AlignMap

Coming across two blogs relating especially poignant and insightful  personal experiences with medication compliance defeated my plan to abstain from  posting while I develop a new project (more about that at a later date).

My repeated criticisms of contentions made about treatment adherence without evidence notwithstanding, I’ve long held the belief, based on my interpretation of my own clinical experience (at best, a particularly shaky n=1),  that (1) healthcare practitioners who have an empathic understanding of their patients’ struggles with compliance can better assist those individuals in that effort than the equally competent but unempathic colleagues and (2) one way of gaining and deepening such empathy is through reading personal account by patients – like these.¹

Patient Compliance Overlaps Parent-Child Compliance

Bending, not Breaking at  Chez Perky describes a special subcategory of  medication adherence, a child’s resistance to medication. This excerpt evokes the sense of the mother’s dilemma  and indicates how much energy, thought, and time she has invested before calling the pediatrician for help:

Getting him to take his medication has always been a struggle, as you may remember. That’s why the Daytrana Patch was such a lifesaver. But it had too many downsides for his profile to be the optimal answer. It didn’t work as well for him as the Focalin does. But getting him to take a medicine orally is next to impossible. We have two good weeks, and then two weeks of hell, then two good weeks, then two weeks of pure hell, and so on. We are currently in hell, and I’m not sure it’s only going to last two weeks.

His latest trick is that he won’t open his mouth to take the medicine, but even once he does, he gets the medicine (which was mixed into mango sorbet – don’t ask… he has a discriminating palate) in his mouth and then won’t swallow it. He stands there and cries and refuses to swallow for what seems like forever, but is really somewhere between 5 and 15 minutes, and then either spits it out or forces himself to throw up (no, I’m not exaggerating). Occasionally he’ll swallow it under threat of not getting potato chips in his lunchbox, but that threat doesn’t hold a lot of weight anymore.

From Mandated To Self-Motivated Treatment Adherence

Two posts, Why I Take My Medicine and  Recovery: What Helped Me to Recover from Schizophrenia, at Overcoming Schizophrenia focus on compliance. The latter examines the importance of  legally mandated treatment (often known as “Assisted Outpatient Treatment” or “outpatient commitment”) in the writer’s case while the first entry describes the catastrophic consequences of the writer’s past nonadherence and the rationale the writer has found most useful in maintaining compliance. This excerpt summarizes that reasoning:

Medication compliance is a life-long routine because there is no cure schizophrenia, however, there is treatment. If I stop taking the medication I have an increased risk for a relapse, another psychotic break, and symptoms will return. My chances of a relapse increase each day I do not take my medication; so far I have accidentally skipped two days total over a span of one year on Abilify. I take pride in the responsibility I carry out every day of my life.

Each of these posts is worthwhile reading for clinicians who want to understand and help their patients in the realm of medication compliance and for patients and the family and friends of patients involved in those struggles.

1. I know – my concept is not scientifically supported; there are few studies that address this point and the results of those are open to varying interpretations. I do have two defenses: (1) I point out that I have no proof of this hypothesis so at least readers are not being misled and (2) My blog, my rules.↩

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From Nov. 3, 2008 American Medical News - By Doug Trapp

American Medical News Critiques West Virginia Medicaid Incentive Program

The graphic above is the heading for an American Medical News¹  story about the West Virginia Medicaid patient incentive plan.  The basics of the West Virginia plan and my perspective on it was discussed in this blog two years ago at West Virginia Medicaid Compliance Contracts – The Plan, The NEJM Perspective, & The Rest Of The Story.

See if you can guess AMA’s perspective from the clues in the headline:

When incentives lack appeal:
Medicaid reform meets confusion, skepticism

That’s right – in formal terms, this means  “Incentives used in the West Virginia Medicaid reform plan to encourage certain behaviors in patients lack appeal, thus causing confusion and skepticism.”

In less formal terms, it means “The West Virginia Medicaid reform plan stinks.”

