NEJM: Take a pill, win a prize? The art of hovering
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Researchers from the Philadelphia VA Medical Center said that scrapping conventional methods and replacing them with more modern, interactive approaches that include automation could help improve adherence rates.
“That care model [reactive, visit-based model] falls short not just because it is expensive and often fails to proactively improve health, but also because so much of health is explained by individual behaviors, most of which occur outside healthcare encounters,” David A. Asch, MD, MBA, and colleagues wrote.
“Indeed, even patients with chronic illness might spend only a few hours a year with a doctor or nurse, but they spend 5,000 waking hours each year engaged in everything else—including deciding whether to take prescribed medications or follow other medical advice, deciding what to eat and drink and whether to smoke, and making other choices about activities that can profoundly affect their health,” they wrote.
Strategies that aim to tailor care to the patient have made headway in the hospital and work to better transfer care from the hospital to the home (care coordination).
However, “all these activities occur outside the conventional, billable, clinical encounter—and all reflect some sort of hovering over people in their daily lives,” the authors wrote. While visiting nurses and other care is helpful, it is also expensive and the industry is looking for a more cost-effective, efficient solution.
Asch et al referenced a previous study that looked at warfarin use and automated hovering. The study evaluated patients on warfarin. The pill was administered through a pill dispenser at the patient’s home and connected to a lottery system. The patient would automatically be entered into a daily drawing with a chance to win $100. The patient was notified if the number was chosen but if he or she had failed to take the pill then he or she was disqualified.
“The system provided daily engagement, the chance of a prize, and a sense of anticipated regret: no one wants to receive news of winning only to be disqualified for nonadherence the previous day,” the study authors wrote.
During the study, the system reduced the rate of incorrect doses from 22 percent to 3 percent and also reduced the rate of out-of-range INRs from 35 percent to 12 percent. The authors noted that such a system could help improve medication adherence for patients discharged from the hospital with congestive heart failure or acute coronary syndromes.
“This system uses technology with an engagement strategy informed by behavioral economics to hover over patients,” Asch et al wrote.
The authors also said that these programs could result in cost savings, as they have the potential to prevent hospitalizations. And while these types of programs can help to improve care, they also raise concerns such as being perceived as an invasion of privacy. “Others may worry that hovering is too intrusive or paternalistic—though patients could easily opt out,” the authors wrote.
Lastly, the authors said that it remains unknown in what settings these approaches will be most useful. “There are both clinical and research opportunities in pursuing an approach that is just as rigorous as our approach to other areas of medicine,” the authors summed.
Asch and his colleagues received a $4.8 million Healthcare Innovation Award from the Centers for Medicare & Medicaid Services to study an automated hovering approach in heart attack patients.