Nonadherence to diabetes medications costly

This is follow-up commentary to an article I Tweeted about earlier this week.

JCP: “[Express Scripts] found that patients who were adherent to oral diabetes drugs had 235 fewer emergency department visits and 50 fewer inpatient hospitalizations per 1000 patients, resulting in an average of $500 saved per patients and a total decrease of $210 million in health care spending in 2016…Patients who were nonadherent were found to have 1.3 times higher medical costs and 4% higher total health care costs compared with adherent patients, a difference of $11,176 vs $10,683, respectively.” – No surprise. Poor control of chronic diseases like diabetes can lead to lots of complications, including admission to a hospital for advanced care.

Nonadherence to medication is tricky. Proposed solutions to the problem are many. Actual solutions to the problem are few. The issue is that there’s no one-size-fits-all approach to the problem. People behave like people. Some will do a great job managing their disease, while others won’t. The more complicated the disease management, the more likely that adherence will slip. And management of patients with diabetes can get very complicated.

The difficulty comes when multiple healthcare providers are involved. There are often multiple medications, complicated administration regimens, and so on. I witnessed this firsthand while caring for my mom during the last year of her life. She was a complicated patient, and her medication regimen changed frequently depending on the physician seen and which area of the disease was the focus of treatment; the old whack-a-mole approach to medicine. With that said, my mother was a best case scenario. Her ability to manage her medications was inspiration. However, even as a pharmacist I found it difficult to keep track of what was going on at times. There were times when I would re-sort and organize her weekly medications three times in a ten day period. Crazy.

My opinion is that adherence strategies are still in their infancy. There are simply too many variable when it comes to patients take their medications correctly. The most important thing, in my opinion, is getting people to take a stake in their own disease management. That should be the primary goal. The rest is window dressing at this point.

Use of digital pills to measure opioid ingestion [article]

Here’s an interesting article from the January 13 issue of the Journal of Medical Internet Research (JMIR): Digital Pills To Measure Opioid Ingestion Patterns In Emergency Department Patients With Acute Fracture Pain: A Pilot Study (1)

A group of researchers out of Boston utilized digital pills (eTectRx, Newbury, FL, USA) to observe the ingestion patterns of oxycodone for patients discharged from the hospital following an acute extremity fracture.

Eighteen patients met inclusion criteria for the study, but only ten consented and were enrolled. Of the ten, eight had usable data. Not exactly a large number, but you gotta’ start somewhere.

Study drug was dispensed in capsule form. The digital pill was compounded with oxycodone tablets using a standard capsule-filling machine by the hospital’s investigational drug services pharmacy. Compounded digital pills were dispensed in blister packages.

When ingested, the gastric chloride ion gradient in the stomach activates the digital pill, transmitting a unique radiofrequency signal that is captured by a hip-worn receiver. The ingestion data is then transmitted to a cloud-based server where it can be viewed and analyzed. Because each digital pill emits a unique frequency, the system can record multiple simultaneous ingestion events, which is very cool.

It turns out that the digital pill did a pretty good job of recording the patient’s ingestion of their pain meds. It wasn’t perfect, and they had some technological issues along the way, but overall it results look promising. Imagine being able to see how your patients are taking their medication in real-time. You could even use the data coming from the digital pill to determine if a patient had ingested too many capsules at once.

The use of digital pills definitely has potential.

From the abstract:

Results: We recruited 10 study participants and recorded 96 ingestion events (87.3%, 96/110 accuracy). Study participants reported being able to operate all aspects of the digital pill system after their training. Two participants stopped using the digital pill, reporting they were in too much pain to focus on the novel technology. The digital pill system detected multiple simultaneous ingestion events by the digital pill system. Participants ingested a mean 8 (SD 5) digital pills during the study period and four participants continued on opioids at the end of the study period. After interacting with the digital pill system in the real world, participants found the system highly acceptable (80%, 8/10) and reported a willingness to continue to use a digital pill to improve medication adherence monitoring (90%, 9/10).

Conclusions: The digital pill is a feasible method to measure real-time opioid ingestion patterns in individuals with acute pain and to develop real-time interventions if opioid abuse is detected. Deploying digital pills is possible through the ED with a short instructional course. Patients who used the digital pill accepted the technology.


  1. Chai, Peter R et al. “Digital Pills To Measure Opioid Ingestion Patterns In Emergency Department Patients With Acute Fracture Pain: A Pilot Study”. Journal of Medical Internet Research1 (2017): e19.

Medication non-adherence, is more technology the proper response?

EMR & EHR: “Of all the things that irrationally inflate health costs, one of the top concerns is people who just don’t take their prescribed medications. Medication adherence doesn’t sound like a high-tech issue, but a lot of interesting technologies are being thrown at the problem…. At the recent Connected Health Conference I talked to several companies taking on the difficult adherence problem from different angles. Medisafe aids patients in self-monitoring, Insightfil creates convenient packaging that groups pills the ways patients take them, and Dose doles out medication at prescribed times.”  – The author goes on to describe some of the technology. The content is worth a few minutes of your time.

