Transcript Modern Treatment of Disease and the Challenge of Medication

MODERN TREATMENT OF DISEASE:
THE IMPORTANCE OF MEDICATION
ADHERENCE
CURRENT EVENTS
•Per capita national health expenditures: $9,523 (2014)
•Total national health expenditures: $3.0 trillion (2014)
•Total national health expenditures as a percent of Gross Domestic Product: 17.5%
(2014)
•Saving money on prescriptions:
•~8% of U.S. adults (7.8%) did not take their medication as prescribed, 15.1%
asked a doctor for a lower-cost medication, 1.6% bought prescription drugs
from another country, and 4.2% used alternative therapies.
•Adults aged 18–64 (8.5%) were twice as likely as adults aged 65 and over
(4.4%) to have not taken their medication as prescribed to save money.
•Among those in the 18–64 group, uninsured adults (14.0%) were more likely
than those with Medicaid (10.4%) or private coverage (6.1%) to have not taken
their medication as prescribed to save money.
•The poorest adults (incomes below 139% of the federal poverty level) were the
most likely to not take medication as prescribed to save money.
National Center for Health Statistics (2014):
http://www.cdc.gov/nchs/fastats/health-expenditures.htm and
http://www.cdc.gov/nchs/data/databriefs/db184.htm
COMMON MEDICAL CONDITIONS
Colds, Sinus and Ear
Infections
• Folk remedies
• Antibiotics are now the
mainstay
• Cost $4 to hundreds for
common infections
• Problem with resistance
Flu
• Those most at risk were
infants, the elderly and
those with chronic
diseases, especially
asthma and decreased
immune systems
• Mortality rates were very
high as there were not
treatments
• Annual flu shot
• Cost of flu shot is about
$0-$35
COMMON MEDICAL CONDITIONS
Arthritis
• Past: few effective tx’s
• Patients suffered with this
deforming and
debilitating disease
• Now have “TNF” inhibitors
and anti-inflammatory
drugs
• $4 for generic Ibuprofen
to $1,000 a month for new
injectable TNF therapy
Many Cancers
• Surgery if possible ( $$$
with uncertain outcome)
• Modern imaging
technology have made
early detection and
prevention key – MRI is
about $1-2,000
• Better chemo drugs but
still very toxic
• Cost of chemo can be
$$$ per treatment
OSTEOPOROSIS
• 40% white women, 15% white men over 50
• Age, gender and race as risk factors for low bone
mineral density
• There are good screening techniques (ultrasound, DEXA)
• Forearm, hip, spine fractures
• 20% -40% of those with a hip fracture expire within 6
months
• High medical costs to treat, increases in nursing home
admissions
• Boniva, Actonel, Fosamax – increase density but also
cause other problems such as GI irritation, possibly more
brittle bones
SCHIZOPHRENIA
1-2% of all adults
What is it? Positive and Negative sx
50% become permanently disabled
Drugs to treat can offer some relief
Zyprexa, Risperdal, Seroquel, Abilify, Mellaril, Haldol,
Thorazine, and others
• Side effects are problematic: metabolic, parkinsonlike symptoms, drooling, somnolence, excitement,
etc.
• Modern drugs cost $300-$800 per month compared
to $4-50 for older therapies
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STOMACH ULCERS
• Duodenal and Peptic ulcers
• We used to treat by regulating the stomach acid
which was sometimes counterproductive
• Surgery was an option that in the past was widely
accepted (thousands, including hospital stays)
• H2s and PPIs as well as recognition there was a
bacterial cause of ulcers as well
• Tagament, Zantac, Axid, Pepsid, Prevacid, Prilosec,
etc. at a cost of $4-100 a month
HEART DISEASE
• Causes can include family history, sedentary lifestyle,
obesity, diabetes, high blood pressure, high cholesterol
to name a few
• Drugs to treat all these conditions
• Each of the previous examples showed how drugs can
be used to treat - in this case the root cause treatment
may be to increase cardiovascular fitness through diet
and exercise - - weight loss
• Literally hundreds of drugs you may have heard of like
Lipitor, Crestor, various insulin, Ally, Zocor, Norvasc,
Inderal, and lots and lots of others
• Costs are all over the board from $4 to many hundreds
per month
SUMMARY
• Drugs are an important part of medical care, representing
about 10% of each health care dollar(1)
• Over time, drugs reduce the total cost of care, even when
these drugs become very expensive
• Modern medicine has made great advances – more is
needed (e.g. Schizophrenia)
• BUT: What happens when people don’t take their
medications?
