Transcript Mapi

Lessons learned from a multi-diseases study
using a patient online community
Benoit Arnould and Hélène Gilet, Mapi
Michael Chekroun, Carenity
ACO Summit
Philadelphia, 2nd June 2015
© Mapi 2014, All rights reserved
1
Mapi Patient-Centered Global Research Services
Real World
Evidence
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IV & Observational
studies

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Registries
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Recruitment
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and engagement
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Outcomes
REMS/EU-RMPs
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Direct To Patients
(ProClinica)
HEOR & Strategic
Market Access

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Strategic Insight:
identify risks and
opportunities,
prioritize
investments
Generate &
Communicate on
clinical, economic
and PRO evidence
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Regulatory & HTA
submissions
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access solutions
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Research and
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Generation: Mixed
Methods Research
and statistical
analysisaccess
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reviews
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Newsletters
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and endpoints
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Acts as an advisor
to client subsequent
to approval to
maintain drug
compliance
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Provides native
knowledge through
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Provides postapproval
pharmacovigilance
and clinical auditing
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Key words from ACO Summit day 1
Adherence, compliance & persistence
We will (briefly) discuss why it is so difficult to measure,
understand, and improve!
Patient Engagement
We would very much like to have patients engaged in the solution
we think are good for them,
BUT…
Should we not first engage ourselves in solution that work for
them?
Quality Metrics
Measuring quality is essential for our systems.
The challenge is to conduct appraisal in a way that favours actual
improvement in quality, and not just improvement in metrics…
© Mapi 2014, All rights reserved
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Co-authors
Senior Research Manager
HEOR & Strategic Market
Access, Mapi
[email protected]
T : +33 (0)4 72 13 59 78
Senior Director – Global
Patient-Centered Outcomes
HEOR & Strategic Market
Access, Mapi
[email protected]
T : +33 (0)4 72 13 69 53
M : +33 (0)6 80 45 55 28
Founder & CEO, Carenity
[email protected]
T : +33 (0)1 84 17 42 71
M : +33 (0)6 85 61 75 55
© Mapi 2014, All rights reserved
4
Non-Adherence is a REAL problem!
"Medication non-adherence rates typically range from
30% to 60%.“
"Half of the patients for whom appropriate medication is
prescribed fail to receive the full benefits because of
inadequate adherence to treatment."
"Poor adherence to treatment of chronic disease is a
worldwide problem of striking magnitude.“
"Adherence to long-term therapy for chronic illnesses in
developed countries averages 50%. In developing
countries, the rates are even lower. It is undeniable that
many patients experience difficulty in following
treatment recommendations."
* "Medication Nonadherence: Finding Solutions to a Costly Medical Problem," Gottlieb, Drug Benefit Trends 12(6)
** Adherence to Long-Term Therapies: Evidence for Action, World Health Organization, 2003
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Many different reasons of non-adherence
Intentional
Beliefs
Disease
Treatment
Industry
Response to actual
treatment
Side effects
Regimen
Formulation
Perceived efficacy
Financial
Unintentional
Patient characteristics
Forget
Poor eyesight/literacy
Don’t understand
instructions
Lack of knowledge
Treatment issues
Device or container
difficulties
Formulation problems
Tablets of similar colour
Regimen too complex
Can’t get rx or drugs
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6
Adherence a major concern but…
No unique simple solution to improve adherence
A huge amount of resources is allocated to make patients more
adherent
Health care system need to work on:
Priorities
– Do we target the right patients?
– Do we address their actual needs?
Solutions
– Do we take the right actions?
– Are the results of our actions lasting and their effects maintained?
Effectiveness
– What is the best program?
– How can we generalise an experiment?
Cost-effectiveness
– What is the value?
– Who will pay for it?
7
7
01/06/2
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Adherence studies face important limitations
Validity of measurement
What is really measured?
Reliability of measurement
How far can we consider results are close to reality?
Social desirability bias
Do study participants tell the truth?
