The Patient's Journey to Adherence

An Exploration of Factors, Studies,

Education and Drug Delivery Devices

The Patient's Journey to Adherence

New and emerging treatment options and drug delivery devices such as autoinjectors, prefilled syringes and pulmonary treatment devices for chronic conditions have required patients to self-administer medication as part of their treatment regimen. Every year, more patients are introduced to injection and pulmonary treatment devices and although self-management offers patients convenience and time, adherence rates are still less than 50 percent after six months of treatment.1

The impact of nonadherence on the pharmaceutical industry is lower drug consumption, lower sales, lower expectations of drug efficacy and lower brand equity.1 Adherence is a multidimensional concept, and along with self-administration of drug delivery devices there are a variety of cognitive, emotional and environmental factors that can cause inconsistencies in treatment. This document will explore factors of patient non-adherence, onboarding, common device usage errors, user studies and recommendations for improving adherence.

Patient nonadherenceOnboardingCommon device usage errorsUser studiesImproving adherence

1

9

15

21

26

Five dimensions of nonadherence: 2

Patient-Related Socioeconomic

Condition-Related Treatment-Related

Health Care Team / Health System

17+83+L

Factors of Nonadherence

of patients don’t think their medication is needed414%

Patient Nonadherence 2

10+17+20+25+29+31+46+49

of patients admit to forgetting a

prescribed medicine 3

of patient’s don’t understand prescription

dosing instructions6

of respondents had taken less than the

recommended dose 3

of patients stated their prescribed medicine costs were too high 4

of patients stopped taking medication before

the supply ran out 3

of patients are concerned about side-effects 4

of patients are unable to get the prescription filled,

picked up or delivered 4

46%31%

25%17%

29%

20%

10%

49%

Patient-Related Factors of Nonadherence2

• Forgetfulness

• Stress, anxiety, anger

• Physical challenges

• Knowledge about disease

• Perceived risk/susceptibility to disease

• Understanding need for medication

• Expectations or attitudes toward treatment

• Perceived benefit of treatment

• Confidence in ability to follow treatment regimen

• Motivation

• Fear of dependence

• Feeling stigmatized by the disease

The following section provides a brief overview of the five dimensions.

3 Patient Nonadherence

of patients admit to not filling a prescription 3

Socioeconomic-Related Factors of Nonadherence2

• Medication cost

• Demographics (age, race and gender)

• Low health care literacy

• Lack of family or social support network

• Burdensome schedule

• Lack of health care insurance

• Limited access to health care facilities

• Inability or difficulty accessing pharmacy

• Cultural and lay beliefs about illness and treatment

Health Care Team/System-Related Factors of Nonadherence2

• Poor provider/patient relationship (time spent, communication style, follow ups and monitoring)

• Poor provider communication (skills contributing to lack of patient knowledge or understanding of the treatment regimen)

• Lack of knowledge on adherence challenges and of effective interventions for improving it

• Inadequate reimbursements

• Poor medication distribution systems

• Limited capacity of the system to educate patients and provide follow-up

• Patient information materials written at higher literacy level

• High drug costs, co-payments, or both

• Poor access or missed appointments

• Lack of continuity of care

5 Patient Nonadherence ”I have been on the drug

more than 15 years with three different providers. You have

to almost beg for training.“– market research participant

Condition-Related Factors of Nonadherence2

• Severity of symptoms from chronic conditions

• Lack of apparent symptoms

• Rate of progression and severity of disease

• Depression

Treatment-Related Factors of Nonadherence2

• Complexity of medication regimen (number of daily doses; number of concurrent medications)

• Treatment requires mastery of certain techniques (injections, inhalers)

• Duration of therapy

• Frequent changes in medication regimen

• Lack of immediate benefit of therapy

• Medications with social stigma attached to use

• Actual or perceived unpleasant side effects

• Treatment interferes with lifestyle or requires behavioral changes

Patient Nonadherence 8

COPD

/ Asth

ma

33%51%

62%

Patient Medication AdherenceDia

betes

Osteo

poro

sis

Hype

rlipide

mia

Multip

le Sc

leros

is

Depr

essio

n

Hype

rtens

ion

Canc

er

Medication Possession Ratio (MPR)5 are the most common measures of medication adherence using refill records. They are usually reported as percentages of the time when a patient has medication available.

