You're making a mistake when you swallow aspirin with only a few sips of water. If your stomach hurts afterward, that's because the barely diluted painkiller is burning your stomach lining.
Many people take this common drug incorrectly. Although seemingly trivial, the problem is one symptom of a ubiquitous inattention to the proper use of medication. In fact, about half of patients taking any drug don't follow instructions. In medical terms, they're noncompliant.
The problem costs billions of dollars each year. All told, prescription drug mishaps, in which noncompliance is a major factor, result in $76 billion in direct medical costs annually, according to a 1995 University of Arizona, Tucson, study. Between 3% and 5% of hospital admissions stem from patients' failure to comply with drug orders, according to a 1992 study at the University of California, Berkeley.
Just last month, Merck & Co. warned doctors of 36 hospitalizations due to mistakes patients made with its new osteoporosis drug, such as not drinking enough water or taking the drug before sleep.
Health plans are working harder to reduce noncompliance because of the high toll it exacts on patient health and their own pocketbooks. One driving force are new disease-management programs, which try to avert serious medical troubles in people with chronic conditions. Another is a push by pharmacists to be paid for counseling patients on proper drug use.
As a result, doctors and hospitals might find themselves with more tools to tackle noncompliance and more financial responsibility for it.
Right now, HMOs and other payers are replacing scattered efforts to improve compliance with more systematic approaches. For example:
The Southern California region of Kaiser Permanente mailed questionnaires to 5,000 patients age 65 and older as part of a three-year research project. Pharmacists then scheduled office visits with respondents who listed the most complex ailments and prescriptions. "The first purpose is to find ways to prospectively identify elderly patients with medication troubles," said Matt Nye, a Kaiser pharmacy administrator. "The second is to learn if our model of care-in which the pharmacist screens and intervenes-improves outcomes." Results of the just-completed study are being calculated.
A unit of Aetna Health Plans in Hartford, Conn., recently combed the drug claims of 13,000 enrollees with hypertension, diabetes or high cholesterol. Proper medication use can keep these illnesses from leading to heart attacks and other adverse events. Enrollees who filled prescriptions late or skipped refills altogether received pamphlets urging them to talk with their pharmacist.
"We're starting with an educational pamphlet," Aetna pharmacist Janet Thomson said. "Certainly, we're looking at trying more comprehensive approaches as time goes on."
Northwest Pharmacy Services, a pharmacy-benefit manager in Puyallup, Wash., will go so far as to give some patients electronic pill vials, which will cost the company $180 per patient annually (See related story, p. 46). The vial sounds an alarm when medication should be taken, and it notes usage. Pharmacists will review the data when patients return for refills and counsel patients with poor records. "Our goal is to increase compliance, therefore reducing costs," said Norm Reitz, NPS president. The program, which begins in July, targets asthma, diabetes and epilepsy.
NPS hasn't calculated its costs or the number of beneficiaries involved. It expects to save more in better outcomes and reduced medical costs than it spends on the vials.
In popular thinking, medication problems largely are ascribed to unforeseen interactions and improper doses. The truth is, noncompliance is at least as culpable as poor prescribing, and some pharmacists believe it lies behind the bulk of problems.
"Doctors' prescribing is generally very good. Computers are standard practice today, and they deftly deal with misdosing and drug interactions," said Kaiser administrator Nye. "The real problem is patients don't understand the necessity of their medication, how to take it and how to self-monitor. On the occasions I have had to take medication, even I don't always take it properly."
Noncompliance is believed so widespread, particularly in chronic illnesses, that Aetna pharmacist Thomson wasn't surprised to learn 54% of enrollees in her project weren't filling prescriptions as scheduled. Actual compliance could be worse. "We were looking at this one little piece. (Noncompliance also) could be things like taking too little medication or not taking it with food," said Thomson, who heads drug utilization evaluation at Aetna Pharmacy Management.
Despite full prescription coverage, only 14% of Medicaid patients in California continued taking hypertension medication for one year, according to a 1994 study at University of Southern California in Los Angeles. "Most of them just plain stopped, and these people were getting it for free," said Jeff McCombs, associate professor of pharmaceutical economics and policy at USC. "The bottom line is that the 86% (who were noncompliant) ended up costing the state about $600 more in the first year."
Hypertension is one of the toughest compliance cases because its victims don't feel ill and therefore aren't motivated to take medication. The disease is garnering particular attention because of its costly and sometimes fatal health consequences.
Suffering from an asymptomatic illness like hypertension is one factor that puts patients at high risk for serious drug-related problems.
Other indicators of high risk are multiple prescriptions and drugs with narrow-therapeutic ranges. Multiple prescriptions raise the odds of dangerous interactions and noncompliance, and the patients involved often are elderly or very ill.
Narrow-therapeutic drugs can be catastrophic when small changes are introduced. For example, aspirin increases the potency of a common blood thinner, Coumadin, possibly triggering hemorrhages. In contrast, Vitamin K weakens the drug, so blood clots can return.
Patients' reasons for noncompliance are the "subject of several thousand research papers," Nye said. They include financial concerns, unpleasant side effects, a dislike of drugs, illiteracy and ignorance of the consequences.
Pharmacists say they can help matters.
