Health System Loyalty Programs: An Innovation in Customer Care and Service

This article discusses the potential opportunities and benefits for patient care loyalty programs within healthcare organizations. Loyalty programs for commercial businesses have proved successful at promoting customer retention, encouraging positive customer attitudes, and increasing referrals to others. This consumer-driven approach of customer care could be translated to patient care in health care systems, but this is not a common occurrence. Accountable Care Organizations (ACOs), in which patients are free to move among health care centers and physicians, see a high turnover of patients. Several studies have shown a range of 38 – 60% patient turnover rate each year in certain ACOs. This article proposed the introduction of a loyalty programs within an ACO will help with patient retention and overall satisfaction. Potential aspects of patient loyalty program include benefits to loyal members such as parking vouchers, cab and bus vouchers, and cafeteria discounts. Benefits could be customized for patient’s personal care needs, such as customized messages for certain disease states or healthy eating coupons.

This loyalty program model would offer three key benefits. First, greater likelihood for patient allegiance would allow for more comprehensive care, and cost and outcome management. This would benefit both patients and health care organizations. Second, it offers potential improvement in patient-satisfaction scores for reimbursement purposes. Third, tailoring of patient-centered care plans would promote a holistic population health model over a traditional hospital-centric model of care. In order to avoid abuse of the healthcare system as a result of loyalty programs, member rewards should be based on length and strength of loyalty rather than frequency of use. Overall, by involving patients in their own health management, and improving the business aspect of health systems, health care loyalty programs carry many potential benefits.

I feel that promoting patient retention is a key benefit of this type of loyalty program. Patients are much more likely to experience a continuity of care when they stay within a certain healthcare network and all parts are affiliated with one another. Do you think a health system loyalty program could be successful? What potential drawbacks does something like this present?

McMahon, L., Tipirneni, R., Chopra, V. Health System Loyalty Programs: An Innovation in Customer Care and Service. JAMA. 2016;315:863-864. doi:10.1001/jama.2015.19463.

How to Get Better Care with Lower Costs? See the Person, Not the Patient

This article discusses the importance of interacting with individuals as “people” not “patients” in order to provide a more all-inclusive type of care. This is especially important for older adults, who experience chronic health problems, functional limitations, physical challenges, and a deeper reliance on social support. Programs such as disease state management fail to recognize a person as a whole, with many other factors affecting their health and outcomes than just one specific disease itself.

The process of a person-centered care program means putting people in charge of their own health. It involves taking time to identify their personal needs, preferences, and values, consulting familial support if needed. When this information is combined with a health and functioning assessment, the person is able to shape their own personal goals rather than those based simply on medically-defined clinical outcomes. This process allows for the development of a care plan and implementation strategy individual for each person. By allowing each person to identify their own personal goals, and providing the needed support for it to happen, they will be much more motivated and successful in striving for those goals. This process has been developed with and supported by the American Geriatrics Society (AGS).

Three critical indicators of quality person-centered care for older adults are high functional quality of life with minimal intervention, healthcare providers acting in an efficient, convenient manner, and ability to easily navigate the care system as needed. The degree or extent of each of these indicators will vary for each person based on individual functional abilities, family support, and more.

There are several models that embrace this paradigm. They have been able to demonstrate that there is an opportunity for better care for high-need older adults at lower costs. These cost savings may not seem favorable initially when considered on a short-term small scale. This is the case with remote mail-order pharmacies for prescription refills rather than direct pharmacy interaction. However, Washington University’s care management program under the CMS Medicare Coordinated Care Demonstration Pilot is working on proving the long-term benefit of face-to-face interaction over mail-order pharmacy experience for individuals in the older adult population. Considering the points made in this article and the person-centered care approach that is outlined, do you think the emphasis we are seeing currently in mail-order pharmacy for many Medicare patients will be short-lived

Westphal, E., Alkema, G., Seidel, R., Chernof, B. How to get better care with lower costs? See the person, not the patient. J Am Geriatr Soc. 2016; 64:19-21. Doi: 10.1111/jgs.13867 

Statin-Associated Autoimmune Myopathy

This review article looked at an extremely rare side effect of statin therapy that affects roughly 2-3 of every 100,000 people. It is an autoimmune myopathy that can develop at any point in patients receiving statin treatment, which involves muscle weakness, muscle-cell necrosis evidenced by a biopsy, and HMG-CoA reductase autoantibodies. Unlike other statin side effects, symptoms will not improve after discontinuation of therapy, but rather persist or even progress, and require immunosuppressive therapy. The myopathy can affect not only skeletal muscles but also cause joint pain or a rash. Patients with this condition will experience symmetric proximal weakness, and extremely elevated creatine kinase levels.