Patient Onboarding and Drug Delivery DevicesThe first 30 days after diagnosis is the time when a patient is first introduced and trained on their injection or pulmonary treatment device. After receiving in-office training, patient's return home and are expected to adhere to a prescribed treatment by self-injection or inhaler. Many times, patient's have difficulties recalling the exact process that a trained health care professional conducted at the hospital or doctor’s office. Memory recall is important for adherence. The more information delivered by the health care provider, the lower the probability to correctly recall the information. Typically, only half of the correct information is retained. Other variables include physical factors, such as mobility, age and dexterity impairments associated with specific therapeutic categories, which make it challenging

to use the device. Emotional factors, such as fear and anxiety associated with self-injecting, can lead to avoidance behaviors impacting treatment. A combination of these factors can result in user errors, injuries and adverse events. The cause of these factors can often be tied to ineffective training and a lack of awareness of administration techniques, procedures and sequences. Drug delivery device instructions for use (IFU) have multiple steps that must be correctly followed. Any variance from the structured protocols has the potential to adversely affect the effectiveness of the drug and could lead to intervention and changes in the patient’s treatment plan.

of medical information provided by a health care provider is forgotten immediately.7 40+40+20+L40 to

80%

9 Onboarding

PRIMARY CAREPHYSICIAN NURSE TRAINING

SPECIALIST

RECEIVE DISEASEMGMT. / TRAINING

MATERIALS

RECEIVE DISEASEMGMT. / TRAINING

MATERIALS

PHARMACY

RECEIVE DISEASEMGMT. / TRAINING

MATERIALS

30 DAYS

ADDITIONAL TRAINING / EDUCATION

VIA WEB

NEXT OFFICE VISIT 90 DAYS

60 DAYS

RECEIVE DISEASEMGMT. / TRAINING

MATERIALS

FIRST INJECTION:AT HOME

Patient Onboarding Timeline

of patients have a higher risk of nonadherence due to poor physician/patient communication8 19%

Message Erosion

Sales RepBio Pharma Company HCP Patientday(s) of training Approx. 30 mins of training Approx. 30 mins of training

A study on patient adherence conducted by the New England Journal of Medicine found patients feel their physicians don’t spend enough time explaining the drug requirements and the importance of completing the full dose.23

The Training Process from Pharmaceutical Company to Patient

13 Onboarding

multiple mistakes and would not have benefited from self-administration of the potentially life-saving treatment if the need arose” Dr. Rana Binds, MD, Assistant Professor, Internal Medicine, Division of Allergy and Immunology, UTMB. The UTMB study also focused on correct usage of inhalers resulting in an outcome of 93 percent of patients using their inhalers incorrectly. Again more than half the patients missed three or more steps with the most prevalent being a failure to exhale fully before using the inhaler.10

Study of Correct Usage of Drug Delivery DevicesAccording to a study conducted by the University of Texas Medical Branch in Galveston (UTMB), most patients use their autoinjectors incorrectly. Patients were asked to demonstrate the steps needed to correctly self-administer their autoinjectors, with more than half missing three or more steps. Mistakes made by patients included failing to hold the device in place for the required amount of time, not pressing the device hard enough to trigger the release of the drug and not choosing a suitable injection site.10 “Despite the redesign of the autoinjector for easier use, most patients continued to make at least one mistake with the device. Most patients made

93+7+L of patients use their inhaler incorrectly1093%

Common Device Usage Errors 16

MDI• 93% of MDI users demonstrated imperfect technique • 63% missed 3 or more steps