Now, try the subheading:

West Virginia is one of the first states to offer inducements
for patients who pledge to follow physicians’ orders,
but most of those eligible aren’t taking the bait.

Let me suggest that the key words are “… most of those eligible aren’t taking the bait,” a figure of speech that leads me to suspect that it required the totality of the author’s self-discipline to forgo his impulse to add “Thank God” at the end. After all, I’ve never read a story in which good things happened to anyone who does “take the bait.”

At the risk of provoking the AMA to reconsider its position, I agree with their point that the bureaucratic implementation of the incentive plan is – hmmmm, let’s call it suboptimal. In fact, I am probably more critical of the plan’s structure than is the AMA. More about this a little later.

The Criticisms

The  article’s  basic argument is presented in the excerpts that follow:²

The program, which began almost a year ago in most parts of the state, is a novel attempt to use incentives to boost enrollees’ personal responsibility and ownership over their health care. Eligible enrollees who agree to a wellness plan, follow other physician directions, and show up on time for medical appointments can receive free additional benefits, such as help with quitting smoking and membership in Weight Watchers. Those who don’t take the option are relegated to a basic plan with somewhat fewer benefits than their existing plan.

Enrollment in the enhanced plan so far has been low. About one-third of West Virginia’s Medicaid beneficiaries — who numbered 392,000 in 2007 — are eligible for Mountain Health Choices based on their relative good health. But only about 15,500, or 12%, of those eligible had signed up as of Sept. 30, according to state counts. Another 3% had begun the enrollment process.

Why hasn’t the program been more popular?

Some patients simply might not know about or understand the program. Others might not read well enough to grasp the details. But even for those who want to pick the enhanced option, it’s not always simple.

For starters, Medicaid enrollees are instructed to call their primary care physician. “Many don’t have a primary care provider,” said Renate Pore, president of the patient advocacy group West Virginians for Affordable Health Care. “They don’t know who they’re supposed to call.”

Some eligible enrollees might not see a need for extra benefits, said Sarah Chouinard, MD, medical director of Primary Care Systems Inc., a health center in Clay, W.Va. For example, a 30-year-old woman with seasonal allergies might think she just needs her allergy prescription and annual Pap smear, not a wellness plan and extra hospital coverage.

The requirement that patients commit to regular office visits could pose a barrier for those with limited transportation options, said Rodney Fink, DO, director of clinical service for Access Health, a group of six health centers in southern West Virginia, including the Beckley facility where Dr. Bennett works.

Some observers say the state needs to do a better job of selling beneficiaries on the extra benefits. Dr. Fink said doctors also need to do a better job of focusing their patients’ attention on it.

… The Deficit Reduction Act of 2005 gives states authority to offer varying benefit levels to Medicaid enrollees. A few states, including Idaho and Kentucky, responded by offering incentives to beneficiaries who adopt healthier behaviors. Other states, such as Florida and Wisconsin, set up similar programs under waivers from the Centers for Medicare & Medicaid Services. The Deficit Reduction Act of 2005 lets states offer varying benefit levels to Medicaid enrollees.

But West Virginia took the concept one step further by limiting benefits for Medicaid recipients who do not promise to follow a wellness plan and listen to doctors’ orders. The state is now on the line to prove the tactic will work.

The ultimate goal of Mountain Health Choices is to forge relationships between patients and physicians that lead to healthier lifestyles and better preventive care, said Shannon Landrum, spokeswoman for the West Virginia Bureau for Medical Services in Charleston. …

Parents must agree to pick a medical home for their child, bring the child on time for a minimum number of office visits, and ensure that immunizations are up to date and prescriptions are followed. The agreement is similar for adults, with the addition of required screenings, such as colonoscopies, glucose levels and mammograms.

Some points of contention

The West Virginia program is more controversial than other states’ because it automatically bounces nonparticipating beneficiaries — possibly without their knowledge — into the basic plan. Once there they encounter more restrictions than in traditional Medicaid, such as caps on prescriptions and mental health services.

