Taking our medicine

Apparently even the promise of no co-payments isn’t enough to entice some patients to take their medication.

For those who missed it yesterday, a new study reported that when a group of heart attack survivors was offered prescription medication fully covered by their health plan, fewer than half took the drugs. In fact, the researchers struggled to even get enough people signed up to take part in the study.

Coverage by the Associated Press produced what surely must be the health care quote of the month, from one of the researchers who was involved in the study: “My God, we gave these people the medicines for free and only half took it.”

A quick summary: The study involved 5,855 adults who had recently been hospitalized with a heart attack and who had been prescribed one or more medications afterwards to lower their risk of another cardiac event. About half of them were prescribed preventive medications with no out-of-pocket costs; the rest were given prescriptions with the usual co-pay. At the end of one year, fewer than half of the patients overall were actually filling their prescriptions – and there were only minor differences in the adherence rate between those who had a co-pay and those who didn’t.

So what is up with that? Are patients so unwilling to comply with taking their prescribed medication that they can’t even be motivated by free drugs?

That’s certainly one way to interpret this study. But I suspect there’s more going on here than a straightforward case of collective noncompliance.

Adhering to a medication regimen involves multiple, interrelated steps. For starters, patients have to buy into the notion that they need medication and that it will somehow benefit them. They have to fill the prescription at the pharmacy. They have to remember to take the drugs each day, and take them correctly. They have to remember to get refills. They might have to deal with unwanted side effects. Adherence can go off the rails at any one of these critical points.

Although it’s often assumed that cost is a major influence on whether patients get their prescriptions filled, the NEJM study suggests that it perhaps isn’t as important as other factors – and that if clinicians want to devise effective strategies to encourage adherence, they need to do more than address the money angle.

I’m aware of at least one study that found a surprisingly basic reason for why some patients don’t take their medication: They simply don’t like the idea of taking a lot of pills each day.

It would be interesting to know the extent to which psychology might be contributing to medication non-adherence. The patients in the NEJM study had all recently had a heart attack. On average, they were 53 years old. Among at least some of them, perhaps their vision of themselves was that they were mostly healthy. Perhaps they weren’t emotionally ready yet to accept that their health had changed or that they were going to need medication for the rest of their life.

On top of this, there are strong American cultural attitudes about aging and infirmity. We tend to regard disease as a burden on society and often blame the sick for “not taking better care of themselves.” Should we be surprised when people resist taking prescription medication because, consciously or not, they don’t want to be perceived as one of those sick, costly individuals?

The study in the New England Journal of Medicine did reinforce that when patients stuck with their medication regimen, they were less likely to have a second cardiovascular event. Overall, health care costs for these people also were somewhat lower. The savings weren’t huge but then again, it often can take years to see a measurable payoff from this kind of health intervention, and the study wasn’t designed to track long-term results.

Did the elimination of co-pays help some patients more than others? It’s probably safe to assume that it did, at least among those for whom cost was the main barrier. For other folks, though, it’s clearly going to take more than this to raise the adherence rate. A better understanding of both the practical and emotional issues involved might be a good place to start.

Pill City

You know your life is changing when the number of prescription medications you take each day begins to inch its way up.

It’s a fact that Americans pop a lot of pills. I recently spent a few minutes researching this issue online and made some rather eye-opening discoveries. A report issued last year by the Kaiser Family Foundation estimated U.S. spending on prescription drugs at $234.1 billion in 2008. According to the report, the number of prescriptions increased 39 percent – from 2.8 billion to 3.9 billion – during the decade between 1999 and 2009.

Here’s the statistic that was really surprising: In 1999 the average number of retail prescriptions was 10.1 per capita. By 2009, this had risen to 12.6 per capita.

Some of these undoubtedly were one-time medications, such as a course of antibiotics, rather than pills being taken 365 days a year. But when you consider that some people get by with one or two prescriptions a year (or perhaps none at all), it’s clear from the math that plenty of others are probably making up for it, and then some, with significant quantities of prescription medications.

A couple more tidbits from the Kaiser Family Foundation report: About 62 percent of American households have at least some prescription drug expenses annually. The likelihood of spending money on prescription medications goes up with age; 58 percent of Americans under age 65 had at least one prescription in 2007, but for those older than 65, it was 90 percent.

Is this a bad thing? Not necessarily. When correctly prescribed and taken, medication undoubtedly helps people manage asthma, allergies, depression, diabetes, high blood pressure, pain and more, allowing them to function and possibly sparing them – or at least reducing their risk – of more serious problems down the road.