Most common error:• 66% of users failed to fully exhale prior to using their MDI

MDI Device Technique1. Remove caps from MDI and spacer and then connect = 18% performed step incorrectly2. Hold MDI and spacer together and then shake = 38% performed step incorrectly3. Exhale to functional residual capacity or residual volume = 66% performed step incorrectly4. Tilt head back or keep level = 21% performed step incorrectly5. Insert mouthpiece between lips = 15% performed step incorrectly6. Actuate canister once = 25% performed step incorrectly7. Inhale slowly and deeply = 25% performed step incorrectly8. Should hear a hissing sound not a whistle = 52% performed step incorrectly9. Hold breath 5-10 seconds = 25% performed step incorrectly10. Wait 30-60 seconds = 38% performed step incorrectly11. Shake again before a second actuation = 42% performed step incorrectly

Autoinjector Epinephrine• 84% of users demonstrated imperfect technique • 56% missed 3 or more steps

Most common error:• 76% of users failed to hold unit in place for at least 10 seconds after triggering

Autoinjector Device Technique1. Remove safety cap = 38% performed incorrectly2. Hold device in palm = 60% performed incorrectly3. Using a swinging motion, place the orange tip on the outer thigh = 43% performed incorrectly4. Push in hard until the trainer function is heard = 55% performed incorrectly5. Hold in place for 10 seconds = 76% performed incorrectly

Common Errors with MDI and Epinephrine Autoinjector Drug Delivery Devices10

36%

Year 1

Prescription Refill Rates9

Year 2

23%

Year 3

17%

Age Adherence9

24.2%

18-49

33.1%

50-59

31.2%

60-69

38.5%

70+

Race / Ethnicity Adherence9

native american

otherasian

black american

caucasian

hispanic

21.7%

21.7%29.5%

18.4%

33.2%15.6%

Gender Adherence9

31.2% 31.0%female male

Common Device Usage Errors 18

Other studies reinforce lack of correct drug delivery device administration technique

Care takers, patients and physicians lack knowledge of correct autoinjector technique.

Assessment of self-administered epinephrine among food-allergic children and pediatricians.11

101 families were enrolled which included food-allergic children and teenagers who were prescribed a self-injectable epinephrine, primarily by pediatricians and allergists. Patients were prescribed EpiPen (n = 93), EpiE-Z Pen (n = 11), and Ana-Kit (n = 3).

Twenty-nine attending pediatricians were enrolled (mean fourteen years in practice; mean four epinephrine prescriptions/year).

Familiarity with the devices was as follows: EpiPen (86%), EpiE-Z Pen (17%) and Ana-Kit (7%).

Seventeen pediatric residents were enrolled. 65% were familiar with the EpiPen and only one resident was familiar with Ana-Kit. The study found that physicians, teenagers and parents of food-allergic children cannot correctly administer a self-injectable epinephrine. The study also found physicians lacked familiarity with the devices and highlighted the need to improve patient and physician education.

Common Device Usage Errors 20

18%

68%

84% of attending pediatricians were

familiar with and able to demonstrate

use of an epinephrine autoinjector correctly

of participants demonstrated use of an epinephrine

autoinjector incorrectly

of participating pediatricians failed to

review device use with patients

of patients use their autoinjector

incorrectly10

36%76%of pediatric residents

were able to demonstrate use of an epinephrine

autoinjector correctly

92+10+84

+10+78+10+76

76%

78%

84%

93%of participants failed to perform all the MDI IFU steps correctly

of participants failed to perform all the turbuhaler IFU steps correctly

of participants failed to perform all the diskus IFU steps correctlyof participants failed

to perform all the peak flow meter steps correctly

Physicians fail to provide assessment or demonstration. A study published in the American Academy of Pediatrics investigated the extent that children, ages 8 through 16 with mild, moderate, or severe persistent asthma used metered dose inhalers, turbuhalers, diskuses, and peak flow meters correctly. The study also focused on five pediatric practices to find out how often health care providers assess and demonstrate use of metered dose inhalers, turbuinhalers, diskuses, and peak flow meters during pediatric asthma visits. All of the medical visits were audio-recorded. Children were interviewed after their medical visits, and their device technique was observed and rated by the research assistants.

