Experts | University of the Sciences

Health Literacy: Recognizing the Need for Better Communication

In 2003, the National Assessment of Adult
Literacy found that only 12% of Americans were proficient in health literacy. As defined by the Patient Protection and Affordable Care Act of 2010, health literacy is the “degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions.” By the basis of this definition, literacy rates do not directly correlate with health literacy rates. The fact that nearly 9 out of 10 Americans experience difficulty when using everyday health related information that is readily available sheds light on the need for interventions to improve communication.

Researchers have found that low health literacy can be a major contributing factor to poor medication adherence, which together, can impair treatment success for patients. Simply put, if patients are unable to understand what medications they are taking and how they should be taking them, clinicians cannot expect clinical benefits from their prescribed treatment regimens. It is in these instances that the utility of the pharmacist can be appreciated. As one of the most readily accessible health care providers, pharmacists are a in a unique position to improve provider-patient
communication and bridge any gaps in misunderstanding that are caused by health illiteracy. For example, upon discharge from a hospital, patients are often bombarded with packets of discharge paperwork, lists of medications and a stack of new prescriptions. One study that examined the
relationship between health literacy and hospital reutilization found that patients with low health literacy were more likely than patients with adequate health literacy to return to the hospital or emergency room within 30 days of discharge. If a pharmacist could determine the health literacy level of the patient and counsel accordingly, patients would be able to walk away with an enhanced understanding, which could provide the foundation for medication adherence and potentially reduce re-hospitalizations. The issue is that at this time, it is not so easy to determine what level of health literacy patients fall into so it would be especially difficult to determine this in a quick visit to a retail pharmacy. However, with improved patient-clinician interactions, health literacy levels could be determined more efficiently thereby paving the way for patient-specific solutions.

While there is no Hooked On Phonics approach to improve health literacy, steps have been made in the right direction. As an objective of Healthy People 2020, health literacy and the knowledge of its
barriers  are getting an increasing amount of attention. As initiatives like the National Action Plan to Improve Health Literacy tackle the issue head on, clinicians can implement strategies to shorten the gap in misunderstanding and thereby improve health outcomes.

Anita A. Pothen, PharmD ‘14

Medication Adherence: Would You Accept the Challenge?

Adherence and compliance are commonly used terms when referring to patients taking their medications as prescribed. While both of these words have their own connotation, one term suggests a more collaborative effort. Concordance implies that patients and doctors have an interactive dialogue, which produces a mutual understanding of treatment regimens thereby increasing the likelihood of adherence. While prescribers and pharmacists would be ideal advocates of medication concordance, they are often unable to provide the necessary dialogue because of time constraints. Observant of this lapse in care, initiatives around the nation have begun to embark on improving adherence.

One initiative is the Script Your Future campaign launched by the National Consumers League, which aims to spread awareness about medication non-adherence. Script Your Future shapes an integrated approach by incorporating various health care providers with a number of public and private partners to address the issue comprehensively. The campaign also provides adherence tools, action plans and other resources to both the patient and the provider to improve adherence. Aside from initiatives like Script Your Future, medication adherence has become integral component in many national efforts, including Million Hearts^TM and the National Council on Patient Information and Education. Such programs recognize that the success of patients adhering to medications is based on interaction and patient empowerment.

What is especially encouraging about campaigns like these is that they provide a great opportunity for student pharmacists to get involved and expand their knowledge about medication adherence.  Employing pharmacy students in this effort sheds light on a viable solution to address the issue that many clinicians simply do not have the time for. Pharmacy schools around the nation have even teamed up with other health care disciplines to take on the challenge of creating innovative methods to promote adherence. Recently, a research study found that pharmacy students are not always getting enough education on adherence while in school. By engaging and motivating students to come up with new ideas to tackle medication non-adherence, students are able to develop their own understanding while helping patients at the same time.   

