The Context-Aware Pill Bottle and Medication Monitor Video – Great Without Glitz
There is nothing technologically unique about the Context-Aware Pill Bottle and Medication Monitor (an accurate but not euphonious and decidedly not catchy name) from the University of Calgary, and there is certainly nothing slick in the production values of the video about that appliance. Yet, it is indeed a must-see presentation.
The first portion of the video, which explains the intent, positive effects, and workings of the mechanism, will appear familiar to anyone who has seen promotions for medication dispensers/reminders, but the portion that follows the “Critique” heading enters uncharted territory to those who don’t routinely attend research meetings. It is during this critique, you see, that the same individual who presented all the benefits of the device discusses possible flaws in its design. The informative critique is not only enlightening but also heartening.
Of course, this is a video version of a research paper. One shouldn’t expect an ad agency to suggest the same sort of balanced presentation to a client trying to sell a product.
Still, one can dream.
The Context-Aware Pill Bottle and Medication Monitor1, May. Video and two page paper, duration 3:58. Also as Report 2004-752-17, May.))
Abstract: The video illustrates and critiques a context-aware pill bottle/stand that reminds the elderly when it is time to take their medication. A medication monitor situated in a caregiver’s home displays awareness information about the elderly user’s medication compliance.
__________
Agarawala, A., Greenberg, S. and Ho, G. (2004). The Context-Aware Pill Bottle and Medication Monitor. In Video Proceedings / Proceedings Supplement of the UBICOMP 2004 Conference. ((September 7-10, Nottingham, England↩
Shortly after publishing Patient Compliance And The F Word, my post about Jonathan Richman’s essay, The Only Way Pharma Can Improve Compliance: Fun, I serendipitously heard from Katrina Firlik, MD, who introduces herself as a neurosurgeon-turned-entrepreneur, now founder and chief medical officer of a new start-up in the medication adherence space: www.healthprize.net.
On checking that site, I found the above graphic (click on image to enlarge) which held out the promise of, as the title of this entry notes, “more adherence fun.”
Once is happenstance, twice is a trend, … one more linkage between compliance and fun and we’ll have ourselves a movement.1
HealthPrize Technologies – Motivating Treatment Adherence With Incentives
I must admit that my immediate, automatic reaction to theHealthPrize Technologies site was a flinch. Like most healthcare professionals, I am unaccustomed to seeing treatment adherence linked to winning prizes.
It’s all based on the simple idea that people respond to two things: money and fun. So we’ve developed a system that links adherence-tracking technologies to a series of financial incentives, like points, prizes, and cash. And the better consumers are about taking their medication, the more chances they have to win and the more fun they’ll have.
Differing opinions about the appropriateness of offering incentives for compliance with healthcare regimens is hardly a new topic. A partial list of AlignMap posts on this issue includes
The contentiousness triggered by this methodology has more to do with cultural, philosophical, and ethical concerns than pragmatic results. There is an impressive amount of evidence that supports the notion that fiscally based incentives (e.g., cash, coupons, and merchandise) can increase rates of treatment adherence.
Currently, an odd dichotomy of opinions on the matter exists. There is relatively little criticism heard, for example, about corporate wellness programs offering prizes and other incentives to obese participants who lose weight or to tobacco-using participants who are able to stop smoking. Offering those same prizes or similar incentives, however, to participants for following a prescribed medication regimen or undergoing indicated medical screenings is likely to result in charges of unethical behavior, mind control, and disreputable motives.
Given that some bioethicists insist that only an absolutely neutral presentation of treatment options to patients is acceptable, the idea of offering prizes for executing a course of treatment is sure to result in controversy.
For my part, incentives seem one more tactic that has been shown to enhance treatment adherence in some patients. In that sense, it falls in the same category as reminders, the use of pill boxes or automated medication dispensers, regimen simplification, adding a second medication to ameliorate the primary drug’s side, educating the patient about the workings of the medication, …
The key ethical issue would seem to be distinguishing the use of incentives to drive the behaviors necessary to execute a prescribed treatment from the use of incentives to drive the mindless ingestion of one pill or another.
It’s important because incentives have been shown to be effective for a significant number of patients (albeit not all)
It’s important because, as I have pointed out on occasion, 2 repeating the same processes tends to produce the same results. In the case of patient compliance, that means trying the same adherence enhancement that didn’t work the first 821 times probably won’t work the 822nd time. Trying something new (not just another version of the same tired idea), is essential; trying something that has only been used on a limited scale, such as incentives, is astutely logical.
Finally, it’s important because we need to be looking for methodologies that enhance compliance by enhancing the alliance of the patient with those involved in his or her healthcare, including clinicians, Pharma, third party payers, and other stakeholders. Fun would be a potent force to effect that alignment.
I cannot predict how effective this particular take on using incentives to improve treatment adherence will be clinically, and I certainly have no idea if HealthPrize Technologies will prove a commercial success. It does seem, however, that adding a potentially useful, currently unavailable weapon to combat certain kinds of unintentional noncompliance to our clinical armamentarium could be – well, fun.