Here’s the thing, technology may not be the solution.

 

There’s no question that medication adherence is a problem. How big is the problem? Well, according to an article in The American Journal of Medicine, 28% of new prescriptions never get filled, and among patients who do fill their prescriptions,  adherence rates are less than 50%. The New England Healthcare Institute NEHI in 2009 [PDF] estimated that the cost of non-adherence was about $290 billion annually. It’s probably well over $300 billion now, but the number I see in most presentations is $290 billion. Hey, it’s a good, scary number.

Medication adherence, or non-adherence as the case may be, not only complicates things for patients but for the entire healthcare system.

The problem is well defined, i.e. people aren’t taking their medications properly, but the solution has eluded healthcare for a long time. That’s likely because the reasons for non-adherence vary widely and have been debated and discussed as long as I’ve been a pharmacist. Have we made progress? It’s hard to say. I suppose it all depends on your definition of progress. We have lots of medication adherence tools at our disposal; reminder systems, mobile applications, smart medication organizers, alert systems for medication bottles, and so on. I suppose that could be considered progress.

All these toys have a place in medication adherence, but the fundamental problem goes well beyond their scope. Medication adherence is a multi-faceted problem with roots in psychological behavior, socioeconomic background, and demographics.

However, one thing that people seem to overlook is that the contact point for most patients and their medications is a pharmacist. According to a recent report published by the National Community Pharmacy Association (NCPA), “the biggest predictor of medication adherence was patients’ personal connection (or lack thereof) with a pharmacist or pharmacy staff.”

A patient’s introduction to medication use should begin by developing a relationship with a pharmacist at the point of care, whether that’s a hospital or a community pharmacy. In hospitals, patients should speak with a pharmacist upon admission, and again upon discharge. No patient should ever leave the hospital without speaking to a pharmacist or without medications in hand.

This is an oft-overlooked opportunity within healthcare systems. For hospitals that don’t have the resources to speak with every incoming and outgoing patient, look to your local community pharmacies. Find community pharmacies in the area that are willing to partner with the healthcare system to provide bedside medication delivery and consultation, thus beginning the process of building a working relationship between patient and pharmacist. As the patient moves from the hospital back into their daily routine, the relationship with their pharmacist will continue to grow. The payoffs are huge, especially for those patients with chronic diseases like diabetes, asthma, hypertension, hypercholesterolemia, and so on.

Not all patients are willing or able to be compliant, but some are, and those are the ones we hope to reach. Using a cost for non-adherence of $300 billion annually, a conservative positive impact of 10% could add up to more than #30 billion a year in savings, not to mention the positive impact on a patient’s quality of life.

Bottom line, get a pharmacist involved early and often. Medication adherence, it’s what we do.

Is multi-dose packaging really a solution to medication adherence?

Multi-dose packaging has been a part of pharmacy for longer than I’ve been a pharmacist. It’s mostly been limited to long term care (LTC), such as nursing homes, rehab facilities, etc. It’s not something that’s commonly used in acute care hospitals for a host of reasons, most notably medication regimens frequently change in acute care settings. Multi-dose packaging works best when the patient is stable and medications can be dispensed for multiple days, hence the popularity in LTC.

Recently articles have been cropping up for companies attempting to use multi-dose packing technology in the ambulatory care setting, i.e. outpatient pharmacy. The most recent of which is an article in the Tampa Bay Times, describing the M5000 robot (1) by MTS Medication Technologies, an Omnicell company. Check the video below.

Continue reading Is multi-dose packaging really a solution to medication adherence?

Saturday morning coffee [February 21 2015]

“An error doesn’t become a mistake until you refuse to correct it.” – Orlando A. Battista

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The mug below was sitting next to my laptop filled with chocolate covered espresso beans last Saturday morning, Valentine’s Day. A gift from my lovely wife. Apparently she’s aware of my addiction. It made me smile.

MUG_Valentines
Continue reading Saturday morning coffee [February 21 2015]

The yin and yang of mobile healthcare

My “swag bag” from the unSUMMIT contained an issue of Specialty Pharmacy Continuum, a throw-away pharmacy journal focused on specialty pharmacy practice. Like most throw-away pharmacy journals I read these days, I found the content timely and interesting.

One of the articles – Get Appy! New Tech a Bridge to Patient Care – discusses how Avella Specialty Pharmacy is using mobile technology to connect with their patients. Apparently Avella is pretty forward thinking.
Continue reading The yin and yang of mobile healthcare

Saturday morning coffee [August 9 2014]

“If you think a weakness can be turned into a strength, I hate to tell you this, but that’s another weakness.” -Jack Handey

So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The coffee mug below is relatively new. It’s one of two that I picked up in Las Vegas at M&M World during one of my daughter’s volleyball tournaments earlier this year.

