Review
Leveraging behavioral economics to promote treatment adherence: A primer for the practicing dermatologist

https://doi.org/10.1016/j.jaad.2021.05.049Get rights and content

The problem of suboptimal treatment adherence among patients with dermatologic or other diseases has not been adequately addressed in health care. Despite a wide range of efficacious therapies, nonadherence remains a primary driver of suboptimal clinical outcomes. Novel solutions to address this unmet need can be found in behavioral economics. By leveraging our understanding of human decision-making, we may better promote treatment adherence, thereby improving quality of life and decreasing economic burdens. Behavioral economics has been studied extensively in relation to topics such as health policy and health behaviors; however, there is a dearth of research applying this approach to chronic diseases and only a handful within dermatology.

We conducted a scoping review in PubMed to identify articles that discuss behavioral economics and its application to treatment adherence in dermatologic patients, with a particular focus on psoriasis, followed by a summary of key ethical considerations. We found that such principles can be employed in cost-effective, scalable interventions that improve patient adherence to a range of medical therapies and lifestyle modifications.

Introduction

Nonadherence to treatment is a pervasive and largely unacknowledged problem for those with chronic diseases, believed to account for over 100,000 avoidable deaths and $100 billion in unnecessary medical costs each year.1 Dermatologic conditions, which vary widely in pathology and treatment modalities, are not immune to this problem and similarly face suboptimal efficacy and safety outcomes as a result of nonadherence.2 This is perhaps best exemplified by psoriasis, a chronic inflammatory disease that affects an estimated 8 million Americans.3 This disease features a quality-of-life (QOL) burden comparable to that of diabetes mellitus or cancer, a financial burden amounting to an estimated $135 billion annually and low rates of treatment adherence.4, 5, 6, 7, 8 Despite the fact that multiple highly effective treatment modalities exist for psoriasis, an alarming 40% of patients do not adhere to their prescribed medications.9, 10, 11 This presents a serious concern for patients, as treatment adherence is necessary for the effective management of symptoms and sustained disease control.12 Moreover, improvements in adherence interventions may result in superior population-level QOL and economic outcomes than any improvement in specific medications.13, 14, 15 It is therefore essential that dermatologists explore novel approaches to increase treatment adherence in their patients.

In this article, we first discuss applications of select principles of behavioral economics to improve treatment adherence in dermatology using psoriasis as a disease model. Behavioral economics is an underutilized and potentially powerful strategy to better understand why patients may not take their medications as prescribed. Unlike traditional economists, who view people as rational actors consistently making decisions based on what will best further their self-interest, behavioral economists propose that human decision-making is irrational, yet predictably so.16

Underlying this concept is the Dual Process Theory, which describes 2 separate cognitive systems that simultaneously control choices: intuition (system 1) and reasoning (system 2). System 2 is characterized by thoughtful deliberation. System 1, the predominant force in guiding everyday decisions, is defined by quick, emotionally driven intuition that is repeated and observable.17 Behavioral economics in health care leverages these “predictably irrational” system 1 decisions to better encourage patients to make healthy choices, such as appropriately adhering to a therapy regimen.18

Central principles in behavioral economics that have been implemented and studied in health care settings include anchoring, decoy effect, framing, financial and social incentives, loss aversion, precommitment, present bias, regret aversion, and status quo bias (Table I).19, 20, 21, 22, 23, 24, 25, 26 Next, we briefly explore the ethical considerations related to the application of these principles.

Section snippets

Methods

We conducted a scoping review in PubMed on September 9, 2020 to identify articles that discuss behavioral economics and its application to treatment adherence in dermatologic patients, with a particular focus on psoriasis. When examples of the application of these principles in dermatology, or in psoriasis specifically, were not available, we searched for examples in other medical disciplines.

Conclusion

Patients with dermatologic diseases, like psoriasis, face high QOL and financial burdens comparable to those of other major chronic illnesses. While there exist several efficacious treatment modalities, suboptimal adherence necessitates the development of interventions that aim to overcome this obstacle. Behavioral economics offers promising approaches to the improvement of treatment adherence by leveraging our understanding of human decision-making. When used appropriately and in addition to

Conflicts of interest

Dr Merola is a consultant and/or investigator for Abbvie, Amgen, Bayer, Dermavant, Eli Lilly, Novartis, Janssen, UCB, Celgene, Sanofi-Regeneron, Biogen, Pfizer, BMS, and LEO Pharma. Drs Perez-Chada and Cohen, and Author Woodbury have no conflicts of interest to declare.

References (56)

  • C.S. Ahn et al.

    Adherence in dermatology

    J Dermatolog Treat

    (2017)
  • I.M. Michalek et al.

    Global Report on Psoriasis

    (2016)
  • G. Raho et al.

    The burden of moderate to severe psoriasis: an overview

    Pharmacoeconomics

    (2012)
  • E.A. Brezinski et al.

    Economic burden of psoriasis in the United States: a systematic review

    JAMA Dermatol

    (2015)
  • A.W. Armstrong et al.

    Pathophysiology, clinical presentation, and treatment of psoriasis: a review

    JAMA

    (2020)
  • M. Kamata et al.

    Efficacy and safety of biologics for psoriasis and psoriatic arthritis and their impact on comorbidities: a literature review

    Int J Mol Sci

    (2020)
  • S.H. Ko et al.

    Lifestyle changes for treating psoriasis

    Cochrane Database Syst Rev

    (2019)
  • M. Augustin et al.

    Adherence in the treatment of psoriasis: a systematic review

    Dermatology

    (2011)
  • M.J. Murage et al.

    Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review

    Patient Prefer Adherence

    (2018)
  • I. Belinchón et al.

    Adherence, satisfaction and preferences for treatment in patients with psoriasis in the European Union: a systematic review of the literature

    Patient Prefer Adherence

    (2016)
  • C.L. Carroll et al.

    Better medication adherence results in greater improvement in severity of psoriasis

    Br J Dermatol

    (2004)
  • N.A. Chaudri

    Adherence to long-term therapies evidence for action

    Ann Saudi Med

    (2004)
  • R. Horne et al.

    Concordance, Adherence and Compliance in Medicine Taking

    (2005)
  • R.B. Haynes et al.

    Interventions for helping patients to follow prescriptions for medications

    Cochrane Database Syst Rev

    (2002)
  • A. Tversky et al.

    Judgment under uncertainty: heuristics and biases

    Science

    (1974)
  • D. Kahneman

    Thinking, Fast and Slow

    (2011)
  • D. Ariely

    Predictably Irrational, Revised and Expanded Edition: the Hidden Forces That Shape Our Decisions

    (2010)
  • I.J. Bateman et al.

    Decoy effects in choice experiments and contingent valuation: asymmetric dominance

    Land Econ

    (2008)
  • Funding sources: None.

    IRB Statement: Not applicable.

    Reprints not available from the authors.

    View full text