OPINION18 June 2013

More than a spoonful of sugar


How behavioural economics helps the medicine go down and improves healthcare adherence, by Crawford Hollingworth.

People are not always very disciplined when it comes to taking medication. Whether it’s to cure an illness, prevent one from worsening or to manage a chronic condition, it is estimated that around half of patients forget to take their prescription medication.

This is not only detrimental to a patient’s long-term health; it also increases healthcare costs. If medication is not taken correctly, conditions can worsen or complications can result. In the US alone, experts estimate that the bill for non-adherence runs close to $300 billion dollars annually.

So healthcare professionals are particularly interested in analysing this problem and looking at ways – ideally cost-effective ones – through which to solve it. Which is where behavioural economics comes in.

Ignoring doctor’s orders
The behavioural sciences can help us to understand this issue and provide us with a rigorous, strategic framework with which to analyse adherence and non-adherence.

For example: One reason for non-adherence might be our tendency to put off unpleasant things until tomorrow. We prefer to enjoy today. Behavioural economists call this ‘time inconsistency’ and ‘discounting the future’. Because medication often has short-term, unpleasant side effects, or is a hassle to take and can interrupt your plans, people sometimes choose to defer taking it and so suffer the consequences of poor health as a result.

We are also comfortable with the status quo and dislike change in our daily lives and routines. A medication programme is sometimes a very complex affair; for example Parkinson’s, heart disease or type-2 diabetes all require considerable medication management, not only in the taking of the drugs themselves but also the effort required to check in with doctors, to collect prescriptions and pick up or buy medication. Consequently, we can suffer from inertia – preferring instead to keep our lives running on the same routines.

Linked to this problem is the hold our habits have over us. Habits are deeply ingrained in our brain and muscle memory and it can take as long as two months or even more to build new ones. Completing a complex programme of medication over the long-term involves creating new habits and adapting our existing habits and routines to fit in with the programme’s demands. If we don’t manage this, we are likely to forget to take our medication at the right time and frequency.

We might also sometimes fail to take our medication because of situational reasons or changes in the environmental context around us. We might be great at remembering to take our medication at home but forget when we are travelling away, where there are not the same cues and triggers to remind us.

The cure
Behavioural economics can not only help us to understand patient behaviour, it can also provide us with a toolkit with which to develop potential solutions to ‘nudge’ and ‘steer’ behaviour and ensure patients are on track with their medication.

There are already some innovative solutions that use behavioural economics to improve medical adherence. For example, a US company has recognised the problem of forgetfulness and the lack of routines and habits in taking medication and launched GlowCaps – an intelligent lid for prescription bottles. GlowCaps give off both light and sound indicators for any scheduled medications, vitamins and supplements. The device is programmed with the exact prescription, and the cap glows progressively more intensely when the patient misses their deadline. If the patient still fails to act, it plays a tune, and if this doesn’t prompt action it will send a text reminder or recorded message to their phone.

At the end of each week and month, GlowCaps will email the patient a progress report telling them how they’re doing – which people often seem to respond to out of sheer competitiveness. As one user puts it, “It’s almost kind of like a game”. Not only are these great behaviour prompts, but, over the long-term, they could actually help to instill the habit of taking medication regularly.

An alternative solution was tested by researchers Kevin Volpp and George Loewenstein et al. The researchers conducted a small-scale experiment to see if they could use lotteries to improve medical adherence. They gave patients on Warfarin medication a special pillbox with a daily reminder feature. If volunteers opened up their pill box according to their prescription, they were entered into a daily lottery with a 1 in 5 chance of winning $10 and a 1 in 100 chance of winning $100 (pilot 1 ); or a 1 in 10 chance of winning $10 and a 1 in 100 chance of winning $100 (pilot 2 ). The results were encouraging. The mean proportion of incorrect pills taken fell from 22% before the trial to around just 2% for both pilots.

Another trial, using a suite of ‘nudges’ in letters to patients, has also had remarkable success. The behavioural economics research consortium ideas42 partnered with the Medicaid Leadership Institute and the SoonerCare team from the Oklahoma Healthcare Authority to implement a randomised controlled trial for diabetes patients. Letters were sent out to 2,500 patients diagnosed with type-2 diabetes who had not yet begun statin medication. Patients received one of four interventions:

  • One group received the basic letter, encouraging them to call their doctor to arrange a cholesterol check and discuss a statin prescription.
  • A second group received a $5 gift card with their letter which could be activated after attending an appointment.
  • A third group received a letter which had been redesigned to include a selection of ‘behavioural nudges’, such as making the consequences of remaining untreated more salient or including post-it note reminders.
  • A fourth group received both the nudge letter and the $5 incentive

The results were astounding. Those who had received the behavioural nudge letter (the third group) saw a 78% increase in response compared to the control group. The team are now looking into how to develop this initiative further.

TB is also being tackled by providing short-term incentives to achieve a long-term cure for patients with the disease. The behavioural problem lies in the fact that although TB is a very treatable disease, the treatment is a long, complex affair which has unpleasant side effects to begin with – often causing patients to stop their medication at an early stage or to stop prematurely as soon as they begin to feel better. So the culprit is time inconsistency – we prefer comfort now rather than comfort and health later.

Ideally, treatment can be managed through directly observing and caring for the patient – but this is expensive and difficult to implement, particularly in developing countries. So Amit Srivastava, a microbiologist at the Children’s Hospital, Boston, has devised a cellphone-based system using incentives to increase adherence. He provides TB patients with a month’s supply of medication, together with specially designed urine tests. When patients take the urine test, coloured dots appear, revealing a numerical code that the patient simply texts to their healthcare provider. If the pattern of dots indicates metabolites of TB drugs in the urine, the patient receives an automatic reward of free cellphone minutes. So the system helps to fight time inconsistency with an instant reward. And it is very efficient – one healthcare worker can follow 50 patients and the only technology needed is a cell phone. No internet or visits are required.

In general, behavioural interventions show the most promise when compared to more standard approaches, such as information or social interventions. A meta-analysis of 37 randomised controlled trials looking at improving medical adherence found that behavioural interventions generally had the greatest impact on adherence, especially those which looked at simplifying dosage demands from say, two doses to one dose per day, and those which provided monitoring and feedback, like the GlowCaps initiative described earlier.

Crawford Hollingworth is a co-founder of The Behavioural Architects