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Wikipedia Entry for Compliance (Medicine)

I was reading Todd Defren's PR Squared blog post today about Wikipedia, and if a company should or should not create an entry for themselves. It got me thinking more about Wikipedia, and using it as a go to source for information.

I do not use Wikipedia regularly, however I find increasingly useful for trivial information, such as who is Lonelygirl15, since I missed all the YouTube ballyhoo.

I think UGC (user generated content) is fantastic, however I do not think it is always an authoritative source. With that in mind, I looked up the my favorite terms: medication adherence, medication non-adherence, medication compliance and medication non-compliance. The only listing was Compliance (Medicine).

From the Wikipedia entry:

"Compliance (or Adherence) is a medical term that is used to indicate a patient's correct following of medical advice. Most commonly it is a patient taking medication (drug compliance), but may also apply to use of surgical appliances such as compression stockings, chronic wound care, self-directed physiotherapy exercises, or attending counselling or other courses of therapy.

Patients may not accurately report back to healthcare workers because fear of possible embarrassment, being chastised, or seeming to be ungrateful for a doctor's care.

Causes for poor compliance include:
• Forgetfulness
• Prescription not collected or not dispensed
• Purpose of treatment not clear
• Perceived lack of effect
• Real or perceived side-effects
• Instructions for administration not clear
• Physical difficulty in complying (e.g. opening medicine containers, handling small tablets, swallowing difficulties, travel to place of treatment)
• Unattractive formulation, such as unpleasant taste
• Complicated regimen
• Cost of drugs"

The listing goes on to discuss "Adherence: An estimated half of those for whom medicines are prescribed do not take them in the recommended way. Until recently this was termed "non-compliance", and was sometimes regarded as a manifestation of irrational behavior or willful failure to observe instructions, although forgetfulness is probably a more common reason. But today health care professionals prefer to talk about "adherence" to a regimen rather than "compliance"...."

And "Drug Compliance: It is estimated that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations...."

And "Concordance: Concordance is a current UK NHS initiative to involve the patient in the treatment process and so improve compliance...."

Overall it is a great listing. Wikipedia (rather the authors & editors) address the causes, the percentage of patients who are non-adherent, and the differences between adherence and compliance and concordance.

I guess I will have to live the listing title: Compliance (Medicine).

Today's Abstract

Today's medication adherence related abstract, "Supporting the Patient's Role in Guideline Compliance: A Controlled Study", comes from The American Journal of Managed Care, and even has a link to the full article.

Objective: Clinical messages alerting physicians to gaps in the care of specific patients have been shown to increase compliance with evidence-based guidelines. This study sought to measure any additional impact on compliance when alerting messages also were sent to patients.

Study Design: For alerts that were generated by computerized clinical rules applied to claims, compliance was determined by subsequent claims evidence (eg, that recommended tests were performed). Compliance was measured in the baseline year and the study year for 4 study group employers (combined membership >100,000) that chose to add patient messaging in the study year, and 28 similar control group employers (combined membership >700,000) that maintained physician messaging but did not add patient messaging.

Methods: The impact of patient messaging was assessed by comparing changes in compliance from baseline to study year in the 2 groups. Multiple logistic regression was used to control for differences between the groups. Because a given member or physician could receive multiple alerts, generalized estimating equations with clustering by patient and physician were used.

Results: Controlling for differences in age, sex, and the severity and types of clinical alerts between the study and control groups, the addition of patient messaging increased compliance by 12.5% (P <.001). This increase was primarily because of improved responses to alerts regarding the need for screening, diagnostic, and monitoring tests.

Conclusion: Supplementing clinical alerts to physicians with messages directly to their patients produced a statistically significant increase in compliance with the evidence-based guidelines underlying the alerts.

(Am J Manag Care. 2008;14(11):737-744)

MY COMMENTS
I am always pleased when another study confirms that patient messaging improves patient compliance. Especially with the rising cost of healthcare, every preventative step should be taken to ensure patients have the best data about their care and their risks.

It is troubling however that the patient messaging was in the form of letters that had a 10 business day delay from the doctor getting the notification "to allow physicians to contact their patients first, if they choose, or to indicate via fax or phone that there are clinical reasons why alerts do not apply (eg, an allergy not revealed by claims data)". This study did take place in 2006, and I am surprised they did not use email messaging as well.

Here is an exampled of the alert for the doctor:
Your patient is at least 55 years old, has claims evidence for diabetes, has an additional cardiovascular disease risk factor (eg, history of cardiovascular disease, dyslipidemia, microalbuminuria), and has no claims evidence for an angiotensin-converting enzyme (ACE) inhibitor. The American Diabetes Association recommends that, in these patients, with or without hypertension, an ACE inhibitor be considered to reduce the risk of cardiovascular events. If your patient fits this clinical profile, and if not already done or contraindicated, consider starting an ACE inhibitor and titrating the dosage as tolerated.

Here is an example of the patient alert:
• Our data show that you may have diabetes.
• If you have diabetes, it may help you to take a type of drug
called an ACE inhibitor.
• You may not be taking this drug.
• Ask your doctor if you should take an ACE inhibitor.

Now with that 10 day delay the doctor can reach out to the patient and suggest a medication. The reinforcement from the health plan helps the patient adhere with the doctor's recommendation. Same applies for screenings, diagnostic and monitoring tests.

This also raises the question: "My insurer told me to get this test or take this pill. If I do not do it, will they deny claims in the future?"

Would you have this fear if your health plan was monitoring your adherence based on claims data? Would you prefer a 3rd party to deliver these messages?

Please let me know your thoughts.

Thanks!

Phillips Develops The iPill

Sorry to have been off on posting over the last week. I came across this article in Reuters that I found interesting, and slightly scary. We want develop the best method for increasing medication adherence, but is this the way?

What do you think?

AMSTERDAM (Reuters) - Dutch group Philips has developed an "intelligent pill" that contains a microprocessor, battery, wireless radio, pump and a drug reservoir to release medication in a specific area in the body.

Philips, one of the world's biggest hospital equipment makers, said Tuesday that the "iPill" capsule, measures acidity with a sensor to determine its location in the gut, and can then release drugs where they are needed.

Delivering drugs to treat digestive tract disorders such as Crohn's disease directly to the location of the disease means doses can be lower, reducing side effects, Philips said.

While capsules containing miniature cameras are already used as diagnostic tools, those lack the ability to deliver drugs, Philips said.

The "iPill" can also measure the local temperature and report it wirelessly to an external receiver.

The company plans to present the "iPill" at the annual meeting of the American Association of Pharmaceutical Scientists (AAPS) in Atlanta this month.

The iPill is a prototype but suitable for serial manufacturing, Philips said.

(Reporting by Niclas Mika; Editing by Greg Mahlich)

The Great American Health 2.0 Motorcycle Tour



Thanks to ScribeMedia for allowing me to embed this great video from David Kibbe, Director of the Center for Health Information Technology, American Academy of Family Physicians.

Dr. Kibbe hit the road earlier this year to produce (with Scribe) this documentary about Health 2.0. He rode his Honda Gullwing up and down the East Coast, interviewing some of the players in the H20 space, many of which I have blogged about. Included are interviews with the CEOs of MedHelp, Healthline, Hello Health, Patient's Like Me, American Well and change:healthcare.

Two other interviews I enjoyed: New York Times Well blogger Tara Parker-Pope who doesn't like the term Health 2.0 because it connotes a software package; and a CVS Minute Clinic RN who is not only providing patients with quick diagnoses in the pharmacy, but also encouraging and setting-up PHRs for them.

Google also makes an appearance in a quick conversation about, what else, Google Health.