The Capshell, featured at the Yanko Design Blog, operates much like the other automated pill dispensers:
The device records when medication is taken, and shows the user the correct intervals programmed by the pharmacist. If not activated at the correct time, the device sends an alert to the users phone via text, or “SMS.” Once in the grip of the user, it opens easily by turning round, revealing the opening corresponding with the time of day. This way of opening is helpful to the elderly, as it eliminates hard-to-open caps. Each days replacement tube is labeled clearly with text and with Braille numbering.
The packaging is, however, unique. The steel and gray containers seem a 1990s update of the venerable pneumatic tubes, a design dating to the early 1800s.
Pneumatic Tube used in some US post offices
Even the opening latch mechanism seems familiar.
Capshell
I am keeping the Capshell in mind. It should look great in Mom’s Manhattan pied-a-tier.
A plethora of compliance-pertinent videos are now available online. I’ve begun posting some of these flicks on this blog’s tumblelog counterpart, AlignMap In Cites.
Videos selected for the AlignMap In Cites Patient Compliance Theater meet one or more of the following inclusion criteria:
Presentations of patient compliance research that briefly and clearly present highlights of findings
Tips targeted to patients or clinicians that may improve adherence
Demonstrations of and infomercials about devices that ostensibly enhance adherence – or at least amuse me.
Testimonials from patients and pontifications from clinicians that provide useful information, reveal pertinent attitudes that could have a positive or negative impact on patient compliance, or surpass a difficult to articulate but easy to recognize threshold of – oh, let’s call it eccentricity.
Anything else that strikes my fancy.
The following videos in the list that follows have been posted to AlignMap In Cites in the past 24 hours. The links below go directly and only to the post indicated. These posts can also be accessed en masse by going to the AlignMap In Cites home page and scrolling back through the chronologically listed posts.
Now Showing
The AlignMap In Cites Patient Compliance Theater
Infomercial about the e-Pill Cube Pill Timer and Pillbox My first impression, based on the rather complex explanation of its operation, is that the device might be better positioned as a test of cognition rather than a convenient medication dose reminder.
Importance of Patient Compliance in Healing: Presented by a clinician and targeted to patients. Excerpt: So, do what the doctor tells you. Try to be compliant. Try to get better. And if you need our help, we’re Baker Chiropractic. We put patients first.
Video Demonstration Of Zume From Health 2.0 Conference
The Zuri electronic medication reminder application produced by Zume, which was discussed in this blog three months ago (see Popularizing Patient Compliance Technology), was demonstrated at the Health 2.0 Conference (San Francisco, Oct 2008).
The video has made it to YouTube and, while the production values owe more to – well, YouTube than Coppola or Spielberg, the potential utility of such instruments is made clear.
Readers may recall that I recently promoted Expanding The Patient Compliance Knowledgebase by considering data from fields beyond healthcare that are potentially pertinent to treatment adherence.
With that in mind, read the following excerpts from Texts You Can Believe In1 By Farhad Manjoo, published at Slate.com Oct. 27, 2008, mentally changing the context from political campaigns to patient compliance (don’t worry – it’s not difficult):
… you might think that automated phone calls will make a difference in the presidential race. They won’t. Robo-calls are the pyrotechnics of politics: They create a big disturbance, but they don’t have a prolonged effect. Numerous studies of robo-call campaigns show that they’re ineffective both as tools of mobilization and persuasion—they don’t convince voters to go to the polls (or to stay away), and they don’t change people’s minds about which way to vote. So why do campaigns run robo-calls? Because they’re cheap and easy. Telemarketing firms charge politicians between 2 and 5 cents per completed robo-call; that’s as low as $20,000 to reach 1 million voters right in their homes.
Compared with TV advertising, door-to-door canvassing, and mega-rallies, automated phone calls are seductive because they harness modern telecommunications technology in the service of political persuasion. …
On the surface, these texts don’t seem that different from robo-calls—they’re both automated messages and both easy to ignore. But for reasons that aren’t completely understood, text messaging is different: We pay attention to short messages that pop up on our phones.
These conclusions arise out of work by Donald Green and Alan Gerber, two political scientists at Yale whose book, Get Out the Vote: How To Increase Voter Turnout, is considered the bible of voter mobilization efforts. Green and Gerber are the product of a wave of empiricism that has washed over political science during the past decade. Rather than merely theorizing about how campaigns might get people to vote, Green, Gerber, and their colleagues favor randomized field experiments to test how different techniques work during real elections. Their method has much in common with double-blind pharmaceutical studies: With the cooperation of political campaigns (often at the state and local level), researchers randomly divide voters into two categories, a treatment group and a control group. They subject the treatment group to a given tactic—robo-calls, e-mail, direct mail, door-to-door canvassing, etc. Then they use statistical analysis to determine whether voters in the treatment group behaved differently from voters in the control group.
