The National Association of Chain Drug Stores (NACDS) joined four patient groups in signing a letter to House and Senate leaders about the importance of including programs like MTM in any healthcare reform plan. Here’s the text of their letter:
The text of the letter follows to Senate Majority Leader Harry Reid (D-NV), Senate Minority Leader Mitch McConnell (R-KY), House Speaker Nancy Pelosi (D-CA) and House Minority Leader John Boehner (R-OH).
To the Bipartisan Congressional Leadership:
On behalf of millions of consumers, patients, healthcare providers and others, we are writing to urge you to include in any health reform legislation provisions that address chronic disease management through appropriate medication use. More than 133 million people, or almost half of all Americans, live with a chronic disease. Access to effective medications as well as services that promote medication adherence are essential in improving the health of these individuals. We urge Congress to recognize the role of healthcare providers such as pharmacists in chronic disease management.
Seventy percent of all deaths in the United States are attributed to chronic diseases. Many of these deaths and their associated costs are avoidable. Only 50 percent of patients with chronic diseases take their medications as prescribed, leading to unnecessary and often expensive complications. Failure of patients to properly take their medications accounts for approximately $290 billion annually in total direct and indirect healthcare costs. Investments in programs that foster adherence to appropriate and effective medication therapies will benefit both patients and the healthcare system.
Evidence shows significant improvement in the health status of patients with chronic diseases through pharmacist-provided medication therapy management (MTM) services. MTM includes services that are designed to promote appropriate medication use and reduce the risk of adverse events, which cost $47 billion annually due to hospital readmissions. MTM has also been shown to reduce utilization of more costly medical services such as emergency room visits and unnecessary physician visits.
Congress recognized the importance of medication adherence and appropriate medication use when it required Part D plans to offer MTM to Medicare Part D beneficiaries under the Medicare Modernization Act of 2003 (MMA). However, additional action is needed to make this benefit more accessible and to realize the benefit’s full potential. Our organizations support H.R. 3108, the Medication Therapy Management Benefits Act of 2009, as one important step to address medication management for seniors with chronic diseases. H.R. 3108 would strengthen the Part D MTM benefit by improving current eligibility requirements and further targeting the benefit to certain dual-eligibles and those in transitions of care. In addition, H.R. 3108 takes important steps in standardizing the menu of MTM services Part D plans must offer. We also favor provisions included in the both the Senate HELP Committee and House Energy and Commerce Committee health reform bills that provide for grants to establish community health teams to support a medical home model which would include MTM plus grants to implement medication management services in the treatment of chronic disease.
While our interests are diverse, we reach consensus on the importance of proper chronic disease management. Enhancing the Medicare Part D MTM benefit is an important step in improving the health of patients and reducing unnecessary costs. We look forward to working with you to address this important issue as part of health reform this year.
A new national media study among 966 viewers of a news clip highlighting the potential dangers of generic brand drugs revealed that nearly half of viewers (46%) reported that they are less likely to purchase generic drugs after watching the video.
Participants were most likely to be “disturbed” by the news story and had a negative perception of all generic drugs after watching it.
It’s hard to really judge the resultswithout seeing the new story, this is “disturbing” to me. Would patients respond similarly to advertising promoting a brand over the generic? What if there is a clinically insignificant difference between the brand and generic that gets picked up by the media? What would have happened if the brand drug had been advertised in a favorable light after the study.
Though there are potential dangers in generic drugs, most studies find them therapeutically equivalent. Many times switching to a generic in the same class, though statistically different, has the same clinical outcome. The media and the general public often do not understand this difference.
The savings from the use of generic drugs to the individual patient and to the health care system at large is astronomical. I wish every pharmacist had the power to substitute drugs (simvastatin for Lipitor, omeprazole for Nexium, etc). This would be an invaluable service to our patients, and many of us already take the time to contact doctors for a switch in cases where patients can’t afford medications or the brand is not covered. In some states pharmacist have a little power to do this on their own. In a hospital setting, pharmacists routinely provide this service. A few simple switches could save the health care industry a fortune.
