’s not new in marketing. Without the correct delicacy however, you get a fumbling disaster which tries too hard and fails.

So, between the patronising and the ancient Greek, lies a tone of voice that resonates. Finding it is a beautiful thing.

In the Rx marketing process, healthcare professionals have long been viewed as the biggest kids in the room, the holders of the power. Our first need was to have them on board, understanding and agreeing with our key messages, weighing up the facts and writing scripts like mad. Get the gate open – step back and watch the newly medicated sheep trot through. Understand the HCP, connect with their emotions and functional requirements and bang, product launched, sales incoming, off we go.

In these less bullish days (fewer new products, more chronic care, empowered patients), a new challenge has knocked on our door. Driving depth of use, and not just breadth, is an urgent requirement. It’s no longer enough to get a prescription written. We need to ensure that the sufferers have some part to play – complying, understanding, loyalty, enjoyment.

But as we shift towards end user strategy, we cannot lose sight of the HCP role. We need to acknowledge that instead of guarding the gate, the professional is becoming part of the medicine experience for the end user. This new dynamic means different ways of insight delving, tactical delivery etc.

We would be daft not to review how other industries have made this transition, especially other industries with gatekeepers as part of their brand journey. There isn’t a direct equivalent for the healthcare professional in industries such as automotive/computer/banking, but a lot of our challenges have been faced by these groups. In other words, these professionals are rarely or never responsible for public safety, but they also contribute to the brand experience for that most important player – the end user.

BMW invests hugely in understanding its end user. Only then does it understand its store environment, and then its independent sales advisors. In reconciling these insights, the showroom scene becomes a piece of the brand experience set up to gain loyalty from the customer.

I was lucky enough to sit next to a biggie at First Direct at dinner recently. With this service offer, their telephonists are the main touch point for consumers, their position is of unusually high responsibility within the brand journey. The satisfaction and loyalty of First Direct customers in general suggests that other companies could do well to infuse their call centre staff with new levels of responsiveness.

These two examples, and countless others, are strongly relevant to the healthcare model. They can help us learn how to respond to this turning environment, as we stand besides an open gate and really get to know those sheep.

There’s a really interesting new theory circulating called transmedia planning. A quick background: transmedia storytelling was a trend identified by the cultural academic Henry Jenkins, where entertainment brands used different media streams to tell pieces of a story or plot. Transmedia planning was born when a number of strategists, including Faris Yakob, adapted Jenkins’ theory for the marketing world.

TMP places control in the users’ hands by asking us to “Allow your audience to assemble your brand story”. It’s an interesting evolution of 360° marketing where one idea is expressed uniformly by multiple channels. TMP allows ideas (or parts of ideas) to reach consumers from a slightly different point of view, but deliver consistent value and meaning around a brand.

Hive’s business plan adopts a transmedia approach in the context of the important changes happening in healthcare. You don’t have to have read our recent blog comments to know that informed, or partially informed, patients are increasingly the norm. Growing access to different information sources gives patients more control over their treatment. The web allows communities to form and discuss treatment and results. Consumers are showing they need more than shallow promises and that’s where TMP fits the bill.

We have to remember though that the transmedia concept evolved in an unconstrained consumer world. In its purest form, TMP can’t apply directly to prescription brands because of the necessary limitations on patient communications. However, prescription drug users still form communities to share experiences about treatment, particularly those with chronic conditions. Using a transmedia approach here involves setting up the dialogue between prescriber and patient, but acknowledging that some of the dialogue and beliefs around the brand may also be acquired from less informed sources. The reality for patients/consumers is, the relative weight of advice sourced online vs the prescriber is not always as you would imagine.

Building relationships in any industry is about engagement with people. In the healthcare mainstream, the critical commitment may still be the prescriber’s. But it’s vital to remember that the prescriber is not the person experiencing the brand in a hands-on manner. Its time our communication to professionals and patients alike began to reflect that.

Those of us on the industry side of healthcare may dismiss today’s news as another headline doing damage to an industry that delivers benefit to millions. But in claiming “The difference in improvement between patients taking placebos and patients taking anti-depressants is not very great”, lead researcher Professor Irving Kirsch raises some undeniably challenging questions.

For one thing, the “effect” is not limited to mental health trials. One RCT in patients with acute duodenal ulcer (Lanza et al. 1994) consisted of three treatment arms: the then-new drug lansoprazole (Zoton/ Pravacid), an older drug, ranitidine (Zantac) and placebo. As per experimental law, the 44 patients receiving placebo had the same diagnosis as the other patients and were examined alongside them. After two weeks about a third of the placebo patients were healed, and after four weeks just under half of them were healed.

Here’s another in angina: (Boissel et al 1986) 35 patients with severely limited functional status were treated for 6 months only with placebo and short-acting nitroglycerin. The placebo dosage was blindly titrated over this time until an “optimal” response was seen. Twenty seven of the 35 patients showed substantial improvements over this period. Overall the number of angina attacks dropped from 10.3 to 2.4 a week with a corresponding decrease in nitroglycerin tablets used. It seems unlikely that these people would have simply gotten better had they stayed at home and had no treatment. But, with inert treatment in a clinical trial, they did get better.

