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Medication Use and Rate of Hospitalizations Among Patients Who
®
Utilize the En-Vision ScripTalk Prescription Label Reader
Tatyana Spektor, Bruce I Gaynes OD PharmD
Department of Ophthalmology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL
Department of Ophthalmology, Edward Hines, Jr. VA Hospital, Hines, IL
Background
Methods
By 2020, it is estimated that the blind and low-vision populations in the
United States are expected to increase by 70%.1 Currently, there are more
than 25 million American adults who report significant vision loss, implying
either complete vision loss or difficulty seeing, even with the aid of glasses.2
Individuals with decreased visual function have been shown to have
diminished quality of life and decreased functional abilities of daily living,
making it more challenging to maintain independence.3 This is likely the
reason why individuals with visual impairments are more reliant on both
community and family support systems and, compared to those with
adequate vision, are less likely to go outdoors alone.4 A study from
University of Melbourne showed that even mild impairment of vision is
correlated with more than a twofold risk of death within five years.5 Though
additional research is needed to determine the reason for this increase in
mortality, it is known that individuals with vision impairment have higher
hospital admission rates compared to their counterparts with adequate
vision.6 Likewise, it is known that inability to administer medication is the
leading cause of institutionalization worldwide.
Study design was a retrospective cohort study. From 2006-2011, 864 patients
at the Hines Veterans Affairs Hospital were identified as being enrolled into the
ScripTalk® program following successful completion at the Blind Rehabilitation
Center. Electronic medical records of a subset of 84 living patients using
ScripTalk who were deemed as high-risk patients were reviewed. Criteria for
high-risk patients included either prescription of a drug with a low therapeutic
index or consumption of multiple drugs to treat a disease. Thus, patients that
were prescribed either warfarin, anti-epileptics (phenytoin, carbamazepine),
anti-arrhythmics (digitalis, amiodarone) or greater than four anti-hypertensive
medications were classified as high risk. Additionally, congestive heart failure
patients with overt symptoms that are medically treated were classified high
risk. Lastly, patients with multiple cardiovascular risk factors were regarded as
high risk (insulin-controlled diabetes, coronary artery disease treated with
aspirin, and previous myocardial infarction or stroke).
A study of a 2006 national survey of more than 30,000 participants has
shown that individuals with vision loss are more likely to suffer from comorbidities such as diabetes, heart problems, hypertension and stroke,
compared with an age-matched population with full vision.7 One of the
many challenges that visually impaired individuals face comes with properly
taking medications. One study showed that a major factor of medication
noncompliance in the elderly is the inability to read prescription labels.8
Diligence in taking medication is especially important for those prescriptions
that have complex instructions on how to properly take the drugs, and could
pose serious side effects if the dosage is not correctly administered.
The American Foundation for the Blind (AFB) conducted a survey that
detailed the troubles of reading prescription and over-the-counter
medication labels for those with vision impairments. Of the nearly 100
participants of the survey, almost every individual mentioned instances of
adverse consequences from being unable to read the labels, leading to ED
visits, hospitalizations and increased anxiety. Nearly every participant of the
survey admitted to being dependent on another person in order to take the
proper medication dosages.9
For those individuals who either do not have a support system or choose to
live independently, there are options available to assist in taking
medications. One such option is ScripTalk®, an audible prescription reader
created by En-Vision America, Inc., which uses radio-frequency
identification (RFID) and text-to-speech technology to help those with visual
impairment lead more independent lives. A pharmacist uses ScripTalk®
computer software to encode a “Talking Label”, a specialized sticker with a
microchip and antenna embedded inside that is secured to a medication
container, similarly to a standard prescription. The label is encoded with all
the relevant information that the patient will need to know about the
medication, including drug name, proper dosage, side effects, warnings,
pharmacy name and phone number, and prescription number. The patient
places the medication on top of the tabletop device and presses a single
button to hear all of the label information.10
The two primary goals of the ScripTalk® station are to prevent life
threatening emergencies caused by dosing errors and to help patients live
their lives with independence and the level of privacy that they desire,
helping to eliminate the need for assistance in reading prescription. To date,
there are no studies that describe the efficacy of the ScripTalk® station in
reducing medication errors or medication noncompliance. Furthermore,
there is little data to suggest that use of such devices have any impact on
disease outcomes. The aim of this study is to provide a descriptive analysis
of ScripTalk® users to be used as a starting point for future research into
the efficacy of this prescription drug label reader in prevention of
hospitalizations due to drug-drug interactions.
