Potential cost savings of medication therapy management in safety-net clinics

Medical cost associated with chronic disease has been on the rise, and becoming an economic burden on the national level. Almost 50% of the $1.13 trillion national medical expenditure is associated with chronic disease treatments each year in the United States. MTM service provided by pharmacist may be a solution to the problem by improving treatment management and health outcomes through the adjusting of medication regimen and counseling of patients.

In order to determine how MTM services can impact potential cost savings, the study focused on the MTM service that is delivered in safety-net clinics from October 2009 to September 2013 in Maryland. The targeted population was mainly low-income, underserved Latino with age ranging from 26 to 83 years. Pharmacist provided face-to-face consolation and interventions and follow-up appointment as needed.

Within the four years, 110 male and 136 female patients received MTM where over 2,000 medications. There was an average of 8.5 medication and 4.8 chronic diseases per patient. Through the MTM service, 814 medication-related problems are identifying, resulting to an average of 3.3 problems per patient. Among the most common medication-related problems include subtherapeutic dose (38%), nonadherence (19%), and untreated indication (16%). The overall medication-related problems corresponds to $115,220-$614,570 which calculates to $141.55 to $755 for every problem identified.

The total cost of MTM service including the pharmacist’s salary, the administrative and operational cost totals to $57,307, showing that a significant amount of medical cost can be avoid with the pharmacist-provided MTM services. This study validated the importance of MTM services on a both the medical and economic level and proved that it is something that should be implemented into more practice settings to serve a larger population in the health care system.

Truong HA, Groves, CC, Heather BD. et al. Potential cost savings of medication therapy management in safety-net clinics. JAPhA. 2015:55(3):269–272.

JAPhA. 2015:55(3):269–272

Putting words into action: A simple focused education improves prescription label comprehension and functional health literacy

Prescription labels are point-of-use communication for patients. The clarity and accuracy of the labels is essential to patient understanding about the usage of the medications. Reports show that over 33% of the English-speaking adults in the United States have limited functional health literacy, which indicates a limited ability to read, understand and follow instructions on prescription labels. Limited functional health literacy contributes to serious drug therapy problems and accounts for an economic cost of $73 billion each year.

The study described in the article aimed to observe the effect of redesigned prescription labels to be more user-friendly and patient-centered to minimize medication errors caused by misunderstanding of prescription label instructions. The study then compared evaluated the levels of comprehension between patients using the currently existing labels and those using the redesigned ones.

This multisite, randomized- controlled trial was conducted in senior centers and involved a total of 118 seniors with an average age of 75.9 who are on at least 2 prescription medications daily and able to read, speak and understand English. The patients are randomized into 4 different groups: current Rx label- control, current Rx label-intervention, redesigned Rx label-control, and redesigned Rx label-intervention. In the groups with interventions, participants received an education on critical information on an Rx label provided by student pharmacists. The level of participant’s comprehension of the labels was assessed using Modified LaRue Tool (MLT), which has 25multiple choice and open-ended questions about Rx label information.

Results show that in groups using the redesigned Rx labels, a significant increase in MLT score was observed both before (23.0 ± 2.3 vs. 21.0 ± 2.4; P <0.001) and after (23.8 ± 1.7 vs. 22.1 ± 3.1; P <0.001) the intervention. Both groups using the current Rx labels with or without intervention, however, did not show significant improvement on the MLT scores. I agree that the current prescription labels could be better designed. As in the redesigned label above (B), the instruction information is more clearly presented. The time of the day the medication is to be taken is organized in a table and the warnings and counseling points are formatted to draw attention. I believe that pharmacists can take on the role in redesigning prescription labels on a larger scale to benefit all patients. The design of the labels can even be tailored to the needs of different populations, such as enlarging the fonts on labels for the elderly who may have declining eyesight.

Tai, BWB, Bae, YH, LaRue, CE. et al. Putting words into action: A simple focused education improves prescription label comprehension and functional health literacy.  JAPhA. 2016;1-8 (Published online Feb 24, 2016).