Let’s not forget that a placebo isn’t necessarily a tablet. In two studies (Cobb et al, NEJM 1959. Dimond et al, J of Cardio. 1960) surgeons were only informed once in the operating room which patients were to have a complete internal-mammary artery operation, and which were to receive sham surgery. Both studies showed that most of the patients were much better after “surgery” regardless of whether they had actually received it or not.

These examples of a high response rate in a placebo arm are not uncommon. For centuries, it has been known that sick people frequently get better when administered an inert intervention by a healer or medicine man. It’s hard to account for the substantial improvement in these patients.

Increasingly, the term “placebo effect” has been a dismissive one, given to justify a response that cannot really be understood. To me, it seems that at some point the role of the patient’s ‘mind-over-illness’ must be considered. Indeed, the word “placebo” is being challenged by medical anthropologists, who ask how placebos, an inert substance by definition, can have any effect at all. If it does something, it is not inert. There must be something else at play driving this change.

Daniel Moerman in his excellent book Meaning, medicine, and the “placebo effect”, suggests a very different approach to this problem. He uses the term “Meaning response” and defines this as “the psychological and physiological effects of meaning in the treatment of illness”. The meaning response can be applied to most of the results traditionally attributed to placebo effect. As a definition it gathers the elements of the non-physiological into treatment success, aiming at a better understanding of this phenomenon.

Once you acknowledge that treatment ‘meaning’ exists alongside mode of action and plays a role, it’s only a short distance to another important realisation. This is directly relevant to us: by understanding meaning in the eyes of the end user, we can feed this insight into the HCP strategy. Adapting and optimising our communications can only help drive a better brand experience, a better consultation and perhaps better outcomes.

What do you think?

I came back from a meeting yesterday to find that our big pink sofa had finally arrived. Naturally, this was a sign to put the kettle on and get comfy. Naturally, we got round to talking about what makes prescription brands “engage” with people.

Engagement stretches from a transient coupling of user and product to a loyal relationship rich in mutual benefits. This depends on how much emotional value is delivered. The most successful brands in the world, like Apple, appeal to our most highly evolved values. Healthcare brands with a life-changing reputation (Seretide, Herceptin) come closest to this.

Most Rx brands however, don’t inspire much in end users. We take them for short term relief, or because the doctor/pharmacist said so, and never develop more than a functional relationship with them. Medicine is not something we buy because we want to.

But even though we’re largely indifferent, we can still forge long-term commitments with treatments because “we probably should”. Millions stick with a daily hypertensive because their physician has confirmed that their lifestyle hasn’t done them many favours. Changing brands only happens thus, when the doctor sees fit. There’s no dialogue going on here, but while there is forced engagement, does it really matter? We believe it does matter.

As preventative medicine becomes more of a priority, competition will drive prescription brands into more emotionally accessible areas. Certainly they will have to compete for prescriber loyalty.

For patients, new ways of engaging might go further than driving revenue. Putting a friendlier face on those boring old blood pressure pills might make people more adherent to their medication and perhaps think about taking more control of their health in other ways.

A recent post about the rise of the informed patient attracted some insightful comments. Dr J got me thinking about knowledge, responsibility and a few things in between.

Patient education is a good thing and we need more of it. The EMEA roadmap for 2010 promises more access to accredited medical information. Ideally this will help override the reams of flimsy information that, as Dr J points out, are in abundance.

I think the EMEA have their work cut out for them. How much information do people need for a start? Is it OK to broadcast an advert simply telling people to be more active, or do we need a clearer link to the real consequences of obesity? And what if we overload people with information – will we scare them into doing the wrong thing? Will they just stop listening?

What really alarmed me was Dr J’s comment that, even when patients know their onions, they often balk at decision time. Perhaps we know enough, but we’d still like to blame someone else if things don’t work out. Or is it the other way round – are we being urged to take more responsibility for our treatment, but don’t have enough insight to make decisions?

There’s a great take-out from this: We must be on the ball if our minds are boggling with the same question that patients’ are. What we all want to know is: how do we embrace patient empowerment without compromising medical integrity?

Looking forward to your thoughts on this one.

A few years ago, the rest of this consultation would have been relatively straightforward. I would ask some questions, run a couple of tests, recommend a treatment and the patient would feel reassured. Nowadays however, it tends to go rather differently.The patient will, more than likely, have already been on various websites looking for a diagnosis. They may also have looked into the different treatments available, even compiled a folder of information for discussion. They want and expect to be actively involved in their diagnosis and treatment plan. And if they aren’t completely satisfied with my opinion, they’ll get someone else’s. In short, “trust me, I’m a doctor” no longer holds much water.

Never before have patients been so well informed, so involved and influential in their healthcare. With a finger on the public pulse, the government is planning for personal healthcare budgets so that each patient can choose their hospital, consultant and treatment. Since I graduated 10 years ago, the face of medicine has become almost unrecognisable. It’s more like going shopping than to the doctor.

How does this make us healthcare professionals feel? I’ll be honest; a little mixed. The quality of information available to patients varies enormously and can sometimes do more to confuse than to clarify the situation. On the other hand it’s likely that a patient who feels invested and in control of their wellbeing will live a healthier lifestyle and engage with the required treatment. Isn’t that the aim?

Whatever the implications, the NHS claims to hold the needs and wishes of the patient at its core. This makes sense ethically and politically. The question is, why are healthcare communications agencies still servicing healthcare professionals before satisfying the public interest?