Cutting Costs by Cutting Pills

According to some disturbing data released yesterday by the CDC, many US adults aren’t following doctor’s orders. And it’s not just the very young or very old, who, it could be claimed,  don’t know any better.

It turns out that adults under the retirement age are twice as likely to skip their prescribed medications in order to save money to save money.

And although spending on drugs is expected to increase an average of 6.6% a year from 2015 through 202, 20% of adults regardless of age, have asked their doctors for a lower cost treatment.

Americans spent $45 billion out-of-pocket on retail prescription drugs in 2011. But, “if you’re not insured or you face high co-payments, you’re going to stretch your prescriptions,” says Steve Morgan, an associate professor at the University of British Columbia’s School of Population and Public Health in Vancouver. “Even among insured populations, there is this invincibility mindset among the very young. Older people are more likely to adhere to chronic therapies over a longer period of time than younger.”

The study also found that 13% of those ages 18 – 64 reported not taking their medications as prescribed to reduce costs compared with 5.8% of those 65 and older.

Strategies that alter the way adults take their medications include skipping doses and consuming less than the prescribed amount. About 11% of those aged 18 – 64 also delayed filling a prescription compared with 4.4% of those 65 and older.

Uninsured adults were more likely to have tried to stretch their medications than those with Medicaid or private insurance.

But are such savings worth it? Failing to take medication as prescribed may actually increase costs to the U.S. health system, particularly if medication non-adherence results in increased hospitalizations, or complications of chronic diseases.

Anytime a patient chooses not to take drugs as prescribed, the pharmaceutical industry pharma loses sales. A recent study estimated that pharma loses $564 billion globally to non-adherence to drugs. Not surprisingly then, the industry is experimenting with reminders, to increase adherence. Nevertheless, a nudge from a text or a talking pill container might not inspire patients who are penny pinching.

I’d love to stay and chat, but I need to run to the pharmacy to refill my blood pressure meds that I ran out of several days ago!

i-Nhaler i-Mprovement?

Asthma is one of the world’s most common chronic diseases, affecting some 300 million people and almost 5 percent of the world’s population. It’s also the 5th most costly condition in the US  – an estimated at $56 billion annually. But as we’ve reported here previously, a significant number of people with asthma either don’t use their asthma medications or use them incorrectly.

Improving asthma control is known to reduce the cost of treating asthma by eliminating unnecessary hospitalizations, ED visits, and office visits. The additional cost of an uncontrolled asthma patient compared to a controlled asthma patient is estimated at $3,000-$4,000  per patient annually.

So, we were interested to learn last week that the FDA approved a sensorized asthma inhaler that can track usage and transmit the data to a smartphone and the web. The manufacturer – Asthmapolis will begin to market the asthma sensor and both English and Spanish language versions of the companion software in the US very soon.

“Our mission is to make it easier for patients and their physicians to do a better job of managing asthma with less effort than traditionally required.” said David Van Sickle, co-founder and CEO of Asthmapolis.

The small and lightweight device attaches to the end of most inhalers, and the app tracks the time and location of each medication discharge and reminds patients to use it if they forget.

In clinical studies of the Asthmapolis system, uncontrolled asthma declined by 50%, and more than 70% of patients improved their level of control.  In addition it can identify trends in a patients asthma triggers and symptoms over time and provide patients with personalized education on how to improve their asthma.

Not only will the device talk directly to the patients, physicians and other health care providers will be able to identify, in near-real-time, patients with uncontrolled disease and attend to them before they suffer a severe exacerbation.

“Despite all we know about asthma and how to treat it, the majority of patients still do not have the disease under control, and traditional approaches to self-management have been time-consuming and complicated,” said Inger Couture, chief regulatory officer of Asthmapolis. “The Asthmapolis technology makes it much easier to track symptoms and use of metered dose inhalers, allowing patients, their families and their doctors to gain a valuable new perspective on the disease.”

And that can only be a good thing.

Prescriptions, Physicians, Patients and Payers: Let the battle commence!

