Biologic drugs are finding growing success in addressing chronic diseases — from diabetes and rheumatoid arthritis to multiple sclerosis and Crohn’s. A significant rise in self-injection therapies is contributing to the trend. And yet, a recent study1 of injection naïve patients found that only 50% reported receiving a visual representation of the self-injection from a healthcare provider (HCP). Moreover, only 13% reported having the opportunity to demonstrate the self-injection process on themselves in front of their HCP and to receive feedback.
The study explored deficiencies in training for patients who use self-injecting medical devices and sought to determine how pharmaceutical companies can better meet the disease management needs of these patients. It uncovered a mixed-methods approach to training practices and unmet needs of the patient and identified innovative opportunities to improve self-injection training.
A total of 42 participants completed the remote study. They included 24 biologic- and self-injection naïve patients across nine chronic disease areas and 18 HCPs across eight clinical specialties.
Inconsistent training practices
There is currently very little guidance on how HCPs should train patients, as product labels do not specify what constitutes adequate training. Nor is a requirement to train patients before permitting their self-injection universally applied, which can lead to inconsistent practices. In addition, HCPs often cannot adequately train patients, especially in the current healthcare environment where physicians must contend with shortened time blocks for each patient. What’s more, HCPs, pharma companies and patients disagree on who should be responsible for training patients.
The study suggests there are considerable gaps in training and patient support during biologic initiation and inconsistencies in formal demonstration and the opportunity to discuss proper injection device use. Responses from both HCP and patient participants support the premise that when device training does occur in an office setting, it is typically a time-constrained, single-instance event. The study also suggests that very little formal guidance is provided to HCPs on teaching patients how to self-inject, as nearly all HCPs reported relying on a trial-and-error approach to develop their practices. If HCPs are not properly trained on self-injection steps, this knowledge cannot be passed down to the patient.
Unmet patient needs
The study results determined that the emotional burden of self-injection is often not taken into account during HCP training. Patient anxiety can include concerns about incorrect technique, fear of side effects, lack of self-confidence, the stigma of illness and social embarrassment, frustration with illness and treatment, and anxiety associated with needles.
Training that focuses only on the mechanics of a device is not sufficient to relieve the patient’s apprehension and anxiety associated with self-injection. Even though patient satisfaction tends to be higher when both knowledge and emotional needs are met, HCPs may neglect the emotional aspects of training, which can cause otherwise capable patients to never start or discontinue their self-injection therapies.
Memory decay following the single-session approach is another factor working against the patient. Neuropsychologist Roy Kessels has determined that 40–80% of medical information presented by HCPs is forgotten immediately, and of the information remembered, only half is remembered correctly.2 His findings are supported by the forgetting curve theory, which postulates that 50% of the information HCPs give to their patients when prescribing a self-injection is forgotten within one hour, 80% is forgotten in two days, and 90% is forgotten in a week. This tendency is especially troublesome for patients on therapies with longer periods between injections, such as those where patients inject every 12 weeks, which can increase the possibility of patient recall issues.
Patient participants also discussed the shortcomings of materials offered by biologic brands.
Innovative opportunities to improve self-injection training
The study offered several recommendations to improve patient initiation when starting biologic therapy:
- Distribute injection training over a series of short, frequent sessions, rather than a single-instance event, to provide patients adequate time to absorb and retain the information.
- Provide patients with the resources to perform “just-in-time” training before injections in the early stages of their therapy. This approach makes training readily available exactly when and how the learner needs it.
- Develop ways to employ teach-back methods — whereby HCPs determine a patient’s understanding by their ability to repeat back information taught to them — through video or other means to access more patients and eliminate the reliance on in-person demonstration.
- Develop a structured, consistent resource for biologic initiation that establishes a standard for HCP communication strategies and instruction techniques.
- Emphasize the importance of patients establishing routines, managing emotions and adapting lifestyles to self-injection therapy, rather than relying solely on injection mechanics and safety.
- Reduce emotional overwhelm by empowering patients to develop personalized self-injection rituals, which studies show can help mitigate fears and anxieties associated with self-injection, leading to an increase in confidence.
- Encourage pharmaceutical manufacturers to implement alternative strategies for biologic initiation to ensure more predictable outcomes, given the limited time and resources HCPs have for training.
The current paradigm for biologic initiation does not meet the needs and expectations of patients prescribed a self-injection course of therapy. Development of more formal and structured training sessions, improved HCP knowledge and awareness of injection devices, use of demonstration devices for injection practice, and focus on both the emotional and mechanical aspects of training have the potential to increase patient confidence, reduce training burden on HCPs, and improve the probability of patient success on biologic therapy.
“The current paradigm for biologic initiation: a mixed-methods exploration of practices, unmet needs, and innovation opportunities in self-injection training.” Expert Opinion on Drug Delivery. June 2021.
- “Patients’ memory for medical information.” Journal of the Royal Society of Medicine. May 2003.
Joe Reynolds is the senior manager of strategy and patient insights for Noble, an Aptar Pharma company specializing in developing patient-centric drug delivery training devices and onboarding solutions for pharmaceutical brands.