Can devices improve medication adherence?

Link to the article in the Wall Street Journal.

My reaction:

Blister packing works well and is relatively easy for brand name manufacturers to incorporate.  I could see this as a possible competitive advantage.  Generic manufacturers have little incentive to add this cost.

If you want something to remind you then an alarm on the cellphone seems to have the most utility.  You could also set up a service that uses text messaging to remind and confirm.  Physical devices don't make sense to me.

DMAA "Responds" to Business Week Article Slamming Disease Management

The response was weak but did make a good point. The best example they could cite was a program that lowered co-payments to encourage better medication adherence. This was not the standard DM referred to in the article. But it does emphasize that low cost interventions to increase compliance can have a very favorable return on investment.

Small Benefit, Positive ROI for Automated Adherence Reminder Calls?

George Van Antwerp of Silverlink pointed me to this report on the impact of an automated calling service on medication compliance.  Overall medication compliance increased by 2%.  This may not sound like much but it probably has a positive return on investment (ROI).  Basically, one reduced hospitalization due to improved compliance can pay for a lot of low cost interventions.  I hope someone publishes the actual ROI for this program.

Can Patient Counseling Lower Adherence?

The abstract of a recently published article, "A systematic review of adverse events in placebo groups of anti-migraine clinical trials", stated:


"We found that the rate of adverse events in the placebo arms of trials with anti-migraine drugs was high. In addition, and most interestingly, the adverse events in the placebo arms corresponded to those of the anti-migraine medication against which the placebo was compared. For example, anorexia and memory difficulties, which are typical adverse events of anticonvulsants, were present only in the placebo arm of these trials. These results suggest that the adverse events in placebo arms of clinical trials of anti-migraine medications depend on the adverse events of the active medication against which the placebo is compared. These findings are in accordance with the expectation theory of placebo and nocebo effects."

Could counseling on all common side effects lower adherence by increasing the incidence of adverse events?  I could not find any research on this subject.  Therefore,  I likely would draw the line, as I actually did in the USP-DI side effects listing below, at reviewing the adverse events that require medical attention.  I am not sure whether I would want to exclude information from the printed counseling materials.

Side Effects of This Medicine

Along with its needed effects, a medicine may cause some unwanted effects.Most side effects of sumatriptan are milder and occur less often with thetablets than with the injection. Although not all of these side effects mayoccur, if they do occur they may need medical attention.

Stop using this medicineand check with your doctor immediately if any of the following side effectsoccur:
Rare
Chest pain (severe); changes in skincolor on face; convulsions (seizures); fast or irregular breathing; puffinessor swelling of eyelids, area around the eyes, face, or lips; shortness of breath, troubled breathing, or wheezing

Check with your doctor right away if any of the following side effects continuefor more than 1 hour. Even if they go away in less than 1 hour, check with your doctor before using any more sumatriptan ifany of the following side effects occur:
Less common
Chest pain (mild); heaviness, tightness,or pressure in chest and/or neck

Also check with your doctor as soon as possibleif any of the following side effects occur:
Less common
Difficulty in swallowing; pounding heartbeat; skin rash, hives, itching, or bumps on skin

_____________________________________________________________________________________________________________

Other side effects may occur that usually do not need medical attention.Some of the following effects, such as nausea, vomiting, drowsiness, dizziness,and general feeling of illness or tiredness, often occur during or after amigraine, even when sumatriptan has not been used. Most of the side effectscaused by sumatriptan go away within a short time (less than 1 hour afteran injection or 2 hours after a tablet). However, check with your doctor ifany of the following side effects continue or are bothersome:

More common
Burning, discharge, pain, and/or soreness in the nose; burning, pain, or redness at place of injection; change in sense of taste; discomfortin jaw, mouth, tongue, throat, nose, or sinuses; dizziness; drowsiness; feeling of burning, warmth, heat, numbness, tightness, or tingling; feeling cold, ?strange,? or weak; flushing; lightheadedness; muscle aches, cramps, or stiffness; nausea or vomiting

Less common or rare
Anxiety; general feeling of illnessor tiredness; vision changes

Other side effects not listed above may also occur insome patients. If you notice any other effects, check with your doctor.

Medication Reminder Systems

I don't think that reminder technology tied to prescription containers make sense for the vast majority of people. The Boston Globe covers a system that might benefit select patients with a lot of medications or complicated dosing schedules. The device blinks when a dose is due then starts beeping louder and louder if the dose is missed. It can be programmed via the web but someone needs to fill the cups, hopefully accurately, every week. The device costs less than $100, has large labeling, but isn't exactly portable. A $30 per month monitoring fee will track compliance and send notices to the select caregivers.

I wonder how a cellphone-based system would compare with reminders, pictures of the correct medication, patient feedback that they took the dose and even collection of other health status indicators (e.g., weight, blood pressure, glucose). Can anyone point me to such a system?

13% of Health Care Costs Due to Poor Adherence

At least according to a report from the New England Health Care Institute. They provide a very good review of the literature that makes the case that improving medication adherence may be the most valuable approach to improving patients' quality of life and lowering overall costs. I particularly like that they included more approaches than just lowering patient pay. Technology now allows us take action to help more patients at a much lower cost. For example, SilverLink combines decision support and communication systems while ValueOptions PharmaConnect identifies over 8,500 alert types and notifies the patient's trusted advisor (their own physician).

Lowering Patient Pay Only One Way to Improve Medication Adherence

Peter Pitts of the Center for Medicine in the Public Interest (partially funded by drug companies) and a former FDA associate commissioner argues that lawmakers should include reducing patient pay as a key part of health care reform.

I argue in a recent issue of American Health & Drug Benefits that other methods may work better at a lower cost. Excerpt:

"Programs to help patients maintain adherence can focus on incentives (such as lower patient pay), refill reminders, or interventions supported by analytics that detect adherence issues. Lowering copayments or coinsurance provides an easy-to-implement solution with proved short-term benefits; however, little is known about the long-term, lasting impact of this approach. Other potential incentives may tie lower patient pay, contribution to health savings accounts, or lower deductibles to completion of health risk assessments, participation in disease management programs, or maintaining adherence for defined durations (eg, every 6 months). This begs the question whether lowering patient pay offers better value than other services, such as those that detect and notify providers of poor adherence. Lowering patient pay by $5 for every chronic medication would cost upwards of 10 times more than intervention services that focus on adherence plus other medication therapy problems, missing preventive services, and gaps in evidence-based care."

Patients Fail to Pick Up 6.8% of Rxs

I was surprised by the higher abandonment rate for the drugs with co-pays of more than $99. These drugs tend to be high-cost, but unique drugs for often debilitating conditions. I am curious if patients in commercial health plans often do not find enough value in these drugs or whether they find other sources.

Current e-prescribing systems do not notify the physician when a patient does not pick up their prescription. This increases the importance of systems that integrate medical and pharmacy data and notify physicians about patients without recommended medication therapy for key conditions.

from PharmaLive: http://pharmalive.com/news/index.cfm?articleID=617277&categoryid=9&newsletter=1

"A prescription is defined as abandoned when a patient submits a retail prescription to a pharmacy but never actually picks it up.

Looking at U.S. commercial plan claims for 2008, Wolters Kluwer Health found that prescription abandonment increased by 34 percent nationally compared to 2006 --- jumping from an average of 5.15 percent in 2006 to 6.8 percent in 2008. It also found that abandonment increased as the amount of the co-pay increased, especially for new prescriptions. For example, new prescriptions with co-pays of $100 or more carry an abandonment rate of just over 20 percent; while with co-pays of $10 or under, the abandonment is only 4 percent."