Is disruptive health technology misbehaving?

Artificial intelligence, robotics, and nano-devices, among other rapidly expanding technologies have an overwhelming potential to shape many aspects of our not too distance future, not least our medical care.

With somewhat ease, we can now visualize a future with automated referrals, prescribing, monitoring and discharge – streamlining and synchronizing the care we receive.

However, it will be critical that such advances do not undermine what behavioural science and psychology have cemented over the last half century: that, contrary to standard economic theories, humans are not always rational. How we make decisions, such as whether to take a medicine, are complex and multi-factorial.

Consultations can often be key to ensure the optimal decision is reached. However, with automated services such as robotic drug dispensing, such human-human interactions will be lost.

Devices do not always have to be ‘unhuman’ though; many have been designed to be behaviourally smart. Such devices consider the irrational facets and individual complexities in human behaviour to improve outcomes and help people make better decisions for healthier, happier lives.

With the expanding accessibility of big data there is also a new opportunity to take advantage of, as quantitative behavioural insights and analysis can facilitate increasingly tailored and personalized support through medical devices.

Incorporating an understanding of human behaviour into artificial intelligence and other innovative medical devices will be vital in future healthcare, but done correctly could offer great potential to improve health outcomes.

Pharmacy – it’s an open-door policy for patients

Pharmacists and medicines go hand in hand, so it’s no surprise that assisting patients with medicines is what pharm-assist are best at.

The thing with medicines is that despite how good they are, they work most effectively only when they are taken as prescribed. The act of ‘not taking medication as prescribed’ is known as non-adherence, a straight forward term for behaviour that emanates from a complex set of beliefs. The resulting behaviours are not conducive to optimising outcomes for patients’ health.

There are many perceptual and practical factors that influence the patient’s motivation and ability to adhere to agreed treatments(1), and it’s estimated that non-adherence is somewhere between 30-50%(2). This in turn results in poor health outcomes for the patient, but also it becomes costly for the NHS in terms of the medicines wasted (an estimated £110 million worth of medicines are returned to pharmacies annually)(3) and the burden this creates for the healthcare system to keep on offering alternatives.

Non-adherence is not just a problem for developed countries, but places a burden on medicines outcomes globally; there are the same perceptual and practical concerns for developing countries(4,5). Regardless of location, once patients gain access to medicines trade-off between necessity (needing the medicines) versus the concerns (e.g. about potential long-term side-effects) come into play. This underpins a common need for healthcare systems, of all sizes and resource levels, to adopt ways to improve adherence.

What’s the solution?

The good news is, there are many ways to help patients remain adherent to their medicines and the role for pharmacists in supporting patients can be pivotal. There is an increasing call for medicines information to be embedded in the community and not just confined to a clinician’s room. Pharmacies can provide an ideal environment for patients to have an informal conversation about their medicines without the time pressures that are often associated with appointments with clinicians.

There is huge choice and flexibility for patients, with over 11,500 pharmacies in England(6) hence the potential impact of channelling adherence programmes through pharmacies can make a real difference to non-adherence rates. Internationally, organisation such as the Commonwealth Pharmacy Association are also working to increase access to pharmacy expertise in resource-scarce settings. Moreover, what’s needed by pharmacists to support behaviour changes are not complex or expensive.

Pharmacists can hold more than just the keys to the medicines cabinet, they are experts in medicines and their vital role in the community allows them to advise and support patients in making the most of their medicines.
1. Clifford S, Barber N, Horne R. Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: application of the Necessity-Concerns Framework. J Psychosom Res. 2008 Jan;64(1):41–6.

2. NICE Clinical Guidance 76: Medicines adherence: involving patients in decisions about prescribed medicines and supporting-adherence; 2009 Jan.

3. Pharmaceutical waste reduction in the NHS: A best practice compilation paper; 2015 June

4. Oqua D, Agu KA, Isah MA, Onoh OU, Iyaji PG, Wutoh AK, et al. Improving pharmacy practice through public health programs: experience from Global HIV/AIDS initiative Nigeria project. SpringerPlus. 2013;2:525.