Recruitement bias
Where can non-adherent patients be found, through which
channel can they be enrolled in studies?
© Mapi 2014, All rights reserved
8
Concept and measurement
of Acceptance
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Acceptance in Health Beliefs Model
Rosenstock (1966,1974), Becker & Mainman (1975), Becker & Rosenstock (1984),
Marant (2011)
Socio-demographics
(age, sex, social
category, etc.)
Perceived
susceptibility
Perceived
severity
Health value
Individual
psychosocial
characteristics
(personality, cognitive,
characteristics, etc.)
Acceptance
Behavior
Perceived
benefice
Perceived
barriers
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10
APTEO study: methodology
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APTEO study objective
APTEO = French acronym for « l’Acceptance des Patients
vis-à-vis de leur Traitement : Etude Online »
(or "patient acceptance of their treatment: online survey")
Objective: to evaluate, for a variety of chronic diseases,
the level of patients’ acceptance of their medication in real
life using a patient online community
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Carenity: 60,000 patients and 1,000 conditions
Top 20 conditions on Carenity
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APTEO study design
Observational, cross-sectional study
Data collected (completed by patients):
Demographic characteristics (age, gender, occupational status,
geographic location)
Clinical characteristics (chronic disease, date of diagnosis, current
treatment, comorbidities)
ACCEPT questionnaire (25 items)
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ACCEPT questionnaire:
6 treatment-attribute specific dimensions …
treatment-attribute
specific dimension
Number
of items
E.g. item label
Acceptance/Medication
Inconvenience
5
Q1: Do you find it inconvenient to prepare
your medication?
Acceptance/Long-term
Treatment
3
Q5: Will you have to take your medication
for a long time?
Acceptance/Regimen
Constraints
5
Q6: Do you find that having to remember
to take your medication is inconvenient?
Acceptance/Numerous
Medications
1
Q11: Do you find that you have a lot of
medications to take?
Acceptance/Side
Effects
5
Q16: Are these side effects unpleasant?
3
Q20: Do you find that your medication is
effective for you?
Acceptance/
Effectiveness
Response
choice (same for
all items)
• "Yes, and I
don’t find this
easy to
accept"
• "Yes, but I
find this easy
to accept"
• "No"
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… + 1 general acceptance dimension
General
Acceptance
dimension
Acceptance/
General
Number
of items
3
Item labels
Response
choice (Likert-type
scales)
Q23: Do you agree with the following
statement: "My medication has more
advantages than disadvantages"?
"Totally disagree"
"Somewhat disagree"
"Somewhat agree"
"Totally agree"
"I don’t know"
Q24: Given the advantages and
disadvantages of your medication, do you
consider it to be an acceptable solution?
"Not at all acceptable"
"Not very acceptable"
"Somewhat acceptable"
"Totally acceptable"
"I don’t know"
Q25: Are you convinced that in the long
term, it is worth taking your medication?
"Not at all convinced"
"Not really convinced"
"Somewhat convinced"
"Totally convinced"
"I don’t know"
© Mapi 2014, All rights reserved
16
ACCEPT is available in 16 languages
English for Canada
English for the UK
English for the USA
French for Canada
French for Switzerland
German for Germany
German for Switzerland
Italian for Italy
Portuguese for Brazil
Russian for Russia
Slovak
Spanish for Argentina
Spanish for Colombia
Spanish for Mexico
Spanish for Spain
Spanish for the USA
© Mapi 2014, All rights reserved
17
References ACCEPT
Gilet H, Chekroun M, Arnould B. Patients’ acceptance of their medication: Results from a French
multidiseases study with patient online community using the ACCEptance by the Patients of their
Treatment (ACCEPT©) questionnaire. 2014. ISPOR 17th Annual European Congress, Amsterdam, The
Netherlands, 8-11 November 2014.
Gilet H, Chekroun M, Arnould B. How can patient online communities inform industry about barriers to
medication acceptance and unmet needs? Lessons learned from a French multi-diseases study using a
patient online community. 2014. ISPOR 17th Annual European Congress, Amsterdam, The
Netherlands, 8-11 November 2014.
Arnould B, Gauchoux R, Meunier J, Gilet H, Regnault A. Validation of ACCEPT, a new generic measure
to assess how patients with chronic diseases balance between the advantages and disadvantages of
following the recommended treatment regimen in real-life. 2013. ISPOR 16th Annual European
Congress, Dublin, Ireland, 2-6 November 2013.
Marant C, Longin J, Gauchoux R, Arnould B, Spizak C, Marrel A, et al. Long-term treatment
acceptance: what is it, and how can it be assessed? Patient. 2012;5:239-249.
Gauchoux R. Acceptability studies: a new way of assessing adherence and understanding its
determinants in real life. PRM Newsletter. 2011;8:1-2,14.
Chretin S, Viala-Danten M, van Ganse E, Patrick DL, Arnould B, Longin J. The missing piece between
treatment experience and intention to persist: testing the internal consistency reliability and
predictive validity of acceptability. 2010. ISPOR 13th Annual European Congress, Prague, Czech
Republic, 6-9 November 2010.
Marant C, Spizak C, Longin J et al. Development of the ACCEPT© questionnaire to assess acceptability
of long-term treatments: qualitative steps. 2009. ISPOR 12th Annual European Congress, Paris,
France, 24-27 October 2009.
Marant C, Longin J, Spizak C et al. What does acceptability mean for patients and how should it be
measured? Qualitative steps for the development of a new measurement instrument for pharmacies:
the "ACCEPT©" questionnaire. 2008. ISPOR 11th Annual European Congress, Athens, Greece, 8-11
November 2008.
Saussier C, van Ganse E, Auge-Caumon MJ et al. Measuring the contribution of treatment
acceptability to the understanding of patient adherence to long-term treatments. Results from a pilot
study conducted with In fine PHARMA®: a pharmacies network dedicated to pharmacoepidemiological
surveys. 2008. ISPOR 11th Annual European Congress, Athens, Greece, 8-11 November 2008.
© Mapi 2014, All rights reserved
18
Definition of the analysis population
Patients included in the analysis population:
Patients suffering from any chronic diseases
Patients currently receiving a treatment for this disease
Patients who had completed at least one item of the ACCEPT
questionnaire
Adults
Patients living in France
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19
APTEO study: results
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20
Patient population
 30,000 patients
registered on
Carenity.com
4,880 participants
4,193 patients
included in analysis
population
19 diseases with more than 30 patients:
- Type 2 diabetes (N=669)
- Multiple sclerosis (N=426)
- Type 1 diabetes (N=251)
- Ankylosing spondylitis (N=297)
- Fibromyalgia (N=248)
- Rheumatoid arthritis (N=215)
- Arthrosis (N=163)
- Bipolar disorder (N=143)
- Breast cancer (N=137)
- Depression (N=104)
- Lupus (N=100)
- Crohn’s disease/Ulcerative colitis (UC) (N=98)
- Chronic obstructive pulmonary disease
(COPD) (N=74)
- Psoriasis (N=68)
- Parkinson’s disease (N=65)
- Hypertension (N=64)
- Asthma (N=51)
- Epilepsy (N=45)
- Myocardial infarction (N=33)
+
942 patients with
other diseases
A unique population of patients:
Population size: data on more than 4,000 patients analysed
Variety of diseases: more than 270 chronic diseases, among which 19 including more than 30 patients
© Mapi 2014, All rights reserved
21
How do patients accept their treatment?
Score "Acceptance/General"
Box = interquartile range (Q3-Q1); + = mean; — = median; upper and lower bars = observed max and min values.
Boxplots are ranked based on mean Acceptance/General score.
© Mapi 2014, All rights reserved
22
How do patients accept their treatment?
Score "Acceptance/General"
Box = interquartile range (Q3-Q1); + = mean; — = median; upper and lower bars = observed max and min values.
Boxplots are ranked based on mean Acceptance/General score.
© Mapi 2014, All rights reserved
23
How do patients accept their treatment?
Score "Acceptance/General"
Box = interquartile range (Q3-Q1); + = mean; — = median; upper and lower bars = observed max and min values.
Boxplots are ranked based on mean Acceptance/General score.
© Mapi 2014, All rights reserved
24
How do patients accept their treatment?
Score "Acceptance/General"
Box = interquartile range (Q3-Q1); + = mean; — = median; upper and lower bars = observed max and min values.
Boxplots are ranked based on mean Acceptance/General score.
© Mapi 2014, All rights reserved
25
How do patients accept their treatment?
Score "Acceptance/General"
Box = interquartile range (Q3-Q1); + = mean; — = median; upper and lower bars = observed max and min values.
Boxplots are ranked based on mean Acceptance/General score.
© Mapi 2014, All rights reserved
26
How do patients accept their treatment?
Score "Acceptance/General"
Box = interquartile range (Q3-Q1); + = mean; — = median; upper and lower bars = observed max and min values.
Boxplots are ranked based on mean Acceptance/General score.
© Mapi 2014, All rights reserved
27
Type 1 diabetes – Mean Acceptance/General score = 61.2
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
59.9
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
48.2
52.9
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance/Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
68.5
67.0
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Type 1
Min – Max all
diabetes
diseases
18
2 – 18
32
0 – 32
26
0 – 26
39
1 – 39
19
0 – 24
36
11 – 49
49
23 – 58
15
6 – 19
37
17 – 39
24
8 – 25
37
7 – 37
38
7 – 38
33
9 – 39
Numerous medications
31
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
37
39
32
7
23
8
8
16
22 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
© Mapi 2014, All rights reserved
28
Type 1 diabetes – Mean Acceptance/General score = 61.2
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
59.9
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
48.2
52.9
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance/Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
68.5
67.0
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Type 1
Min – Max all
diabetes
diseases
18
2 – 18
32
0 – 32
26
0 – 26
39
1 – 39
19
0 – 24
36
11 – 49
49
23 – 58
15
6 – 19
37
17 – 39
24
8 – 25
37
7 – 37
38
7 – 38
33
9 – 39
Numerous medications
31
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
37
39
32
7
23
8
8
16
55 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
© Mapi 2014, All rights reserved
29
Type 1 diabetes – Mean Acceptance/General score = 61.2
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
59.9
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
48.2
52.9
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance/Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
68.5
67.0
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Type 1
Min – Max all
diabetes
diseases
18
2 – 18
32
0 – 32
26
0 – 26
39
1 – 39
19
0 – 24
36
11 – 49
49
23 – 58
15
6 – 19
37
17 – 39
24
8 – 25
37
7 – 37
38
7 – 38
33
9 – 39
Numerous medications
31
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
37
39
32
7
23
8
8
16
55 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
© Mapi 2014, All rights reserved
30
Type 1 diabetes – Mean Acceptance/General score = 61.2
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
59.9
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
48.2
52.9
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance/Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
68.5
67.0
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Type 1
Min – Max all
diabetes
diseases
18
2 – 18
32
0 – 32
26
0 – 26
39
1 – 39
19
0 – 24
36
11 – 49
49
23 – 58
15
6 – 19
37
17 – 39
24
8 – 25
37
7 – 37
38
7 – 38
33
9 – 39
Numerous medications
31
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
37
39
32
7
23
8
8
16
55 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
© Mapi 2014, All rights reserved
31
Type 1 diabetes – Mean Acceptance/General score = 61.2
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
59.9
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
48.2
52.9
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance/Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
68.5
67.0
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Type 1
Min – Max all
diabetes
diseases
18
2 – 18
32
0 – 32
26
0 – 26
39
1 – 39
19
0 – 24
36
11 – 49
49
23 – 58
15
6 – 19
37
17 – 39
24
8 – 25
37
7 – 37
38
7 – 38
33
9 – 39
Numerous medications
31
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
37
39
32
7
23
8
8
16
22 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
© Mapi 2014, All rights reserved
32
Breast cancer – Mean Acceptance/General score = 38.6
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
86.5
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
53.5
71.1
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance /Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
35.4
37.7
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Breast
Min – Max all
cancer
diseases
10
2 – 18
14
0 – 32
12
0 – 26
1
1 – 39
5
0 – 24
34
11 – 49
53
23 – 58
12
6 – 19
35
17 – 39
12
8 – 25
17
7 – 37
13
7 – 38
17
9 – 39
Numerous medications
28
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
76
74
66
37
42
7
5
32
22 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
© Mapi 2014, All rights reserved
33
Fibromyalgia – Mean Acceptance/General score = 33.7
Dimension
(Min – Max all diseases)
Mean
score1
Acceptance/Treatment
Inconvenience
(59.9 – 96.3)
89.6
Acceptance/Long-Term
Treatment
(46.3 – 61.3)
Acceptance/Regimen
Constraints
(52.9 – 76.7)
47.4
62.1
Acceptance/Numerous
Medications
Acceptance/Side Effects
(35.4 – 81.4)
Acceptance /Effectiveness
(37.7 – 79.8)
1
Higher score is better;
2
51.5
53.7
Item
Preparation
Mode of administration
Form
Storage conditions for journeys
Taking discreetly
Long time in the past
Long time in the future
Routine
Remember to take
Find time to collect
Remember to take with oneself
Always having on oneself
Frequency
% response "Not easy to accept"2
Min – Max all
Fibromyalgia
diseases
4
2 – 18
8
0 – 32
5
0 – 26
2
1 – 39
10
0 – 24
41
11 – 49
55
23 – 58
18
6 – 19
32
17 – 39
23
8 – 25
27
7 – 37
23
7 – 38
29
9 – 39
Numerous medications
52
12 – 55
Side effects
Unpleasant side effects
Disabling side effects
Medication due to side effects
Risk of serious side effects
Effective
Protecting enough
Rapid effect
58
59
50
21
27
25
19
49
22 – 76
22 – 74
16 – 66
2 – 37
8 – 58
4 – 29
3 – 25
11 - 49
Higher percentage is worse
0-19%
20-39%
40-59%
60-79%
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Discussion, conclusions
and next steps
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Conclusions
ACCEPT profiles are easy to interpret.
Confirmation and quantification of « well-known » facts
Acceptance scores show clear contrasts between
diseases
Unmet needs
Patients priorities
Contrasts give guidance for interpretation
Across diseases:
On which diseases is innovation most needed?
Within disease:
Do subgroups of patients face more issues than others?
Priorities:
What are the most prevalent and impactful barriers to treatment
acceptance?
– Efficacy, Safety, Duration, Number of drugs, Convenience, Constraints…
– Specific features (item level)
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Applications for Health Care Providers:
addressing strategic and tactic questions
Prioritization:
What sort of innovation/solution is likely to match market unmet
needs?
Segmentation:
Which subgroup of patients could benefit most?
Personalized solutions:
Through finely granulated identification of barriers, efficiently
spend resource on adequate solutions:
Give potential risks meaningfulness and reality (eg monitoring blood
glucose in Type 1 diabetes patients)
Give potential benefits a reality! (eg chemotherapy in breast cancer)
Adapt solution to patient values (remember the invention of
therapeutic window for AIDS patients – it was past century!)
Overcome practical barriers (eg eye-drop devices for elderly, or
prescribe combos)
Address their needs! (eg switch to more active drugs in Rhumatoïd
Arthritis)
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Ultimately, the patient experience is the key to adherence
Patient experience in real life
Patient experience in
health care environment
PROs help to assess and communicate that experience
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[email protected] | www.mapigroup.com
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