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Successful management of long-term conditions requires patients to commit to lifestyle changes and may require the prolonged use of medication. Although a patient will spend more than 8000 h/year self-managing their disease, only a small proportion of this time is spent interacting directly with their healthcare team. Prescribing medications and making lifestyle recommendations are fundamental to disease management, but optimising patients’ adherence to medication and supporting lifestyle changes are key challenges. Indeed, it is estimated that half of the people with chronic conditions do not take their medication as instructed.1
Patient behaviour is one of the primary barriers in achieving optimal treatment outcomes, including adherence,2 ,3 and is fundamentally driven by beliefs relating to health, illness and treatment.4 These psychological barriers—combined with a multitude of practical barriers—influence their ability, capacity, resources and motivation to start and continue treatment.2 To overcome these barriers, healthcare professionals (HCPs) need to rigorously and systematically apply their understanding of behavioural medicine. Technological advances combined with an improved understanding of behaviour patterns offer a unique opportunity to re-evaluate how to address these beliefs and provide better support to patients.1
Following a consultation, patients are routinely left to self-manage their condition on a day-to-day basis. However, future healthcare paradigms must augment the consultation with key elements such as interactivity, feedback and sustained personalised support. The internet, smartphones and tablet computers offer opportunities to collect and share data and provide a huge potential to engage with patients at their convenience. Pharmaceutical companies, healthcare providers, healthcare entrepreneurs and technology companies have recognised this potential and are exploring new ways to support patients in going ‘beyond the pill’. Aspects of healthcare being targeted include medicines adherence, behavioural support (eg, exercise programmes, smoking cessation), education, symptom monitoring and patient engagement.
Some of the more innovative approaches use a combination of digital platforms, including smartphone or tablet applications (‘apps’), web portals and integrated device technologies. Linking real-time personal clinical data via wearable technology to the patient's HCP provides further possibilities to enhance patient support. Digital support packages are starting to provide individuals with fully tailored care plans that encompass both clinical and psychological support. Motivational and behavioural change techniques (eg, cognitive–behavioural therapy, motivational interviewing, adaptive psycholinguistics) are now integrated within some digital interventions to promote positive health behaviours.5 However, it is essential to identify those factors that drive long-term interest in these support packages. For example, some programmes have applied ‘gamification’ to include an element of challenge and incentive.6 Other strategies include providing reward schemes or encouraging loyalty through integration with social networks.7
Programmes such as these have the potential to provide HCPs with longitudinal insights into disease and behaviour, which cannot be gained from periodic consultations. Some systems also permit two-way information exchange between the patient and their HCP, which triggers additional support when symptom control is suboptimal or provides real-time responses to questions or concerns. Several initiatives with this objective have already been launched or are in development, including programmes for diabetes,8 HIV/AIDS,9 asthma10 ,11 and chronic obstructive pulmonary disease (COPD).12
The benefits of two-way feedback between patients and HCPs were demonstrated in a randomised controlled study in which patients with COPD received alerts on their smartphone when environmental conditions were such that they were at higher risk of exacerbations.12 Patients used smartphones to complete a daily symptom questionnaire, and if their symptoms suggested that they were experiencing an exacerbation they were contacted by an HCP, thereby permitting prompt intervention and providing a sense of ‘being watched over’.12 Both the use of environmental forecasts and the symptom monitoring appeared to reduce the frequency of exacerbations.12 A similar approach is available for people with asthma: the ‘MyAsthma’ app combines an information library, weather and pollen warnings, and personalised reminders.10 The app also includes a daily test that patients can use to assess and record their condition with the option to compile a report for use in consultations with their doctor. Another approach currently being investigated in patients with COPD is the ‘Me&My COPD’ program (NCT02300090). This comprises a smartphone app, a web portal and a Bluetooth-enabled relief-medication inhaler to actively monitor worsening disease control, thus helping patients to manage any changes in their condition.
Development of these patient-support products requires collaboration between multiple organisations and individuals. The expertise of primary HCPs is essential to identifying unmet needs and understanding how such support can optimise existing care pathways and target interventions, and ensuring that the data generated are useful for the management of patients. HCPs are also in a position to reassure patients about the security, probity and accuracy of any support provided. In the development of these tools, behavioural medicine specialists are necessary for their understanding of patient psychology and how to effectively target interventions to enhance health outcomes and adherence. Pharmaceutical companies and technology experts, including product designers and computer scientists, are involved in the creation of the product's infrastructure, design and marketing, and in the application and maintenance of novel devices. One example of such a collaboration is ‘mySugr’,13 an app-based product for patients with diabetes that has been developed and backed by a network of technical, marketing and medical experts, investors, pharmaceutical companies and healthcare innovators. Other relevant parties include patient organisations, payers, regulatory bodies and groups that generate clinical guidance.14 Achieving this ‘virtuous network’ of stakeholders is essential to maximise health outcomes.
Despite the rapid progress in innovative digital strategies, challenges remain. One corollary of the rapid pace of technological advance is that the appropriate level of regulatory oversight is not yet clear. One possibility is that these challenges can be addressed through a further evolution of the novel adaptive licensing strategies currently being trialled in Alzheimer's disease and breast cancer.14 ,15 Another question concerns who should pay for these technologies. If successful, these tools will result in better outcomes for patients, and the resulting reduction in healthcare burden provides clear incentives for healthcare providers and, of note, supports an argument for reimbursement of costs in the same manner as prescribed medicines. However, the development and implementation of new technologies requires advance funding. Increasingly, regulatory agencies and healthcare systems require companies to demonstrate real-world improvements in health outcomes provided by new medicines. This transition means that the pharmaceutical industry must evolve to become more than a provider of medicines. These new digital tools can meet this need by contributing to real-world evidence on health status, disease progression, outcomes, patient behaviour, and medicine use and adherence, thereby providing an incentive to pharmaceutical companies and other healthcare entrepreneurs to fund the development of these new tools.
Going ‘beyond the pill’ provides a holistic support package to patients and enables clinicians to monitor the progress of treatment and adherence to the prescribed therapy. Ultimately, these new approaches aim to combine evidence-based medicine, behavioural science and novel device technology to transform treatment outcomes in chronic disease.
Funding Medical writing support was provided by David Finch of Complete Medical Communications, funded by AstraZeneca PLC. AstraZeneca was given the opportunity to review the manuscript to ensure scientific and medical accuracy, regulatory compliance and protection of intellectual property.
Competing interests DH has received sponsorship to attend international meetings and honoraria for lecturing, attending advisory boards and preparing educational materials from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Pfizer. His department has received research funding from AstraZeneca. He is a member of the GOLD Board of Directors & Science Committee. LB is a full-time employee of AstraZeneca. AM was a full-time employee and shareholder in Spoonful of Sugar, a UCL Business company at the time this manuscript was developed. Andrew has previously worked, or is currently working, as a consultant for the following pharmaceutical companies: Pfizer, AstraZeneca, Merck Serono, GlaxoSmithKline, Merck Sharpe & Dohme, Roche, Shire and Otsuka.
Provenance and peer review Commissioned; internally peer reviewed.
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