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.

Should Pharma Pay Patients?

Paying patients to take their medicine. It may sound crazy, it may freak out compliance folks, but apparently it works. As previously reported by Word on Health, one -third to one-half of all patients do not take their medication as prescribed, and up to one-quarter never fill their prescriptions. These lapses cost more than $100 billion dollars annually because those patients often get sicker.

To combat this, both the US and Europe, have begun to use financial incentives to improve patient adherence. Here in the US, insurance companies have started to fund incentive schemes as they have found it costs them less in the long run if medication adherence improves. Last year, the New York Times published an article advocating the use of incentives to improve adherence. They cited a successful Philadelphia program whereby people prescribed the blood-thinner drug warfarin could win $10 or $100 each day they took the drug. A computerized Informedix Med-eMonitor pillbox recorded if they took the medicine and whether they won that day. Among patients enrolled in the program, the average amount of incorrectly taken pills or missed pills dropped from 22% to 2.3%.

Another study at Queen Mary’s hospital in London looked at the effect of incentives on the adherence of schizophrenia patients. Investigators found that offering financial incentives increased adherence, improved health and social outcomes and prevented rehospitalizations in 4 out of 5 patients. Preventing re-hospitalization saves a vast amount of money and is far better for the patient.

But, is paying patients really the answer? Maybe not.  A review of patient targeted incentives by The Health Care Foundation concluded that, while “financial incentives can work to bring about discrete, one-off changes in patient behavior…there is insufficient evidence to say that financial incentives can affect complex behavior change, although there is some evidence for temporary improvements.” The key words here are ‘one-off’ and ‘temporary’ – this is a short-term solution, not long-term. In both the aforementioned studies adherence went back down after the incentives finished.  In the study at Queen Mary’s, lead investigator and psychiatry professor Dr. Stefan Priebe admitted that, for most patients, you would probably have to keep the incentive going. The Philadelphia study showed similar results. However, given the potential long-term savings, if payments must continue indefinitely, Dr. Kevin Volpp said “it wouldn’t necessarily be a bad thing.”

So, is there another option? In 2004, Malotte et al. constructed one of the only incentive experiments that simultaneously looked at other methods of improving adherence. They compared different  methods to increase repeat testing in persons treated for gonorrhoea and/or chlamydia at sexually transmitted disease clinics. The results suggested that monetary incentive did not increase return rates. In this study, a reminder telephone call was the most effective intervention.

Although financial incentives work, they are not a realistic long-term solution. Better communication and patient empowerment appears to be the key. Find out how SRxA’s team of Health Outcomes specialists can improve your adherence programs.

Man develops own life-saving heart implant

A serious heart problem inspired a man with Marfan syndrome to develop a device that offers hope not just for himself but for thousands of other patients with the same condition.

In 2000, Tal Golesworthy, a process engineer from the UK, was told that the aortic root in his heart had expanded and was in danger of splitting. He had two choices; undergo surgery to insert a mechanical valve or risk a sudden and fatal heart attack.

The first option filled him with almost as much dread as the second. Surgery would involve cutting out the damaged section of the artery  and replacing it with a piece of tubing. It would also mean that he would be placed on warfarin, a blood-thinning drug, also used as rat poison, which carries the risk of severe bleeding. “That’s not something I wanted to rely on for the rest of my life,” said Golesworthy. “The thought of that dismayed me more so than the surgery.”

Golesworthy thought he could engineer a better solution. What excited him was the use of. He believed that by combining magnetic resonance imaging (MRI) and computer-aided design (CAD) with rapid prototyping (RP) techniques he could manufacture a tailor-made support that would act as an internal bandage to keep his aorta in place.

The concept, he hoped, would reduce the risk of harmful clots forming due to the mechanical valve and importantly, eliminate the need to take warfarin. Time was crucial if Golesworthy was to save himself. So he enlisted the help of Prof Tom Treasure, a cardiothoracic surgeon at Guy’s Hospital, and Prof John Pepper, a surgeon from the Royal Brompton Hospital.

“Although conceptually, it was very simple to do, the actual engineering was significantly more complex.” explained Golesworthy.

He set about devising a means of wrapping the aorta in a sleeve to prevent it expanding, and came up with a solution called Ears — external aortic root support — which is now being marketed through his firm, Exstent.    The team looked at a number of different processes, such as 3D embroidery, but ended up using a standard medical polymer, polyethylene terephthalate (PET) in a textile solution. The mesh weighed less than 5g, was an exact fit for the ascending aorta and could be sutured into place by the surgeon.  Each sleeve is created using scans of the individual patient’s aorta and computer-assisted drawing to produce a bespoke device.

The process, from proposal to final product, took just under two years.  “My aorta was dilating all through that period,’”said Golesworthy.

Golesworthy believes that projects such as this demonstrate that the interface between engineers and the rest of the world isn’t functioning in the way it should. “When it does function, huge advances can be made in a very short time period, on very little money,” he said. “We have changed the world for people with aortic dilation and we have done it on a fraction of the cost.”

In May 2004, Golesworthy became the first recipient of his own invention.  Since then, 23 patients have successfully had the implant fitted and another seven are hoping to undergo the procedure.

Word on Health is continually amazed at what people can do when their life is on the line. Although as  Golesworthy himself says “When you’ve got the scalpel of Damocles hanging over your sternum, it motivates you into making things happen.”