A new spin on improving adherence

Non-adherence to treatment is an epidemic in medicine. Non-adherence to prescription medications results in healthcare-related costs of 100-290 billion USD yearly (1). More frightening are the 125,000 estimated deaths due to non-adherence annually (2). Both physicians and insurers have vested interests in improving adherence to improve clinical outcomes and decrease healthcare expenditure. While non-adherence is rampant in all medical specialties, dermatology faces unique challenges given its multiple treatments modalities (i.e., topical, oral, injection, phototherapy), which can be challenging to administer, inconvenient, and time-consuming (3). Many specialties, including dermatology, are eager to find ways to improve adherence; specific areas of interest are in adapting concepts related to behavioral economics and gamification. Innovation in the fitness industry provides a lens through which we can study adherence and an application of these concepts.

Peloton®, a New York-based exercise equipment and media company founded in 2012, has taken the fitness market by storm with its crown-jewel product: a stationary bike (4). Indeed, the stationary bike which is often relegated to the basement to collect dust is now arguably the hottest product in a saturated fitness equipment market. Riding on this successful model, Peloton® has expanded to the treadmill market. The explanation for this phenomenon is straightforward: Peloton® has integrated its exercise equipment into the very fabric of modern society – social networks. With a WiFi-connected 22-inch touchscreen display mounted in front of the stationary bike, Peloton® users can stream live and on-demand classes to compete with other cyclists from around the world in rigorous workouts led by world-class instructors. To put this craze in perspective, the single-most joined class had over 11,000 users (4). On the surface, the Peloton® model is simplistic. However, under greater scrutiny, one will recognize several important concepts lending to the cult-like adherence to this exercise modality: gamification, conformism, and convenience, all of which underlie principles of behavioral economics.

Gamification refers to the concept of applying game playing features (e.g., points, competition) to other domains to promote engagement. Companies have adopted gamification to promote initiation and retention of desired behaviors (including adherence), and this industry is valued at over 5.5 billion USD (5,6). Peloton® utilizes gamification through interactive leader boards (score based on pedaling speed and resistance) within its live cycling class. A randomized controlled trial compared intrinsic motivation and physical activity adherence in 36 patients with type 2 diabetes mellitus assigned to an experimental group (smartphone app with gamification concepts to promote exercise) to control over 24 weeks. The experimental group had higher intrinsic motivation (p < .05) and physical activity score (p < .05). Intrinsic motivation was associated with increased use of the app (p < .05) (5). Review of Apple App Store applications reveals over 132 health and fitness apps utilizing concepts of gamification, reflecting interest from the public in this concept. Apps with more gamification elements had higher motivation and game scores (6). To some extent, the mental barrier of delayed gratification for physique and fitness improvements can be taxing. Peloton® provides a means to more immediate gratification, shifting the goal of exercise to competing and improving score from session to session.

Conformism refers to habitually adopting the customs, rules, or styles of a group. Humans are social beings – we long inclusion, acceptance, and cooperation. When channeled positively, social pressures can be beneficial. Social constructs such as friendship not only allow pediatric patients to cope with their diagnoses but may also promote adherence (7). Especially in teenagers, telling an acne patient that the treatment they have been prescribed is what all the others at school are using to control their acne is a powerful motivator (8). Peloton® classes make use of these concepts of inclusion by motivating users through shout-outs and virtual high-fives to want to join classes and cycle with peers and friends while engaging in friendly competition.

Finally, the convenience associated with Peloton® use cannot be overstated. For many, exercise entails a cumbersome process involving commuting to and from the gym and waiting for machines/equipment to become available. Peloton® dispels many of these concerns through on-demand, at-home classes. Similarly, the medical literature supports simplicity in promoting adherence (9). A randomized controlled trial of 21 patients with mild-to-moderate acne vulgaris compared adherence to once-daily application of clindamycin phosphate 7.2%-tretinoin 0.025% gel to separate daily applications of clindamycin phosphate 1% gel and tretinoin 0.025% cream. The combination medication treatment group had higher median adherence over 12 weeks compared to the dual-product group (88% versus 61%; p<.05). Outcomes were also improved: the combination application group had a 51% reduction in acne lesions compared to a 32% reduction in the dual-product group (10).

Medicine and the fitness industry are continually exploring ways to promote the complex issue of adherence. However, it is important to appreciate the fundamental concepts governing human actions, which can often be simplified to basic behavioral economics. Utilizing gamification, simplifying regimens, helping patients to see short-term results, and framing treatments as part of a societal norm for their condition may all aid in improving adherence. By using Peloton® as a framework, we can put a new spin on the age-old problem of treatment adherence.

Disclosure statement

Dr. Feldman has received research, speaking and/or consulting support from a variety of companies including Galderma, GSK/Stiefel, Almirall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant, Abbvie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate and National Psoriasis Foundation. He is founder and majority owner of www.DrScore.com and founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment. Mr. Ramachandran and Mr. Bashyam have no conflicts to disclose.