Political scientists have run dozens of such studies during the past few years, and the work has led to what you might call the central tenet of voter mobilization: Personal appeals work better than impersonal ones. Having campaign volunteers visit voters door-to-door is the “gold standard” of voter mobilization efforts, Green and Gerber write. On average, the tactic produces one vote for every 14 people contacted. The next-most-effective way to reach voters is to have live, human volunteers call them on the phone to chat: This tactic produces one new vote for every 38 people contacted. Other efforts are nearly worthless. Paying human telemarketers to call voters produces one vote for every 180 people contacted. Sending people nonpartisan get-out-the-vote mailers will yield one vote per 200 contacts. (A partisan mailer is even less effective.)
Meanwhile, pinning leaflets to doors, sending people e-mail, and running robo-calls produced no discernible effect on the electorate. Green and Gerber cite many robo-call studies, but the most definitive is a test they ran during the 2006 Republican primary in Texas. Gov. Rick Perry recorded a call praising a state Supreme Court candidate as a true conservative. The robo-call was “microtargeted” to go out only to Perry supporters—people who’d be most open to his message. But as Green and Gerber show, Perry supporters who received the call reacted no differently from those who’d been kept off the list. They were no more likely to vote, nor, if they voted, to vote for Perry’s candidate.
These findings create an obvious difficulty for campaigns: It’s expensive and time-consuming to run the kind of personal mobilization efforts that science shows work best. Green and Gerber estimate that a door-canvassing operation costs $16 per hour, with six voters contacted each hour; if you convince one of every 14 voters you canvass, you’re paying $29 for each new voter. A volunteer phone bank operation will run you even more—$38 per acquired voter. This is the wondrous thing about text-messaging: Studies show that text-based get-out-the-vote appeals win one voter for every 25 people contacted. That’s nearly as effective as door-canvassing, but it’s much, much cheaper. Text messages cost about 6 cents per contact—only $1.50 per new voter.
… I joined Obama’s text list around that time. (I would have joined McCain’s text message list as well, but he doesn’t have one.) Since then, I’ve received two or three messages a week from the Obama campaign. A typical one: “Help Barack. Tell your friends & family the last day to register to vote in CA is this Monday, Oct 20th! Visit VoteForChange.com to register NOW. Please forward.”
The texts reminded me to watch the convention and the debates and to donate money to the Red Cross when Hurricane Gustav hit. In September, Obama asked me to text him my ZIP code. I did, and now I get location-specific messages—alerts to phone banks and debate-watching parties in my area, reminders of registration deadlines in my state, and appeals for me to volunteer in neighboring states. The messages are rendered in a friendly, professional tone (they refer to the candidate as Barack) and have been free of both fundraising appeals and any kind of negative campaigning.
The beauty of text messaging is that it is both automated and personalized. This is true of e-mail, too, but given the flood of messages you get each day (no small amount from Obama), you’re probably more attuned to ignoring e-mail. Text messages show up on a device that you carry with you all day long—and because you probably get only a handful of them each day, you’re likely to read each one.
This is especially true when the message seems to have been tailored to you specifically—Obama’s often are. The campaign knows a lot about me: At the least, it knows that I live in California, and because I joined the text-message list in order to learn the V.P. pick, that I’m fairly interested in politics (and therefore likely to vote). It’s possible that they might know even more; given my ZIP code and my phone number, they could potentially have tied my text-message account to my voter registration file, allowing the campaign to send me messages based on my party registration, whether I usually vote by mail, and whether I sometimes forget to vote. (It doesn’t appear that the campaign knows what’s in my registration file, though; I’m registered as a permanent absentee voter, but the campaign hasn’t asked me to mail in my ballot yet.)
Because text messages allow for such precise targeting, it seems likely that over the next week the Obama campaign will direct its appeals to voters in battleground states, especially first-time voters that the campaign has registered during the past year. In 2006, political science grad students Aaron Strauss and Allison Dale studied how newly registered voters responded to text-message reminders sent out just before the election. The text messages increased turnout by 3.1 percentage points. Strauss says there’s a simple reason why: “The most prevalent excuse for registered voters who don’t cast a ballot is, ‘I’m too busy’ or ‘I forgot.’ Texting someone is a convenient, targeted, and noticeable reminder for them to schedule their Election Day activities with a block of time set aside for going to the polling place.” In a post-election survey, Strauss and Dale asked voters whether they found the text messages helpful; 59 percent said yes.
Vote For Treatment Adherence
So, does text messaging research done in the political arena apply to the world of healthcare recommendations?
Well, I dunno.
For one thing, it may be a moot point.While I have surveyed the basic research on personalized text messaging as a compliance enhancement tool, I’m not well versed enough in this field to ascertain if counterparts to the type of election campaign messaging studies described in the article already exist.
For example, that I’m not familiar with a healthcare equivalent of Get Out the Vote: How To Increase Voter Turnout by Donald Green and Alan Gerber, the how-to handbook based on well designed research utilizing control groups 2 described in the Slate article, does not mean it hasn’t been produced.