Data was collected and analyzed for 296 patients, which resulted in the following findings:The study found that a majority of the health care providers did not demonstrate or assess child use of metered dose inhalers, turbuhalers, diskuses, or peak flow meters during pediatric asthma visits.

Patients lack knowledge of correct asthma drug delivery device technique12

21 Common Device Usage Errors

”I wasn't aware of all the training. I kinda’ feel upset the doctor never mentioned anything like this.“ – market research participant

Device Trainer User StudiesMultisensory Learning13

Multisensory learning incorporates cross-modal cues of visual, auditory and somatic senses as part of the learning process. Studies regarding individual processing of multiple sources of information have shown improvements including precision, accuracy, processing speed and memory retention as compared to unisensory learning.

of patients reported they should have used a training device74+26+L74%

23 User Studies

Passive

ActiveDo - Have Actual Experience

Discuss & ExplainThink

Act 80%90%

Hear, See, & Touch

Hear & See

See

Hear

ReadVisual

Auditory

Visual

Auditory + Visual

Auditory + Visual + Somatic

10%20%30%50%70%

Instructions for Use (IFU) Only

Mechanical Trainer & IFU

Talking Trainer & IFU

Error Correcting Trainer & IFU

Aver

age E

rrors

(O

ut of

15 St

eps)

84%

86%

15%

Device Trainer Errors

Device Preference

prefer error correcting device training

across all groups confidence INCREASED

decrease in ANXIETY

26% 12%16% 6%4 errors 1.9 errors2.5 errors 0.9 errors

Background

In July 2014, an independent market research company, sponsored by Noble®, conducted a user study to evaluate training stimuli with regard to self-injected therapies. Outputs included qualitative measures related to patient preference, satisfaction and performance.

Methodology

The study consisted of four homogeneous groups used to evaluate the effectiveness of an independent variable: training. This process followed a structured protocol to prevent adverse effects due to errors or biases. Participants were divided into four test groups including:

• Group 1: Instructions for Use (document only) • Group 2: Instructions for Use and talking trainer • Group 3: Instructions for Use and mechanical trainer • Group 4: Instructions for Use and error correcting trainer

Findings

All self-reported and performance measures were evaluated in relation to participants learning preference, confidence, anxiety and number of errors within each group. Findings revealed patients using training devices had a reduction in errors as well as a decrease anxiety and increase in confidence. Findings also revealed as the level of device training interaction (mechanical, talking and error correcting) with participants increased the number of errors decreased.

Multisensory Device Training

User Studies 26

BackgroundIn March 2014, an independent user study was conducted by Noble to evaluate education stimuli for self-administered inhalable therapies. Outputs included qualitative and quantitative measures related to patient performance, and cognitive capabilities including satisfaction and anxiety.

MethodologyThe study was designed to evaluate the preference of an independent variable: training. This process followed a structured protocol to prevent adverse effects due to errors or biases. Participants completed the study of a 12-step inhalation process. Pre-interview, during-interview and post-interview surveys were administered to evaluate the preference of training methods on confidence, anxiety and inhalation outcomes.

Findings

Upon completing the fieldwork portion of the study, all self-reported and observational measures were evaluated in relation to training preferences and the prevention of errors. While the interviews were qualitative in nature, surveys and other tools provided access to a variety of metrics related to training and onboarding support. Below charts are a summary of these findings and how they related to the objectives of the user study.