Enjoy!

Engage With Grace: One Slide Project

Last week at Health 2.0, Alexandra Drane and Matthew Holt launched a movement asking everyone to take two minutes at the end of each presentation to show just one slide. The slide asks if you can answer for yourself and your loved ones 5 simple questions about what you want for care at the end of your or their life.

Matthew and Alexandra ask that you download the slide, start a viral movement, have these conversations and transform end-of-life care. To learn more visit Engage with Grace, where you can download the one slde, register for free, learn how to start the conversation and store your answers to the questions.

The questions are very morbid, but deal with an important issues: will your wishes be followed in the event of a terminal illness, do you have an advocate, where do you want to die, do you have a living will, power of healthcare attorney.

Visit the website, think about these questions, answer them and spread the word.

Thank you.

Real Cost of Medication Non-adherence for Diabetics

So I write about the importance of medication adherence on this blog, on Twitter and speak to people everyday about dangers of medication non-adherence and the affect it has on 50% of the patients in the US.

Recent Guidline research published by MedAdNews found that 6 in 10 Americans are now non-adherent to their medications. Now lets talk about what this really means in cost for diabetes patients and the strain medication non-adherence has on the US healthcare system.

The June 2005 issue of Medical Care, a journal by the American Public Health Association, published a study demonstrating that Diabetes patients who are highly compliant with their treatment programs have a 13% hospitalization risk for a diabetes-related problem, but patients with low compliance have more than twice the risk at 30%.

The same study stated the combined drug and medical costs for the most compliant patients average $4,570, which is almost 50 percent below the $8,867 cost for the least compliant group.

A recent report from the CDC states that diabetes rates are rising in the US. More than 23 million Americans have diabetes, with about 1.6 million new cases diagnosed among adults last year.

So currently, according to all these estimates, 13.8 M diabetics are non-adherent to their medication regimes, and cost the healthcare system $122 BILLION. With proper medication adherence, this figure can be reduced in half.

And this number is only going to go up, with almost 1M non-adherent diabetes added each year at a cost of $8.8 Billion.

And this is for one chronic disease.

There are several factors related to why patients are non-adherent to their medications and I do not mean to beat up on diabetics, but I just wanted to illustrate the real costs associated with not taking medications properly.

Medication Adherence and Asthma Symptoms Abstract

Today's Medication Adherence related abstract comes from The HighWire Press. My comments are at the end.

Brief-interval telephone surveys of medication adherence and asthma symptoms in the Childhood Asthma Management Program Continuation Study. BG Bender, A Rankin, ZV Tran, and FS Wamboldt

BACKGROUND: Although it is known that most patients do not consistently take controller medications every day, the impact of non-adherence on asthma control is not well documented.

OBJECTIVE: To establish the relationship between medication adherence and symptom control in adolescents and young adults with asthma.

METHODS: A total of 756 adolescents and young adults diagnosed as having mild to moderate asthma on entry into the original study underwent 6 monthly telephone interviews as an ancillary project to the Childhood Asthma Management Program Continuation Study. Participants were queried about medication use and symptom control within each 1-month interview window. Strategies adopted to improve self-report accuracy included use of repeated interviews, confidential reporting to staff unknown to the participants, and use of questions focused on recent behavior.

RESULTS: Only participants who were consistently on inhaled corticosteroids (ICSs) for the entire 6-month study interval were included. Three groups of patients were contrasted: those not on ICSs (n = 420), those on ICSs with high adherence (> or = 75% of medication taken, n = 90), and those on ICSs with low/medium adherence (< 75% of medication taken, n = 148). Participants in the low/medium adherence group reported, on average, less symptom control and more variability in wheezing, awakening at night, missed activities, and beta2-agonist use during the 6-month period, although most in this group perceived their asthma to be under good control.

CONCLUSION: Despite extensive patient education and support, diminished ICS adherence was frequent and undermined symptom control in this group of adolescents and young adults with mild to moderate asthma.

MY COMMENTS
This is another one of these, uh really? abstracts relating to poor medication adherence and lack of symptom control, but supports the fact that if you do not take your controller medications, you will not be able to control your symptoms.

My feelings about adolescents and asthma medication is that they will not take their ICS unless they are having an attack. Forgetfulness and stigma, I believe, are the two drivers of this non-adherence. It would have been nice if the researchers had added the question: "Why didn't you take your ICS"?, but they will probably have to do another study to get this question answered.

What I Am Reading - Health 2.0 Conference Wrap-ups

What a way to kickstart the week by finding out what I am reading today!

I know, it is very exciting - contain yourself!

There are still blog posts surfacing from last week's Health 2.0 Conference, and I'm sure more to come:

- Matthew Holt, the co-founder, muses about his final thoughts and addresses criticism on the conference at The Healthcare Blog.

- Jane Sarasohn-Kahn from the Health Populi blog reflects on her personal experiences around the conference as a moderator, panelist and participant.

- A medical librarian's review of the health search engines featured at the conference on the AltSearchEngines blog. Reading this has inspired me to once again revisit and tackle writing a post about the various health search engines and their results for medication non-adherence.

- Amy T from Diabetes Mine writes a brief post about her Health 2.0 experiences with a diabetes focus of course!

John from Chilmark Research did a great job of covering Health 2.0 and is now covering The Center for Connected Health's 2008 Symposium. This Boston symposium also features a number of speakers who were at Health 2.0.

Alexandra Carmichael, from CureTogether, proposes an Open Source Health Research Plan.

Cary Byrd from eDrugSearch comments on a study that found higher drug costs in poorer neighborhoods.

John Halamka (who is a localvore) from Life As A Healthcare CIO writes about the ROI for EHRs.

Enjoy!

Health 2.0, LLC Launches Health 2.0 Advisors

One of the first announcements to come out of the Health 2.0 Conference is the formation of Health 2.0 Advisors, "an advisory service formed by four principals with national reputations at the nexus of health care and technology."

From their Press Release:

"The mission of the new advisory service is to partner with clients to critically evaluate the continuing evolution of the Health 2.0 marketplace and how its tools and processes can maximize business value."

"The firm is a joint venture between Health 2.0, LLC, and a team of four individuals: Matthew Holt, a Health 2.0 pioneer and co-founder of the Health 2.0 Conference; Brian Klepper, an expert in change dynamics in health care; Michael L. Millenson, an author, consultant and expert in quality of care and consumerism; and Jane Sarasohn-Kahn, a respected health economist and founder of THINK-Health."

This is an amazing combination of talent in the Health 2.0 space and will certainly help large Health 1.0 organizations identify the value in adopting Health 2.0 technology.

Several critics have recently been complaining about the problems of monetizing Health 2.0 and signaling the end of the movement. Obviously with the 1000+ attendees at the Health 2.0 Conference (including Google, Microsoft, and Yahoo!), it doesn't seem to be ending anytime soon!

Matthew has consistently advocated for larger healthcare organizations to adopt the technology of the smaller, more nimble emerging Health 2.0 companies. Hopefully Health 2.0 Advisors will help bridge the gap between what is not working in the current healthcare system and the new technology that can effect a positive change, improve outcomes and reduce costs.

"Across health care, a wave of innovation has begun in earnest," said Holt. "For stakeholders in the health care industry, understanding Health 2.0 has become absolutely mission critical. At Health 2.0 Advisors, we're about ROI and guiding our clients to unlock the tremendous value of Health 2.0."

Well said sir! I wish them the best of luck with their new venture.

Following The Health 2.0 Conference

Unfortunately am not able to attend this year’s Health 2.0 Conference in San Francisco, but I am monitoring it off and on via live blogs and Twitter for the following two days.