As initiatives around the nation continue to deploy this reserve of medication adherence activists, we see a new way to achieve clinician-patient relationships that will be increasingly concordant without
increasing the burden on the provider. What can we take away from all of this? The tools are there; the people are there; the interest in patient care is there. It is now up to the current clinicians to amalgamate these forces to produce a harmonious solution to medication non-adherence.

Anita A. Pothen, PharmD ‘14

Money Makes the World of Big Pharma Go Round

“Money makes the world go round” –whether you first heard the idiom in the 1960’s musical “Cabaret” or as the title of an R&B song by R. Kelly, the popular phrase is highly relevant to the pharmaceutical industry (pharma).   According to the World Health Organization (WHO), the global pharmaceuticals market is worth $300 billion a year. The Centers for Medicare and Medicaid Services found that retail prescription drug spending in the US rose to $263 billion in 2011, and did so at a faster rate compared to previous years. This rise was attributed to increased prices, especially for new and existing brand name medications. Following this trend, pharmaceutical companies are striving to what they do best—increase profits. A key component that has been linked to lead down this route of increased profits is medication adherence.

The logic seems simple enough—if  pharmaceutical companies can entice patients to remain adherent to their drugs, they can maximize profits while the patients attain the clinical benefit. Existing patients may stop taking a certain medication for any number of reasons, including costs.  Having recognized this, companies are attempting to offset the costs of losing customers by investing in incentives to keep them adherent. Pharmaceutical companies like Merck, Astra Zeneca, and GlaxoSmithKline are providing funding to patients in an effort to keep patients taking their medications. Aside from traditional coupons and vouchers, there is an increased effort in tackling the costs with patient assistance programs. For example, if a patient needs a product made by Shire, they can apply to get assistance for that medication that they otherwise would not be able to afford. While there are many groups like the Partnership for Prescription Assistance, which help patients identify companies and other affiliates that are willing to contribute to costs, one may wonder what incentive the companies who make these drugs have to give them out for free. A look at the 2011 report from the Capgemini Consulting group could explain. This report found that on average, it costs pharma 62% more to market to new patients versus the costs of keeping existing ones.

While it would be comforting to know that pharmaceutical companies are funding medications for the sole satisfaction of increasing accessibility of costly drugs, it’s not pragmatic. Money does make the world go round—especially if you are talking about the $300 billion pharmaceutical world. While the palms of big pharma continue to itch, we can only hope they keep the importance of adherence on their minds.

Anita A. Pothen, PharmD ‘14

Forecasting Medication Non-Adherence: A Profitable Approach That Helps Patients

$290 billion a year—a study by the New England Healthcare Institute found this to be the amount spent in the United States as a result of medication non-adherence and other avoidable issues. An analysis by Capgemini Consulting estimated that $188 billion account for pharmaceutical industry losses in the United States for the same reason. With such considerable monetary losses in addition to the health risks associated with non-adherence, the profitable future for health information technology (health IT) is becoming increasingly apparent.

After recognizing the significant financial costs associated with non-adherence, many insurance providers are utilizing new initiatives based on health IT that aim to predict non-adherence in an effort to proactively address the issue. In early 2011, CVS Caremark introduced its Pharmacy Advisor™ Program, which pays special attention to patients with chronic conditions like diabetes, who are likely to be non-adherent.  In April of 2012, Express Scripts^® launched a similar predictive tool called ScreenRx, which detects risk for medication non-adherence and then subsequently provides personalized interventions for those patients. Additionally, companies like RxAnte^© and Allazo Health^© apply behavioral science, predictive analytics and claims data to formulate algorithms that will allow them to determine which patients would be at an increased risk for non-adherence. They then take it a step further by tailoring interventions according to patient characteristics.

So since there’s no magic crystal ball one can look into to predict medication non-adherence, how do these companies determine who to monitor and intervene with? The key to the above-mentioned initiatives is the incorporation of patient behavior in forecasting non-adherence.