But there’s a dark side to all of this. The prevalence of prescription drug use in the U.S. has given rise to polypharmacy, or multiple prescriptions that can increase the risk of unwanted side effects and potentially dangerous drug interactions, especially among the elderly. There’s also “prescribing cascade,” which happens when a prescription medication produces side effects, the doctor prescribes another medication to combat the side effects, which results in yet more side effects, yet another medication and on and on.

Adherence can become an issue as well. It gets complicated when someone takes a dozen prescription medications daily – some once a day, others twice a day, some with food, some without, some that can be taken together, others that can’t. It can be challenging to even remember a regimen like this, let alone stick to it day after day.

For all of the apparent emphasis on pills, many people don’t like taking them. In a study conducted a few years ago, researchers queried older adults about their prescription medication habits and found multiple reasons why these individuals didn’t always take their pills. At the top of the list was cost – but people also often cited concerns about side effects and drug interactions, or didn’t really believe the drug was necessary.

There were some rather strong reactions to a CNN story earlier this year that asked, “Are you taking too many meds?” One person’s comment: “Big pharma is one of the greatest contributors to the wreck and ruination of America.” (I noticed that very few of the commenters addressed the opposite question: Are you not taking meds that would truly benefit your health?)

The truth probably lies somewhere in a gray zone. In recent years there seems to be a trend toward being more thoughtful when prescribing drugs. There’s growing awareness, for instance, that statins to lower cholesterol may not be all that helpful to individuals who have no previous history of heart attack. More recently, the effectiveness of multivitamins for middle-aged women has been called into question. Evidence-based guidelines are forcing more consideration of when a drug is genuinely appropriate.

Most of us are unlikely to get through life without needing a few prescription medications along the way. It’s smart to ask questions to make sure a prescription drug is truly necessary, and smart to take it if the honest answer is yes.

Photo: Wikimedia Commons

Scrimping on health care

More Americans are skipping doctor visits and scrimping on prescription drugs to save money, a new survey has found.

The survey, released today by the Consumer Reports National Research Center, found that the percentage of people who reported cutting corners on their health care rose from 39 percent to 48 percent over the past three years. The poll was conducted this past June and involved a representative sample of 1,200 adults.

The findings reinforce what many observers have been saying all along: Consumers are pressured by health care costs and some of them are opting to delay or forego care, perhaps unwisely.

- 21 percent of the survey participants said they had delayed seeing a doctor because of the cost.

- 16 percent didn’t fill a prescription.

- 12 percent skipped a scheduled dose without first discussing it with their doctor or pharmacist. (The poll unfortunately wasn’t designed to examine whether those who reported skimping on care ended up with health consequences down the road.)

- Survey respondents in lower income brackets were more likely to cut corners than those who earned more.

- Although generic drugs are cheaper than name-brand versions and their use is widespread, 41 percent of the respondents said their doctor only sometimes – or never – recommended a generic. The survey also uncovered misconceptions about generic drugs; nearly 40 percent of the participants expressed concerns about the safety and effectiveness of generic drugs, suggesting a need for more education on this front.

- In most cases, the cost of prescription drugs was not discussed during the visit with the doctor. Two-thirds of the survey respondents didn’t know what their medication would cost until they picked it up at the pharmacy.

- The majority of those surveyed said they were concerned about the influence of the drug industry on physicians’ likelihood to issue prescriptions – but it appears patients also can be swayed by drug advertising. Eighteen percent of the respondents said they had asked their doctor to prescribe a drug they saw advertised, and the majority of the time they received it.

What can patients do to ensure they’re spending wisely on prescription medications? Consumer Reports offers some advice: If you’re concerned about the cost, bring it up with the doctor, especially if it involves a medication you’ll need to take long term. In many cases you might be able to substitute with a generic. Pharmacies also can help with discounts, or help connect you with programs that offer lower-cost prescription medications.

The Consumer Reports survey doesn’t let clinicians off the hook either, noting that they need to be more aware of the financial impact of their decisions. Some studies in fact suggest that nine out of every 10 health care dollars spent in the United States is ultimately determined by health care providers rather than by patients.

Although this survey underscores how cost-conscious many people are when it comes to health care, it makes another point that’s subtle but important: When consumers pay more out of pocket for health care, it might force them to think twice before spending the money but it doesn’t guarantee they’ll be smarter or more well-informed, or that they’ll make better choices. Furthermore, what looks like a short-term cost saving could turn out to be more expensive in the long run, particularly if people are skipping medications they truly need. If the Consumer Reports poll is any indication, there’s still considerable work to be done on how we approach the entire monster issue of health care costs.