But, it seems to me that there are only a limited number of possible scenarios:
1. There are no healthcare counterparts to the type of research described for voter mobilization text-messaging.3 In this case, the seemingly obvious next step is, absent evidence that the healthcare and political fields are fundamentally different, using the work already done in the latter sphere as a basis for confirmatory studies applicable to healthcare.
2. There are healthcare counterparts to the type of research described for voter mobilization text-messaging. In this case, it becomes useful to ask how those results compare.
If voter mobilization and healthcare compliance behaviors with respect to text-messaging are similar, the likelihood that there exists a universal set of responses to recommendations made to individuals – whether the recommendation is to floss after meals, buy a hybrid rather than a gas-guzzler, take medication as prescribed, vote for Ralph Nader, buckle up, read the AlignMap blog, or see the new Mel Gibson movie – is enhanced, as is the utility of exploring what is known about this phenomenon in other fields.
If voter mobilization and healthcare compliance behaviors with respect to text-messaging do not correlate, the key becomes investigating why those differences exist.
3. We stick with the isolationist party line, AKA the Fortress Healthcare approach, pretending that our field is so fundamentally different that it is a unique universe unto itself.4
__________
Subtitle: “Forget robo-calls—Obama’s text messages are this campaign’s secret weapon”↩
I am making, for the purposes of this post, the somewhat daring assumption that the research methodology used in Get Out The Vote and the other voter mobilization studies is as designed as carefully and executed as rigorously as claimed.↩
Again, I’m making the assumption that the research methodology used is valid↩
It is also, one suspects, a unique universe in which the stars and planets revolve around a flat Earth.↩
Both posts are thoughtful, insightful, and provocative and I can wholeheartedly recommend both as worthwhile reading.
And yet, those entries inexplicably lack two vital components, which I feel obligated to proffer as a supplement of sorts to the efforts of my brother blogger. This response, by the way, has nothing to do with the failure of Alex Sicre, the author at Medication Non-Adherence, to acknowledgment my own posts on the topic of Compliance-enhancing Robots, including Cute, Cuddly Robot Pets Remind Elderly To Take Pills, …
No, if I were going to have hurt feelings – not that I do, mind you – it would be over the diss implicit in the failure to mention my development and promotion of The RoboCop Compliance Program. Based on the percepts electronically implanted into the hemi-mechanical hero who was the prototype for the law enforcement robots featured in the RoboCop movies, the Program is simplicity itself:
RoboCop (Dr. RoboCop to you) presents the healthcare recommendations.
RoboCop enhances compliance with his trademark line, which also serves as the Program’s slogan (Click to hear RoboCop Treatment Adherence Slogan)
[audio:complyx.mp3]
1. A Misanthropic, Wildly Speculative, Tangential Soliloquy
In the literature I’ve found, as well as the sources quoted in the two posts at Medication Non-Adherence, the focus (and often the exclusive focus) is on caring for the elderly. I assume that choice is predicated on two of the fundamental driving forces in contemporary society:
Greed: The elderly are a large and rapidly growing portion of the population, and there is an often referenced, albeit rarely articulated, generic commitment from the government to fund their care.
Responsibility abrogation: My own cohort is facing the increasing likelihood that our parents, if not already in need of assistance, will require extra help in the near future, and I certainly intend to do everything I can to assure that the next generation, including my two sons, shoulder their obligation to care for their elders. It is clear, however, that few of us face this task with enthusiasm. Dispatching a robot to care for Grampa James may be a tad less empathic than Jimmy, Jr helping out, but, hey, it’s better than being pushed onto an ice floe.
I would, nonetheless, suggest that other population segments might provide good candidates for such services. The example that comes to mind is my son who suffered a head trauma followed by a coma and a recovery period of 1-2 years. Especially during the rehabilitation period just after his return home from the hospital, he required constant monitoring. Although 90%+ of his behaviors were appropriate, he would unpredictably have cognitive lapses, one consequence of which was that his adherence to medication doses and schedules was erratic. A robotic companion would have eased the burden on me as his sole caregiver and would, I suspect, have been easily accepted by him. A number of other diagnostic and age groups might benefit as well.
Specialized robots for specialized populations.
Just a thought.
2. Photos You can’t tell your robots without a program.
These carebots from GeckoSystems Inc. cost: $19,950 each, including delivery and two-day training.
This video is from the same company, GeckoSystems Intl. Corp, showing CareBots providing healthcare support of elderly, in this case, it presents “One family’s reaction to a CareBot™ for their mother.”
The graphic below is found at Carebots & the good life, a site produced by the Philosophy Department of the University of Twente, which is one of the three participants in the 3TU.Centre for Ethics and Technology. They are “looking for a PhD student to work on the project “Carebots and the good life: An anticipatory ethical analysis of human-robot interaction in (health) care”.