One commonly used model in analyzing health behavior is the Health Belief Model (HBM). This model explains that a patient’s behavior when it comes to health is motivated and influenced by varying perceptions. In essence, the HBM finds that perceived susceptibility, perceived benefits, perceived barriers and perceived seriousness all contribute to decision making when it comes to health, which in this case, would be in reference to taking their medications.

So how relevant is patient behavior when it comes to medication non-adherence? Express Scripts^® found that 69% of medication non-adherence was attributed to patient behavior factors including simple procrastination and forgetfulness. With even more advancements in health IT, providers will be able to dissect and rationalize reasons for non-adherence and further analyze patient behavior to formulate optimal regimens that will save billions of dollars all while promoting better health outcomes.

 Anita A. Pothen, PharmD’14

Drugs Don’t Work in Patients Who Don’t Take Them

These are the words of former U.S. Surgeon General C. Everett Koop. While the concept is simple, practitioners have been researching and implementing innovative methods to get the point across. Before we look at this, let’s first define the terms.

Adherence, persistence, and compliance—in reference to patients taking their meds, these all mean the same thing right? Not necessarily. These seemingly synonymous words have their distinct differences and varying methods of measurement that should be considered. Simply put, compliance is represented by a percentage of doses taken as prescribed in respect to timing, dosage and frequency. On the other hand, persistence counts the days a patient has had their medications over time. If a patient is considered persistent, we can confirm that they have been taking their medications for “x” number of days. What we do not know is if they are adherent. Just because a patient is persistently taking their medication, we cannot assume they are following the regimen from their doctor. Adherence suggests that a patient sticks to their drug regimen as prescribed with respect to the drug, dosage, and frequency. Sounds like compliance right? While the terms are similar, compliance has a more passive connotation whereas adherence aims for a coordinated effort between the doctor and patient.

In particular, adherence can be cumbersome for patients who have suffered a myocardial infarction. Seeing that less than 50% of patients follow their heart medications as prescribed, the University of Pennsylvania Health System was awarded a grant from the Centers for Medicare and Medicaid Services that aims to improve adherence in these patients with an estimated savings of over $2.7 million over 3 years. As an incentive, patients are able to win money based on a lottery system with the caveat being that the patient must have had taken their medication the day before in order to be eligible. This will be determined by electrical signals sent from the bottle to the doctor, which seems similar to devices like MEMS^TM products. If patients do not take their meds, they risk not receiving a cash reward. By incentivizing compliance with partial reinforcement, researchers may make taking medications a little more enticing.

While this is only one approach, it is the overall goal of this study as well as many others to stress the importance of adherence, even if it means incorporating positive reinforcement. As indicated by the collaborative connotation of the word, the success of adherence lies on the input from the provider and the motivation of the patient.

Anita A. Pothen, PharmD ‘14

CER Lectures and program

University of the Sciences is hosting an informative three-part lecture series focusing on Comparative Effectiveness Research (CER).  The aim of the lecture series is to introduce the campus to the concept of CER and build a foundation of knowledge.  The lectures scheduled for January 30th, February 28th and March 28th.  The topics include CER and health information technology, CER and the use of real-world data and the future of CER.  Speakers include Dr. Jean-Paul Gagnon, Dr. Marcus Wilson and Dr. Sandy Schwartz.  All lectures will be held on campus.  For more information on the lecture series, go here.

This lecture series is a prelude to Mayes' College annual Making the Connections  program.  The Making the Connections program will highlight a panel of speakers from the pharmaceutical industry, payers, providers and patients who will be speaking about the impact of CER on their sector of health care.  The  Making the Connections program will be held April 16th, from 5:30-7:30 at USciences campus.