Getting practical with medication adherence

If patients aren’t taking their prescription medications properly, maybe the problem doesn’t rest entirely with their level of health literacy or motivation. Maybe what they really need is more help incorporating their pill regimen in their daily routine.

This is the premise of a newly published article in the Nursing Clinics of North America journal, which examines potential strategies for getting people to take their medication correctly.

Medication adherence is a significant issue. Those who study it have estimated that 30 to 50 percent of Americans take their prescription drugs incorrectly, resulting in billions of dollars each year in additional health care costs to treat the consequences. Although it’s a problem that can occur at any age, it tends to be more prevalent among older adults who are more likely to be taking multiple prescription drugs.

Researchers at the University of Missouri examined a collection of previous studies and concluded that much of the effort to improve medication adherence has focused on things such as the patient’s knowledge, motivation and cognitive abilities – and that this approach hasn’t always worked very well.

What they call for instead is a “personal systems approach” – that is, giving people practical ways that help ensure they take their medication correctly.

This could include strategies such as “putting pills next to the coffee maker as a reminder to take them each morning or using technology like cell phones and computers to set reminders to take medications,” Cynthia Russell, an associate professor of nursing at the University of Missouri, explained in an accompanying news release.

The researchers make several concrete suggestions. One of them is creating a routine that encourages and reinforces adherence. Another is involving a supportive family member or caregiver. Monitoring techniques, such as pill-bottle caps with embedded computer chips that record each time the bottle is opened, might also help people stay on track.

There are many, many reasons, of course, for why people don’t take their medication correctly. Sometimes they don’t think they need medication, or don’t want yet another daily pill. Sometimes they’re reluctant to accept the side effects. And sometimes they just can’t afford to fill the prescription.

If you think of this as a continuum, though, these issues tend to cluster at the front end, when the medication is first prescribed. Once the patient has agreed to try the medication, fills the prescription and brings the pills home, a whole different set of challenges arises – namely, the day-to-day routine of remembering to take the medication and taking it as directed.

I’m not a forgetter. I’m very motivated to take my medication, it’s part of the daily routine and over the past six years, I think I might have forgotten only once. (I’m not quite so adherent with veterinary medications, although the issue here isn’t my memory; it’s the prospect of forcing a pill down the throat of a hissing, protesting, unhappy cat.)

For many people, though, forgetfulness and inconsistent routines are significant reasons for falling off the medication wagon. In a study published earlier this year, researchers queried more than 8,000 people who had been prescribed medication for high blood pressure but weren’t complying. The chief findings: ”forgetfulness” and “being too busy” topped the list of reasons for non-adherence.

The researchers make a telling observation:

Our findings indicate that events interfering with daily routine had a significant impact on adherence. Medication adherence appears to be a patterned behavior established through the creation of a routine and a reminder system for taking the medication. Providers should assess patients’ daily schedules and medication-taking competency to develop and promote a medication routine.

All of the clinician’s careful work to explain why a medication is needed and how it should be taken can be completely undone if the patient goes home and then forgets, or can’t stick to a routine. When it comes to medication adherence, the practical things really do seem to matter.

Photo: Wikimedia Commons

The cost of adverse drug events

If you ever doubted that adverse events involving prescription drugs are costly, consider a new study that looks at what happens when these patients end up in the emergency room.

The study, which was published this week in the Annals of Emergency Medicine, tracked 1,000 patients who came to the emergency room at Vancouver General Hospital in Vancouver, B.C., Canada, for six months in 2006.

What the researchers found: 12 percent of these patients sought emergency care because of an adverse drug event, defined as “an unwanted and unintended medical event related to the use of medications.” Although this may not sound like a large number, the impact in terms of cost and utilization was substantial. Patients who came to the ER with prescription drug-related problems weren’t necessarily at greater risk of dying than other ER patients – but they were more likely to spend additional days in the hospital and more likely to have additional outpatient doctor visits. When they were tracked across six months of followup, their median monthly cost of care also was almost twice as high as that of other emergency patients – $325 (in Canadian dollars) vs. $96.