Last week the FDA announced that it wants to remove obstacles to America’s most commonly used drug treatments.  If the Agency gets its way, some drugs used to control chronic conditions, such as high cholesterol, diabetes and asthma may soon be available without prescription.  But in doing so, they have reopened a  big can of worms. One that brings into question the very nature of health reforms, preventative medicine and improved access to healthcare.

Here’s the proposal: The FDA would create a new class of “safe use” drugs. While consumers would not need a prescription, they would still need to get clearance from a pharmacist or from specially designed websites to purchase them.

Battle lines are being drawn! With physicians on one side, and patients, pharmacists, pharma and payers on the other.

Doctors are most definitely not thrilled by the idea. Removing the prescription requirement for an inhaler refill, for example, doctors fear they would be taken out of the loop on everyday care decisions.

Insurers, on the other hand are embracing the move. They recognize that they could save big bucks if physician visits weren’t required for run-of-the-mill complaints and ongoing medication monitoring. They might even save on the costs of the drugs themselves because, depending upon how they’re classified, most health plans don’t pay for over-the-counter treatments.

Pharmacists see it as validation of their expertise and pivotal role in primary healthcare and the pharmaceutical industry, who has repeatedly asked for permission to sell such drugs over-the-counter, must surely be cautiously optimistic.

Even normally conservative regulators are supporting the move. “Greater over-the-counter and behind-the-counter access will lower costs and make healthcare more accessible to consumers,” former FDA commissioner Scott Gottlieb said via Twitter. “It’s a good idea, long overdue.”

Even so, the FDA will have a fight on its hands as it moves to turn its proposal into reality. The American Medical Association lambasted the idea in USA Today, saying that patients need guidance from doctors. The doctors’ association also points out that giving patients more control could complicate coordinating care, such as, tracking all the drugs a patient uses to prevent interactions.

But, as The Washington Post points out, FDA sees the doctor’s visit as a hindrance to care; some patients don’t seek treatment if they have to see a physician first. “Obviously, it’s much easier for you to go to your drug store and pick up an item than it is to make an appointment, take a prescription, drop it off and get it filled,” says Nancy Chockley, president of the National Institute for Health Care Management.

About 20% of prescriptions written in the United States currently go unfilled. Removing obstacles that keep Americans from managing their own health care is, according to one patient, namely me, a good thing.

The FDA contends, and I agree, that some consumers may not even go as far as getting a prescription because of the “cost and time required to visit a health-care practitioner.  Earlier this month, I stood in line at my local pharmacy for thirty minutes to pick up a refill prescription for blood pressure meds. On reaching the end of the line I was told that there was no prescription. The pharmacist called my doctor and the lack of prescription was confirmed. I called my doctor and was told I would need to make an appointment to have the prescription renewed. I pointed out that I had done that one month earlier and that nothing had changed regarding my health. I was then informed that it was a new policy to issue prescriptions on a month-by-month basis rather than provide automatic refills. Even when I pointed out that I have a chronic condition that I’m doing my best to manage and part of that management is the medicine I have been taking for years, they wouldn’t sway. No doctors visit, no prescription.  And the kicker, I couldn’t get an appointment to see my doctor for a week…meaning, I had to go 7 days without blood pressure meds, all so my doctor could better manage my care!

Practicing medication adherence is very hard when your doctor won’t give you medication…and leaves me wondering if this policy change had more to do with revenue generation than improving chronic disease management.

My personal experience aside, at the heart of this discussion is a fundamental disagreement over what role doctors play in managing patient care. The FDA proposal views a trip to the physician as a hindrance to care, whereas doctors see that visit as crucial, especially as chronic conditions become increasingly prevalent.

The FDA proposal is still in formative stages, meaning there’s still a lot of space for this debate to evolve. Where the discussion heads on this particular issue could end up guiding health policy on what role doctors play in managing patient care – and, at what point, the patient takes charge.

I, for one, can’t wait to see how it plays out, assuming of course that I’m not dead from uncontrolled hypertension!