The mechanism of development of statin-induced autoimmune myopathy is not fully understood, but it is thought to be affected by the increase in HMG-CoA reductase in muscle cells exposed to statins. This in turn can cause an autoimmune response against the HMG-CoA reductase, especially in genetically susceptible patients. This includes those expressing the class II HLA allele DRB1*11:01, which is significantly connected to development of HMG-CoA reductase autoantibodies.

For most patients with statin-induced autoimmune myopathy and HMG-CoA reductase antibodies, discontinuation of statin treatment followed by administration of immunosuppressant therapy is the best course of treatment. A few patients, particularly those who experienced only minor muscle weakness, have displayed improvement after discontinuing therapy without the need for immunotherapy. Notable treatment options include prednisone, methotrexate, azathioprine, mycophenolate mofetil, intravenous immune globulin, and rituximab. Appropriate tapering of immunosuppressants based on patient response and recovery is recommended. Some patients may relapse and require long-term treatment for this condition. Overall, when this condition is promptly identified and treated, patients experience positive outcomes and an overall improvement in muscle strength.

Statins are a very common course of treatment for dyslipidemia, and overall present a favorable side-effect profile. Rare but serious side effects such as this one are definitely worth pharmacists taking note of and making patients aware of the potential risks associated with the medication. Because patients showed positive outcomes when the problem was promptly identified and treated, it is important for patients to be made aware of what to look for before starting a statin medication.

Longo, A. Statin-associated autoimmune myopathy. N Engl J Med. 2016; 374:664-9. doi: 10.1056/NEJMra1515161.

Pharmacist-driven antimicrobial optimization in the emergency department

This article reviewed the influence of a pharmacist-driven antimicrobial stewardship/ optimization service in a non-trauma emergency department of a hospital. The impact of a nurse-driven chart review was compared with a pharmacist-driven chart review. Impact was based on the number of clinical interventions made, along with resistance patterns identified from wound and urine cultures. The nurses assessed 499 patients with positive cultures, and intervened on 50% of the cultures which indicated the need for an intervention. The pharmacists assess 473 patients with positive cultures, and intervened on 80% of those that needed intervention. Interventions were based on inappropriate therapy. Also, E. coli, the most frequently isolated urinary organism, displayed a fluoroquinolone resistance rate of 38%.

This antimicrobial stewardship program showed 30% more pharmacist interventions compared to nurse interventions for “bug-drug” mismatches. Proper prescribing of antibiotics is an essential part of offsetting antibiotic resistance. This program shows that pharmacists are a key part of modifying antimicrobial therapies when needed. The high fluoroquinolone resistance rate suggests that alternative therapies may be better for some urinary tract infections, such as nitrofurantoin.

I thought this was an interesting article, because of the increase in antibiotic resistance and various efforts to offset this increase. It seems that the pharmacists are in a better position to assess and address proper prescribing of antibiotics than the nurses, because ultimately they are the medication experts. With this in mind, do you think it is beneficial for pharmacists to be able to prescribe antibiotics to patients?

Davis, L., Covey, R., Weston, J., et al. Pharmacist-driven antimicrobial optimization in the emergency department. Am J Health Pharm. 2016; 73:49-56. Doi: 10.2146/sp150036.


Pembrolizumab and nivolumab: PD-1 inhibitors for advanced melanoma

This article looked at the progress of two new drugs for advanced-stage melanoma that target the PD-1 receptor. They were recently approved by the FDA for treating patients with unresectable or metastatic melanoma. Pembrolizumab and nivolumab are antibodies that prevent the PD-1 receptor, a programmed cell death receptor, from interacting with its ligands by binding with the receptor. This allows the body to have a better anti-cancer immune response.