The official Health 2.0 Conference blog is a little slow to update as all the contributors are currently making the event run smoothly, however I believe they will update it throughout the conference.

Craig Stoltz is posting on his Web 2. Oh…Really?blog as well as cross posting on The HealthCare Blog.

I was told the Ozmosis Community blog is also updating throughout the conference.

On Twitter, some people are using the "Health 2.0” tag others are using the "#health20con” tag. Either tag shows up in a Twitter Search for either term. You can even search for a product that is demoing or person who is speaking at the conference to see who is tweeting about them.

NOTE: You do not have to have a Twitter account to see these feeds or to search.

Others are not using tags, but providing great coverage:

Scott Shreeve from Crossover Healthcare, Mark Schrimshire, Unity Stoakes from OrganizedWisdom, Dr. GreeneRobert Hendrick from change:healthcare, and Carlos Rizo.

I apologize if you are also blogging or twittering and I do not mention you. Please comment if you want to be included and I will update at the end of the day to add your feed.

Thank you and enjoy the conference!

UPDATE: Bob Coffield compiled a RSS Feed and a Search Feed for all of the Twitter tags. Much easier to follow. Thanks Bob!

InfoMedics Announces New Patient Adherence Survey and Launches Adherence Driver™

InfoMedics recently announced the results from a new survey examining the behaviors of patients on prescription medications. These results were presented at the 2nd Annual Digital Pharma Conference October 15th, and also coincide with the launch of InfoMedics Adherence Driver™, which they will demonstrate at the 5th Annual Patient Adherence & Persistence Summit USA at the end of this week on October 23rd.

Smells like Conference season, considering the Health 2.0 Conference launches tonight, and there are four more events on the horizon in the next two weeks!

While the results are not groundbreaking, they further reinforce the disconnect between patients and doctors regarding medication adherence.

1,017 responded to Zoomerang's invite to participate in InfoMedics, Inc.'s 2008 "Following Doctor's Orders: Patient Prescription Behaviors" survey. All had taken prescription medications, with no particular demographic breakdown.

Survey Says (my comments are in BOLD):

34% do not always fill a new prescription from their doctors; another 5 percent said they never fill those prescriptions.
The latest poll I saw was around 30% - getting higher, wonder if economy affected this answer? Probably too early.

46% said there is a chance they would not tell their doctor if they stopped taking a medication or decided not to fill a prescription. This is bad. Obviously if a doctor doesn't know you are not taking your medication, they will not know how to effectively treat your ailment. Good thing there is blood work to determine medication levels.

67% forget to take their medication at times. Last figure I have from 2007 is 87% - so that is a pretty steep decline.

9% said they would keep taking a medication if they started feeling worse. Not a very engaged population number.

34% sometimes, often or always stop taking medication if they feel better. This number sounds low.

46% are careless at times when taking medications. Sound about right.

32% are always motivated to take a newly prescribed medication. Better than 30%!

When asked for multiple responses about where they go for medication information, 51 percent of respondents said they look to the Internet for this information; 49 percent said they ask their pharmacists and 37 said they ask their doctors.
This follows Manhattan Research's Cybercitizen® Health v8.0 report that stated 53% of patients prefer to look online for health information.

Overall this survey is pretty representative of the current research, with a good indicator that adherence rates are not going above 50%. I am looking forward to seeing the whole survey when it is published.

AlignMap Betters My Robotic Posts

As has happened in the past, Dr. Showalter from AlignMap has written a better and more thoughtful post about the future of robotic medication adherence assistance than I did last week.

Dr. Showalter's post reminds me (as our emails about blogging have in the past) that I sometimes only "report" what I find, not adding anything of merit with my own thoughts, observations, etc....  Also that I do not add any visuals.

I thank Dr. Showalter for his great additions to my previous two posts regarding medication adherence and healthcare robots, as well as adding a personal real world context for the use of these aids.

He also referenced his own blog post about a Tamagotchi-style Pill Pet reminder that I never saw. It alerts patients when to take their pills and when to go to the MD. If the patient is not adherent, the Pill Pet get sicks and eventually dies. This aids adherence by hopefully making the patient care more about the health of a robotic pet than their own.

I will close with Dr. Showalter's favorite compliance program:

1. RoboCop (Dr. RoboCop to you) presents the healthcare instructions.

2. RoboCop enhances compliance with his trademark line, which also serves as the Program’s slogan: "You have 20 seconds to comply."

Of course it is cooler and has more effect on the AlignMap blog as he has visuals and audio!

Ryan Haight Online Pharmacy Consumer Protection Act to Become Law

President Bush signed the Ryan Haight Online Pharmacy Protection Act (H.R. 6353) on October 15th making it a law. Congrats to this administration for seeing this act through.

Most people believe that online pharmacies are scams selling fake or illegal pills at high rates for ED, and oxycontin. With the passing of this law, hopefully more legitimacy will be given to online pharmacies in the public view.

Also helping to make online pharmacies more respected are Health 2.0 companies like eDrugSearch which "brings together the world’s most highly respected online pharmacies through a comprehensive, easy-to-use search engine."

They vet all the pharmacies their search engine queries and also provide "up-to-the-minute price search, detailed drug information, and other advanced features that make it the premier portal for online prescription medication shoppers. Our advanced search features enable members to identify pharmacies with specific licensing requirements, third-party accreditations, Better Business Bureau memberships, and more."

eDrugSearch's founder, Cary Byrd, an impassioned advocate of safe online pharmacies, wrote a great summary of the Ryan Haight Online Pharmacy Protection Act's provisions last month on his blog.

Here is the condensed version. Thanks again to Cary for for the succinct write-up.

- Amends the Controlled Substances Act to prohibit the delivery, distribution, or dispensing of controlled substances over the Internet without a valid prescription. Exempts telemedicine practitioners.

- Defines “valid prescription” as a prescription that is issued for a legitimate purpose by a practitioner who has conducted at least one in-person medical evaluation of the patient.

- Adds definitions to the Controlled Substances Act relating to online pharmacies and the issuance of prescriptions over the Internet.

- Imposes registration and reporting requirements on online pharmacies.

- Authorizes the Attorney General to issue a special registration under this Act for telemedicine practitioners.

- Increases criminal penalties involving controlled substances in Schedules II, IV, and V of the Controlled Substances Act.

- Authorizes states to apply for injunctions or obtain damages and other civil remedies against online pharmacies that are deemed a threat to state residents.

Patients have cited access to medications as being a barrier for medication adherence. If you have trouble getting your meds and affording them, look to online resources like eDrugSearch to provide you with the best prices and services that will deliver you scripts to your door.

I hate to sound like an advert, but with the economy the way it is, medications should not be sacrificed in this dire time, and there are less expensive alternatives than going to your local pharmacy. I am all for supporting small, locally owned businesses (we go to a druggist in Southport where my wife got penny candy as a girl), however one's health and medication regime come first - if you cannot afford to pay for small town service, look for alternatives.

Blog Action Day 2008: Poverty

To honor Blog Action Day 2008: Poverty I have read several blogs about the issue and have been touched by some personal stories, Global Poverty Facts and Stats and this MSNBC article which summarizes a report by The Working Poor Families Project which might change your perceptions of the poverty line in the US.

"The report defines a low-income working family as those earning less than twice the Census definition of poverty. In 2006, the most recent year for available data, a family of four earning $41,228 or less qualified as a low-income family. The number of jobs with pay below the poverty threshold increased to 29.4 million, or 22 percent of all jobs, in 2006 from 24.7 million, or 19 percent of all jobs, in 2002."