Conclusion

Based on a review of secondary literature, errors are significant adherence barriers for patients using pulmonary delivery devices. The findings of this user study suggest that training devices could be effective tools to increase patient confidence and decrease anxiety, two variables that are closely associated with adherence and patient outcomes. Though the findings were robust and insightful, follow-up research is recommended to further evaluate the effects of device training on actual patient errors and long-term outcomes.

Respiratory Device Training

27 User Studies

73+76+41+18+61+90+84+56of participants reported a decrease

in anxiety after evaluating device

trainers

of patients do not completely read the

instructions

of patients rated the value of a trainer 7 or higher

of participants prefer error detection

technologies

of patients use their auto injection device

incorrectly

of participants prefer device trainers

that incorporate multisensory technology

of participants reported increased confidence using a

smart training device

61%56%

90%

76%

84%

73%

41%

18%

of patients have never used a trainer

BackgroundAccording to a recent study by the University of Texas Medical Branch at Galveston, 84% of patients use their auto injection device incorrectly. Based on literature review and other activities, this study further explores the relationship between device training and patient compliance.

Objective:

Investigate if compliance differs between patients who trained with a training device versus those who did not train with a training device. To accomplish this objective, patients were placed into the following groups:

• Group 1: Patients who did train with a device trainer • Group 2: Patients who did not train with a device trainer

MethodologyThis research consisted of a 31-question online survey to patients who regularly self-administer a prescription injection medication. Patients were asked detailed questions related to the training and onboarding of their injectable prescription drug.

Findings

• Patients prefer multisensory learning.

• As age increases, the value of device training increases.

• Patients who use a trainer are less likely to discontinue treatment.

• Patients who use a trainer are more compliant.

• Patients who are recommended to use a trainer by their HCP and use as recommended or more, are more compliant.

Conclusion

Based on the statistical analysis of the data, with a 90% confidence level, training devices improve compliance. With 99% confidence, patients who use a trainer as recommended by their HCP improved compliance. Therefore, not only is it of value to have the training device, it is also important to use it in a manner consistent with how the physician recommends. With more than half of patients having not used a trainer, the opportunity for increased compliance is high.

Link Between Device Training and Patient Compliance

29 User Studies”

It’s almost like you have a nurse right there...“ – Mimi

revealed patients with reminders have a higher tendency to adhere to medication compared to patients without reminders. The study published in Dove Medical Press found a significant adherence increase in groups receiving reminder intervention compared to control groups: 66% higher incidence of adherence with reminders vs. 55% without reminders.14

Recommendations for Improving Adherence

Reminders

A common reason patients don’t take their medications as prescribed is forgetfulness. There have been a number of studies conducted focusing on reminder methods to aid patients with treatment regimen compliance. An examination of multiple, controlled, trial studies analyzed the use of opt-in reminders in the form of text messages, automated phone calls and audiovisual reminder devices. The findings

48+52+L48%

As stated previously there are multiple dimensions affecting nonadherence. The following section will explore ways to improve adherence based upon common factors of the five dimensions.

Improving Adherence 32

of patients have an increase of adherence when receiving written and oral education.20

Another study conducted by Huang et al. found participants who received text message reminders showed a decrease in delayed and missing doses compared to the controlled group which did not receive text message reminders.15 To aid with patient adherence, some providers, retail pharmacies, and pharmaceutical and third-party companies are investigating and implementing multiple reminder methods including texts, automated phone calls, emails and smartphone applications along with reminder devices, such as smart pill bottles and pill organizers.6,16

Better Physician/Patient Communication

The relationship between physician and patient has been shown to be a factor in increasing adherence with both the quality and quantity of visits being important.17 Some of the methods that have been shown to increase adherence include COPE principles17, SIMPLE18 and “Find out more”.19 All of these methods include patient education as a component.