In a 2-year-old program at Kaiser Northwest, pharmacists teach patients how aspirin and hot showers fight the itching and flushing caused by Niacin, a cholesterol-lowering drug. After learning how to manage side effects, about 80% of patients continue taking Niacin. Generally, at least half drop Niacin for more expensive drugs because of the side effects, said Mike Kinard, Kaiser Northwest regional pharmacy manager in Clackamas, Ore.
"We also follow the patients to be sure they reach their therapeutic goal," Kinard said. "When the patient comes in for routine visits, the pharmacist looks at any lab tests to make sure their blood cholesterol is at a safe level and consults with physicians."
The Kaiser program is an example of pharmaceutical care, a philosophy aggressively promoted by pharmacists' associations. Pharmaceutical care describes services that go way beyond simple medication dispensing, such as consulting with physicians, educating patients and monitoring outcomes.
The pharmaceutical-care movement is one reason noncompliance has become a hot issue. Disease management, the other primary force, says health plans should define the best care for people with long-term conditions. It emphasizes preventive measures to slow progression of disease (June 12, 1995, p. 30).
Pharmacists already must explain to Medicaid patients how to take their medications and the possible side effects, at least in writing. The mandate was part of the 1990 Omnibus Budget Reconciliation Act. About 40 states now require the same limited counseling for all patients with new or changed prescriptions. California law says pharmacists actually must talk with patients.
Kaiser argues that concentrating on high-risk cases is a better use of resources.
A recent USC/Kaiser study compared pharmaceutical care for high-risk patients, state-mandated counseling and counseling at pharmacist discretion. Patient satisfaction was high in the Kaiser model, where high-risk patients received the most counseling. It was highest in the group where everyone was counseled automatically.
Preliminary data show the high-risk Kaiser model reduces hospital admissions and costs per admission. Some data indicate that general counseling also lowers hospital costs, although less significantly. Neither program appears to cut office visits or drug expenditures, said McCombs of USC.
Pharmacist associations claim immense potential returns. Pharmaceutical care could save 120,000 lives and $45.6 billion each year, according to the American Society of Health-system Pharmacists and other members of the Coalition for Consumer Access to Pharmaceutical Care. The estimates are based on the coalition-funded University of Arizona study of drug mishaps.
The National Association of Retail Druggists, Alexandria, Va., urges pharmacists to bill health plans using its 2-year-old pharmaceutical-care claim form. Recently, more pharmacists are reporting success, NARD spokesman Todd Dankmyer said.
Several pharmacy-benefit management firms are paying pharmacists for counseling services as part of trial disease-management programs.
Starting in July, Wisconsin pharmacists will get higher Medicaid payments, provided they prove pharmaceutical care led to better patient care. Acceptable outcomes include more appropriate drugs and higher compliance, said Mike Boushon, a pharmacy consultant at the Wisconsin Department of Health.
The new reimbursement will depend on how much time pharmacists spend on the problems-from $9.08 for one to five minutes up to $38.55 for more than 30 minutes.
In Washington state, Medicaid is paying pharmacists $4 for six minutes of extra work and $6 for longer periods, in addition to a dispensing fee of $3.65 to $4.50.
Its Medicaid waiver, which is part of a HCFA study, ends Sept. 1. By then, HCFA expects data on increases in reported problems. A May 1997 report will cover changes in patient outcomes and healthcare consumption.
A second HCFA study is ongoing in Iowa. Pharmacy computers are checking new prescriptions against a central Medicaid databank of patients' medication profiles. Because many beneficiaries obtain drugs from multiple pharmacies, the search could turn up late refills and drug interactions that otherwise would be overlooked.
"Greater than 90% of pharmacies are computerized, but you have multiple systems, and it isn't always easy to get them to communicate," said Kathleen Gondek, a HCFA researcher. "The ability to catch problems depends on the system." The project will continue until June 1997.
Some observers worry that pharmacists aren't ready to practice pharmaceutical care.
For example, Boushon of the Wisconsin Health Department fears many pharmacists won't feel comfortable working so closely with physicians.
Pharmaceutical care "is a great opportunity for pharmacists," said Mary Sevon, a pharmacy benefit consultant in Fairless Hills, Pa. "But not everybody is innovative enough to recognize that. How does a male pharmacist counsel a woman on vaginal problems? How much do you say about side effects before patients are too scared to take the drug? I've talked to pharmacists in downtown environments; they're not going to get out from behind a bulletproof counter."
Others have great hopes for the future.
Within a year, the University of Pennsylvania Health System aims to give its primary-care doctors and some hospital departments on-line access to the medication profiles of employees in its health plan.
The Philadelphia-based provider is working with a pharmacy-benefit manager to develop even better information systems.
"Think about this scenario: Every physician uses a personal computer to put in prescription information, the printer spits out a hard copy for the patient to take to the pharmacy, and we check a database to see if the prescription was filled," said Jeffrey Bourret, director of pharmacy at 556-bed Hospital of the University of Pennsylvania, Philadelphia. "We should have that capability. There are studies I've read where 17% of patients leaving physicians' offices decide at that time they're not going to take their medications.
"It is managed care that is leading to this throughout the country," Bourret said. "I know pharmacists who are so depressed because of managed care. To me, managed care means better drug therapy."