It’s not clear if the results would be similar among ER patients in the United States, although I suspect they are. The researchers controlled for age but there may have been other factors - overall health, for instance, or level of health literacy or overall number of prescription drugs being taken - that increased the likelihood these patients would experience an adverse drug event in the first place. Some of these additional factors also might have made it more likely the patient would be hospitalized or need additional followup care.

All in all, this study comes with a couple of important messages. First, adverse drug events often aren’t glaringly obvious, high-cost incidents, a fact that sometimes makes them less noticeable to the public. The researchers calculated the additional median cost in the hundreds, rather than thousands, of dollars.

Secondly, these incidents often fly below the radar screen in many ERs. If anything, they tend to be under-recognized. In an accompanying news release, the study’s lead author, Dr. Corinne Hohl, said, “Medication-related problems are not necessarily the first thing we look for in an emergency patient when we are trying to diagnose what is wrong.”

The real issue, the authors point out, is that the vast majority of adverse drug events are preventable.

Lowering the incidence of misadventures with prescription drugs won’t be easy, though. It’s a multi-level problem with no single solution.

Are patients these days simply being prescribed too many medications? Undoubtedly they are.

Polypharmacy, or the use of multiple prescription drugs, is becoming much more common, making it more challenging for people to take each drug correctly as prescribed and increasing the risk of unwanted drug interactions. Over-the-counter supplements have added yet another wrinkle, not only in their potential for outright misuse but for the risk of bad interactions with prescription drugs as well.

Do patients fully understand how to correctly take a prescription medication? Details matter; often you have to read the fine print. The label on my thyroid medication says I should take it on an empty stomach before breakfast. But the two-page handout I get from the pharmacy each year is much more specific: Take it at least one hour before breakfast, otherwise it won’t be absorbed as effectively.

Although price-shopping saves money, consumers should be aware of the down side. When they use two or more pharmacies so they can get a deal on a particular prescription drug, potentially bad interactions can be missed because the pharmacist doesn’t have their complete medication history.

The Vancouver hospital where this study took place is trying to make some changes. For starters, data from the study are being used to develop a screening tool to help ER doctors identify which patients are most at risk of an adverse drug event. Hohl said they also want to create an evaluation platform to help physicians with their prescribing practices.

“We hope eventually to be able to prevent many of these events from even happening in the first place,” she said.

Photo: Wikimedia Commons

Noteworthy 1.1

I know I’ve said this before but I’ll say it again: So much to blog about, so little time. Here are some highlights from the many tidbits that have crossed my desk recently:

- Yahoo! recently issued its year-end list of the top searches for 2010, and pregnancy was at the top of list for health searches, followed by diabetes. The rest of the top 10, in order: herpes; shingles; lupus; depression; breast cancer; gall bladder; HIV; fibromyalgia.

Among the top searched questions on Yahoo! in 2010 was how to lose weight. A top obsession? Bedbugs, which came in at No. 7.

- Here’s an interesting report from LeaseTrader.com: In a rush by professionals to escape leases for high-priced cars, male doctors are at the head of the pack. LeaseTrader.com’s analysis looked at cars valued at $40,000 or more that were being dumped on the marketplace by customers who were downsizing their finances. Male doctors were ahead of lawyers and even financial executives in ridding themselves of expensive leases for Maseratis, Mercedes and BMWs. The report suggests that declining reimbursement and uncertainty surrounding the future of health care are prompting some physicians to cut back on their personal spending.

- Will Santa Claus be delivering the latest electronic gadget to the children in your household? Don’t let them strain their eyes by peering too long at digital devices, warn eye experts.

There’s actually a name for it: “computer vision syndrome,” or CVS, which includes back and neck pain, dry eyes and headaches. Some nuggets of advice: Use proper lighting, remind your kids to blink often and to give their eyes a rest every 20 minutes or so, and make sure they wear their prescription glasses if they have them.

- For all the national clamor about obesity, there’s one age group that seems to be overlooked - the 18- to 35-year-olds. The University of Minnesota is launching a new clinical trial to look at ways of using technology and social media to engage young adults. The CHOICES trial (Choosing Healthy Options in College Environments and Settings) will test a for-credit course model that uses web-based social networking to prevent unhealthy weight gain among 44o student participants.

It’s being offered at Anoka-Ramsey Community College, Inver Hills Community College and St. Paul College. Trial participants will be given cooking demonstrations, exercises for stress management, and other information and activities to help their improve their sleep, eating and physical activity patterns. Half the participants will be randomized into a control group with fewer interventions and no social networking. At the end of the two-year trial, results will be compared to see which group fared better.