Infanoid (pictured below) is from CareBots Project (Robotic Platforms). Many other photos and movies of human-emulating robots can be found at this site
Graphics Note: The image atop this post is my adaptation of a scene from Lost In Space. The role of the patient is played by the nefarious Dr Smith. The caregiver robot is, of course, Robot from the show. As everyone knows, Robot is a Model B-9, Class M-3 General Utility Non-Theorizing Environmental Control Robot.
Zuri – Medication Reminder and Compliance Recorder
An article in today’s (August 19, 2008) Wall Street Journal, Tools Help Patients Interface With Doctors By Victoria E. Knight, opens with this excerpt, a success story about the Zuri, an electronic medication reminder and compliance recorder still in beta:
When Tajel Shah sought laser surgery to correct her shortsightedness, the surgeon said she would need to use eye-wetting drops every hour and take a medication for three weeks to ready her eyes for the procedure — a tough regimen for the working mother of two to follow.
“I thought there’s no way I am going to be able to do this unless I have some sort of physical reminder,” said the 38-year-old from San Francisco.
Then a friend told her about the Zuri, an iPod-sized device that sends patients reminders to take their medications and records their compliance, which users and, if they choose, their doctors can track through a companion Web page.
The Zuri’s maker, Zume Life Inc., a San Jose, Calif., start-up, was looking for beta testers. Ms. Shah signed up.
Technicians put Ms. Shah’s medication schedule on a Web page and downloaded the information into the device. When the device beeped, Ms. Shah could see which medication she needed to take on its screen, and, by pressing a button, confirm whether or not she had taken it. Aided by the device, she said she was able to adhere to the surgeon’s plan, and she had the surgery in January.
… Rajiv Mehta, Zume Life’s chief executive, said the company expects to launch a version of the product next spring. The device will cost about $200, and users will pay a $40 or $50 monthly subscription fee for the Web-based services.
The article goes on to extol the virtues and promise of
“self-care”1 tools that companies including Intel Corp. and Microsoft Corp. are developing to help people monitor their own health and receive feedback from caregivers.
In oversimplified terms, both Intel’s Health Guide and Microsoft’s HealthVault store, organize, analyze, and distribute a variety of healthcare data gathered from a wide array of sources.
The Evolution Of The User Interface In Healthcare Technology
On reading the WSJ article, my first response was – well, OK, my first response was “Where do you sign up to have the WSJ open an article with five paragraphs of a success story featuring your business’s product?”
My very next thought, however, was that the user interface of these gizmos is likely to evolve as have other technological marvels, such as the automobile and the computer. The extent to which new tools are put into use by the population, however obvious their value, is limited by the difficulty, expense, and unfamiliarity of that tool.
In other words, what are the chances my Aunt Hazel from Broken Arrow, Oklahoma will find the Zumi a must-have healthcare device as long as it is a $200 pseudo-iPod with a $40 per month fee that technicians have to set up?
Of course, Aunt Hazel wasn’t interested in driving a car until automatic transmissions became widely available and her best friend began driving her own Ford.
I suspect the the responses by patients to the instruments like the Zuri fall into one of three broad classes:
Patients like Ms Shah who have the right problem, the right circumstance, and the right perspective to embrace and use the tool as is, right off the shelf.2
Patients who mistrust and are adamantly resistant to (choose one or more) electronics, doctors, healthcare recommendations, sharing personal information, …
Patients, like Aunt Hazel, who won’t use a medical tool like the Zuri until it is easier, cheaper, more well known, …
Group #1 is on board already. Group #2 is unlikely to buy into the process regardless of logic, persuasion, or receiving lottery tickets as incentives. But Aunt Hazel’s group? That’s where the action is. Make those electronic whizbangs less intimidating, less difficult, and less expensive.
Then, ask Aunt Hazel to try it out.
Footnotes
__________
The quotation marks enclosing self-care are the work of the WSJ folks, and, no, I don’t know the rationale for this punctuation practice.↩
It isn’t clear that if Ms Shah was charged for the Zuri’s use or if it is offered free while still in beta. An out of pocket cost of $240 to enhance compliance of a 3 week course of treatment might have rendered the Zuri less attractive to Ms Shah↩
Aetna-sponsored Clinical Trial Of Lottery As Incentive For Coumadin Therapy Adherence
This story has been kicking around for over a month, evoking a variety of responses from the lay press, healthcare-oriented blogs, bioethicists, and the occasional patient compliance junkie.
Apparently, I can’t resist getting in on the action.
The Clinical Trial
The Aetna Foundation is funding a University of Pennsylvania clinical trial to determine if chances to win a daily low-stakes lottery effectively promotes adherence among coumadin patients.
Patients have a one-in-five chance to win $10 a day as long as they’re taking the pill, and a one-in-100 chance of winning $100. People could win about $3 a day on average, or a total average of $540 over the life of the study.