(1) National Center for Health Statistics:
http://www.cdc.gov/nchs/fastats/health-expenditures.htm
OUTCOMES
• Economic
• increased cost of medications
• lower total health care costs
• Clinical
• better control of disease, symptoms
• Humanistic
• patient satisfaction with therapy
WHEN PATIENTS DO NOT TAKE THEIR
MEDICATIONS CORRECTLY:
• they may not get better
• conditions can worsen
• patients relapse
THE COSTS OF NONCOMPLIANCE:
• Only about 50% of patients take medications correctly
• Between 177 and 290 billion dollars annually in unnecessary
costs (almost triple 10 years ago)
• 125,000 unnecessary deaths (relatively constant)
• 10% (more than 1,000,000) of all hospitalizations may be due
to noncompliance costing nearly 50 billion dollars
• 40% of nursing home admissions
• 50% of all medication use is non-compliant
• $2,000 per year in additional MD visits PER PATIENT
Fung, B. The $289 Billion Cost of Medication Noncompliance, and What to Do About It. The Atlantic.
http://www.theatlantic.com/health/archive/2012/09/the-289-billion-cost-of-medicationnoncompliance-and-what-to-do-about-it/262222/ See also, National Council on Patient Information
and Education, 2007 Agenda Setting Report
ttp://www.talkaboutrx.org/documents/WPRelease07302007.pdf
HEALTH EFFECTS
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increased morbidity
treatment failures
exacerbation of disease
more frequent physician visits
increased hospitalizations
death
ECONOMIC EFFECTS:
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increased absenteeism
lost productivity at work
lost revenues to pharmacies
lost revenues to pharmaceutical manufacturers
DIMENSIONS OF COMPLIANCE
• Initial noncompliance or defaulting
• 2% - 20%, possibly as high as 50% in some studies
• Refill compliance or persistence
• Improper medication use vs. rational noncompliance
BENCHMARK COMPLIANCE RATES:
Drug Category
Adherence
Estimate
Persistence
Estimate
Prostaglandin Analogs (e.g.
Xalatan, Travatan)
47%
37%
Statins
56%
61%
Bisphosponates (e.g. Boniva,
Fosamax)
56%
60%
Oral anti-diabetics
66%
72%
ARBs
63%
66%
OAB medications
28%
35%
Comparing Adherence and Persistence Across 6 Chronic
Medication Classes; Yeaw & Benner et al., Am Jour Managed
Care Pharmacy 2009;15(9):728-40
PERSISTENCE
• after 1 year as much
as a 50 percent
decline
• after 5 years,
compliance as low
as 29% to 33%
• greatest declines in
first six months
80
Percent
• Product persistency
curves
100
Cozar
Fosamax
Zocor
60
40
20
0
1
3
5
7
9 11 13
Months
IMPROPER MEDICATION USE:
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Over or under use, wrong time
Taking the wrong medicine
Not finishing medication
Administration errors
Using another persons medication
Using old, possibly expired medication
THE PRESENT SITUATION
• Measuring compliance
• patient reports, clinical outcomes, pill counts,
refill records, biological and chemical markers,
monitors
• MPR: medication possession ratio
• We need to be able to distinguish between
patients not responding and patients not
complying.