This obviously means there is a problem with the rise of poverty in the US.

"This was a time when we had solid and robust economic growth," said Brandon Roberts, co-author of the report.

"The number of low-income families rose to nearly 9.6 million, or 28 percent of the total population, in 2006 from 9.2 million, or roughly 27 percent, in 2002, according to the report. The number of children in low-income families rose by roughly 800,000 during the same period, climbing to 21 million from 20.2 million."

And it is not as if these people are not working. "72 percent of low-income families work, with adults in low-income working families working, on average, 2,552 hours per year in 2006, the equivalent of one and one-quarter full-time jobs."

So how does this relate to medication non-adherence? If patients are finding it difficult to pay for food and clothing for their family, medications are very low on their priority list. I wonder what the cross reference of the people in low income working families to those who are uninsured?

So take today (scratch that, everyday) to remember how fortunate you are, even if you have lost a lot of money in the stock market. Almost half the world — over three billion people — live on less than $2.50 a day, and at least 80% of humanity lives on less than $10 a day.

Go make a donation to your local foodbank or donate to Heifer International which provides you the opportunity to donate small amounts of money towards larger purchases of livestock to transform entire communities in 53 countries and 28 US states.

Please do something if you can. Thank you.



Microsoft to Join Scripts, Navigenics and Affymetrix in 20 Year Genetic Screening Test

I read a blurb in ePharmaceuticals about Microsoft teaming up with Scripps Translational Science Institute, Navigenics and Affymetrix "to study the impact of genetic screening on individuals' behavior. The aim is to determine what effect, if any, information about one's chances of contracting a particular disease has on how people live their lives."

"Researchers will study the genomes of up to 10,000 employees and family members of the Scripps Health system in San Diego who volunteer for the project and will monitor changes in their behavior over a 20-year period. Under the plan, Affymetrix will scan participants' genomes and Navigenics will interpret the results and provide participants with guidance on how to lessen the chances of contracting diseases to which they may be genetically predisposed. Participants will be able to store their tests results, and related data, in a Microsoft HealthVault account."

This study is pretty significant to me and I'm sure to the Genomics community - too bad we will have to wait 20 years to see the results. I have had a few conversations, online and off, about the importance of genetic testing and what it will really do to change patient behavior.

One person claimed genetic testing has to be covered by insurance to determine risk factors to enable behavioral change - ie. if you are at risk for diabetes, control your weight and diet. Another person thought that no matter what people know about their "health future" and possible conditions, they will do little to change their behavior.

I am on the fence about testing on a personal level, but feel that people who want to have it done and can afford it, should have it done. 23andMe now offers a $399 personal genetics service - which is pretty hard to pass up. I know that if I found out something horrible, and shared it with my wife, she would want /make me to change my lifestyle to reflect what "might" happen - so that is a deterrent. On the hypocritical flip side, I would like to have my children tested for just that reason.

Last month, Sergey Brin (co-founder of Google and husband of Anne Wojcicki, 23andMe's co-founder) wrote on his personal blog about 23andMe and his higher risk of developing Parkinson's. This created a lot more buzz around 23andMe, genetic testing and PD - bringing the issue back into the national forum. I wonder if Google Health and 23andMe will launch their own study?

I am very interested to see what becomes of Scripts study and to see if people will change their behaviors based on their genetic makeup. Perhaps they will start reporting at the 5 year mark to give us a taste of what how patients are trending? Unless there are incentives provided, I doubt many people will change their behavior. ie. people smoke for years, knowing it can kill them, but as soon as their company /health plan offers them an incentive to quit, they try to quit.

I already know I am at risk for diabetes, cancer and heart disease, based on my family history - but one day soon I will get tested to see everything else that is in my DNA. Perhaps it will be this year's Christmas present to the family.

Another Home Robot to Improve Medication Adherence

I found this blurb in the Journal of Telemedicine and Telecare about another home robot to improve medication adherence:

"We have developed a prototype home robot to improve drug compliance. The robot is a small mobile device, capable of autonomous behaviour, as well as remotely controlled operation via a wireless datalink. The robot is capable of face detection and also has a display screen to provide facial feedback to help motivate patients and thus increase their level of compliance. An RFID reader can identify tags attached to different objects, such as bottles, for fluid intake monitoring. A tablet dispenser allows drug compliance monitoring. Despite some limitations, experience with the prototype suggests that simple and low-cost robots may soon become feasible for care of people living alone or in isolation."

Like my previous post about the Carebot, this is pretty creepy, but it can be the future of home eldercare. Think of I, Robot. I do not see how this can work right now, unless a trust level is developed between the patient and the robot. I can imagine a patient ignoring the robot, unless the patient is already engaged in their medication regime, and needs the help to remember.

I'll be interested to see how this rolls out and how their clinical trials improve medication adherence.

Death of Health 2.0? Let's Start With A Business Model

There have been a number of blog posts over the last few weeks about the demise of Health 2.0, many of which use the death /merger of Revolution Health signaling the end, as well as a few blog posts supporting the future of the movement. There was some intense debate between esteemed members of the H2.0 community through said blog posts, comments on blog posts and more blog posts - all of which I decided not to comment on because those that were commenting and creating the posts know more about the space than I do.

However, I saw two posts today that I thought summed up the economic situation as it relates to Web 2.0 and the health of Health 2.0.

The first of which was written by Dmitriy Kruglyak, from Trusted MD, a healthcare blogging network that FD I have been a member of since July of 2007.

It includes the famous Sequoia Capital presentation to their portfolio companies, quotes from TechCrunch signaling the "ignoble end of Web 2.0", and Dmitriy's own analysis on how this effects Health 2.0:

"I am not going to beat this dead (dying?) horse. If you paid attention to this blog over last two years you would not be surprised at this turn of event. I will just say that an "average" Health 2.0 company that gets mentioned in the news is typically orders of magnitude lower in terms of traffic, engagement and monetization than their Web 2.0 cousins......As I said time and again, Web 2.0 is becoming just as toxic as dotcom (or subprime mortgages and credit default swaps). Conventional wisdom takes a while to form but this process is picking up pace. You can take a guess what will happen with derivative (copycat) ideas, like Health 2.0."

Doesn't sound very promising. Yet it is true. How can a movement and companies sustain momentum in a down-turned economy if there isn't a sound business model? VCs have been throwing money at companies that are cool, but do not have a sound plan or any intention of making money. I look to Twitter, which is valued around $25M (maybe more now), but does not have a business model, and doesn't plan to make any money in the next couple of years. They just received another round of financing this summer. Granted Twitter is very cool and I use it, but there must be something more going on that I am missing here. The value of the community is how Twitter is valued and what they might be able to make from that. Sounds like Facebook, which was valued at $15B at one point from $150M in earnings.

Same with Health 2.0 companies. Lots of them are very cool, but rely on ad revenue or a freemium package. I signed up for a 60 day trial of a PHR to check it out, but when it came time to "buy" a year subscription, I said "no thanks". There wasn't enough offered for the paid service that I could not get from a free service.

This brings me a post from Ben Heywood, Co-Founder and President of Patients Like Me from last week on the PLM "Value of Openness" blog: "I believe we, as the eHealth community, need to focus on two major goals: 1) solve patients’ problems, and 2) create business models that allow us to do #1....I don’t want to prognosticate about what types of business models will work for all Health 2.0 companies as the industry evolves (because, ultimately, this is an evolution). It’s up to each company to figure that out. I do believe that there’s no wrong path when you keep both those goals in your sights."

And this sums up what needs to happen to keep the Health 2.0 movement alive.