Patient Education

Patients who are provided with written and oral education regarding their diagnosis, management, treatment and medications have been shown to have higher adherence rates.20

Education and Brand Preference

A study conducted by HealthPrize asked physicians “if a particular medication as compared to competitors in the same class, offered a medication adherence service for patients, how would it influence their view of that medication?”21

Patient Education with Drug Delivery Device Trainers

Drug delivery device training tools have been developed to support patients in learning how to properly use their drug delivery devices. These devices are customized to the needs of specific patient populations and delivery platforms to accurately mimic device characteristics and build adherent behaviors in patients. Currently, marketed training devices use mechanical reset and multisensory technologies (visual, auditory, and tactile) to complement health care provider training and create consistent training experiences for patients.

”You’re getting the information as you do it. You don’t forget certain instructions like I do.“ – Joyce

33 Improving Adherence

90% 12%79%decrease in missed doses for participants receiving text message reminders

higher adherence rate with reminders

decrease in delayed doses for participants receiving text message reminders

”The training device takes the anxiety away.

– Blair“

Common errors that can be addressed through device training include:

• Injection into an unapproved site

• Failure to remove device cap before actuating the device

• Insertion angle of needle or positioning of the device on the injection site

• Improper sequence to prepare or unlock safety mechanisms

• Recapping the device and damaging the needle or accidentally actuating the device

• Premature or out-of-sequence actuation of the device

• Improper hold time to receive a full dose These devices help to establish a baseline for training and ensure that a consistent experience is received each time a patient self-injects. After in-office training, patients should repeat and practice at home to reinforce memory recall and establish muscle memory, which can help prevent errors and build confidence. The key is to provide this training device prior to the patient's first injection, so that the learning curve occurs in a “simulated” training environment that provides corrective feedback vs. trial and error with the “actual” drug delivery device. The error-correcting trainer is just one example of improved training technology that includes the addition of electronics, smart sensors, audio, LED, and tactile simulations. This technology makes patients aware of their errors in real time, increases message recall through repetition, and utilizes multisensory technology that engages the five senses, which helps solidify learning. For example, Noble's Smart Injection Practice Pad is equipped with technology that detects and corrects errors via the pad and not the pen. Integrating proprietary electronic technologies into the pad instead of the pen helps reduce cost, miniaturization of electronic components and adds ease to manufacturability.

Improving Adherence 36

48% 72%61%37%of physicians

believe in education as an influence to

improve adherence 21

of physicians said they “might be more likely to”

or “would view it in a more positive light” for a product

that had a medication adherence program

of patients were adherent to their treatment when

doctors probed for nonadherence causes,

discussed personal beliefs and provided disease education19

of physicians said they would be more likely to meet

with a pharma rep if the pharmaceutical company

offered a medication adherence program

Customized Educational and Training Solutions

Noble believes improved patient education is key, and to that end, offers customized solutions for pharmaceutical companies in an effort to help patients use their inhalers and injectable devices correctly. Noble assists in the design of simulated devices for training purposes, which can use multiple modalities such as voice-guided training and error correction, platform technology that can be built into training devices or packaging, and ancillary support tools, which monitor patient behavior and notify them if an error is made.

As technology continues to develop at a rapid pace, medical manufacturers, too, must evolve to incorporate technological advances that will help improve the patient experience. Improved training technologies like error correction and wireless features allow brands to engage patients and provide personalized training content based on individual patient needs and performance.

As new brands continue to launch and augment markets, they will continue looking for strategies to differentiate themselves from competitors. In the modern era of patient-centric care, those able to provide a superior product and educational experience to patients will be competitively positioned to benefit from the loyalty established with patients and health care providers.

About Noble

Noble, the leader in onboarding and device training, is a patient-centered product development and manufacturing company. Noble works closely with the world’s leading pharmaceutical and biotechnology companies to develop educational and training solutions. Solutions are designed to provide positive patient onboarding experiences, reduce errors and improve patient outcomes. Cross-disciplinary designers and engineers provide fully customized solutions from the first concept sketch through production in both regulated and non-regulated environments.