New Medication Bottles and Labels Improve Patient Compliance/Adherence

So does a new and improved label for a prescription bottle really improve patient compliance?  Similarly, does a flattened (versus a round) bottle make a patient take their medication more consistently? Would having all medications packaged in a blister pak alleviate the ailment of medication forgetfullness?   This Wall Street Journal article suggests that it does.  In fact, the research it points to does show that there is improved medication taking behavior.  But hold on, for those patients on multiple medications multiple times a day, would having 5-10 different sets of blister packs really help?  It might, but then again so would a well designed pill box with the days/times labeled and a translucent cover so that you can see if the medications were taken or not fairly readily.  These inexpensive boxes are reusable and do not increase the carbon footprint already associated with medications. 

As for the improve labels and bottles that are more easily readable - I am all for it!  As my eyes tire from writing this blog, I can only imagine how difficult it is to read the label on an 8 dram (very small) prescription bottle that is only ~2 inches high. 

My recommendation to anyone who takes a medication - be sure to incorporate it into your daily life - leave it near your toothbrush or take it with your meal (if OK with your pharmacist) or leave it by your bedside.  And if you need help on how to take your medication, ask your pharmacist. 

Brand Name and Generic Drug Manufacturers Teaming Up? Proper Drug Disposal as the Common Thread

Brand name and generic manufacturers are finding a reason to team up...against a local California municipality.  Alameda County passed a law requiring drug manufacturers to establish, and fund, a mechanism for consumers to properly dispose of their medications.  Proper disposal of medications will help minimize the environmental exposure to potentially harmful chemicals such as hormones, antibiotics and other drugs.  Most experts agree that a majority of the medications get into the environment through human and animal urine/feces containing the drugs or their metabolites.

Currently, sewage treatment plants are not designed to remove these substances so another strategy is to limit the exposure by preventing the drugs from getting into the environmnet.  Drug take-back programs, such as the one called for by Alameda county, are costly.  A similar program in British Columbia costs about 1/2 million dolllars a year to run, for about a population of 4 million people.  If this catches on, this would be a costly venture for drug manufacturers, to say the least

PhRMA, the Generic Pharmaceutical Association and the Biotechnology Industry Organization are jointly filing a lawsuit in the United States District Court in Oakland on Friday.   Only time will tell how this shakes out.  For more information, see the New York Times article . 

State-based Insurance Exchange bill vetoed in NJ

The fact that Chris Christie vetoed a bill which would have allowed insurance exchanges to operate in NJ indicates that he does not have confidence in the implementation of the insurance exchange program developed under the affordable care act.  New Jersey will default to the Federal Option.  NY and CT  declared moving toward a state-based exchange system while DE is utilizing the State Partnership Option    Selection of a state-based, federally based or state-partnerships must be declared to Secretary Sebelius by December 14, 2012.  State-based exchanges maintain control over which qualified health plans (QHPs) operate within the state while partnerships utilize a combined state/federal management model with the hope of transition to a fully-funded state-based exchange.  Those declining to establish a state-based exchange default to the federally managed option wherein the federal government will adopt a clearinghouse model and allow any QHP and will determine individual eligibility for tax credit and cost-sharing benefits.  Citing the unknown cost to the NJ residents, Christie opted for the federal option, also without knowing what the cost will be for the residents.   Only time will tell how this new healthcare world will unfold.

Proper Disposal of Medications - New Law in New Jersey

Governor Christie recently signed a bill put forth by Somerset County Sen. Christopher "Kip" Bateman (R-Somerset), requiring the state Department of Environmental Protection (DEP) to issue recommendations for the proper disposal of unused medications. Further, the bill requires health care institutions to submit to the Department of Health and Senior Services and the DEP a plan for proper disposal of unused prescription medications. Failure to implement these rules will result in fines for the health care institution.

Remember the following guidelines when disposing of personal medications:

1. Mix medicines (do NOT crush tablets or capsules) with an unpalatable substance such as kitty litter or used coffee grounds;

2. Place the mixture in a container such as a sealed plastic bag; and

3. Throw the container in your household trash For most medicines, DO NOT FLUSH them down the toilet. There are a few you can flush down the toilet - check with your pharmacist if yours is one of them.