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Current Methods of Improving Adherence Do Not Work

Behavior, including adherence behavior, are the keys to improving outcome in a variety of diseases. We must rethink our adherence strategy by using Intelligent Engagement to control the plecosystem of adherence technologies.
Some Background
It is important that any solution becomes so easy to use that it ties into System 1 or “fast brain” thinking. As a quick review, System 1 Thinking is efficient, requires little active thought process, is automatic, rapid, contextualized, intuitive, independent of working memory; and basically a series of habits or reflexes. This is important because it is estimated that over 95% of our actions do not involve the conscious reasoning or System 2 Thinking. System 2 Thinking (slow brain) is slow, controlled, requires high effort, is rule based, logical; but is not used much by humans for day-to-day activity as it just takes too much energy and concentration.
As stated earlier, no single technology will suffice. Probably every reader of this series has been approached by dozens or even hundreds of companies suggesting that their innovation, their device, their program or their approach will forever solve the problem of too many sick patients using too many resources and requiring ever more expensive medical care.  But all of the “solutions” up until now have been lacking- until now.
A new technology, the Virtual Health Assistant combined with a variety of wearables, adherence devices and data-bases hopes to change all of this!  But, I get ahead of my self…
Thousands of health behavior studies dating back more than a lifetime have lead to more than 50 theories and models on health behavioral change. These models and theories have guided the actions of hundreds of thousands of physicians, nurses and health educators attempting to promote wellness and improve disease management. In her textbook, Health Behavior and Health Education, Theory, Research and Practice Karen Glanz, a professor at Emory University lists the five most cited health behavior theories: Social Cognitive Theory, the Trans-Theoretical/Stages of Change Model (Prochasta), Health Belief Model, the Social Support Model and Social Networks Model.
These as well as dozens of other less recognized theories have been proven in small clinical trials to improve health behavior in humans. But, putting these theories into practice has been a challenge. A recent systemic review by authored by Nieuwlaat  et. al, Interventions for Enhancing Medication Adherence concluded: “Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective… the full benefits of treatment cannot be realized.”
The basic approach at health plans and integrated systems is to use a call center approach or face-to-face appointments along with email and text messaging. Physicians use face-to-face visits. But, human-to-human interaction efforts are very resource intense. So in real world settings, the behavioral health theories and models can be effective but face scalability and cost barriers.
The Annals of Internal Medicine in 2012 published a study funded by AHRQ authored by Meera Viswanathan, PhD, et al; Interventions to Improve Adherence to Self-administered Medications in Chronic Disease in the United States. In this study, the authors found 4,124 citations concerning the concept of “improving adherence” in published, searchable medical literature. Of course, one of the conclusions was that the out-of-pocket cost influenced adherence.  But, in addition their conclusion stated: “…case management, and patient education with behavioral support all improved medication adherence,” but …“evidence is limited on whether these approaches are broadly applicable…”
These conclusions are demonstrated tangibly by the dramatic increase in obesity along with the almost unimaginable rise in the incidence and prevalence of diabetes and prediabetes. Given the facts, how can anyone conclude that a healthcare-provider-focused approach to adherence, ie lifestyle, diet and exercise, over a lifetime is not futile? Our healthcare delivery system is poorly equipped to “educate,” and “case manage a population at scale."
But, technology can, and it will aid in not only these aspects of care, but also in many others.
The second article in this series will focus on the general classes of technologies being developed and deployed for improving health behavior.

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