Noble understands every client’s needs are unique.

”After all, we’re still human. And we do make errors. I do ‘em all the time!

– Rita“Improving Adherence 38

Patient Onboarding

There are many variables contributing to patient adherence and therapy acceptance during onboarding including anxiety, confidence, memory and understanding the correct administration technique. These patient factors can detrimentally influence attitudes and perception toward medications and drug delivery devices, resulting in training gaps and treatment barriers.

Device Training

These devices have been designed to mimic actual commercial drug delivery devices, providing a low-cost, reusable solution for safe and effective onboarding.

Injection Product features – AI and PFS trainers:

• Off-the-shelf platforms and customized solutions, including proprietary technologies• Technologies range from resettable mechanical to smart features, such as sensors, audio and error-correcting• Trainers designed to mimic actual device characteristics: - Shape and design - Needle puncture and insertion forces - Needle tip - Breakout, glide forces and viscosities - Controlled plunger speed - Shroud lock-out

Respiratory Product Features – MDI and DPI trainers:

• Off-the-shelf platforms and customized solutions, including proprietary technologies• Technologies range from resettable mechanical to smart features, such as sensors, audio and error-correcting• Trainers designed to mimic actual device characteristics - Shape and design - Inhalation forces - Lock-out

Training Support Products Designed to create a complete training program and solution. • Angle aid tools • Clip-on assistive tools • Administration assistive tools • Training packaging • Training IFU

39 Improving Adherence Improving Adherence 40

LED ErganomicsAudioCustomizable Error Correction

Sensors SyncingTactile Feedback

Development and Production

Noble’s proven repeatable process takes client opportunities from concept to distribution. Our team works meticulously to define and answer product challenges, ultimately producing superior designs optimized for manufacturability and high-volume production. Our in-house design lab provides Noble with the ability to produce prototypes and conduct extensive engineering and benchmark testing, with quality assurance involved at every level through project realization.

Noble’s dedication to delivering quality products extends beyond our corporate headquarters. Our ISO 9001 and 13485 certified global manufacturing partners use a systematic approach to perform in-line functionality testing, in-process inspection, analysis and line improvements with other production testing including 100 percent verification testing of critical product features and functionality before delivery.

Choose Noble

As the number of patients being required to self-administer medication via drug delivery devices continues to grow, training and education will remain a critical success determinant of a patient’s ability to safely and effectively use these devices and adhere to therapy. Novel training technologies such as mechanical and smart, error-correcting autoinjectors, prefilled syringes and pulmonary delivery devices, angle aid tools, auditory packaging and other multisensory solutions help empower patients to lead healthier lives.

In the modern era of patient-centric care, products that are able to provide superior onboarding and patient experiences will be well positioned and benefit from reduced patient errors, while improving patient satisfaction and outcomes.

41 Improving Adherence

Device training happens here.

Through faith and teamwork, be an industry leader in innovation, resulting in value growth, allowing all stakeholders

and our community to prosper.”“

Noble’s focus is to drive innovation in onboarding and device training, bringing value to our clients.