PLM's business model is very straightforward: "We build online communities where patients share structured information about their disease to help themselves and others. In turn, we make money by selling that data." PLM is very transparent, and tell their members this upfront, and members encourage the selling of data, as this will help the pharma companies and device manufactuers improve their offerings to patients. PLM also received $5M in VC financing, so that gives them a bit of a cushion until they turn a profit.

Some Health 2.0 companies have gone under, others (like ZocDoc) are still receiving VC funding. It is an interesting time to be in the infancy of the Health 2.0 movement. I have faith that it will continue as long as the innovators create a needed product and can monetize without charging the consumer in a time when patients are having difficulty paying for their healthcare at the Health 1.0 level.

InnovationRx Announces Medication Adherence Awareness Month

I found this press release earlier in the week from InnovationRx, announcing a pilot program in CA for their pharmacy based adherence programs. I saw their presentation at the DM colloquium earlier this year and found their services to be very similar to Intelecare's, however InnovationRx is a paid service, not a free service to patients like Intelecare's consumer offerings. Also in the announcement was the declaration of Medication Adherence Awareness month, co-sponsored by the American Pharmacists Association, the FDA OWH and the Pharmacists Planning Service.

Of course I was very excited to hear about Medication Adherence Awareness Month, however I could not find any information on any of the aforementioned partner websites, nor on InnovationRx's website either. I emailed my medication adherence enthusiast buddy Dr. Showalter from AlignMap, and looked at his blog, but no info there either. I even did a Google Search, but could only find InnovationRx's press release (excerpt below).

Every month for me is Medication Adherence Awareness Month, as everyday I educate patients, caregivers, industry executives (Health 2.0 companies, health plans, pharmacies, non-profits, etc...) on the pandemic that is medication non-adherence.

QUICK STORY: My wife and I were at a wedding last weekend for one of her best friends, and inevitably the question of "what do you do" came up. I hate to bore people in social situations about healthcare issues (most of the guests were in the fashion industry and artists, musicians, etc...), but found that everyone I spoke with had no idea the impact medication non-adherence has to patients and the US economy. And they were interested. I even spoke with a heart surgeon, who said "sure I know about medication non-adherence, but I did not know it was so rampant".

So here is a salute to Medication Adherence Awareness Month! Please spread the word and stay adherent to your medications, and let others know about the importance of their doctor's prescribed care plan. 1 in 2 patients does not take their medications as prescribed, costing the US $300 BILLION annually in unnecessary healthcare costs and lost revenue. 84% cite simple forgetfulness as the reason for their non-adherence.

Medication non-adherence is America's Biggest Drug Problem, but it need not be.

From BusinessWire:

"InnovationRx, a wholly owned subsidiary of Innovation Group (UK:TIG: news, chart, profile) , today launched a medication adherence awareness campaign targeting pharmacists and patients in California. The campaign, a pilot for a nationwide effort, aims to provide pharmacists with resources that will help their patients to achieve medication adherence and improve health. InnovationRx is collaborating with the American Pharmacists Association (APhA), the Food and Drug Administration's Office of Women's Health (FDA OWH), and Pharmacists Planning Service, Inc. (PPSI) for this campaign.

Medication non-adherence is a costly and prevalent problem in the United States. As part of Pharmacy/Medication Adherence Awareness Month, InnovationRx and its partners will raise awareness of the consequences of non-adherence and showcase programs that are available to help patients simplify their medication regimen and build reminder systems."

New Medication Adherence Blog

I discovered a new Medication Adherence blog called Medication Adherence Group 7. Almost as catchy as the title of my blog ;). It appears to be run by "Group 7, University of Texas at Arlington". UT of A also has a two other groups on Blogger: Group 12 and Calvino Saputra which also write blogs.

So far Group 7 have only posted a few posts which mention the causes of non-adherence and what you can do to help stay adherent.

I look forward to seeing how their blog develops.

Text Messaging's Healthcare Applications

One of the topics I enjoy talking about in regards to Health 2.0 is the effect text messaging will have on healthcare. Intelecare already uses (and has used for 3 years) text messaging as one of the delivery methods for our patient /caregiver created medical adherence reminders. BJ Fogg at Stanford held a Texting4Health conference in February, where a number of uses for texting in healthcare were presented, such as texting for AIDS testing clinics, and a smoking cessation program. Other companies, such as WellSphere, are also using texts as way to transmit health related information - such as where you can find a health food store or gym in your immediate area.

I have been looking at trends in mobile advertising and text usage, but I didn't really think that it had reached this point.



According to eMarketer: "The average mobile subscriber in the US sent and received more SMS text messages than mobile telephone calls during Q2 2008, according to Nielsen. This was the second consecutive quarter in which the average number of text messages was significantly higher than the average number of phone calls."

This is simply outstanding. As you can see from the chart, it is not just the tweens and Millenials using texts. My X Generation still sends more texts, and the 56 + crowd even does it. The US is also still way behind the rest of the world.

Quick Story: In 1999 or 2000 I was on a ski trip with my half-brother, Ricardo, who grew up and lives in London. He was looking at his phone and punching buttons (he was 18 or so at the time). I asked what he was doing, and he said "texting my friends". I asked what that was, he explained, and I said "why don't you call them"? His answer was that it was simpler, cheaper, and he can do it on "the sly".

It took me up until last year to really embrace sending text messages. I started with simple texts like "running late" or "what are you up to", which led to more complicated answers to queries, directions, twitter updates, etc... Now instead of "call me" it is "text me".

The uses in healthcare, for me, are most readily available for tracking information like glucose readings (I think SugarStats uses this), blood pressure monitoring, etc... I don't think texting your physician will catch on so rapidly, but it can happen.

AJ Fortin has a great post from this spring: 101 Things to Do With A Mobile Phone in Healthcare.

What are other uses you can think of for texting in healthcare? Please add your comments!

Found Around the Web Today

It has been awhile since I have posted a "What I am Reading" or "What I have Found" post, so here you go. Some interesting stuff out there that sparked my interest.

From Reuter's Health, a report on Sex Bias in Control of Cancer Pain:

"How well pain is managed in people with cancer apparently differs between men and women, new research hints. Dr. Kristine A. Donovan, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, and colleagues examined pain severity and the adequacy of pain management in 131 cancer patients newly referred to a multidisciplinary cancer pain clinic." Full Story

From LifeScript, a study that shows 1 in 5 Diabetics do not take their medication as prescribed. "Too many diabetics are neglecting to take life-saving prescription medicines regularly, one study warned. Published in the Archives of Internal Medicine, the study estimated that 21% of diabetics fail to adhere to their prescription schedule." Full Story

Allan Showalter, MD from AlignMap discusses the Implications Of The Redundant Patient Compliance Review. I like to post abstracts and some compliance reviews, but his blog posts are always more insightful, biting and from an MD's perspective. Full Story

And lastly, from the International Journal of STD and AIDS: Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil. Full Story.

Wal Mart and Caterpillar Team Up for No-Copays

I have said it in meetings, in emails and on Twitter: Wal Mart can revolutionize healthcare in this country. They have the power to change the way patients get and pay for their medications. Already, Wal Mart has changed the pharmacy industry by introducing their $4 generic drug program in the fall of 2006. This program made every pharmacy, from Target and CVS to Farmer Joe and Hannafords, also offer $4 generics to compete.

This program has saved Wal Mart customers $1 BILLION already. THAT is impressive.

One of the programs for aiding the US healthcare system and helping patients become healthier is employer /health plan sponsored lower co-pays and free medication for chronic diseases. This is not my original idea, as several companies have offered these services to their employees, but one that I fully support and believe will make a difference in medication non-adherence. As we know, forgetfulness is the #1 reason, with drug prices, side effects and drug education being the other factors that contribute to this pandemic.