A Med-eMonitor is used to calculate compliance. When patients open the box, a question on a screen asks whether they’re taking the medicine and they must press a button to indicate yes. That puts those who are eligible for the lottery into that day’s drawing. If they don’t press the button, they miss their shot at money for that day. Winners are notified each morning with a message sent back over the phone line.
Patients who do not report taking their medications are also notified if they would have won the cash but were ineligible because they did not follow their medication regimen.
The Responses
Many reports provided a straightforward account of the trial, but others have played up the cash incentive and the lottery/gambling angles. An example of the those focused on the money, by my subjective evaluation, is Bribe Me, Doc.3 The title notwithstanding, the reporting is reasonably balanced (several articles and, especially, posts attacked the use of cash incentives more aggressively on moral grounds), but the questioning of the compliance enhancement strategy being studied is reflected in these excerpts:4
The University of Pennsylvania study, funded by the Aetna Foundation, is part of a worldwide trend to use financial rewards to entice people to take care of themselves. From a Canadian quit-smoking initiative that tantalizes people with $3,000 gift cards to a British anti-drug effort that rewards rehabilitation with cash, it seems the prospect of good health – and in some cases, survival – is no match for money as an incentive.
Bioethicist Richard Ashcroft says the use of financial incentives potentially undermines personal responsibility. “Why are we rewarding people for doing something they should be doing anyway?” asks Ashcroft, who alongside leading British researchers is conducting a multi-year study on the economic, philosophical and psychological significance of health incentive programs. But if these initiatives lead to a positive outcome, Ashcroft says, they could be tolerated as a means to an end. “You know people will respond to an incentive like money more easily than they will respond to an argument based on reason,” he says. “It’s an uncomfortable truth … in the health field that people aren’t always rational in their decision-making.”
Commentary
A full discussion of compliance-enhancing incentives is beyond the scope of this post and has been addressed in this blog previously. Instead, I’ll offer some comments on pertinent issues that were not been covered in the 20 or so articles about this study I’ve read.
Several healthcare professionals raised similar points to that made by Richard Ashcroft, i.e., the use of cash incentives diminishes the personal responsibility of the patient.
My first and almost automatic response is that adherence to healthcare is not exclusively an individual’s personal issue. Noncompliance increases healthcare costs for all of us, one way or another, and unnecessarily uses the resources to the loss of all those individuals (that would be you and me) who may require healthcare services. Productivity is decreased when health problems of workers are not properly treated. Noncompliance may lead to lack of treatment or inadequate treatment of communicable diseases that consequently puts others at risk for the same disorder in the short term and for even more virulent or more difficult to treat forms of the disorder if inadequate treatment leads to the formation of resistant strains of the disease. If the consensus is that forced treatment or quarantine is necessary in some cases to protect the public, then it is difficult to condemn a less rigorous tactic if that is sufficient for public protection.5
On consideration, I’m not fully convinced of the premise that cash incentives necessarily destroy personal responsibility. To make that argument, it seems to me, one would also have to protest against penalties for noncompliance on the same grounds. E.g., fines for traffic violations are unethical because they diminish personal responsibility. Individuals should stop at red lights and adhere to speed limits because of internal motivators rather than external coercion. Of course, my reaction may be skewed by too many years on the parent-child battle line, efforts that long ago caused me to abandon the second half of the proposition “you [my son] must do the right thing and do it for the right reason.” A more pragmatic attitude toward motivation prevails on the home front these days.
I do enthusiastically agree with Richard Ashcroft’s observation that “in the health field that people aren’t always rational in their decision-making.” In fact, if I ever ascend to the role of Universal Emperor Of Healthcare, my first decree shall be to require all healthcare theorists to write that line 1,000 times on the chalkboard. Today, however, I will only add that there are few, if any, fields of personal functioning (e.g., caring for ones health, managing money, finding a career, falling in love, … ) in which decision-making is rational.
I find almost no discussion of the impact the lottery aspect of the incentive might have on the patient-doctor relationship. Is there, for example, any risk that the patient who forgot to take his pill for the first time last night, might, on receiving word that he would have won last night’s jackpot had he been compliant, be miffed at the doctor, who will inevitably be seen as representing the incentive system? Or if there is a snafu,6 are the folks whose legitimate winnings dissipate in a computer error going to blame the clinician? Who will be responsible for explaining this to the patient, re-establishing a working relationship, taking the time to fix the errors, etc?7
As long as incentives are being passed out to patients, how about providing parallel incentives to the responsible clinicians and any family or friends who take the role of care provider on an everyday basis so that all those involved in treatment are headed toward the same goal? Gee, what’s the word for that? Oh yeah, that would align the stakeholders.
In any case, by using the electronic monitoring device described, the researchers are actually testing if chances to win a daily low-stakes lottery effectively promotes the pressing of a “Yes, I took my medicine” button among coumadin patients. My hunch is that it will.
I will also repeat the recommendation I made in a previous post
[The] British Medical Journal includes a concise debate between two experts on this issue. While the point each makes are predictable and I suspect few readers will be swayed from their convictions held prior to perusing the article, the opposing perspectives, which are stated clearly and thoughtfully, are useful in considering the ethics and clinical pragmatics of this methodology.