5. Khanam MA, Lindeboom W, Koehlmoos TLP, Alam DS, Niessen L, Milton AH. Hypertension: adherence to treatment in rural Bangladesh–findings from a population-based study. Glob Health Action. 2014;7:25028.

6. General Pharmaceutical Services in England: 2006/07 to 2015/16; 2016 November

The lost and forgotten – Are some groups of people continually excluded from research?

It is well-recognised that certain sectors of society are repeatedly underrepresented in research studies. Ethical guidelines for the inclusion of children, women and the cognitively impaired in research exist, but researchers tend to bias recruitment towards ‘normal’ people, applying the ‘one-size fits all’ approach to results and missing important physiological and psychological insights that could be gained from including a diverse group of individuals.

We should ask ourselves why certain groups, such as the elderly, ethnic minorities and people with a history of mental health, hearing impairment or complex comorbidities, are excluded in research: is the exclusion scientifically justified by the study (i.e. the evidence collected from the study can be generalised to all patients), or are they excluded because of the difficulty in managing vulnerable groups and the trouble and budget/ time constraints of going through research ethics committees’ applications? Although current ethical guidelines require a justification of both inclusion and exclusion groups, a recent review of trials on secondary prevention of cardiovascular disease found only one of 113 studies justified their exclusion criteria1.

Exclusion might, in some cases, be decided by the participant. For example, parents might not be comfortable with their children taking part in research, women of childbearing age might prefer to keep away from clinical trials and ethnic minorities might be reluctant to participate unless engaged through community support. In other cases, the inclusion criteria of the studies might be too restrictive. For example, a recent study found that depressed individuals included in antidepressant efficacy trials did not reflect the typical patient treated in clinical practice and 82% of depressed patients would have been excluded by the enrolment criteria2.

Excluding these groups from research comes with a range of implications: lack of sample diversity to be able to understand how the illness and treatment works, lack of information about the effectiveness of treatments across all members of society, and the potential danger of generalising the findings to those excluded groups which, in turn, might not even have access to treatment.

This has strong implications for adherence interventions and many ‘real world’ interventions may fail because we know that people who are the most ‘non-adherent’ might not partake in research. For example, a depressed patient has 1.76 times the odds of being non-adherent than a non-depressed patient3. Similarly, the most non-adherent groups to self-administered treatment for tuberculosis are prisoners, vulnerable migrants, homeless/people on temporary housing and people misusing alcohol or other substances4. It is likely that all these groups would be misrepresented (deliberately or not) in evidence-based adherence strategies.

Exclusion of patients from the developing world is another problem. For example, the difficulty of maintaining adherence rates to HIV medication in developed countries is well-documented5 but HIV-infected patients with the greatest adherence issues in those countries are repeatedly excluded from adherence intervention research even though this vulnerable group would benefit the most from these interventions6.

1 Schmidt, AF. et al. (2014). Justification of exclusion criteria was underreported in a review of cardiovascular trials. Journal of Clinical Epidemiology, 67(6):635-644.

2 Preskorn, SH, et al. (2015). How commonly used inclusion and exclusion criteria in antidepressant registration trials affect study enrollment. J Psychiatr Pract. 21(4):267-74.
3 Grenard, JL, et al. (2011). Depression and Medication Adherence in the Treatment of Chronic Diseases in the United States: A Meta-Analysis. Journal of General Internal Medicine, 26(10):1175-1182.
4 NICE. Tuberculosis in vulnerable groups. Local Government briefing [LGB11]. September 2013. 5 Bonolo PF, et al. (2008). Vulnerability and non-adherence to antiretroviral therapy among HIV patients Minas Gerais State, Brazil. Cad Saude Publica. 24:2603-2613.
6 Enriquez, M & McKinsey, DS (2011). Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level. HIV/AIDS. 3:45–51.