Wal Mart and Caterpillar are taking this idea a step further by offering no co-pays for employees taking Tier-1 generics.

"Caterpillar Inc. and Wal-Mart Stores Inc. have embarked on a pilot drug program that could revolutionize the prescription drug industry, officials from both companies said Monday.

Select salaried and management employees of Caterpillar as well as its retirees and surviving spouses can get Tier-1 generic drugs filled for no co-payment at all Wal-Mart, Sam's Clubs and Neighborhood Market stores now through Dec. 31, 2009, as part of the program that began earlier this month.

The co-payment for the generic drugs is $5 at other pharmacies.

While about 70,000 Caterpillar employees are affected now, that could expand to include union-represented employees who opt into the company's HMO plan beginning Jan. 1, 2009, said spokeswoman Rachel Potts. Open enrollment begins in November."

I think this is another fantastic program and shows the real power Wal Mart has to influence the US Healthcare industry.

"The goal of the pilot program, on which Caterpillar and Wal-Mart negotiated for several months, was to remove unnecessary costs from the health care equation, said Todd Bisping, Caterpillar's pharmacy benefits manager.

It does that by eliminating the middle man, so to speak, in the pharmaceutical management process. Most companies contract with an outside pharmacy benefits manager to set rates on prescription drugs, rates co-payments are designed to cover to defray the company's costs.

Caterpillar negotiated directly with Wal-Mart on the rates, saving it money and enabling Caterpillar to then waive the co-payment for its employees and retirees, Bisping said."

You can read the full story from the Peoria Journal Star.

Personal Voice and other Medication Adherence "Scams"

I subscribe to a number of Google Alerts regarding medication non/ adherence /compliance. For the most part they are pretty spot on regarding articles with my chosen keywords, new research, blog posts etc... At least once a day is a link to a faux blog that simply lists keywords with advertising and links to other spam sites.

Once such site came up today, but also revealed some useful information - ie. NCPIE is promoting October as Talk About Prescriptions Month (more on this in another post) but they have a broken link to the site.



The text isn't well written, but they do promote the importance of medication adherence and the role of the caregiver. It mentions a service called Personal Voice with a link to the website Family Focus Working Caregivers that has broken links and some healthcare information. Overall a horribly designed site, but offers the Personal Voice service which will call your loved ones for you in case you do not have the time to make sure they are taking their medications.



I called the number provided to get an information package. The voicemail thanked me for calling and asked me to dial the extension I wanted. I dialed "0" and got a voicemail that simply stated "Personal Voice". I did a Google Search for "Personal Voice Inc." and here is what I got:



At first I thought it was just a problem with them managing their online reputation - since the first four results are negative. I then read the posts and they all describe the service as a scam. They deduct money from one's checking account monthly, yet do not provide a service. They are tied to another company which is a debit-for-credit-card scam as well.

This just makes me mad. A company using medication non-adherence rates to scare caregivers into signing up for a service that is simply a scam to make money. Luckily they are now being investigated by the FBI. I have encountered a number of email phishing scams this year, and other online attempts to get information, but this is the first I have seen involving medication non-adherence.

Caregivers out there, be careful with the services you sign up for. Make sure they are legitimate and will provide a beneficial service for your loved ones. Check with the better business bureau and do a Google Search to check the company's reputation.

I have not included any links from this post on purpose.

Adheris Study Finds First 30 Days on Antidepressants Critical for Medication Adherence

I had a call a few months back where I was pitching Intelecare's Services. The prospect asked "who are your competitors". I gave the answer, "well, no one". I know it is not the proper VC answer, however, at the time (March) there wasn't anyone in our space doing what we do.

No one has a robust, web-based proprietary medical messaging platform that sends patient and caregiver created reminders via email, text and voice messaging. No one offers our hosted and enterprise solutions to industry. No one has 3.2M users and sends out 4M reminders daily. No one has a pro bono program that gives away their technology. No one is developing the next generation in Adherence 2.0 applications like we are.

Since that call, a handful of competitors have emerged offering similar products. In fact, one such competitor even used the same phrasing we have used on our website for two years to describe the services they offer and the industries they serve.

Competitors aside, Intelecare is still the gold standard - no matter how many other companies come into the space.

Even though our competitors charge for their reminders, we still offer a free service to patients and caregivers to ensure that they are helped with the #1 cause of medical non-adherence, forgetfulness. We still integrate our reminder platform into any existing web portal - both as an out of the box hosted solution and as a fully customized enterprise solution. We still offer our hosted email reminder platform pro-bono to non-profits that specialize in chronic disease states.

That being said, I found a press release from Adheris today announcing a study which results "showed that patients new to antidepressant treatment and those who had restarted therapy after a lapse of 6 or more months were twice as likely to discontinue therapy in the first 30 days of treatment versus patients previously dispensed an antidepressant."

This is significant because the first 30 days of therapy are integral to a patient continuing their therapy. "The practical implications of this study are that while all patients lapsed at an alarming rate over time, increased patient follow-up and education within the first 30 days of therapy in newly treated and lapsed patients restarting therapy are critical to help improve adherence and patient outcomes."

Adheris is a fantastic company that has been in the space for over 9 years. They are focused on increasing patient adherence and education at the pharmacy level. Several times I have been asked to compare our services to theirs - however it is apples and oranges. We are both trying to get to the same goal - increasing patient medication adherence - we just have two distinct ways of doing it.

Medication non-adherence costs the US $300 BILLION annually in unnecessary health care costs and lost revenue. 1 in 2 patients does not take their medications as directed with 84% of them citing forgetfulness as the reason.

I think this market is big enough for a few players with different ideas of how to end this pandemic. It not only takes reminders, but education and lower drug costs to help eradicate the problem which affects us all in one way or another.

Frequency of and Risk Factors for Preventable Medication-Related Hospital Admissions in the Netherlands

Today's medication adherence themed abstract is brought to you by the Archives of Internal Medicine. Adverse medication reactions are not simply restricted to the US. As this study shows, even The Netherlands, with their advanced healthcare system, still could prevent almost half (46%) of their medication related hospital admissions.

Background:
Medication-related problems that lead to hospitalization have been the subject of many studies, many of which were limited to 1 hospital or lacked patient follow-up. Furthermore, little information exists on potential risk factors associated with preventable medication-related hospitalizations.

Methods:
A prospective multicenter study was conducted to determine the frequency and patient outcomes of medication-related hospital admissions. A case-control design was used to determine risk factors for potentially preventable admissions. All unplanned admissions in 21 hospitals were assessed during 40 days.

Controls were patients admitted for elective surgery. Cases and controls were followed up until hospital discharge. The frequency of medication-related hospital admissions, potential preventability, and outcomes were assessed. For potentially preventable medication-related admissions, risk factors were identified in the case-control study.

Results:
Almost 13 000 unplanned admissions were screened, of which 714 (5.6%) were medication related. Almost half (46.5%) of these admissions were potentially preventable, resulting in 332 case patients matched with 332 controls. Outcomes were favorable in most patients.

The main determinants of preventable medication-related hospital admissions were impaired cognition (odds ratio, 11.9; 95% confidence interval, 3.9-36.3), 4 or more comorbidities (8.1; 3.1-21.7), dependent living situation (3.0; 1.4-6.5), impaired renal function (2.6; 1.6-4.2), nonadherence to medication regimen (2.3; 1.4-3.8), and polypharmacy (2.7; 1.6-4.4).