This report is not terribly valuable because it’s not very detailed, but it does tell me that patients internalize what they hear on the news about drugs. If a generic is ever mentioned on the news it’s the 1 in 10 allergic reaction, counterfeit, non-therapeutically equivalent drug. This makes it even harder for us to convince patients that generics are just as good as the brand.
Here are a few studies (the abstracts) comparing brand to generic drugs:
I am a twitter user and have been since before it was cool (my regular Twitter ID is AboutLittleRock but I use PharmistBlog for just this blog. I still haven’t gotten into TweetDeck enough to separate my main feed into it’s different parts). I tweet fairly often. I should really use my PharmacistBlog url to tweet the sciency stuff. Maybe I’ll be better about that in the future (probably not).
Anyway, during the H1N1 outbreak all you heard was how Twitter was causing the overreaction. If it wasn’t for people spreading fear and misinformation on Twitter, the media wouldn’t have been so bad, etc. But the truth is, during all of that talk about how Twitter was spreading fear, the people I follow (and myself) were spreading the “calm down” signal. Here are the only two examples I found in my feed, but there were many, many more like these (from April 2009):
I think the swine flu epidemic is really an epidemic of fear and bored media. MDs I know are exhausted by the demands for tests.
RT @pvponline the swine flu’s 150 deaths sound scary until you realize the REGULAR flu kills 36,000 annually. #swineflu
So, I never really understood why the media was blaming Twitter. Most of the people in healthcare that I follow were being rather level headed.
Today I read an abstract of a study that really looked into this. They archived over 300,000 tweets containing the keywords or hashtags “swine flu”, “swineflu”, or “H1N1”. A random selection of tweets from each hour of each day were coded for content by two raters. The raters found the same thing that I intuitively felt. Twitter was actually not the cause of a mass hysteria. They found that Twitter was actually being used to distribute correct information.
Contrary to some media reports of Twitter fueling an epidemic of misinformation, Twitter can and is already used to quickly disseminate pandemic information to the public.
It’s hard to explain Twitter to those who don’t use it. I get the “you twitter?” confused look from colleagues a lot, even non-health, web colleagues who should know that social media can be powerful. However, Twitter is powerful and I think health care providers are one group that can really benefit from its use.
How I use Twitter:
- To find out what people are reading (people post interesting journal articles about their fields to Twitter all the time)
- To find out what people think (like during H1N1 outbreaks, do people really find it’s a big deal? What are they seeing at their practice areas)
- To network (you meet people in your field from all over the world)
- To ask questions (you can ask what colleagues think)
- To hang out (twitter is just fun)
Physicians have a strong Twitter presence and several articles have been written about best ways for them to use Twitter. Pharmacist can use Twitter for similar reasons.
If you’ve never used Twitter, it’s far more than just a Facebook “status feed” on acid. The box may ask “What are you doing?” but most people do not use Twitter to simply answer that question.
LegitScript, an Internet pharmacy verification organization, did a study using Bing, Microsoft’s search engine in June and July of 2009 finding that their advertisers are less than scrupulous.
LegitScript found that 90% of Microsoft’s ads lead to rogue sites including ones that sell unapproved counterfeit drugs, addictive medications without prescriptions, and ads for pharmacies in Calcutta, Russia and Eastern Europe. All of these “Internet pharmacies” are not legal pharmacies in America.
They searched for things like “generic medications,” “online pharmacy”, “Ambien” and “Viagra” and even actually ordered Cialis from one rogue pharmacy (it turned out to be counterfeit).
The report is actually quite interesting as it looks at how these pharmacies operate and how patients can get “tricked” into buying from these rogue sites.
It’s not really concerning to me that someone searching for Viagra will be directed to a rogue pharmacy. I get Viagra spam in my Inbox everyday. However, I also searched for “Lantus,” “Combivir” and “Plavix” (and a few others) that are not drugs of abuse or drugs for erectile dysfunction and I was directed to rogue pharmacies. These are drugs that patients could have real questions about. These are drugs that will not only not work if they are counterfeit, but may harm the patient if not taken.