• Should recognize noncompliance cuts
across drugs, diseases, prognosis, and
symptoms.
THE PRESENT SITUATION
• Current research
• most studies aimed at measuring,
understanding or improving compliance
• most are single interventions; few
multifaceted interventions have been studied
• more studies have begun to focus on
changes in economic, clinical and
humanistic outcomes resulting from
compliance interventions
• Some studies with asthma, CHD, HTN,
diabetes and others
STRATEGIES TO IMPROVE COMPLIANCE
• multimedia educational campaigns
• patient education, counseling, written
information, special labels
• teaching methods for self monitoring
• contracts with patients
• devices, reminders (mail, telephone), special
packaging
• follow-up
THE “RIM” TECHNIQUE
• Recognize
• using objective and subjective evidence, the
pharmacist can determine if the patient may
have an existing compliance problem
• Identify
• determine the causes of noncompliance with
supportive probing questions, empathic
responses, and other universal statements
• Manage
• develop partnerships with patients
IDENTIFYING NON COMPLIANCE
• information from the patient
• patient comments, concerns, questions
• certain clinical outcomes
• non response to treatment
• information from refill records
POTENTIAL BARRIERS TO ADHERENCE
• Patient factors: knowledge, prior compliance
behavior, ability to integrate into daily life, health
beliefs and perceptions of possible benefits of
treatment, social support (including practitioner
relationships).
• Older patients: multiple drugs, multiple providers,
physical and mental challenges, communication
issues.
• Complexity of regimen.
PATIENTS AT HIGHER RISK:
• Asymptomatic
conditions
• Multiple daily dosing
• hypertension
• Patient perceptions
• Chronic conditions
• hypertension, arthritis
diabetes
• Cognitive impairment
• dementia, Alzheimers
• Complex regimens
• Irregular dosing
protocols
• qd < bid < tid, < qid
• effectiveness, side
effects, cost
• Poor communication
• patient practitioner
rapport
• Psychiatric illness
• less likely to comply
PATIENT CONSIDERATIONS
• Patient skills needed for behavior modification
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problem solving
self monitoring
develop systems for reminders
enlisting social support
identify positive and negative compliance behaviors
ACTIONS NEEDED
• More fully implement the pharmacy care
model
• Challenges:
• pharmacist commitment to pharmacy care
• enhance the key skills necessary for patient care
• develop partnerships with physicians, MCO’s and
patients
• integrate, coordinate and manage drug use
THE COSTS
• Financial
• training, experience, cost of interventions
• Time
• pharmacy management
• Commitment
• pharmacists, physicians, health administrators, patients
THE VISION
• The modern pharmacy practitioner will partner
with patients, physicians (medical home) and
managed care to facilitate achievement of
desired health outcomes. (MI?)
• Managing medication compliance is a primary
means to successful pharmacy care and
better outcomes for patients. The issue of
compliance is complex, but, has important
implications for health practitioners.
VISION / CHALLENGE
• As pharmacists work to improve compliance,
pharmacy care activities must also increase.
Better compliance may result in improved
outcomes, but, it may also mean more drug
related problems.
• over users who take less medication may experience
increased symptoms
• under users who take more doses may experience
more side effects
GOALS FOR RESEARCHERS AND
PRACTITIONERS:
• What is the net impact of pharmacy care on
medication compliance?
• Recommendations:
• Better packaging (blister packs, compliance packaging,
“counter caps”, etc.)
• Case management (medical home, gatekeeper, managed
care, etc.)
• Educational behavioral support (e.g., MI, Pharmacists and
others)
• Make drugs cheaper (when cost is a driver of non-compliance)
• Less complex regimens (once daily dosing)
BENEFITS OF IMPROVED COMPLIANCE:
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Patients - better outcomes and quality of life
Practitioners - healthier more loyal patients
MCO’s - lower total HC expenditures
Pharmaceutical Industry - increased sales