Conclusions:
Adverse drug events are an important cause of hospitalizations, and almost half are potentially preventable. The identified risk factors provide a starting point for preventing medication-related hospital admissions.

Interview With The Chief Scientist of Express Scripts from STLToday

Here is a quickie from the St. Louis Post Dispatch. It seems to be an interview with the Chief Scientist from Express Scripts, however it is just a series of questions and answers without any reference text. I do think these are interesting questions though, and really makes me think about mail order pharmacies.

Why aren't you doing it? The costs are reduced for 90 day supplies. It makes perfect sense to me, since I am on two maintenance medications, yet I still have not done it - why? I do not really know. I printed out the form, and then it sat on my desk for a week. I think I took it home, then it was put in a drawer and lost it. We have since changed health plans, so maybe I will look into it again.

Enjoy the Q and A:

Can you give a brief explanation of Express Scripts' Center for Cost-Effective Consumerism?

The center brings together leading experts in behavioral economics to gain an advanced understanding of human behavior applied to health care. The center uses this information to help bring about positive health behavior change one consumer at a time. Right now, we're focused on procrastination as one major obstacle to better behavior.

One of the center's recent studies found patients were more likely to take medications as directed when they received those medications through the mail. Can you discuss these findings?

The study found that medication compliance was about 8 percentage points higher at home delivery than retail in key therapy classes: diabetes, high cholesterol and high blood pressure. The study involved more than 70,000 patients followed for nine months, and the design was such that we are confident that the difference in therapy adherence was due directly to home delivery.

Do you know any reasons why patients receiving drugs through mail order are more compliant?

There are at least two issues. First, it's clear that some of the noncompliance is due to procrastination when it comes to getting refills. This leads to gaps in compliance because patients wind up not having their medications. Because home delivery offers 90-day supplies, there are fewer refills needed and thus fewer gaps.

Second, our data show that patients in home delivery are far more engaged; they call us more often, log in to our website more often and increasingly view us as a trusted partner. This helps us communicate more effectively with them about their care.

Why don't more patients choose mail order?

Based on our work with the center's advisory board, we think it's more about procrastination than an active decision not to use home delivery.

In the past, moving to home delivery meant filling out forms, calling the doctor for a new prescription written for 90-day fills, etc. Express Scripts has new programs that take almost all of that work off patients' shoulders, so we expect a lot more of them to take advantage of home delivery going forward.

What should employers and other health insurer purchasers do if they want to encourage their employees or members to use mail order?

Clearly, financial incentives are not enough to drive members to home delivery. In addition to making sure patients save money on their co-payments at mail, employers and insurers should work with a PBM partner that can address the issue of procrastination and communicate effectively with patients.

Abstracts from Medline

Today I found several abstracts related to medication non-adherence, specifically these four that deal with measurement. All are from the HighWire Press out of Stanford.

Enjoy!

ONE: Testing the psychometric properties of the Medication Adherence Scale in patients with heart failure

OBJECTIVE:
Many factors may contribute to medication nonadherence in heart failure (HF), but no standard measure exists to evaluate factors associated with nonadherence. To fill this gap, we developed the Medication Adherence Scale (MAS) and tested its reliability and validity in patients with HF.

METHOD:
Questionnaire data were collected from 100 patients with HF at baseline using the MAS, and objective adherence data were collected for 3 consecutive months using the Medication Event Monitoring System.

RESULTS:
Principal component analysis yielded three factors that explained 63% of the variance in medication adherence: knowledge, attitudes, and barriers to medication adherence. Cronbach's alphas for these subscales ranged from .75 to .94, which supported their internal consistency. The Spearman rho correlation coefficients between the Medication Event Monitoring System and Knowledge, Attitudes, and Barriers scores were .25 to .31 (P < .05), demonstrating support for construct validity.

CONCLUSION:
These results support the reliability and validity of the MAS as a measure of knowledge, attitudes, and barriers of medication adherence.

TWO: Revision and validation of the medication adherence self-efficacy scale (MASES) in hypertensive African Americans

Study purpose was to revise and examine the validity of the Medication Adherence Self-Efficacy Scale (MASES) in an independent sample of 168 hypertensive African Americans: mean age 54 years (SD = 12.36); 86% female; 76% high school education or greater. Participants provided demographic information; completed the MASES, self-report and electronic measures of medication adherence at baseline and three months.

Confirmatory (CFA), exploratory (EFA) factor analyses, and classical test theory (CTT) analyses suggested that MASES is unidimensional and internally reliable. Item response theory (IRT) analyses led to a revised 13-item version of the scale: MASES-R. EFA, CTT, and IRT results provide a foundation of support for MASES-R reliability and validity for African Americans with hypertension. Research examining MASES-R psychometric properties in other ethnic groups will improve generalizability of findings and utility of the scale across groups. The MASES-R is brief, quick to administer, and can capture useful data on adherence self-efficacy.

THREE: Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis.

Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil.

The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.

FOUR: Evidence-based Assessment of Adherence to Medical Treatments in Pediatric Psychology

Objectives:
Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown.

Methods:
This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors.

Results:
Ten measures met the "well-established" evidence-based (EBA) criteria.

Conclusions:
Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the "real time" behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

Express Scripts Studies Show Home Delivery Improves Medication Adherence and Generic Sales

Two studies released from by Express Scripts show that home delivery 1) improves patient medication adherence, and 2) increases generic sales. Good for pharmacos for Express Scripts to increase adherence, however bad for pharmacos when Express Scripts wants to increase generic traffic. Good for patients, providers, and payors all around.

It is kind of a duh! revelation when you think that improving access to medication, as well as medication possession will also increase medication adherence. I mean if I have a 90 day supply sent to me at home, I will more likely take my meds on day 32 than I will if I have a 30 day script and need to refill it at my local pharmacy.

The method of introducing the generic was by a letter, another duh! revelation that by increasing patient knowledge of the generic, you increase patient acceptance and uptake. Six months ago my formulary changed and one of my scripts went up to a $75 co-pay. I asked if there was a generic and had my doc prescribe that instead. No one told me of the generic, but if I had been informed, I would have chosen it and lowered my costs earlier. It wasn’t until I was presented with a bill 3x of what I normally paid, that I asked – actually it took two refills to understand the increase, as my wife picked up the first refill and no one told her of the increase.

From MarketWatch

“In one study, compliance, or taking a medication as prescribed by your doctor, was nearly eight percentage points higher for home delivery pharmacy patients taking medications to treat high blood pressure. These patients were 78.6 percent compliant, but those using a retail pharmacy were 70.8 percent compliant.”

“….Cox explained that in addition to cost savings, home delivery promotes better medication compliance through patient communications such as refill reminders by phone or email, renewal assistance, a convenient reorder process, and less frequent re-ordering.”

“In the second study, a letter alerting patients to the availability of a generic alternative, the likelihood of choosing generics in home delivery was 34% greater compared to the impact in retail. The letters were sent following the introduction of generic Ambien(R) (zolpidem) in 2007.”

“Express Scripts estimates that use of generic sleeping aids will increase to 70 percent of all sleeping aid prescriptions in 2008. However, even that increase will not capture the $1.5 billion in additional savings available nationwide for commercial and government-paid plans from realizing the category's full generic potential of 95 percent.”

“The Center was inspired by research showing that a targeted communications program implemented around the 2006 introduction of generic Zocor (simvastatin) was nearly two to three times more effective than financial incentives alone. The greatest impact came among consumers using the company's home delivery pharmacy. The campaign generated over a billion dollars in savings for Express Scripts' pharmacy benefit plan sponsors and consumers.”