To me, it is a little disconcerting that patients searching for information about their HIV medications will be sent to a rogue pharmacy to purchase what might be a counterfeit version.
Heartwire just published an interesting article that says lower blood pressures goals may not beneficial. Blood pressure targets have tended to trend downward over the past few years, and this article flies in the face of that.
We found there is no evidence that reaching a target of below 90 mm Hg diastolic BP will provide additional clinical benefit, but we can’t say whether lowering systolic BP below 140 mm Hg will be beneficial or not; there are no data
Arguedas and his colleagues note that a lower BP target of 130/80 mm Hg is currently recommended for at-risk patients, and they did perform a sensitivity analysis in diabetic and kidney-disease patients, which did not show significant benefits for treating to targets of lower than 135/85 mm Hg. “However, in these two populations, the evidence for a lack of benefit is less robust,” they note.
It’s long been known that people with naturally lower blood pressure tend to do better than those with artificially lower blood pressure, but we still think lower is better. That can lead to adverse effects, including lowering BP too low (that’s discussed in the article) and putting patients on too complicated, and expensive, a blood pressure regimin.
The FDA recently issued a consumer update about tablet splitting, warning that it might not be a good idea. They tell consumers that splitting tablets is a bad idea because: one might get confused about the correct dose, equal distribution of medicine in split tablets is questionable, some tablets are hard to split and not all pills are safe to split.
They go on to say that talking to your pharmacist or physician is important before splitting a tablet.
While the FDA information is correct, I think tablet splitting is actually a way pharmacists can help their patients. In these economic times, a $30 co-pay (not to mention some of the $100 drugs) can mean a lot. We can save patients money by splitting a Lipitor, and that means they’ll be more likely to take the drug and not skip doses to save money.
So, what can we do? I read one suggestion that all pharmacists should split the tablets for the patients. Most retail outlets can’t really afford the time it takes to split pills for patients. I also think that if you’re splitting hundreds of pills a day, you’ll probably be less accurate & more hurried than most patients at home.
I do think that for “split” prescriptions, the pharmacist should spend a little extra time counseling the patient, perhaps direct them to a pill splitter for purchase (they’re around $3-5, well worth it) and explain the importance of splitting the pill correctly, etc. I think we do a good job of that already.
Does counseling matter? It depends. A study was conducted where half the participants were given instructions on how to split the pills and the other half was not. They were given various shapes of pills to split. In the end, regardless of group, researchers found patients’ tablet-splitting resulted in dosage deviations between 9 percent and 37 percent from those intended. Those with experience, regardless of instruction, were most accurate at splitting flat, round tablets. More deviations in dosage were found with the more irregularly shaped pills. To me, this says that maybe the pharmacist should actually observe the technique and give pointers, since doing seems more important than telling.
Another major issue is that the pharmacist doesn’t always know if the pill is to be split. For insurance purposes (and this is fraud, but it happens), some prescriptions for tablets that are intended to be split are written as “1 daily.” The doctor assumes the patient will remember. It is up to the patient to ask the proper questions in that case. I always tend to counsel on “splitting,” especially when I think the pill might be split or when it is important NOT to split a tablet.
I’ve even encountered some patients splitting their pills on their own when they weren’t instructed to do so. For example, the physician prescribed 40mg of Lipitor but Mr. Smith thinks 20mg is just fine and it is much cheaper to get every other month.
I wish we all had time to do drug reviews and say, “Mr. Smith only picks up his Lipitor every other month. What gives?” and then sit down and talk to him, but we don’t. Wouldn’t it be great if our computer systems could pick out those trends? Maybe someday.
There needs to be transparency on the part of the patient’s and the doctors (and insurance companies are a major problem). I think the more “warnings” we issue about the topic, the more patients are going to be afraid to talk about it. What if they tell the pharmacist that the pill is going to be split and they won’t do it? What if they call the insurance company? This shouldn’t be a patient’s dirty little secret. We should encourage patients to discuss any issues they have. If we do notice those types of trends, we should bring up the topic. Mrs. Smith could split an 80 mg tablet and get the dose he needs for the same price.