JAPhA. 2016;1-8 (Published online Feb 24, 2016)

Standardized patients’ preferences for pharmacist interactive communication style: A mixed method approach

Pharmaceutical care is a patient-centered practice, patient-centered meaning that the care is provided in a way that the pharmacist’s skills and knowledge work in concert with patients’ input, their beliefs, preferences, and needs. In order for pharmacist to provide patient-centered care, patient involvement is important. One of the ways of doing so is to shift away from the biomedical model, which is a structured one-way delivery of medication- related information, to an interactive model, where pharmacists ask open-ended questions about a medication to assess patient’s understanding and perceptions about it and respond to their ideas and emotions while correcting misconceptions and filling in any missed medication information.

In this study, researchers looked at patients’ preferences toward different communication styles. This is a study that was conducted over 5 weeks and involved 12 standardized patients and 10 pharmacists. Standardized patients were employed to better compare the communication techniques based on standardized scenarios. Three scenarios were each assigned to four standardized patients, and each pharmacist interacted twice with 3 standardized patients, representing one of each case. The biomedical method was used in the first time and the interactive method on the second time. The pharmacist-patient encounters were video recorded and standardized patients were surveyed and interviewed afterwards. 58% of the SP participants preferred the interactive model, 33% preferred that traditional biomedical model, while one participant had no preference between the two.

Patients who preferred the interactive method reasoned their choice saying that they were more comfortable talking to an “equal”, felt more connected to the medication information provided in contrast to the biomedical model, where they felt like it was “ an information overload”. Patient who preferred the biomedical method stated that the interactive method made them question the pharmacist’s knowledge about the mediation with all the questions asked and felt like they were being quizzed on the information.

The fact that standardized patients were being used and that there were only 12 participates involved in the study make it not completely representative of the patient population. However, it raises the awareness of the two existing pharmacist-patient communication methods, and provided characteristics of both. As seen in the results, the standardized patients each have their personal preference to the communication method being used. As future pharmacists, it is important to be aware of patient’s expectation of care to choose the appropriate communication method for counseling.

Guirguis, LM. Mohammad BM. Standardized patients’ preferences for pharmacist interactive communication style: A mixed method approach. JAPhA. 2016;57(published online Feb 18, 2016).

 JAPhA. 2016;57(published online Feb 18, 2016)

Risk-based strategy for outpatient pharmacy practice: Focus on opioids

The mortality rate related to prescription opioid overdoses in recent years have been increasing. About 80% of opioid overdoses happen in patients who are on multiple opioid prescriptions or on high doses of opioids. The current programs established to solve this problem includes patient screening, prescription restrictions and monitoring, provider education, and implementations of substance abuse treatment. None of these approaches really involved pharmacists, who are the medication expert and potential solution to the problem.

This article explored ways to employ pharmacist’s knowledge and accessibility to get pharmacists involved in this arena. The first step of the proposal centered on identifying patients who are at risk. The therapeutic index measures the safety of individual drugs. Patients who are on drugs with a low therapeutic index are classified to require additional attention during prescribing and dispensing.

The second step directly involves the participation of pharmacist through patient counseling. Although patient counseling has been implemented in pharmacies, the frequency and duration of pharmacist counseling are not at the optimal level. Furthermore, most counseling only happen during the dispensing of a new medication and almost never as routine follow-ups. While pharmacists are trained to provide comprehensive counseling and assist in monitoring the health and medication uses of patients, the revenue-oriented priorities of retail practice limits the opportunity for pharmacists to provide direct patient care. Much of the pharmacists’ work time is devoted to the speeding up the processing, confirming and filling of prescriptions.

The article proposed identifying and selecting the at risk patients who are on low therapeutic index medications for extensive counseling and routine follow-ups. This is a great idea because I think follow-ups are very important for patients especially when they are on medications that can have serious consequence if misused. I believe that pharmacists can have a big impact on preventing opioid overdoses by working to optimize patient pain management while making sure that they are safe through appropriate monitoring and guidance.

Holdsworth, MT, Benson, BE, Dole EJ. et al. Risk-based strategy for outpatient pharmacy practice: Focus on opioids. JAPhA. 2015;55(5):553–559.