A Question of Health

As we’ve said before, and will doubtless say again – the more patients become more actively involved in their own health, the better the outcome.

So we were pleased to learn of a new public education initiative from the U.S. Agency for Healthcare Research and Quality (AHRQ), which encourages patients to have more effective two-way communication with their doctors and other clinicians.

The “Questions are the Answer,” campaign features a website packed with helpful advice and free educational tools for doctors and patients. Among the offerings:

• A 7-minute video featuring real-life patients and clinicians who give firsthand accounts on the importance of asking questions and sharing information. The video has been designed for use in a patient waiting room area and can be set to run on a continuous loop
• A brochure, titled “Be More Involved in Your Health Care: Tips for Patients,” that offers helpful suggestions to follow before, during and after a medical visit
• Notepads to help patients prioritize the top three questions they wish to ask during their medical appointment.

In addition, the site has a series of patient and clinician videos in showing how simple questions can help you take better care of yourself, feel better, and get the right care at the right time. In one of these, Rachelle Toman, M.D., Ph.D., a family physician from Washington D.C., says if you are happy to ask your doctor and grocery store clerk a question, then why not your healthcare provider?

“Patients need to come forth with questions, and providers need to be open about asking their patients questions, and asking their patients to ask questions,” she continues.

Put simply, questions allow doctors to take better care of you.

Are you ready to become an active member of your health care team and get your questions answered?

Drugs That Can Land You in the Emergency Room

It’s midnight at the fire station and a call goes out for a patient who has overdosed. In addition to an ambulance and medic unit, police are dispatched.  As we stage for the police, to ensure that the scene is safe, we speculate as to what we’re going to encounter. Will the patient be conscious? What sort of emotional distress has driven them to this? Is it a serious attempt or a cry for help?  Will there be weapons?

As we mentally run through all types of scenarios, it’s doubtful that many of us have considered that our patient will be an 82 year old great grandmother armed with nothing more than her reading glasses and the remote control.

But increasingly that’s what we might find.  As Americans live longer, we have an increasingly frail population suffering from a greater number of chronic conditions, taking more medications than ever before. Among adults 65 years of age or older, 40% take 5 – 9 medications and 18% take 10 or more.

This type of polypharmacy is associated with an increased risk of adverse events. Older adults are nearly seven times as likely as younger persons to have adverse drug events that require hospitalization.

According to a recent article in the New England Journal of Medicine blood thinners and diabetes drugs cause most of the unintentional overdoses that lead to emergency hospitalization in older patients.

Researchers reviewed the records of 100,000 hospitalization events due to major drug side effects in people aged 65 and above from a representative sample of 58 hospitals.  Almost half, (48%) of adverse drug event (ADE)-related hospitalizations occurred in patients older than 80.

The drugs they looked at included prescription and over-the-counter medications, vaccines, and dietary supplements.

Adverse events were categorized as allergic reactions, undesirable pharmacologic or idiosyncratic effects at recommended doses, or unintentional overdoses.  Other effects included problems due to medication-delivery methods (e.g., choking) and vaccine reactions. Visits for intentional self-harm, drug abuse, therapeutic failures, and drug withdrawal were excluded.

Shockingly, just four medications accounted for more than two-thirds of emergency hospitalizations:

• warfarin (a blood thinner to prevent clots) – 33%
• oral antiplatelet agents (for heart attack prevention) – 13.3%
• insulin (for diabetes) – 13.9%
• oral hypoglycemic agents (for diabetes) -10.7%

Given that emergency hospitalizations caused by ADEs result in significant morbidity and enormous costs it’s not surprising that decreasing harm to patients and reducing costs by preventing re hospitalizations is a goal of the $1 billion federal initiative Partnership for Patients.

Achieving a 20% reduction by the end of 2013 may sound ambitious, but in fact there are a number of simple steps that we can take.

