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WASHINGTON — Pharmacists should be central to efforts to remedy the confounding problem of medication nonadherence, experts said here at a panel discussion sponsored by CVS Caremark Corp.
Pharmacists are more effective than doctors at fostering compliance, Dr. William Shrank of Brigham and Women’s Hospital and Harvard Medical School said at the roundtable, held late last month at the National Press Club. They have more data on the problem and more time to address it, and they “are trusted partners when it comes to medication use.”
Valerie Fleishman, executive director of NEHI, a national network for health innovation, said pharmacists are “underleveraged, highly trained” professionals. “There’s a real opportunity to provide face-to-face and other types of intervention at the pharmacy.”
Sally Greenberg, executive director of the National Consumers League, said: “Pharmacists are incredibly important and probably too often overlooked by patients.” She added that pharmacists, doctors, nurse practitioners and nurses, besides communicating with patients, “should be talking to each other.”
The panel’s moderator, Helena Foulkes, executive vice president and chief health care strategy and marketing officer at CVS Caremark, said that up to a quarter of people never fill new prescriptions, and up to half on maintenance medications stop taking refills within a year. The cost in hospitalizations, nursing home readmissions, disease progression and other medical problems has been put at nearly $300 billion a year.
CVS Caremark is seeking answers to noncompliance, Foulkes said, and has made its research available to all interested parties. That research includes a three-year study of medication adherence in conjunction with Harvard and Brigham and Women’s Hospital. The company organized the roundtable as the start of an initiative “to attract attention to what has become a vexing public health issue,” she said.
CVS Caremark chief medical officer Troyen Brennan noted that the research is entering a predictive phase in order to determine who will and won’t comply with prescriptions. Armed with that knowledge, health care providers should be able to undertake interventions to get people to take their drugs as prescribed, he said.
A population of 100,000 can save more than $54 million a year by “simply taking their medications,” he noted. “It’s a vast improvement.”
Shrank said synchronizing prescription refills for patients on multiple medications is a key to adherence. People with the most complex drug regimens take 23 or more medications and make multiple trips to one or more pharmacies for refills, with only 10% of those being synchronized, he said.
Scott Smith, a program director in the Center for Outcomes and Evidence, called synchronization “low-hanging fruit.”
Brennan said synchronization can be facilitated with mail-order scripts, and added that the subject should also be discussed with primary care doctors. “If we can get them working with us, it makes it sort of practical even in the retail area. … It makes so much sense, but it’s so difficult to get your hands around. But we’re making some interesting first steps there.”
Smith said many “off-the-shelf adherence programs” are “provider-centric,” as opposed to being “patient-centric.” Patients should be prepared for drug therapy by reviewing of their goals, and by recognizing the possible need for changes in routines or work schedules. The start is the most important part of therapy, he said.
“Adherence is really a team sport,” he added. The team includes all providers supporting and promoting adherence, from pharmacy technicians to nurses and physicians, he said.
Peer-to-peer education is particularly powerful, he said, citing the use of Facebook by communities of diabetes patients.
“Nonadherence,” Smith added, “should be dealt with in a nonpunitive way.” Fostering compliance is not a matter of “policing,” he said. Instead, providers should communicate with patients to see if they may not be adhering because of a fear of side effects or possibly the expense of the co-payment.
Greenberg said a doctor’s office is “a hard place to work with as a patient,” because the hours are so limited. Pharmacies, by contrast, offer “patient-centered hours” — allowing prescriptions to be picked up before or after work.
It’s easy to put off a doctor’s appointment if it’s difficult to get in the door and the co-payment is high, she said. “So there’s a weak link there in terms of communications between the doctor and patient,” she added, especially when a patient gets multiple prescriptions.
Physicians, said Fleishman, are in a “data vacuum.” After they write a prescription they don’t know the effects until a patient returns, she said. “That could be three months later, six months later, a year later, or the patient ends up in the emergency department.”