References: 1. Capgemini Consulting. (2011, May). Patient adherence: The next frontier in patient care. Retrieved from https://www. pt.capgemini.com/resource-file- access/resource/pdf/Patient_Adherence The_Next_Frontier_in_Patient_Care.pdf 2. World Health Organization. (2003). Adherence to long-term therapies - evidence in action. Retrieved from http://apps. who.int/medicinedocs/pdf/s4883e/ s4883e.pdf 3. National Community Pharmacists Association. (2006, December 15). Take as directed: A prescription not followed. Retrieved from http://www.ncpanet. org/pdf/adherence/patientadherence-pr1206.pdf 4. Boston Consultant Group. (2003, December). The hidden epidemic: Finding a cure for unfilled prescriptions and missed doses. 5. PMC. (2013, April 11). Patient Characteristics Associated with Medication Adherence. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3692389/ 6. CVSHealth. (2014). Insights: Adherence | CVS Health. Retrieved from http://www.cvshealth.com/research-insights/ cvs-health-research-institute/insights- adherence 7. Kessels, R. P. (2003, May). Patients’ Memory for Medical Information. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC539473/ 8. Haskard Zolnierek, K. B., & DiMatteo, M. R. (2009, August). Physician Communication and Patient Adherence to Treat- ment: A Meta-analysis. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728700/ 9. Banefield, Jennifer, Murphy, Kevin R. (2015, February). Adherence in Asthma and COPD. Retrieved from http://advanceweb.com/web/AstraZeneca/focus_ on_copd_issue11/focus_on_copd_issue11_Adherence_in_asthma_and_copd.html 10. Bonds, R., Asawa, A., & Ghazi, A. (2014, November 18). Misuse of medical devices: a persistent problem in self-man- agement of asthma and allergic disease. Retrieved from www.annallergy.org/article/S1081-1206(14)00752-2/fulltext 11. Sicherer, S., Forman, J., & Noone, S. (2000, February). Use assessment of self-administered epinephrine among food-allergic children and pediatricians. - PubMed - NCBI. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/10654956 12. Sleath, B., Ayala, G. X., Gillette, C., Williams, D., Davis, S., Tudor, G., . . . Yeatts, K. (2011, April). Provider Demonstra- tion and Assessment of Child Device Technique During Pediatric Asthma Visits. Retrieved from http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3065074/ 13. Shams, L., Wozny, D. R., Kim, R., & Seitz, A. (2011, October 18). Influences of Multisensory Experience on Subsequent Unisensory Processing. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198541/ 14. Fenerty, S. D., West, C., Davis, S. A., Kaplan, S. G., & Feldman, S. R. (2012, February 10). The Effect of Reminder Sys- tems on Patients’ Adherence to Treatment. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287416/ 15. Huang, H., Li, Y., Hsieh, Y., Kuo, F., Tsai, W., Chai, S., Lin, B., Kung, P., & Chuang, C. (2013, November 16). Effects of and Satisfaction with Short Message Service Reminders for Patient Medication Adherence: a Randomized Controlled Study. - PubMed - NCBI. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/24238397 16. Enriquez, J. (2014, October 13). Medication Adherence Technologies Take Center Stage - nuviun content library. Retrieved from http://nuviun.com/ content/medication-adherence-technologies-take-center-stage 17. Lakatos, P. L. (2009, September 14). Prevalence, predictors, and clinical consequences of medical adherence in IBD: How to improve it? Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744179/ 18. American College of Preventive Medicine. (n.d.). Medication Adherence Time Tool - American College of Preventive Medicine. Retrieved from http:// www.acpm.org/?MedAdhereTTProviders 19. Lowes, R. (1998, March 5). Patient-Centered Care for Better Patient Adherence - Family Practice Management. Re- trieved from http://www.aafp.org/ fpm/1998/0300/p46.html 20. Practicing Clinicians Exchange. (2011). Strategies for Increasing Adherence. Retrieved from http://www.practicingcli- nicians.com/crohns4/crohns5.html 21. Health Prize. (2015). The physician’s view of medication nonadherence. Retrieved from http://static.correofarmaceu- tico.com/docs/2015/02/20/encuesta_ adherencia.pdf

22. Martin, L., Williams, S., Haskard, K., & DiMatteo, M. (2005, September). The challenge of patient adherence. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1661624/ 23. Jha, S. (2014, November 17). Patient Non-adherence: Perceived Challenge or Next Big Opportunity - Business Today. Retrieved from http://businesstoday. intoday.in/story/pharmaceutical-companies-digital-health-start-up-drug-com- panies/1/211981.html

© 2016 Noble® International, Inc. All rights reserved. Products shown do no contain medication or a needle and are intended for training purposes only. Multiple Patents Pending.