Even a simple handout about the benefits of splitting drugs and “talk to your pharmacist” could encourage transparency and proper technique.
Here’s some info on what you can and cannot split:
I remember a professor telling me in school that homeopathic remedies were “just water.” If I didn’t already a know a bit about homeopathy, i probably would have believed him and decided that homeopathic remedies were harmless. After all, what can a million parts of water with 1 part of active drug do?
Now we hear that Zicam, a homeopathic remedy, can cause anosmia (loss of smell). Zicam has 2 parts per 100 parts water. The active ingredient is zinc gluconate.
So, could bad things happen with other “homeopathic” products sold OTC? Of course. Most of these products have no research done on them. Small amounts of some compounds can elicit adverse reactions. Another big issue is the alcohol content of some of these products. Most of the time, alcohol is the main ingredient.
I don’t consider products like Zicam true homeopathy anyway. I don’t think anyone can buy homeopathy off a shelf. True homeopathy takes into account a person’s mental and physical status – the person as a whole. Treatments are often individualized. You cannot buy that from a shelf. Plus, the nasal route is not generally recommended for homeopathic treatments.
Do I believe homeopathy works? Not really, but I think it can be a great comfort to patients and that can mean a lot. Do I think it needs to be further regulated? Perhaps, but not because those who practice homeopathy do it wrong. There are many who try to get around laws by claiming “homeopathy” when they are delivering active drugs to patients. The FDA needs to step in and regulate those people. In general, a homeopathic dilution is no where near 2 in 100. That’s delivering a compound, not a homeopathic remedy.
I was reading New Scientist and wandered over an article about some neat pharmaceutics research.
Some researchers at Harvard have developed sperm-like nano-devices that swim, propelled by a propeller, in a corkscrew motion. They can be radio-controlled via magnets.
These nanopropellers are made of glass, each has a spherical head 200 to 300 nanometres across and a corkscrew-shaped tail 1 to 2 micrometres long – less than one-tenth the length of a human sperm.
The article talks about vaccine delivery, but I see potential for cancer drugs and other therapy that needs to be highly targeted.
It won’t be something I’ll see within my lifetime, but it is cool new technology.
A new study from London says maybe. According to a study published recently, drugs such as beta blockers and ACE inhibitors reduce the chance of heart attacks by around a quarter and stroke by around a third, even in people who don’t have “high” blood pressure.
Those involved with the study even suggest that maybe our definitions of high blood pressure need to be changed. What we call “normal” is really high. I agree with that. You almost always see better anecdotal results when blood pressures are kept below the “normal” 120-130/80-90.
Even more interesting to me is that the researchers found beta blockers, ACE inhibitors, diuretics, calcium channel blocker and angiotensin receptor blockers to be roughly equally effective at cutting the risk of heart disease and stroke.
I don’t necessarily think that dosing everyone with a polypill is the right choice with the data we know. On the other hand, if I myself were over 55 I might be asking for a statin & ACE inhibitor if I was borderline.
It’s something I think clincians should decide on case by case basis. At the very list, research like this should trigger primary care providers to consider prescribing medications to patient that are “borderline” more seriously.
This is the first time I’ve heard of the “obesity paradox.” Apparently, obesity can lead you to high blood pressure, blocked heart arteries and peripheral arterial disease, but it also has a protective effect too.
Journal of the American College of Cardiology has a study this week about this paradox. They took 40 studies of 250,000 people with heart disease, and obsese patients had decreseased morbidity and mortality compared to lean patients.
They talk about this a little in the article, but from personal experience, even though it was never taught to me, I think health care professionals recognize the “obesity paradox.” One of the first things I learned working in an ICU was that “frail patients do worse.” I had originally thought a patient with a lean body mass would fair much better than a person who came in well over their IBW. That’s not the case many times. Larger people often have more metabolics reserves to fight off diseases than frail people.
The article also suggests that obese people also seek treatment sooner, and visit physicians more often.
Obese people who loose weight fair better than all others, so don’t give up on the dieting.