Experts | University of the Sciences

The Need to Assess and Address Health Literacy

Health literacy is a topic that has been attaining increasing interest in the health care community. A recent article in US News & World Report cites research conducted by Kaiser Permanente and the University of Washington School of Medicine which found that low health literacy was correlated with poorer medication adherence. Given the fact that medication non-adherence costs an approximated $290 billion for the United States, improving health literacy is of prime importance.

To understand this, we must first understand what low health literacy means. Low health literacy
implies that individuals may be unable to carry out tasks as simple as comprehending the information on a medication label. According to the 2003 National Assessment of Adult Literacy, 36% of Americans may be unable to determine something as simple as the time at which a medication should be taken after reading a drug label. The issue of poor health literacy is further complicated by the difficulty of
identifying it. Patients may come into contact with a myriad of health care providers including, doctors, nurses, and pharmacists but may not spend enough time with any one of those individuals for health illiteracy to be assessed and addressed.

In order to address the problem, we must identify it. Following this logic, various health literacy assessments have been utilized as researchers search for novel, yet efficient means to identify the issue in the brief time that clinicians are able to interact with patients. Aside from clinicians, the
duty of addressing health literacy further extends beyond the scope of clinical practice. Health literacy plays a key role in any material that communicates ideas pertinent to health care. As a result, this applies responsibilities to various parties including the government, pharmaceutical companies, and educators.

While we may not always have all the appropriate tools or even the time to be able to classify individuals with low health literacy, it is important to keep the issue in mind. As new and improved assessment tools and interventions continue to develop, it would be wise to implement a
proactive approach of communicating health related ideas in a simple and concise manner which in turn would the benefit patient, providers and payors. 

Anita A. Pothen, PharmD ’14

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

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

What’s So Special About Specialty Pharmacy?

Released earlier this month, the 2012 Drug Trend Report by Express Scripts highlights the decrease in spending of traditional drugs by Americans. Notably, this decrease was offset by an 18.4% increase in the total spending for specialty drugs. As it varies based on patient need, specialty drugs can be defined as those that treat a complex disease state or require a more complex route of administration (i.e. intravenous). With specialty drugs making such a profound increase in costs, it is important to understand their special place in the market.

Following the profound importance of specialty drugs, there has been a subsequent increase in specialty pharmacies. Specialty pharmacies such as Burman’s and Walgreens focus on specific disease states like Hepatitis C, HIV, and Cancer and as a result, have specialty medications more readily available than the traditional community pharmacy. Additionally, specialty pharmacies possess the resources to tailor their services as necessitated by the patient’s condition, which can thereby improve medication adherence.

From a clinical standpoint, specialty pharmacy is especially enticing in its capacity to collaborate with other health care professionals to make optimal treatment interventions in addition to facilitating adherence. As evidenced by Fairview Specialty Pharmacy in conjunction with the University of Minnesota Medical Center, a multi-disciplinary team approach coupled with effective communication can synergistically improve adherence. In this instance, Fairview was able to work with providers to optimize the management of specialty drugs that treat Hepatitis C. According to the Centers for Disease Control, 3.2 million people are chronically infected with the virus. If that wasn’t enough, the drug costs associated with Hepatitis C increased by 33.7% in 2012. With such significant drugs costs on the rise, it is crucial that patients remain adherent to these medications. In a patient with a condition as serious as Hepatitis C, failure to take medications as prescribed puts them at an increased risk of not only costly hospitalizations, but also resistance to future drug therapy regimens which leads to even greater medical costs and potential for treatment failure. By avoiding this, we can see the potential of incorporating a specialty pharmacy. Research has shown that Hepatitis C patients who only used a specialty pharmacy had about an 8.6% increase in adherence as well as a 60% higher likelihood of achieving optimum adherence as opposed to those who used a retail pharmacy.

Thus far, specialty pharmacy has been making its mark. By focusing on conditions with intensive therapy regimens while giving managed care organizations the added benefit of consistent follow-up to ensure better patient adherence, third party providers have been able to cut costs. With its notable benefits from a clinical and financial standpoint, it is expected that specialty pharmacy will further develop as an increasing number of specialty drugs come out of the pipeline.

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

Medication Adherence—There’s An App For That Too!

Medication adherence has been a topic of interest for health care providers, caregivers and third-party providers alike. While practitioners work hard to select optimal drug therapy for their patients, clinical improvements may not always result as expected. This inefficacy in treatment often stems from the inability of patients to adhere to the treatment regimens set forth by providers. While many patients struggle to adhere to their  regimens for a number of reasons, technology-centered initiatives like the MediSafe^© Project are taking advantage of the utility of smart phone applications to steer consumers towards better adherence. MediSafe^® allows patients to scan drug barcodes, add directions and set alerts so that they are reminded to take them in a timely manner. If patients still fail to take their medication on time, the app can be synced to a loved one or caregiver so that they are alerted that the patient did not follow the regimen as indicated. iPharmacy^© is another app available at no cost that offers additional features along with medication reminders.  Some of these tools include a pill identifier, access to information pertaining to drug recalls and a pharmacy locator.

So what if the patient is not particularly keen on the idea of using a smart phone? After all, widespread popularity with smart phones lies predominantly with younger generations. While MediSafe^© in particular is working towards improving accessibility by implementing low-tech solutions, there are additional options already in place. EMMA^®, (Electronic Medication Management System) is an in-house, FDA-approved comprehensive management system for patients with complex medication regimens. EMMA^® houses blister cards of medications that are inserted into the machine like compact discs and can be remotely controlled by pharmacists. The system collects more accurate adherence information, which pharmacists and physicians can access. Though this technology provides considerable accuracy in adherence measurement, it is not a guarantee that all patients will be eligible for coverage and thus may not be able to afford the machine.

While all these approaches differ in one way or another, there is a common theme—improvement in adherence by means of a more involved and integrative strategy that aims to bridge the gap between practitioner initiatives and patient implementation. While finances and the adaptation of the senior population to advances in technology remain as limitations, there is a great deal of progress, such as NCPIE’s National Action Plan that paves the way for better adherence and ultimately, better health outcomes.

Anita Pothen

Pharm.D Candidate 2014

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 .