For example, children in the basic plan are limited to four prescriptions per month, even though a child with asthma and attention deficit disorder could easily hit that limit, said Fernando Indacochea, MD, president of the West Virginia Chapter of the American Academy of Pediatrics. Landrum, however, said a state review of data from three pilot counties prior to implementation showed that children on Medicaid average fewer than one prescription a month.

And while individual mental health therapy is covered under the basic plan, crisis intervention is not, said Bob Hansen, executive director of Prestera Center, a mental health and addictions treatment agency in Huntington.

Georgetown University’s Center for Children and Families on Aug. 9 issued a paper criticizing the state for automatically limiting kids’ benefits via the basic plan. If the program aims to encourage healthy behaviors among Medicaid enrollees, said Joan Alker, the deputy executive director of the center, “I don’t think there’s any evidence that they’re achieving that.”

West Virginia already has learned some lessons that could be applied by other states considering incentives for patient compliance.

Dr. Fink said programs such as Mountain Health Choices won’t work unless staff at clinics and health centers proactively advise patients about their health care options. He added that physicians should form a second line of support and also gauge their patients’ awareness.

Landrum said it can be difficult to engage Medicaid enrollees as they gain or lose program eligibility. About 40% of Medicaid beneficiaries in West Virginia don’t renew their benefits from one year to the next. States that want to change Medicaid from a program that simply pays claims into one that promotes health improvement and wellness need to be patient and look for ways to measure success in the long term, Landrum said.
Hope for the future

To improve physician awareness, the state could notify doctors of their Medicaid patients’ deadlines for choosing a new plan, said Violet Burdette, CEO of Northern Greenbriar Health Clinic in Williamsburg. Eligible beneficiaries receive a Mountain Health Choices enrollment packet 60 days before their Medicaid benefits are changed. They have 90 days to respond.

Burdette also said enrollees might be more engaged if they had to choose either the basic or enhanced plan instead of being channeled into the less generous plan by default. Landrum said only two Medicaid beneficiaries have actively declined the enhanced plan.

Work of enrolling can fall on physicians

Some physicians are excited about West Virginia’s pilot program that offers incentives for Medicaid patients to stick with a wellness plan, even though it does cause extra work for doctors.

Sarah Chouinard, MD, medical director of a health center in Clay, about an hour from Charleston, said her facility has convinced more than a few patients to take advantage of the enhanced benefits in Mountain Health Choices. The clinic, which is in one of the three pilot counties for the program, treats about 7,200 patients, a third of whom are enrolled in Medicaid.

Dr. Chouinard said explaining the initiative to patients requires additional staff time but coordinates well with the medical home model the center offers.

Terrence Reidy, MD, was less enthusiastic. He practices at a community health center in Martinsburg, in the eastern part of West Virginia.

A state Medicaid representative visited his facility about a year ago to explain the role the center would play in promoting the expanded plan. “It seemed like our office was then expected to be the ones to get the patients to sign up,” Dr. Reidy said. The internist hasn’t been contacted by state officials since then, he said in late September.

The center treats about 2,400 Medicaid patients, two-thirds of whom are children. Only about 2% of patients have opted for the enhanced benefits. “It really has not changed our practice a bit,” Dr. Reidy said. Still, consulting even a few patients about their choices of Medicaid benefits and crafting wellness plans adds another unpaid job to his already tight schedule.

One job West Virginia physicians will not have is that of enforcer. The state will review claims records to track patient compliance with the enhanced benefits agreement.

The West Virginia Medicaid Plan As An Example Of Misalignment

If I were a hot-shot psychiatrist – and, as it turns out, I am – I would diagnose a severe case of ambivalence on the part of the creators of the West Virginia Medicaid Incentive Plan.

On one hand there are significant rewards offered to reinforce those desired patient behaviors in the form of a greatly enhanced set of benefits.

On the other hand, it’s as though the administrators fear that the incentives will prove too popular so bureaucratic hurdles (e.g., the requirement that the patient designate a primary provider and take the initiative to sign up for the program)  were created to minimize the number of patients taking advantage of the more extensive, more expensive plan.