1. Make sure that everyone taking medications has an up-to-date list, including all prescribed drugs as well as vitamins, herbs, and OTC medicines. Copies of the list should be kept in their wallet and should be shared with all doctors they see so that the potential for drug interactions can be assessed and avoided.
2. Alert your loved ones that blood thinners and diabetic medicines account for 50% of hospitalizations due to ADEs. Blood thinners and diabetes medications should be regularly monitored by the primary care physician.
3. Encouraging medication compliance can lengthen a person’s lifespan. Too many times patients stop their medications due to a comment made by a well-meaning friend who has  read something on the Internet. Often the doctor is not informed and the patient may not understand the positive effects of the medication or the dangers of stopping them suddenly.

These small measures may not only save the life of your elderly loved-ones, but they may also  reduce your Word on Health bloggers’ middle of the night 911 dispatches.

Improving Inhaler Instruction

Many of us have never been properly trained on how to do or use certain things we really should be good at. Putting on condoms and wearing seat belts are just two that come to mind.  And when we get them wrong, the health consequences can be serious.

The same goes for asthma inhaler use.  Do you shake the device first? Did you breathe in with sufficient force? Did you press the canister at the right time?

Improper use of inhalers is a serious and expensive problem. In the US, 3 patients are admitted to the emergency room with asthma every minute, that’s >5,000 people a day!  Worse still, according to the Asthma and Allergy Foundation of America, 11 people die from asthma every day.

One study estimated up to 94% of patients use their inhalers incorrectly.  The most common mistakes include failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Those of us in healthcare have even seen patients who fail to take the cap off the inhaler before use, and others who use it nasally rather than orally.

This is hardly surprising given that many patients never receive instructions on how to use their inhalers and even those that do, are not routinely followed.  And let’s face it, some of these devices could use training wheels.

Enter the T-Haler, a digital asthma inhaler training device  developed by researchers at Cambridge Consultants.

Patients with asthma can use the inhaler and, via interactive software linked to the wireless device, get real-time visual feedback on the areas that need improving.

Specifically, whether patients have shaken the device before breathing in; whether they use sufficient force when breathing in; and whether they press down the canister that releases the drug at the optimal time. Click here to see a video of the T-haler in action.

Although still a conceptual product, the company says it has been designed as a training device to be available at pharmacies, schools, and clinics for children and adults alike.

They performed a study on 50 people aged 18 – 60 who had no prior experience with either asthma or inhalers and were given no instruction on how to use an inhaler. When tested, about 80% of the participants used an inhaler incorrectly.

They were then given the T-Haler with no further instruction and told to begin. A three-minute on-screen tutorial guided them through the proper use of an inhaler, and the success rate tripled to more than 60%.

“Without any human direction beyond the word ‘go’, participants went from around a 20% success rate without training to a success rate of more than 60% after only three minutes with the T-Haler device,” said Kate Farrell, a senior design engineer, in a news release. “This is more than twice the compliance rate we have seen in other studies with trained participants. Interestingly, a week later, 55 percent were still correctly using the device-showing that they retained what they learned.”

Whether the T-Haler itself will ever make it to market remains to be seen, but the concept of a 3-minute training device seems a no-brainer when it comes to properly using a device that may very well save the lives of the estimated 235 million asthma sufferers worldwide.

Pills That Pack On Pounds

If you are one of those people who are overweight  and would love to blame something other than too much food or lack of exercise, this blog is for you.

According to the Harris County Hospital District’s Drug Information Center, weight gain or loss may not always be attributed to lifestyle. For some, it’s due to the medicines they’re taking.

Certain meds can cause significant weight changes. For example, weight-related side-effects are common in medicines taken by patients with diabetes, high-blood pressure and mental health conditions.

Those likely to experience weight increase include people taking steroids and women on birth control, while those taking antidepressants such as Prozac® and Wellbutrin® are likely to lose weight.

However, this does not mean you should immediately start making changes to your medication regimen. Drugs are weird. They do different things to different people and it’s often impossible to predict which people will have which side effects from which drugs.