Orange M&M's Coffee Mug
Continue reading Saturday morning coffee [August 9 2014]

Using facial recognition for medication adherence?

While doing a routine search of Twitter I came across AiCure (@AiCureTech), which touts itself as “Computer vision and facial recognition technology to confirm medication adherence on mobile devices”. Ok, you got my attention. Unfortunately the Twitter account appears to be dead as the last Tweet listed on the account was from September 25, 2013. The AiCure website is a bit more recent, however. The last item posted to their News & Events section was from March of this year.

There’s a video on the website that gives a basic overview of the process. I would have embedded the video here, but couldn’t figure out how to grab it, which is a real shame because it’s in their best interest to make information easy to share.

After watching the video I’m not entirely sure that the process makes sense to me. The video shows a jogger running on a pier. The jogger receives a notification on her smartphone reminding her to take her medicine. She stops, pops the tablet in her mouth, records the transaction via facial recognition on her smartphone, and then merrily continues on her way. In my experience people that are as “with it” as the person portrayed in the video don’t have any trouble remembering to take their meds; calendar reminders, pill bottle next to the coffee pot, etc. And why is the jogger carrying her medication with her while out jogging? I assume her jogging session wouldn’t last more than an hour or two. Take the med before or after. There’s no sense of the importance of the medication to the patient’s condition, nor is their any sense of the person being so busy that they couldn’t remember to take their medication. It would have made more sense to show some teenager with a serious medication-dependent disease state going through a busy school day. Right? Having so much fun with their friends that they forget to take their medication?

Thoughts on marketing aside, the concept of using facial recognition is intriguing.

From the AiCure website:

The combination of automated computer vision technology with dynamic patient feedback, offers a new gold standard in medication adherence monitoring. The computer vision platform is being extended to develop a robust identification and authentication system for medication.

Much like a voice recognition system, which understands what the user says, AiCure’s sophisticated, patented computer vision system visually understands what the user is doing.

The software-based technology is uploaded onto a smartphone or tablet computer. The user follows a series of pre-determined steps that are instantly recognized and confirmed through the webcam.

Automated DOT® [Directly Observed Therapy] confirms facial identity, medication dosage, correct ingestion, and time of ingestion. In addition, built-in data tools allow for ongoing patient-provider feedback; reminders in case of nonadherence; positive feedback; self-reported data by the patient; and therapy information – all designed to ensure real-time adherence monitoring and improved patient adherence over time.

PillPack: a new way of thinking about an old problem

I read a Wall Street Journal article this morning about an online pharmacy called PillPack that’s doing something a little different. “PillPack mails its customers their medications every two weeks, but rather than putting them into several big bottles, the company pre-sorts them into sealed, single-dose packs, based on when a patient needs to take their medications throughout the day. The pills arrive in a long chain of dose packs, linked together on a recyclable dispenser roll.

It’s not a new concept at all. In fact, the idea has been tossed around in certain pharmacy circles for years. Many companies are capable of providing such a service, but most lack the vision to bring the concept to life. Perhaps PillPack can provide enough value to its customers to make it viable. I really hope it works out for the company. At least they’re thinking outside the box, er, inside the box.

PillPack should really think about partnering with local hospitals and deliver discharge meds to the patient bedside in this handy format. Counsel the patient, make sure they have their meds, automatically enroll them in the mail order service, and so on. Just sayin’.

Gema Kit – NFC-enabled medication compliance tracking for consumers

GemaKitThis is interesting, the use of NFC tags to track patient’s medication compliance. Makes sense when you consider the ubiquitous nature of NFC on mobile devices these days.

MedCityNews: “[Gema Kit] features stickers embedded with sensors that link to a patient reporting website. These small circles go on pills, pill bottles or blister packs. The sensor is proximity-based, so when a person’s cell phone is waved at the sticker, it brings up the reporting portal. In addition to recording when a pill was taken, a user can report symptoms, side effects and mood. The touch-to-activate patches include proprietary technology but also meet NFC Forum Type 2 Tag standards. They can be read by any NFC-enabled mobile device including cell phones, tablets or readers.”

From the website:

The Gema Kit includes:

  • Dual NFC and bar code/quick response coded “patches” of various sizes that the patient adheres to the outside of their pill bottles and packs
  • Links to a free engagement website
  • Back-end data tracking and reporting service for providers

Each patch within the kit is paper thin. Through proximity of a user’s mobile device, the patch enables an instantly to a web-based patient system that will:

  • Enable logging of NIH PROMIS guided, quality of life measures at the point of care, as well as
  • Connecting patient’s to other stakeholders that are important them and to their fight.