This is a breakthrough treatment option, because usually surgical resection is only possible in early-stage melanoma. Chemotherapy is the most common option for patients with advanced-stage unresectable melanoma. Other medication options offer only moderate benefit and significant toxicity. Immunotherapy is an effective treatment for melanoma and other cancers, and even though only about 20% of patients respond to this type of therapy, they usually have long-lasting responses. Adverse reactions experienced from PD-1 inhibitors can usually managed with corticosteroids.

Clinical trials tested the safety and efficacy of Pembrolizumab, and a Phase I open-label trial of 135 patients found that 38% showed an objective response and a progression-free survival time of at least 7 months. 79% of patients had an adverse reaction, but only 13% had a serious adverse reaction. The cost of a single dose for a 70 kg patient is estimated to be $7500, and it is administered via IV every 3 weeks.


Clinical trials tested the safety and efficacy of Nivolumab, including a Phase I open-label trial of 296 patients, 107 of which with advanced, unresectable melanoma. 30.8% of the 296 patients showed an objective response, with an estimated duration of 2 years for the response. The median overall survival time for patients was 16.8 months. 84.1% of the 107 patients with melanoma experienced an adverse reaction, but 22.4% were serious effects. The cost of a single dose for a 70 kg patient is estimated to be $7000, and it is administered via IV every 2 weeks.

It is encouraging to see new targets and treatment alternatives for different types of cancers, although the cost is very high. With more oral and IV medications emerging as valid treatment options, do you think this can have a significant impact on treatment for the disease? Do you think it is likely that more patients would opt for a treatment option like this over chemotherapy?

Ivashko, I, and Kolesar, J. Pembrolizumab and nivolumab: PD-1 inhibitors for advanced melanoma. Am J Health-Syst Pharm. 2016; 73:193-201.


Ibuprofen: Risk, Comorbidities, and Pain Management

Non-Steroidal Anti-inflammatories (NSAIDS) are a commonly used class of drug for pain management, as well as their anti-inflammatory component, and many patients seem to falsely believe that they are harmless. This leads to patients taking them when they may not necessarily need to, without concern for drug interactions or long-term effects. After a recent safety review, the FDA is requesting updated warning labels for over-the-counter NSAIDS. The FDA warns that NSAIDS can increase the risk of heart attack, heart failure, and stroke, not only for patients with heart disease, but also for those without heart disease or risk factors.

NSAIDS are especially useful in treating patients with arthritis, but the American College of Rheumatology advises patients with heart disease to take acetaminophen instead, due to an extensive list of side effects and potential risks. Before recommending OTC pain medications, a healthcare provider should be aware of disease states or conditions, such as kidney or liver disease, hypertension, asthma, patient age, and other medications such as steroids, diuretics, and anticoagulants. Although Tylenol can cause serious liver damage, and lacks anti-inflammatory properties, it is just as effective as ibuprofen for pain and fever reduction, without the extensive side effect profile.

Topical NSAIDS are another potentially safer method of treatment for osteoarthritis inflammation. Because they remain more localized, systemic effects are not as prevalent, and adverse effects were found to be minimal. This information came from a review of randomized, double-blind trials, published in Cochrane Database Systemic Reviews by researchers at Oxford. Ultimately, patients need to be made more aware of the risks associated with NSAIDS, especially such it is such a commonly used prescription and OTC pain medication.

As pharmacists, I think this raises important points about what information to gather from a patient, such as their disease states and medications, before recommending OTC pain medications. With topical pain medications gaining more momentum, and more information available on their side effect profile, do you think this will change the nature of OTC pain medication counseling?

Anderson, Jennifer. Ibuprofen: Risk, Comorbidities, and Pain Management. Today’s Geriatric Medicine.


Medication Disposal Challenges in LTC

Handling disposal of unused or expired medications is a major issue faced by long-term care facilities (LTCF). Roughly 1.5 million pounds of unused medications are accumulated each year by LTCF’s. This can be the result of many factors, including drug-therapy problems such as adverse effects, ineffectiveness, and adherence, as well as patient death. Negative consequences of inappropriate disposal practices includes accidental poisoning, overdose, and environmental contamination.

