The need for (cost)-effective interventions to enhance adherence with osteoporosis medications

Keywords::

• Adherence
• Cost-effectiveness
• Intervention
• Osteoporosis

Non-adherence to medication is a major problem among patients with osteoporosis, affecting considerably the effectiveness and cost-effectiveness of drug therapy. Several studies have shown that ∼50% of patients who were prescribed anti-osteoporotic medications have discontinued their medications within 1 year1,2. Poor adherence results in ineffective use of medication, with occurrence of fractures that could have been avoided3 and, therefore, presents a clinical and economic challenge. Modeling studies have suggested that the clinical benefits of oral bisphosphonate treatments are 40–60% lower than expected when real-world adherence rates are used rather than assuming full adherence4–7, and the incremental cost-effectiveness ratio of anti-osteoporosis medications could up to double when incorporating real-world adherence levels6,7. High levels of adherence are, thus, required to make anti-osteoporosis medications cost-effective7. Strategies which aim to improve and achieve high levels of adherence (≥80%) are, therefore, urgently needed3.

In this issue of Current Medical Research & Opinion, Nogues et al.8 investigated, along an open study, the effectiveness of a telephone-based educational support program developed to assist patients with severe osteoporosis starting daily subcutaneous injection of teriparatide. Persistence data were particularly high (especially for daily drug treatment) as well as satisfaction with the program. These results were in line with similar programs for teriparatide conducted in France and the UK9,10. However, when broadening this issue of adherence to osteoporosis drugs to all available studies, the efficacy of patient education is much more controversial. In a recent systematic review of published adherence-enhancing interventions until July 201211, only five of the 11 trials that addressed a patient education program in osteoporosis reported significant effects. In addition, a recent large-scale randomized trial found no statistically significant improvement in adherence to osteoporosis medications of a telephonic motivational interviewing intervention12. Studies differed in the methodological rigor (inclusion of control group, non-participation rate), selection of patients and last but not least in the type of educational intervention developed, from the one-off provision of an education session to complex interventions with printed material or bone marker feedback to telephone support for up to 2 years. Of the five effective interventions, four involved considerable direct contact with health professionals, usually via the telephone.

In addition to patients’ education programs, other interventions may also be useful to enhance medication adherence in osteoporosis. The same systematic review13 suggests along five studies that less frequent dosing regimens, electronic prescription, and the use of a patient decision aid to facilitate decision-making by describing the available options could be effective methods to improve adherence. Monitoring and providing feedback to patients on bone marker results seems, however, not an effective way to enhance adherence according to four studies.

A recent direction in efforts to improve patient adherence is to develop interventions tailored to the individual14. When messages included in health education programs are adapted to characteristics, needs, and interests of the individual, the messages provided during the intervention will be more relevant, less redundant, and more likely to be read, saved, remembered, and adhered to. An important problem in translating intention to behavioral change is that many individuals, in the end, do not achieve the desired change. Hence, goal-setting by identifying and setting clear action plans is important to translate intentions into actions. Action plans refer to specific strategies (sub-behaviors) aimed at realizing steps within specific periods of time in order to be able to perform the ultimate desired behavior. One of the challenges of such a program was seen in the sustainability of such change and a need for long-term additional support initiatives. To our knowledge, tailored educational programs in osteoporosis addressed lifestyle changes in the prevention of osteoporosis, but not the issue of drug adherence15–19.

Although the value of the educational support program presented by Nogues et al.8 is probably evident, there remains a need for high quality studies that compare the effectiveness of programs enhancing adherence to osteoporosis medications. Pragmatically designed, randomized, controlled trials, preferably stratified according to patient characteristics and with long-term follow-up, would be required13.

Different studies regarding different methodological approaches for patients’ education should also be carried out (and maybe differ) for different drugs. An educational approach may be clinically (and economically) worthwhile for a specific type of drug (such as a daily subcutaneous injection of teriparatide), but not for other types of drugs like weekly oral tablets, subcutaneous injection every 6 months or yearly intravenous injection. In this sense, specific educational programs should be developed (and maybe differ) for every kind of drug and/or administration. The ability to improve the cost-effectiveness might also be different depending on the type of drug and on the impact that non-adherence had on the cost-effectiveness ratio.

An issue that is not being addressed in the present study, but of high importance in a world with limited healthcare resources, is the need to assess the economic value of health interventions11. Health economic evaluation could be very useful to help decision-makers allocate healthcare resources appropriately and efficiently, and therefore optimizing public health initiatives. In particular, within the context of adherence-enhancing interventions, it would be important to know whether such programs would represent an efficient way of allocating resources and, thus, whether such initiatives should be supported. To our knowledge, no studies have yet examined the cost-effectiveness of a specific program to improve adherence in osteoporosis. Modeling studies have, however, been performed to estimate how much we could invest in a program to improve the effectiveness, but remains cost-effective for thresholds society feels acceptable. Such studies suggested that interventions that improve adherence may likely confer cost-effective benefits4–6,20. For example, for a hypothetical intervention that improves adherence to osteoporosis medications by 50%, it would be cost-effective to spend between €140–€239 per year11. The economic value of improving adherence could, however, be situation-specific: the amount of money that could be invested to improve adherence likely depends for example of the baseline fracture risk of patients, or the expected risk of patients (or sub-groups) of being non-adherent below a level that is relevant to influence the effectiveness of drugs11.

In summary, given the large clinical and economic burden of poor adherence to osteoporosis medications, developing effective and cost-effective interventions to enhance adherence would be extremely worthwhile. Several interventions such as a telephone-based educational support program are promising to improve medication adherence in osteoporosis13. To demonstrate that adherence interventions offer benefits, we recommend that such programs are subject to further rigorous clinical (and economic) evaluation.

Transparency

Declaration of funding

The author received no funding in preparation of this manuscript.

Declaration of financial/other relationships

M. H. and A. B. have disclosed that they have no competing interests relevant to the content of this article. CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships.