Sunday, March 8, 2009

Health Myths #1: Adherence & Red Beads

What gets us into trouble

is not what we don't know

It's what we know for sure

that just ain't so

Mark Twain

This is the 1st in a series of posts on widely held and pernicious health myths.

The Myth

There's a lot of talk about improving quality in healthcare. Compared to other industries healthcare lags far behind in adopting the concepts and applying the tools of the quality movement. There is a lot that can be applied, and not just for improving the quality of systems but also for dealing with people.

One of those people-issues is adherence. The problem of poor adherence—the inability of patients to follow their medication regimens accurately and consistently—is widespread and well known. The likely benefits of improved adherence are also well accepted: "Effective ways to help people follow medical treatment would have far larger effects than any treatment itself" (Lancet, 1996).

Given its importance, many studies have been conducted to understand the problem and numerous efforts have been made to solve it. A wonderful overview of medical studies on this topic is Adherence to Medication by Lars Osterberg and Terrence Blaschke. And, many efforts have been made to increase adherence, including more education, easier regimens (e.g. 1 pill a day, rather than 2 or 3), and financial rewards and threats. Nothing seems to make much of a difference.

At first glance, it seems absurd that adherence is so poor. After all, how hard can it really be to take a pill on a regular schedule? Even self-injections (such as for diabetics), though unpleasant, are not especially difficult.

This has led to the myth: people don't adhere because they don't want to; people don't care about their health.

The Red Bead Experiment

Dr. Edward Deming, one of the founders of the quality improvement, used the "Red Bead Experiment" to teach a key point about quality. This experiment is really a performance piece, a skit.

The cast: three workers, a foreman, and a quality inspector

The situation: a bin is filled with beads, of which 80% of are black and 20% are red. The workers use a special paddle to collect beads from the bin, and place these beads in a second bin. The quality of the workers' performance is judged by the percentage of black beads versus red beads in the second bin. A higher percentage being better quality.

The action: foreman tells workers what is expected. Workers transfer one paddle of beads. Quality inspector determines that the second bin has roughly 80% black beads. Foreman fumes and exhorts workers to do better. Workers do their job again, quality inspector checks again, and again the result is about 80%. Foreman is livid, yells at, threatens, demands better performance. Workers try again, quality inspector checks again, 80% again.

The lesson: the workers are limited by the tools at their disposal. There is simply no way to get a higher percentage of black beads out of the first bin with the given paddle. The problem is not one of worker competence or motivation, but of capability. In this case, as in many others, capability must be improved through better tools and processes.

The Reality

The situation with adherence is much the same. The problem is not simply one of poor knowledge or desire—even smart, motivated people have poor adherence. It is in fact a problem of capability.

It is true that each particular activity in a health regimen—taking a pill; checking and recording weight; recording lunch in a food journal; noting an event of pain or nausea—is relatively easy to do. But, if you have 20, 30, 40 or more such activities spread throughout each day, as is common for people with chronic illnesses, it is difficult to do them properly and consistently every day, forever. If you also have a normal, busy life, with the activities and responsibilities of family, work and society, it is in fact extremely difficult. This is why adherence is so poor! It's almost impossible to be properly adherent. At least without better tools.

Quite simply, people need help remembering all of their scheduled health activities and need an easier way to keep track of all them. People need tools or services to make remembering and recording much, much easier than it is today.

To significantly improve adherence, we must discard the myth of irresponsible patients, and take on the challenge of developing tools that help people. We've got to give those workers better paddles if we want fewer red beads.


Mom2Cool said...

Rajiv, I love the idea of Zumelife and what your intentions with it are. This is empowering for a patient not just because of the ease of recording or the tool at hand, but because the tool at hand makes it easier to communicate with one's health care providers. For example if you're following a doctor's instruction to a tee & yet there is not the desired results, rather than not being heard, thought to be lazy or "not wanting to take care of themselves" or worse patronized, this is a tool that would show exacly what the patient has been doing & that perhaps the medication isn't working or adjustments need to be made. We live in a very fast paced world with very tight schedules too and so having a illness or injury it's not always easy to be on top of the medications one needs to take, when etc. The average person is juggling many different things at the same time and so yes an effective way to chart what we've already done and the time we did it & the effect it had, just seems logical. That's what they do in hospitals and doctors offices when they take in all the info you have for them, they mark it down so they can make a judgement and if something is not working they make an adjustment. They would have no way of being able to just "remember everyone"? While we of course are not remembering the same amount of patients that doesn't mean we're not still remembering many facts within the course of the days i.e. the kids, spouses, siblings, co workers, job responsibilities, pets, houses and the list is endless of course. So to chart using the *easiest way possible* just seems logical to me. I think this is a wonderful idea and exciting that someone has come up with a tool such as this...

Rajiv Mehta said...


Yes, one of the benefits is in fact that you and your doctors become better partners in your health. Today, if a medication is not having an impact, it is understandable if your doctor assumes that you aren't taking the medication properly (because adherence is so poor generally). There is a very good possibility that it is the medication that's not working, but the doctor just can't be sure. With our solution, this uncertainty goes away. From our beta users, we have many stories of such situations -- doctors changing medications because they can see that the medication is not working.

Also, as you point out, this helps in making adjustments. You can try something and see if it has an impact. Many of our users have improved their health through making a series of changes, some small, some large, that kept moving them towards a better state of health.


Cassandra said...

Another aspect of the "bad patient" mythology that's sort of missing is around the notion that people do what they are incentivized to do...and a corollary hypothesis I'd suggest is that the most effective incentives are tangible and short-term. Intellectual smarts and complete information are nice, but don't lead to complete compliance. Whether it's exercise, eating right, or taking medications - doing those things "right" often shows no tangible effect in the short-term - no matter what the actual urgency of the impact on health in the long-term might be. Some mentally ill people who "know" better go off their meds, because a)the meds cost money and b) may actually make them feel worse physically or mentally in the short-term, along with keeping their mental issues manageable. It's easy for them to "forget" that. Just like I forget that the desserts and treats I love create the extra weight I hate. In the moment I don't seem to remember or "know" that... Love the red bead story!