CMS requires LTCF’s to have policies and procedures in place for proper medication storage and disposal, but other regulatory agencies, such as the FDA, are also involved in this process, causing high potential for confusion due to inconsistencies and complicated directions. The FDA provides a list of medications is deems as safe to flush down a toilet or dispose down a drain. However, the White House Office of National Drug Control Policy (with FDA input) provides guidelines that say to NOT flush medications, but instead refer to a drug take-back program of disposal in cat litter or coffee grounds. OSHA (the Occupational Safety and Health Administration) provides specific instructions on disposal of materials such as sharps containers, which may often include used Fentanyl patches. The Secure and Responsible Drug Disposal Act went into effect in 2014, authorizing DEA regulations for drug take-back programs. LTCF’s may also be required to adhere to the EPA’s proposed regulations about solid and hazardous wastes.

The increased involvement of regulatory agencies in medication disposal means that LTCF’s should evaluate their current processes of medication disposal and modify them as needed. A team approach of handling medication disposal, including a consultant pharmacist, is recommended. Continuous education and training, best practice guidelines, and self-audit programs are all suggested ways to help promote consistency in procedures.

I think this articles raises an interesting point about managing medications in long-term care facilities. The patients in LTCF take an average of 8 routine medications and three as needed, according to the article. When you consider the large amount of medications, and strong possibility of experiencing adverse effects, as well as the higher chance of fatality among the elderly population, it is understandable how medication disposal is a primary concern for LTCF’s. I was surprised at the conflicting, complicated guidelines and regulations for the process, and can understand how this can pose a major obstacle for many facilities. I think it is important for us as pharmacists to be aware of medication disposal regulations and recommendations, and wonder if there is an effective way to simplify the information for more effective application in long-term care facilities.

Coggins, Mark D., PharmD. Medication Disposal Challenges in LTC. Today’s Geriatric Medicine. 2016;9,8-11.

Lack of efficacy prompts citizen petition to remove phenylephrine from OTC market

In November 2015, two university professors submitted a petition to the FDA to remove phenylephrine from the OTC market due its apparent inability to effectively alleviate nasal congestion. Data from numerous clinical trials indicate that when taken orally, it is no more effective than a placebo, even when taken at four times the FDA-recommended dose. This is due to its extensive first-pass metabolism in the liver, before it enters the blood.

According to the article, phenylephrine was discovered in 1927 and categorized as an analog to adrenaline. It was approved by the FDA in the 1970’s as part of a rushed drug monograph approval process, which allowed it to be approved as an ingredient due to its relationship to adrenaline, without thorough examination of data regarding its safety and efficacy, the majority of which was unpublished.

Alternatives to phenylephrine are available over-the-counter, such as oxymetazoline for nasal stuffiness from a cold, which is available as a topical medications (eye drops and nasal spray). However, if these are used for more than three days, they can actually cause rebound congestion. For patients with allergies, OTC intranasal steroids such as fluticasone or triamcinolone, were recommended as alternatives by the pharmacist cited in the article. Oral pseudoephedrine is also an option, available behind the pharmacy counter, but is still shown to be less effective than topical medications at alleviating symptoms.

Phenylephrine is effective at lowering blood pressure when given intravenously, and is also effective when used topically. Many common OTC medications for nasal congestion contain phenylephrine, such as Sudafed, Theraflu, and Tylenol Cold. I know I have heard complaints many times from friends, family, and patients about these medications not really working effectively for them. I found the information in this article about the quick approval process and clinical studies indicating its ineffectiveness when taken orally to be very interesting. Because its inefficacy stems from its extensive first-bypass metabolism, I feel that it is important for it to remain available as a topical medication. Furthermore, as future pharmacists, we can be aware of the clinical evidence and even make suggestions about topical medications to treat nasal congestion as the best treatment option. I am interested to see how the FDA responds to this petition about the ineffectiveness of phenylephrine in the upcoming future.


Tanzi, Maria G. Lack of efficacy prompts citizen petition to remove phenylephrine from OTC market. Pharmacy Today. 2016; 22.