“Because of the stigma of weight gain, patients may tend to stop taking their medicines or decrease their dosage without talking to their physician,” says Ryan Roux, PharmD, chief pharmacy officer, Harris County Hospital District. “Doing this is a bad thing. It can affect your health in a number of negative ways.”

Instead, it’s important that you tell your physician about any weight changes and then reassess the drugs or dosages taken. The more you can become actively involved in your treatment and be informed about long-term medication use, the better.

Not sure if the meds you’re taking could be to blame?

SRxA’s Word on Health brings you a list of some common medications and their weight side effects listed both by brand and generic name:

Diabetes

Weight promoting

• Actos® (pioglitazone)
• Amaryl® (glimepiride)
• Insulins

Weight loss or weight neutral

• Byetta® (exenatide)
• Januvia® (sitagliptin)
• Symlin® (pramlintide)
• Metformin
• Precose® (acarbose)

Hypertension

Weight promoting

• Lopressor ® (metoprolol)
• Tenormin® (atenolol)
• Inderal® (propranolol)
• Norvasc® (amlodipine)
• Clonidine

Antidepressants

Weight promoting

• Paxil® (paroxetine)
• Zoloft® (sertraline)
• Amitripyline
• Remeron® (mirtazapine)

Weight loss or weight neutral

• Wellbutrin® (bupropion)
• Prozac® (fluoxetine)

Antipsychotic

Weight promoting

• Clozaril® (clozapine)
• Zyprexa® (olanzapine)
• Risperdal® (risperidone
• Seroquel® (quetiapine)
• Lithium
• Valproic Acid
• Carbamazepine

Antiepileptic Drugs

Weight promoting

• Carbamazapine
• Neurontin® (gabapentin)

Weight loss or weight neutral

• Lamictal® (lamotrigine)
• Topamax® (topiramate)
• Zonegran® (zonisamide)

As always, we advise – for more information about the effects of medicines, consult your physician or pharmacist.

I Resolve to Lower My Expectations!

After the over-indulgence of the past few days, are you planning to make New Year’s resolutions? If you’re like the rest of us, chances are, you’re probably going to break them too! Most resolutions, although fuelled with good intent, are little more than clichés and empty promises.

How many of us, wake up a little groggy on January 1^st swearing we’re never going to drink /smoke/stay up all night/ (_*******) again?

If, like thousands of others, your noble intentions fall by the wayside before January is out, we have some advice that might just help.

William McCann, Psy.D, a clinical psychologist at Wake Forest Baptist Medical Center says “I think most people make resolutions that they don’t achieve because they seem so overwhelming.”

He recommends that we should make resolutions that we are sure to be able to follow through on. In other words if you want to be able to say “I did it!” next December 31^st, you need to lower your expectations.

McCann’s sample list of attainable New Year’s resolutions:

• I will eat a little less fried food this year.
• I will drive a little more slowly this year.
• I will help others a little more this year.
• I will interfere in my children’s lives a little less this year.
• I will talk a little less and listen a little more.
• I will smile a little more this year.
• I will be a little better person than I was last year.

Me?  I’m going to try a little of all of the above!  Share your resolutions with us – those you’ve tried, those you’ve failed. We’d love to hear from you.

Daily Asthma Treatment No Different from Intermittent Treatment in Toddlers

As most parents of toddlers with asthma know, a daily dose of an inhaled steroid is usually prescribed to keep the frequent bouts of wheezing at bay. But, the results of a recent study published in The New England Journal of Medicine could likely change all that.

A group of pediatric asthma researchers nationwide, found that daily inhaled steroid treatment was no better at preventing wheezing episodes than treating the child with higher doses of the drug at the first signs of a respiratory tract infection.

They also found that daily treatment was comparable to use of the inhaled steroid intermittently at decreasing the severity of respiratory-tract illnesses, reducing the number of episode-free days or school absences, lowering the need for a “rescue” inhaler for acute asthma symptoms, improving quality of life or reducing visits to urgent care or the emergency room.