MY COMMENTS

8% is a fair amount in the adherence game. Congrats Express Scripts. Also in saving BILLIONS of dollars for their clients, Express Scripts should be commended. And an increase of 34% in generics from home delivery v. retail is outstanding.

At HealthCampDC, we had a short discussion about generics v. brands. The public does not actually know generic names, just the brand. “Oh, give me the generic of Zocor” not “I want simvastatin”. It is up to doctors, PBMs, and pharmacies to alert the patients as to what exists in the generic market to lower health care costs.

I wish two of my meds had generic equivalents, as they are $40 a month – not that this is so much, but it adds up, plus my wife’s scripts, plus our son’s script, and doctors’ bills and specialists. It was so much easier and inexpensive when I was single and did not go to the doctor. I can only imagine what the downturn in the economy is going to do to the average family and their healthcare costs.

Follow-up On Retail Clinics

As a follow-up to my post on retail clinics last Tuesday, here are two links to blog posts which explore the topic more extensively than I.

Jane Sarasohn-Kahn of Health Populi talks about the lower costs and better access of retail clinics but at the price of raising overall costs.

Thoughts from Lab Soft News on the subject.

iGuard Medication Alerts

Do you know about iGuard? I never want to sound like a salesperson, but it is a great service "launched in 2007 as a startup venture funded by Quintiles Transnational...to promote better communication and research about drug safety." Huh? A little bit of hype, and you wonder, how are they going to do that?

On the surface, iGuard is a DDI checker, "a healthcare service that helps monitor the safety of your medications (including prescription drugs, over-the-counter drugs, nutritional supplements and herbal extracts)" like ePocrates, DoubleCheckMD and PharmaSurveyor, but has a lot of other benefits as well. FD I know and have spoken with representatives from all of these companies - and they all do more than just check for drug interactions. I am just placing them in this category for now.

I signed up for iGuard a few months back, seeing if there was any synergy with Intelecare and kind of forgot about it, as I know the drugs I take do not have any interactions with each other. A few days ago I was twittering about another Health 2.0 company, and a VP of Quintiles pinged me to ask if I had heard of iGuard. I replied I had an account and went back to look at it again.

Users add the medications they are taking, and their health problems to see if there are any side effects, and then can get information about said meds and conditions. The interface for the medications is very user friendly with Wikipedia content, prescribing info, indications, fact & figures, side effects, as well as charts based on other users on the same drug and feedback from other patients.

For Niaspan ER, the health information is very straight forward: "This product is used in the treatment of patients with high lipid levels (including cholesterol). It's exact mechanism of action is not well understood." I did not know that researchers and MDs did not know how Niaspan works! Learning already. My risk rating is 2, meaning no harmful long-term side effects or interactions. 2,630 patients using iGuard take Niaspan, 53% have side effects (flushing being the most common), 7.0 satisfaction score (mine is a 9), etc... Point being, lots of great information, and a anonymous comment board to post.

This is what got me thinking about them today however, an email from them that stated the FDA is stopping the import of medicines from Ranbaxy Laboratories due to the concerns they are not following US standard for good manufacturing practices. Here is part of the email:

"Although Tricor is one of the medications manufactured by Ranbaxy, drug shortages are not expected because, in most instances, there are enough other suppliers that can help meet demand for Tricor.

For more information, please visit:
http://www.fda.gov/cder/drug/infopage/ranbaxy/qa.htm

* * * *
WHAT DOES THIS MEAN?

This alert will have very little impact on most patients. However, you should be aware that your pharmacy may dispense Tricor manufactured by a different generic company the next time you get your prescription filled.  The effectiveness and safety of generic medication is equal, but some tablets or capsules look different depending on the manufacturer. If your prescription ever looks different, it is always a good idea to ask your pharmacist why the tablets or capsules look different.

This alert is not related to any safety concerns with Ranbaxy products currently distributed in the United States. If you are using medicine covered by this alert you should continue to take it as directed - the risk of suddenly stopping this medication is likely to be greater than any risk associated with their manufacturing. If you have any additional questions about how this FDA alert affects your medications, please talk with your pharmacist."

I got this email at 7:45 pm last night, after I had "shut down" for the day - and stopped inputing information via the web. I read this around 11 pm and thought wow, this is great. Of course I could get this news with the information I read throughout the day, however it was presented to me before the news broke, and provided me with a calm, knowing that I would be OK with my Tricor.

HealthCampDC Part Two - Something I forgot

Looking over tweets from Friday #HealthCampDC08, I completely forgot about a conversation one of the campers started regarding a blood test he wanted his MD to run for him. It was part of a two year check-up that he had self-prescribed. It was a young MD, who stated that she needed to put a note in his chart that said he was very sexually active to get approval from his insurance. That is not such a great note to have in your permanent file.

The MD was trying to be helpful, and get the test passed, however it was the wrong way to do it. One of the MDs at HealthCampDC stated that “... physicians aren't trained to know where those codes go (DRGs)… we get paid for diagnoses”.

This brought up the question: What is in your file, and will this prevent you from getting insurance down the line?

Do you know what is in your file? Has some doctor made a note that was an incorrect or "fake" diagnosis, yet needed to address an issue for a test?

I have been thinking about writing a post about a recent trip to the emergency room - not the point - but when I was there, I got a chest X-ray to make sure everything was hunky-dory. The technician called a few days later and said the hospital sent me a letter suggesting I get a follow-up X-ray three month later because they found an abnormal "shadow". It probably wasn't anything, but they had to protect themselves in case it was lung cancer.

Of course my wife freaked out, and made me go to our PCP. My MD found nothing to support me getting a chest X-ray and said that my insurance would probably not pay for it. It has been three weeks and I haven't heard anything yet regarding approval.

Point being, what if she put something in my chart that hinted at lung cancer. I did smoke on and off for 12 years (only a few cigs a day) but would this effect me getting health insurance in the future?

Again: Do you know what is in your file? You can request it once a year to check on it and make sure there isn't any false or incorrect information.

RAND Study: Patients Without PCP Go To Retail Clinics

I found this article in in Drug Store News yesterday, but I am a little late to post. On a personal note, when I quit my job and became a independent consultant in the late 90s, I did not have health insurance for a year, then paid for it for two years, never used it and stopped paying for it. I was 26 to 29. When I became engaged, my father-in-law wanted to make sure I had insurance, so his daughter would be covered in case she quit her job. We then set-up insurance through the restaurant I own.

However, my wife and I did not have PCPs for two years, and used the Westport Walk-in clinic as our go to MD. We never had a problem - just walked in and waited maybe 20 minutes at most. I think you could even schedule follow-up appointments The last time I saw my new PCP, I waited almost 45 mins!

The MDs did a great job with all of our medical problems, from Lyme Disease, hypothyroid, nasal infection, to a sprained wrist. Granted a walk-in clinic is more of a medical home that a retail-based clinic, but I wanted to personalize the story a bit.

NEW YORK (Sep. 10) A recently released study by nonprofit research organization RAND Corp. found that many retail-based clinic patients do not have a regular health care provider, which is further evidence as to the important role that retail-based clinics play in today’s healthcare system.

“These clinics appear to attract patients who are not routine users of the current health care system,” stated lead author Dr. Ateev Mehrotra, a professor at the University of Pittsburgh School of Medicine and a research at RAND. “For these patients, the convenience offered by retail clinics may be more important than the continuity provided by a personal physician.”

The study, published in the September/October issue of the journal Health Affairs, analyzed the details of more than 1.3 million visits to retail clinics between 2000 and 2007. The data was obtained from eight retail clinic operators that accounted for three-quarters of the clinics in operation as of July 2007. FULL ARTICLE.

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