The study is part of a five-year national initiative to test innovative, technology-based strategies for helping young adults avoid unhealthy weight gain. Six other studies, besides the one in Minnesota, are under way.

- There’s nothing like a mystery shopper to shed painful light on how organizations sometimes fall short in their customer service. A news release from the Baird Group, which is a member of the Mystery Shoppers Provider Association, offers an inside look at some of the discoveries that mystery shoppers make in health care: A receptionist yakking with a coworker while a patient stands waiting at the counter. Employees taking a smoking break under a sign that says “no smoking.” Staff members ignoring a patient or visitor who is obviously lost.

Although “patient-centered” is the concept du jour, Kristin Baird, whose group works exclusively with health care organizations, says many organizations are “anything but.”

What qualities have she and her mystery shoppers seen in the best organizations? “What I see in these is a concerted focus on making service expectations real through communication, inspection, accountability and action,” she said.

- Finally, the American Pharmacists Association sent out some practical advice for people to manage their medication regimens during the excitement of the holidays:

If you’re going to travel, bring more medications than you expect to use and store them in their original labeled containers. Be aware that some medications, such as insulin, need to be kept cool. If you plan to be in your car for a long period of time, bring a cooler so you can store your insulin inside (but not directly next to ice). Some medications also might require special equipment such as needles or pumps, so be sure to remember all the prescribed parts of your routine.

If you’re flying, keep your medications in a carry-on bag. Check your airline’s regulations, because liquids in some quantities are prohibited on planes. A pharmacist can provide you with smaller bottles if this is an issue.

Have a plan for adjusting your medication regimen. And don’t forget to bring an up-to-date list of all your current medications and vaccinations. Although no one wants to end up in an emergency room or doctor’s office while they’re traveling for the holidays, having a complete and accurate medication list can help make it a little less stressful, both for you and for the providers who need to know about your current treatments.

HealthBeat photo by Anne Polta

OTC? Get a prescription for that

Workers opting into flexible spending accounts are getting a bit of a surprise this year: If they want to set aside pre-tax dollars to help pay for over-the-counter drugs, they’ll have to get a doctor’s prescription first.

The word has been out there for some time that the regulations governing flexible spending accounts are changing. But with the annual open enrollment period under way, many people are just now finding out about it and what it might mean for them. It applies to the drugstore essentials that most of us buy over the counter – such as pain relievers, antihistamines, heartburn medication, and cough and cold remedies. (Insulin is exempt, as are supplies and devices such as crutches, blood sugar test kits and contact lens solutions.)

According to Kaiser Health News, it’s strictly a money move:

Tightening up the tax break on over-the-counter purchases will generate an estimated $5 billion in federal revenues through 2019, according to the Joint Committee on Taxation. That figure represents revenue related not only to FSAs but also to health savings accounts, health reimbursement arrangements and Archer medical savings accounts, all of which are also affected by the change.

If you only occasionally use over-the-counter products, this change may not be a big deal. Many people have probably never bothered setting aside pre-tax dollars for OTC medications, figuring the paperwork wasn’t worth the hassle.

But some households undoubtedly will be hurt, especially if they rely on over-the-counter medication for an ongoing condition – daily low-dose aspirin, for instance, or symptom relievers for allergies. For those on tight budgets, the combination of the tax break and the quasi-savings account for health expenses has been important for managing their finances. If they now have to see a doctor to get a prescription for an over-the-counter product, the inconvenience plus the expense of a co-pay for the office visit might outweigh the financial advantages of using their flexible spending account for OTC purchases.

Although most people dip into their FSA for prescription drug costs rather than over-the-counter products, those OTC items do add up. They account for about 25 percent of flexible savings account expenses, the Wall Street Journal reports.

It’s not clear what physicians think about all of this. The prospect of yet more paperwork to satisfy bureaucratic requirements isn’t exactly happiness-inducing. On the other hand, there’s something to be said for making doctors more aware of their patients’ over-the-counter consumption habits, if for no other reason than to avoid potentially risky drug interactions.

One potential benefit of the new flexible spending rule might be to make consumers more aware of how much they use and spend on over-the-counter products. There’s a tendency to regard OTC products as somehow “safer” than something that requires a prescription. Yet over-the-counter medications can easily be misused or overused, with consequences to the consumer’s health. Asking people to obtain a prescription before they can tap their flexible spending account for OTC expenses is a gentle reminder that over-the-counter products shouldn’t be taken too casually.

Photo: Wikimedia Commons