Can We Improve Patient Adherence by Harnessing Social Forces?

Abstract

M uch of the management of chronic illnesses occurs ou t s i de o f t he hea l t h ca r e sy s t em . Se l f management—i.e., patient’s ability to manage his or her treatment, lifestyle changes, and psychosocial effects of an illness—improves patients’ quality of life and overall prognosis. It is common for patients and their family members or friends to partner around pharmacological and nonpharmacological tasks, a partnership that is generally beneficial to patients. Recent estimates indicate that 50–75% of patients with HF or diabetes have a family member who is regularly involved in their health care, and patients with low health literacy and greater illness burden are more likely to involve a family member. As noted by Lauffenburger et al. in this issue, half of all patients report medication nonadherence. There is a vast literature on patient-focused strategies to improve medication adherence, including improving knowledge, reducing forgetfulness, patient activation, self-efficacy, motivation, and increasing proximal rewards via incentives. However, patients manage their health within the context of their social network and patients’ high perceived social support is associated with better outcomes. Family members and friends may provide practical support (e.g., prepare meals, take patient to appointments) and emotional support to buoy patients’mood, encourage them to follow medical recommendations, and reward them for their efforts. Involving social networks can improve patients’ quality of life, self-efficacy, and relationship quality and reduce hospitalizations. It is with this thesis—that family members and friends play key roles in medication adherence—that Lauffernburger et al. examined insurance data to see if family members’medication adherence predicted patients’ medication adherence within 12months. They examined adherence among 254,144 patients being treated for diabetes, hypertension, hyperlipidemia, hypothyroidism, or mental health conditions (i.e., depression, anxiety), and identified their family members using linked data. Family members’ medication adherence was identified within the 1 year preceding the patients’ date of study entry. Pharmacy refill data were used to calculate medication adherence for both patients and their family members. Patients whose family members were fully adherent (> 80%) had higher adherence than those whose family members were not fully adherent. Rates of full adherence among patients whose family members were fully adherent were 37.3%, compared to 26.9% if family members were not fully adherent. The relative risk was stronger if both pat ients and family members used cardiometabolic medications (aRR, 1.35; 95% CI = 1.28–1.31). If both patients and family members were treated for the same condition, 38% of patients were fully adherent. The authors are to be applauded for finding an innovative way to ascertain that behaviors of family members and patients are connected. Such methodological advances are critical because current electronic health records either do not capture the role of family, or do so superficially through marital status or noting next of kin. Strengths of their study also include the sample size, and the advanced statistical methods to limit confounds of time-varying elements. Having comprehensive data from both patients and family members can lead to applications of advanced statistical methods such as structural equation modeling, the Common FateModel, and the Actor-Partner Interdependence Model. Preliminary applications of these models shed light on the reciprocal emotional experiences and well-being of patients and their family members. Social network analysis has also shown that healthy and unhealthy behaviors are contagious within social networks, and this study bolsters existing evidence using a large, administrative dataset. Developing innovative ways to use existing datasets will deepen our understanding of the linkages between the behaviors of patients and their family members. The authors speculate that encouragement and reinforcement are the most likely explanations of their findings. However, family relationships may be toxic, and negative interactions marked by criticism may worsen adherence and clinical outcomes. Both social approval and disapproval are powerful forces that affect human behavior, and maintaining healthy behaviors is easier when it is congruent with the values or expectations within the social context. Behavioral contagion theory has recently highlighted that both healthy and unhealthy behaviors can spread within social networks. The Published online March 18, 2019