Rather than rehearse the points of these two arguments, I instead suggest that viewers read the original debate by clicking on the link that follows to download the two-page PDF of the paired pro and con articles, provided by the BMJ without charge: ~Is it acceptable for people to be paid to adhere to medication?~
__________
Consider the Medication Blister Pack Lottery Ticket AlignMap’s contribution to pharmaceutical packaging↩
The Courant story, the primary source of this information for most of the blogged and printed reports, is no longer available via live link. I accessed it through the Google cache at Courant Page 1 and Courant Page 2.↩
It should be noted that those involved in the Aetna funded University of Pennsylvania study also recognize the ethical issues involved. Their stance holds that if the incentives prove successful in enhancing compliance, the moral and ethical points should be debated after the study is complete.↩
Some of the argument I make in this paragraph may be implicitly included under “public health” references made in some articles.↩
Oh my, I just flashed on the concept of the healthcare system as I know it taking on the management of a lottery system. What could possibly go wrong?↩
For what it’s worth, classic contingency management, a behavioral system with much supportive evidence, would provide each patient with $X in his account on day one and remove a fraction of that every day the patient was noncompliant. Regardless of how effective the scheme might prove in improving compliance, I cannot imagine approaching, say, my borderline patients, at every session to announce that their compliance last week had cost them $29. It would not be a pretty sight.↩
Patient Compliance Enhancement System Wins Columbia Business School Outrageous Business Plan Competition
According to With This Plan, Everyone Wins, a system for packaging a patient’s medication by dosing schedule (e.g., instead of dispensing a month’s supply of the patient’s five different medications each in its own bottle, the pharmacist would repackage the medications into that patient’s prescribed doses – 1 tablet each of medications A, B, and C on awakening, 2 tablets of medication D with breakfast, lunch, and dinner, and 1 tablet of medication E at bedtime) was adjudged the best entry in the Ninth Annual Outrageous Business Plan Competition,1 an honor accompanied by a $4,575 award.
The referenced post goes on to note that
Prescription noncompliance costs billions in healthcare dollars and thousands of lives each year. Geoffrey Reed ’09 saw the problem first-hand last summer when his grandfather mixed up his medications and ended up in the hospital. Now Reed and Eric Chesin ’09 have come up with a way for pharmacies to organize medications that increases the chance of compliance. The idea, Bluepak, recently won CBS’s 2008 Outrageous Business Plan Competition; their elevator pitch is below.
Commentary
As was the case with the MIT Yunus Challenge award,2 it is heartening to find patient compliance recognized as a problem worthy of the efforts of student competitors at these elite universities.
And, I think the idea is reasonable and and worthy of a trial. I am, however less certain a medication repackaging scheme warrants the “outrageous” tag.3 Hospitals have used this strategy for years, and some pharmacists have long provided the service for some patients. Heck, I’ve suggested this idea myself without one person in the audience retorting “That’s outrageous.”
More to the point, Bluepak appears similar to onePAC, a service featured recently on this blog,4 and the questions I asked about onePac (see previous posts) would apply to Bluepak. 5
Happily, being outrageous or even original, is not a prerequisite for a clinical valid, commercially viable program to enhance medication compliance. Those of us with vested interests in treatment adherence will be interested to see how Bluepak, onePAC, and similar ideas fare in the real world.
Footnotes
__________
From the Columbia Business School press release: To enter the competition, teams comprised of at least one Columbia MBA or EMBA student, submit an executive summary of their business plan and tape a two-minute elevator pitch. A panel of judges, comprised of executives from venture capital firms as well as several entrepreneurs who developed their own successful ventures while students at Columbia Business School, evaluated the pitches and narrowed the field down to five teams. In the final round of competition, each team delivered a formal 10 minute presentation to the judges and the audience. Based on these presentations, the judges decided how much money they would award each venture.↩
According to the previously noted Columbia Business School press release, “The competition, organized by the Columbia Entrepreneurs Organization and the Entrepreneurship Program, encourages students to develop and present creative entrepreneurial ideas that are sufficiently ambitious in scope and scale to be considered “outrageous.”↩
Patients will be scored on how closely they follow their doctor’s orders in taking their prescribed medications, in a move designed to lift adherence rates and improve outcomes for people with chronic conditions.
The article goes on to point out,
The scores will be expressed as a “mark” out of 100, and will be colour-coded to indicate increasing levels of concern as scores get lower. Pharmacists will be encouraged to help patients whose scores are slipping into the red, by packing multiple medicines into blister packs that make it easier to see which drugs are due to be swallowed at particular times. For more difficult cases, patients may be asked to see their GP for a home medication review, which is designed to simplify a patient’s drug regimen.
However, the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores. (Emphasis mine)
The basic mechanisms of the plan are outlined in these excerpts:
The new scheme will work by comparing the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times.