JAPhA. 2015;55(5):553–559

Motivational interviewing for medication adherence

Medication adherence is very important. Patients have to adhere to their medication regiment in order for the medications to produce the best therapeutic response. Medication adherence stems from patient’s internal motivation, which can be stimulated through motivational interviewing.

The study did a telephone survey in 2015 targeting adults over 40 years old, who are currently on at least one prescription medication for chronic illnesses. It was found that about 75% of the 1,020 respondents had engaged in at least one nonadherent behavior within the past year and 50% had multiple nonadherent incidents. The most common behaviors include missing a dose, not refilling the medication on time, self-initiate a lower dose than prescribed, and discontinuation of a prescribed medication without consulting the doctor. Medication adherence is a very common problem and contributes to 33-69% increase in medication-related hospitalization.

The article suggests that motivational interviewing may be the key to change patients’ nonadherent behaviors. Results from a meta-analysis show that there is a 19% increase in noncompliance in patients who has poor communication with their health care provider or pharmacists. The change talk in motivational interviewing is essential in brining about changes in patients. In the cases of patient brining up possible changes for better adherence, it is important to help the patient identify the pros and cons of adhering to the medication regiment. Through recognizing and affirming patients’ feelings and desires to make changes in order to better adhere to their medications, pharmacists can help develop patient’s motivation and reinforce their commitment to make good and healthy changes.

I agree that motivational interviewing allows pharmacists to better identify the barriers that are keeping patients from adhering to their medication regimen and helps encourages medication adherence. Although time remains as the primacy concern in regards to incorporating motivational interviewing into actual practice, I believe it is worthwhile to be implemented into pharmacist’s routine since it is very helpful in identifying and solving drug therapy problems.

Salvo MC, Cannon-Breland ML. Motivation interviewing for medication adherence. JAPhA. 2015;55(4).

Optimizing finite resources: Pharmacist chart reviews in an outpatient kidney transplant clinic

Kidney transplant recipients are often discharged with a complex medication regiment and are closely monitored through follow-up visits after the surgery. Although pharmacists are part of the interdisciplinary team to provide care, their participations are often short-termed due to time and schedule restraints. In order to continue receiving input from pharmacists in the long-term, pharmacist’s recommendations are usually delivered as written notes instead of verbal communications after the 1-month posttransplant milestone. Written notes involve pharmacist-directed comprehensive chart review assessments, while verbal communication is carried out through direct pharmacist participation with transplant providers.

This study looked at the whether comprehensive chart review is a sufficient replacement for the direct participation of pharmacist during clinic visits with kidney transplant recipients. The study followed 219 kidney transplant recipients over a period of 3 months. The investigators reviewed and compared the pharmacist chart reviews, clinic notes, and physician recommendations and rated them different acceptance level for pharmacist recommendations. The 4 categories are accepted, partially accepted, not accepted, and not applicable, which means that the recommendation was not considered applicable due to changes in patient’s clinical status.

During the 3-month period, 175 direct clinic participations and 170 chart viewers were studied. It was found that completing chart reviews is on average more time-consuming than direction communication with the physician with findings of 28 minutes and 10 minutes, respectively. Also, only 28% of the pharmacists’ recommendations via chart review were taken into consideration while 92% of recommendations made during direction interaction between pharmacists and physicians were considered. Furthermore, 14% of the chart reviews were deemed not applicable in comparison to the 1% during the clinic visits.

The study concludes that in comparison to direct interactions, the recommendation method of chart reviews has a lower acceptance rate and is overall a less effective and efficient method for pharmacist to provide care. The low percentages may be due to the ever-changing clinical status of the patients, or the chart reviews being too lengthy that physicians overlook them. Although the study suggested that the participation of pharmacists is beneficial to patient care, I wish to see more evidence about how pharmacists’ recommendations influence patient outcomes in similar studies.

Staino, C, Pilch, N, Patel, S. et al. Optimizing finite resources: Pharmacist chart reviews in an outpatient kidney transplant clinic. JAPhA. 2015;55(6):613-620.