Multivariate logistic regression was used to determine the odds ratio (OR) of
variables associated with medication utilization among various levels of visual
impairment such as use of pillboxes or self reporting of missed medication
doses (TexaSoft, WINKS SDA Software, 6th Edition, Cedar Hill, Texas, 2010,
alpha = 0.05).
Medical Conditions in ScripTalk® Users
71% of ScripTalk® users had diabetes, while 20% of all users were insulindependent. 92% of patients were hypertensive and 41% were being treated for
congestive heart failure. 68% were diagnosed with coronary artery disease. 7%
of users had a history of at least one deep vein thrombosis while 1.2% had
history of pulmonary embolus. 25% had a history of atrial fibrillation, 35%
suffered from a previous myocardial infarct, and 35% had at least 1 stroke. See
figure 1 for a complete list.
Looking at medication use, 55% of patients were on aspirin, 20% on warfarin,
8.3% on digoxin, 8.3% on clopidogrel, and 3.6% on amiodarone. 13% of
patients were on either one or zero anti-hypertensives, while 57% of subjects
were on 3-4 anti-hypertensive drugs (fig. 2 and 3).
The subjects who had a visual acuity of no light perception (NLP) were 17.6
times more likely to have someone remind them to take their medication
compared to other ScripTalk® users (p-value 0.015). Those with NLP were also
5.4 times more likely to miss taking their medications compared to the other
subjects (p-value borderline significant .0505).
Additionally, we found that since starting ScripTalk®, the average number of
hospitalizations per patient was 2.03. The subjects who stated use of a pillbox
at home had an average of 1.73 hospital visits, while non-pillbox users had 2.83
hospitalizations. Patients with a congestive heart failure diagnosis had an
average of 2.31 hospitalizations, while patients who were taking warfarin had
2.30 hospital visits, on average.
Lastly, we found the adherence rate of ScripTalk® users to be extremely low.
The initial data collection took place in September 2011. As of August 2012, out
of the original 84 subjects, 2 have passed away, and only 11 have continued to
order ScripTalk® prescriptions.
The data showed several factors that are correlated with increased hospitalization rates.
While some risk factors such as congestive heart failure are not modifiable, others certainly
can be modified. One such risk factor is use of a pillbox and, in this study, a little under onethird of the subjects stated not regularly using a pillbox. Aside from hospitalization rate, we
also took a look at how visual acuity affected a ScripTalk® user’s ability to take medications.
Our analysis showed that not only do the subjects who have a visual acuity of NLP have
over a 5 time more likely chance of missing their medications compared to subjects with any
other visual acuity, but they are also 17 times more likely to have someone remind them to
take their medications. Thus, not surprisingly, the patients with the worst visual acuity were
the least independent in taking their medications.
Figure 1
Seizure
History of Deep Vein Thrombosis
Arrythmia not including Atrial Fibrillation
insulin dependent diabetes
Atrial Fibrillation
History of Stroke
History of Myocardial Infarction
Chronic Kidney Disease
Congestive Heart Failure
Coronary Artery Disease
Diabetes
Hyperlipidemia
Hypertension
0
10
20
30
40
50
60
70
80
Figure 1: This figure depicts the most common medical conditions of the 84 ScripTalk® subjects.
Most subjects had multiple medical conditions.
Figure 2
Results
The study cohort consisted of 81 males and 3 females ranging in age from 4997. The most common causes of visual impairment (fig. 2) included diabetic
retinopathy (30%), macular degeneration (29%), and glaucoma (18%). All
patients had a best visual acuity of 20/200 or worse. 35% of patients needed
help taking their medications, and 68% of patients sited using a pillbox at home.
61% of the patients who use a pillbox, admitted to filling it themselves without
assistance. 80% of patients did not regularly receive reminders to take their
medications and 31% of patients admitted to having missed taking their
medications as prescribed. Outside of the ScripTalk® device, 38% of patients
did not use any assistive devices to help take their medications, while 24%
used a magnifier.