The MedsIndex scheme has been devised by the Pharmacy Guild, which has already run it as a successful four-month pilot, mainly in Victoria and Queensland.
Pharmacy Guild president Kos Sclavos said research showed patients’ adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take. Among patients taking one pill per day, compliance was about 80 per cent, but fell to 72 per cent for those taking two pills — and to just 64 per cent among patients taking three pills every day. Sclavos said even an 80 per cent compliance raised concerns, as “drug manufacturers don’t confirm their drugs remain efficacious if you are missing one dose in five”. A score of 90 out of 100 suggested room for improvement, but Sclavos said the Guild would ask pharmacists to consider packing medicines in labelled blister packs for patients with scores below 80. “If it’s 75 or lower, they should be seeing their doctor about a home medicine review,” he said. Sclavos said the 200 patients involved in the pilot — which was run merely to ensure the IT systems worked properly — became obsessed by their scores and did not want to come off the scheme. “We’ve had patients coming back saying ‘Please measure me again’ — that’s how enthusiastic patients have been,” Sclavos said. Aaron D’Souza, a pharmacist in Brisbane’s CBD, helped devise and trial the scheme and described its reception by patients as “absolutely fantastic.” “A typical response (to a low score) is ‘Really? I knew I missed some medicines sometimes, but not that much’,” D’Souza said.
Commentary
I am wholeheartedly in favor of compliance with prescribed healthcare measures, including medications, being monitored – in theory. Simply put, noncompliance will not be recognized, let alone be rectified, unless ongoing, routine monitoring is in in place.
Heck, I think it is even possible that compliance monitoring can be accomplished in practice if sufficient care and planning is invested in the effort.
I do, however, have qualms about the proposal written up in The Australian.
First among them is the notion that “the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores.” I’m fully willing to believe that this statement reflects the intent of those responsible for the program.
It does not require much effort, on the other hand, to imagine scenarios in which certain parties would face temptations to change or illicitly abuse this principle.
Not being familiar with systems of Australian healthcare payment or the medico-legal system, I’ll give an example or two based on how the American healthcare system operates.
As healthcare expenses increase, somebody in the government, the insurance industry, or a payer (e.g., an employer) is going to have the epiphany that patients who don’t adhere to prescribed medication dosing cost more than those who do. Clearly it would be not only a cost-saving but also justifiable to reduce the benefits or increase the personal fees paid by this group, members of whom could be identified by an adjustment in the system.
Somewhere else, a lawyer defending a physician accused of malpractice will seek judicial leave to present the patient’s compliance score of 45 as evidence that the treatment failed because of poor adherence rather than the doctor’s error.
And, those justifications may indeed be legitimate. My point is only that there will be pressure to use these scores in ways not currently intended. And once recorded, this compliance rating will be vulnerable to the intrusions of politicians, lawyers, healthcare officials, and others.
My other area of concern is that this important change is predicated on a four month study of 200 patients – “which was run merely to ensure the IT systems worked properly” – and research that “showed patients’ adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take.”
While studies tend to show that decreased compliance is coupled with an increased number of doses per day, that research is not unanimous. Nor are the remedies listed, blister packs of medication and simplified drug regimens, both of which are reasonable responses and which are beneficial to some
patients, panaceas for all nonadherence. And, since most physicians try to minimize dosing for all patients, it is difficult to see how that measure will have a dramatic effect.
The enthusiasm demonstrated by some of those 200 patients notwithstanding, one wonders if the novelty of this program may not wilt after a few months with a corresponding decrease in interest by patients and clinicians.
There are other imperfections as well. The compliance formula, which “compar[es] the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times” has several built-in potential flaws, the most significant of which is perhaps that picking up ones prescriptions at the correct times is not synonymous with taking the medications as prescribed. In the US, it is not unusual for a patient to semi-surreptitiously obtain medications from other countries to reduce costs. Doing so would, I assume, bypass the monitoring system.
Perhaps the point of this jeremiad disguised as a post is that monitoring the compliance of all patients in a practice, an insurance group, or a country offers great opportunity to improve healthcare – but not if it addresses only one area of noncompliance with one set of responses, especially since it puts those those patients at some risk of their compliance records being used to make their healthcare more expensive or less accessible.
I received these responses on 26 March 2008 from Nanette Kirsch, Senior Director, Marketing Communication, Parata Systems, LLC
Q: If all of a patient’s prescriptions are processed and sold in 30-90 day bundles, how are changes in that patient’s medication regimen handled, both logistically and financially? A: That is being managed at the pharmacy level, although we expect to create a process specific to that issue in the near future.
Q: Is there research demonstrating that this type of packaging increases compliance? A: Not that we have conducted yet. But we anticipate collecting such data as we advance into the market and will keep you in the loop on those outcomes.
For example, that I’m not familiar with a healthcare equivalent of Get Out the Vote: How To Increase Voter Turnout by Donald Green and Alan Gerber, the how-to handbook based on well designed research utilizing control groups 
