In July 2013, the Oncology Nursing Society (ONS) held its annual Leadership Weekend. Each year, the organization collects information about oncology nurses, their interests, and their needs. This year, they asked about their membership’s experiences helping patients manage adherence to oral therapies and about their interest in non-CNE training on the topic. The results of the survey, completed by 127 nurses, show that:
• Oncology nurses are experiencing patient non-adherence to oral therapies
• Oncology nurses want and need specific clinical practice assistance to help improve adherence
• Oncology nurses want and will attend educational programs on adherence to oral therapies.
Some findings of interest and importance:
Most Nurses Observe Problems with Adherence
There is evidence that most nurses are observing problems with adherence. Forty-one respondents (32%) said that 25%–50% of their patients have trouble, and another 26 (20%) said that 51%–75% of their patients do. In other words, more than half the respondents said that at least 25% of their patients do not adhere properly to their regimens.
Nurses Highlight Most Common Barriers to Adherence
The nurses ranked various potential causes of non-adherence by their importance to their patients. Cost was viewed as very important by 73 (57%) and important by 31 (24%). Thus, of the 127 total respondents, 104 find that cost, including reimbursement issues and high copays, is a significant barrier to adherence to oral therapies.
Another barrier appears to be side-effect management. Fifty-nine percent said this is an important problem (45 [35%]) or very important (31 [24%]). Cognitive difficulties following instructions are another potential barrier, but perhaps less significant. Although forty-eight (38%) ranked cognitive difficulties as 3 on a 1-5 scale, or of modest importance, another 51 (40%) viewed cognitive difficulties as important or very important in interfering with adherence to oral therapies. Difficulty swallowing seemed to be the least significant barrier, with 55 (43%) suggesting that it was not important or of minimal importance. Twenty-eight (22%) said it was mildly important, and 41 said it was important or very important. Thus, although most of the nurses did not view swallowing difficulty as a critical barrier, it does affect a fair number of patients.
What Do Nurses Need to Help Manage Adherence?
The participating nurses were offered a number of options for possible practical tools or specific aid. They are listed below in order of popularity with the respondents.
• Co-pay and reimbursement assistance was the most positively received form of help with adherence to oral therapies. Here, 119 (94%) of the respondents said they would find the help useful or very useful (70%).
• Side-effect management guides/tear sheets were seen as useful or very useful by another 116 nurses (91%).
• Patient journals/calendars were seen to be useful or very useful by 103 (81%) of the respondents.
• Online resources for both nurses and patients were very positively received, with 100 (79%) respondents viewing them as useful or very useful.
• Patient refrigerator magnets with significant information were also popular, with 72 (57%) indicating they would be useful or very useful.
• Telephone or email follow-up services by drug company or pharmacy were viewed as useful or very useful by 73 nurses (58%).
• Tablet or smartphone apps might be an emerging area of opportunity for drug companies or pharmacies. Fifty-seven (45%) thought they would be useful or very useful.
It’s interesting that the current outreach efforts by pharmaceutical companies and pharmacies rank only one percentage point higher than refrigerator magnets. They’re both 20th century technologies.
What’s also important is that the research differentiated between “online resources” and apps. While both are 21st century technologies, “online” is the substrate -- apps are the wave of the present.
Apps remind, cajole, educate, praise, incentivize, and assist patients in their quest for better health. Apps are at the nexus of safe use, treatment outcomes, and patient satisfaction. And it’s not science fiction.
At present, there are some 17,828 healthcare and fitness apps and 14,558 that can be deemed “medical.” While some are better than others, these numbers tell us one thing – this is not a fad or a trend. It is reality.
I have been working with the Mobile Health Library to help develop their safe use and outcomes support platform. It’s delivered as an app (viable on all tablet and smart phone systems) specifically to address many of the issues called out specifically by the ONS study – facilitating co-pay cards, patient diary functionality, side-effect management, direct physician office communications (via phone, e-mail, and text) and, perhaps most importantly, providing educational services via app-enabled printed materials, website links, and video).
Will our socio-economic “technology gap” lead to a more pronounced “adherence/compliance gap?” It’s an important question. That’s why it’s crucial we remember there is no one-size-fits all solution. But that mustn’t mean we disregard the reality of the growth and pervasiveness of apps, mobile apps. Let’s face it, when it comes to mobile phones, any gap is rather narrow – and it’s getting narrower all the time, literally every day.
The ONS research refers to apps as an “emerging opportunity.” And that’s true. But maybe a better way to phrase it is as an “emergent opportunity.”
Apps are here now. People are using them – more every day, and that includes healthcare providers, patients, and care-givers.
And as Philip K. Dick wrote, “Reality is that which, when you stop believing in it, doesn’t go away.”