Conclusions
Data Description
Cause of Visual Impairment in
ScripTalk® Users
Gunshot wound
Ischemic optic…
Hypertensive retinopathy
Traumatic optic atrophy
Miscellaneous
CVA/embolism
Glaucoma
Macular Degeneration
Diabetic Retinopathy
0
Duration of Visual Impairment in
ScripTalk® Users
Unknown
1-5 years
Number of subjects
This study raised important questions regarding the efficacy and ease of use of the device,
considering that only a year later the retention rate for patients using ScripTalk® was roughly
13%. The reason for this low retention rate is unknown, though possibilities may include
difficulty in obtaining the ScripTalk®-specific prescriptions or challenges with operating the
ScripTalk® station.
The information obtained in this study is an important stepping stone for further studies that
will explore the predictive nature of visual impairment and use of the ScripTalk® system on
rate of hospital admission compared with a visually-sighted control population that is also
deemed high risk. Likewise, in the future, we plan to examine the effect of the device on
medication compliance as measured by refill history.
References
6-10 years
11-20 years
21 or more
20
40
60
80
Figure 2 (left): This figure depicts the visual diagnoses of the 84 ScripTalk® subjects. Some
subjects had more than one diagnosis. Miscellaneous diagnoses include ocular histoplasmosis,
retinitis pigmentosa, bilateral retinal detachment, bilateral central retinal vein occlusion, injury
otherwise unspecified, anoxic encephalopathy, ischemic optic neuropathy
Figure 2 (right): This figure depicts the duration of visual impairment in ScripTalk® subjects.
Figure 3
Narrow Therapeutic Index
Medication Use
80
70
60
50
40
30
20
10
0
Number of Anti-hypertensive
Medications in ScripTalk® Users
1. Congdon, N. (2004). Causes and Prevalence of visual impairment among adults in the
United States. Archives of Ophthalmology. 122(4):477-85.
2. American Foundation for the Blind. (2011). Facts and Figures on Adults with Vision Loss.
3. Knudtson, M.D., et al. Age-Related Eye Disease, Quality of Life, and Functional Activity.
Archives Ophthalmology. (2005). 123:807-814
4. Wang, J.J., et al. Impact of Visual Impairment on Use of Community Support Services by
Elderly Persons: the Blue Mountains Eye Study. Investigative Ophthalmology and Visual
Science. (1999). 40(1):12-19.
5. McCarty, C.A., et al. Vision Impairment Predicts 5 Year Mortality. British Journal of
Ophthalmology. (2001). 85:322-326
6. Evans, J.R., et al. (2008). Hospital Admissions in Older People with Visual Impairment in
Britain. BMC Ophthalmology, 8(16).
7. Crews, J.E., et al. (2006). Double Jeopardy: The Effects of Comorbid Conditions Among
Older People with Vision Loss. Journal of Visual Impairment and Blindness, 100, 824-848.
8. Murray, M.D., et al. Factors Contributing to Medication Noncompliance in Elderly Public
Housing Tenants. Drug Intelligence & Clinical Pharmacy. (1986). 20(2):146-52.
9. American Federation for the Blind. (2011). Access to Drug Labels Safety Report.
<http://www.afb.org/Section.asp?SectionID=3&TopicID=135&DocumentID=4520>.
10. En-Vision America. (2007). <http://www.envisionamerica.com/>.
Zero
One
Number of subjects
Two
Three
Four
Five
Coumadin
Acknowledgements
Anti-arrhthymic Anti-epileptic
drugs
drugs
Special thanks to Rahul Shah, PharmD for his assistance in this work. The kind support of
the Richard A. Perritt Charitable Foundation is acknowledged.
Figure 3 (left): This figure depicts the use of prescription medications with narrow therapeutic
indices in ScripTalk® subjects. Anti-arrhythmic drugs include amiodarone and digitalis. Anti-epileptic
drugs include phenytoin and carbamazepine.
Figure 3 (right): This figure depicts the total number of anti-hypertensive medications that that
were prescribed to ScripTalk® subjects.