JAPhA. 2015;55(6):613-620

Determining the accuracy of open-access databases for identifying commonly prescribed oral medications

Nowadays, people rely on the Internet for a lot of information, and the growing accessibility and availability of Internet health care tools have encouraged patients to learn more about disease states and medication regimens. However, information on the web may not always be safe and accurate. With search engines, like Google, and Yahoo being the most common search methods, the public may be exposed to medical misinformation and scams.

A study looked at the accuracy of open-access databases for identifying commonly prescribed oral medications. The study identified the 200 most commonly dispensed prescription oral medications based on sales volume between 2012 and 2013. Taking into account of the different dosages and brand names, the researchers obtained a total of 302 different medication imprints for 98 medications from the FDA label information. The information found in the open- access medication identification databases that are easily accessed through common search engines is then compared to the medication imprints. The databases studied are Drugs.com, Healthline, the National Library of Medicine Pillbox, RxList, and WebMD; only results that yield one result with matching medication and correct information were considered as an accurate search.

The results show that National Library of Medicine’s Pillbox has the highest percent of accuracy at 89.27%, followed by Drugs.com (86.44%), Healthline (55.52%), RxList (26.81%), and WebMD (26.5%). These results are concerning because none of the most commonly used medication identification databases have a 100% accuracy and some of them even have low accuracy rates of ~27%. It is important for health care professionals to acknowledge the existence of incorrect medication information online and recognize the dangers of patients using that unreliable information. While obtaining information on the web is convenient and free, patients from the general public often have trouble identifying the relevant and credible sources. The consequences of trusting inaccurate drug information can be serious and could lead to serious adverse effects or even death. Pharmacists can become to the solution of this problem by making themselves more approachable and available to patients to make them comfortable in consulting pharmacists about their medication-related needs.

Burde, A, Hoover, R, Sheth, P. Determining the accuracy of open-access databases for identifying commonly prescribed oral medications. JAPhA. 2016;56(1):37-40.

JAPhA. 2016;56(1): 37-40

Unused medications and disposal patterns at home

Medicines are used to treat medical conditions and diseases, but when they expire, become unwanted, or unused, they should be disposed safely to prevent others from accidently or intentionally misusing them. In order to assess how much medicines are left unused and how they are disposed among the patient population, a study conducted from December 31, 2013 to May 2014 surveyed 721 Medicare Part D beneficiaries through telephone.

The study focused on the elderly population and the average age of the survey respondents are 70.4 years old (68% female and 32% male). The result shows that out of the 721 participants, 698 of them are currently taking an average of four prescription medications, summing up to a total of 2,994 kinds of medications. About 8.2% of the medications are classified as unused portions that are not intended for future use. Of the 247 unused medications, pain medications, antihypertensive medications, and antibiotics take up the highest percentages of 15%, 14%, and 11%, respectively. The disposal methods gathered from the respondents during the survey include, kept in cabinet (55.5%), threw in trash (13.8%), take-back program (10.9%), flushed down toilet (9.3%), and gave to friends and family (1.6%).

This existing problem of unused medications indicates a lack of understanding and medication adherence in the patient population. It is especially concerning that antibiotics is listed as one of most common unused medications since the completion of antibiotics is recommended to produce the best effects and prevent antibiotic resistance. The implementation of MTM programs and expansion of take-back programs are possible solutions to this problem. Through one-on-one counseling between a pharmacist and the patient, the patient’s understanding about his/her medications can be better assessed. Any existing and potential drug therapy problems can also be properly identified and addressed through education and adjustments to the medication regimen to improve adherence and reduce unused medications. The most common method of medication disposal being “kept in cabinet” indicates that most people do not know how to handle unused medications. Pharmacists as the most accessible members of the health care profession should take on the active role to educate patients about the proper disposal methods and promote take-back programs in the community.

Maeng, DM, Snyder, RC, Medico, CJ. et al. Unused medications and disposal patterns at home: Findings from a Medicare patient survey and claims data. JAPhA. 2016;56(1):41-46.

JAPhA. 2016;56(1):41-46