The researchers, from the National Institutes of Health (NIH)-funded Childhood Asthma Research and Education (CARE) Network, studied nearly 300 preschool-age children with frequent wheezing in a trial called MIST (Maintenance and Intermittent Inhaled Corticosteroids in Wheezing Toddlers).

“We wanted to understand how to best treat young children who have repeated episodes of wheezing, most of whom appear symptomatic just when they have colds,” says Leonard B. Bacharier, MD, a Washington University pediatric asthma and allergy specialist at St. Louis Children’s Hospital. “Our goal was to start therapy at the first signs of a viral respiratory tract infection or cold to interrupt or slow the progression of symptoms. This trial was aimed to try to prevent wheezing severe enough that requires oral steroids and really gets in the way of children’s lives.”

Children in the yearlong MIST trial were between 12 and 53 months old, had recurrent wheezing and were at high risk for a worsening of asthma-like symptoms that could require treatment with oral steroids and/or a visit to urgent care or emergency room. During the trial, the children received either a dose of budesonide once a day through a nebulizer or a placebo.

At the first signs of a respiratory tract illness, those children who received the inactive placebo received a higher dose of budesonide twice a day, while those who received daily budesonide received a placebo twice daily and kept taking their regular budesonide. Neither the patients nor the physicians knew who received the active drug until the trial was over.

During the study, parents were asked to keep a daily diary of symptoms, such as coughing, wheezing, difficulty breathing or other symptoms that interfered with normal activities, as well as a list of medications, visits to a health-care provider or absences from daycare or school.

Because previous studies had shown that daily inhaled corticosteroid therapy was more effective than placebo, the researchers expected to see the same in the MIST trial. But that’s not what they found.

“The two groups were comparable in terms of episodes requiring oral steroids, symptom days, albuterol use and the time before oral steroids were needed,” Bacharier says. “All of the relevant indicators of disease activity were comparable.”

These results indicate that there are a variety of treatments physicians can consider for children with frequent wheezing, who are not compliant with daily therapy.

A quarter of patients do not fill new prescriptions

As our regular Word on Health readers will know, I’ve had more than my fair share of trips to the pharmacy recently.  Painkillers, antibiotics, anti-inflammatories…the list goes on.  It’s not that I like taking tablets, I needed them.  Having taken time out of my busy life to see a doctor and get a prescription it would never occur to me to leave it languishing in the bottom of my purse.  However, according to a new study almost 1 in every 4 American’s does just that.

The study, published in the November issue of the American Journal of Medicine, evaluated more than 423,000 e-prescriptions written in 2008 for more than 280,000 patients. It was conducted by researchers at Harvard University, Brigham and Women’s Hospital, and CVS Caremark, who matched e-prescriptions with resulting claim data or those who did not claim prescriptions within 6 months.

What they found was that 24% of patients given a new prescription did not fill it. This percentage is higher than that seen in earlier studies.

“While some recent research has used e-prescribing data to evaluate primary non-adherence, we were able to study a nationwide sample of patients. Our finding that 24% of patients are not filling initial prescriptions reflects slightly higher primary non-adherence than seen in earlier studies,” said Michael Fischer, MD, MS, with Brigham and Women’s and Harvard Medical School, and lead author of the study.

Most prior research about medication adherence could not review prescriptions that were never filled by patients. However, the advent of electronic prescribing has provided an opportunity to track initial prescriptions that may have been previously undetected and gives healthcare providers a broader look at patients who never fill their prescriptions.

Researchers said the factors that are predictive of primary non-adherence include:

• the out-of-pocket cost of medications
• socioeconomic factors
• the integration of doctors’ health information systems
• the types of medications.

Prescriptions that are sent directly to mail-order systems and pharmacies are more likely to be filled than e-prescriptions that doctors print out and give to patients, according to the study. The researchers found that medications for hypertension and diabetes resulted in primary non-adherence rates in excess of 25%, while prescriptions for antibiotics and medication for infants were almost always filled.

SRxA works closely with a number of leading health outcomes experts and specializes in providing effective patient adherence programs.  Contact SRxA today to learn more.