I do not believe, however, that the increased expectations placed on the physicians as an uncompensated, de facto administrative assistant and compliance monitor is part of that ambivalence. Nope, I believe that assigning uncompensated tasks, necessary for the functioning of the plan, to physicians and ther offices is merely one more instance of habitual legislative laziness.

Otherwise, one is face with explaining why a the plan’s administrators, who apparently believe in the power of incentives, would create a program that rewards patients but not only fails to reward the clinicians for reaching the same end-points but penalizes them by requiring them to perform work without pay.

Enough of the preliminaries – my contention is that the problems in the design of the West Virginia Medicaid Incentive Plan can best be characterized as a lack of alignment.³

There are so-called pay-for-performance schemes that reward or penalize clinicians, for example, based on the extent to which they follow treatment protocols or on the percentage of their  patients that follow specific pateint protocols, such as designated disease screenings (e.g., mammography or colonoscopy) or participation in disease management programs. There are programs like the West Virginia Medicaid plan that reward or penalize patients for specified healthcare behaviors.  I know of no programs that coordinate both clinician and patient reinforcement systems.⁴

In fact, many programs seem to follow the West Virginia model by offering to reward one group (patients in West Virginia’s case) and simultaneously punishing the other (assigning time-consuming administrative tasks to clinicians without compensation). In these situations, the issue is not a lack of alignment but misalignment.

Further, we’ve only addressed aligning two healthcare stakeholders, the clinician and the patient. In many cases, for example, a patient’s outcome depends primarily on the dedication and efforts of a non-professional caregiver such as a spouse, family member, or friend.  Yet, I find no programs that provide even token rewards for this group beyond generic support groups. Other stakeholders, such as community organizations with healthcare programs, likewise must be taken into account.

And third party payers, bless their hearts, have to be in alignment with other stakeholders if ongoing healthcare efforts are to be have a chance.

And – steel yourselves – on a macro level, pharmaceutical companies and medical equipment manufacturers have to be transformed from miracle workers/sources of all evil (choose one) into participants who gain and lose in unison with other stakeholders.

OK, I only said it was easy to understand the benefits of alignment, not that it was easy to design or implement a well aligned program .

1. American Medical News is a newspaper produced by the AMA for physicians.↩
2. While I have included a large portion of the text and have tried to keep the sense of the original article intact, there is always a risk of distorting the author’s intent. Consequently, I urge viewers to read the entire piece available here: American Medical News↩
3. I use “alignment,” In the context of healthcare, to indicate the condition of the patient, the clinician, and other stakeholders sharing mutual aspirations and grasping the complementary nature of their roles such that each individual or entity involved can support the treatment decision made, even if is not the first choice of a each stakeholder.↩
4. I have purposively chosen the “I know of no programs that … ” sentence format because I continue to believe that healthcare providers and patients benefiting in concert is such an obviously beneficial idea that someone somewhere must have tried it; I just haven’t run across it yet. ↩

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The Impact of Parents’ Medication Beliefs on Asthma Management
Kelly M. Conn, MPHa, Jill S. Halterman, MD, MPHa, Kathleen Lynch, BAa and Michael D. Cabana, MD, MPHb. PEDIATRICS Vol. 120 No. 3 September 2007, pp. e521-e526. Published online August 31, 2007

The Study

This study looked at the effect parental beliefs about asthma medications have on their children’s medication adherence. To determine the parents’ beliefs, they were asked to complete a Beliefs About Medications Questionnaire (BMQ), which measured the necessity, or the extent to which they believed a child’s sickness necessitated taking medication and the concern, or the extent to which a parent worried about possible risks associated with the drugs, such as side effects and potential for dependency. A differential score was calculated by subtracting the concern score from the necessity score. This served as a weighed appraisal of each parent’s beliefs.

Results (excerpted from the study):

Commentary

It’s no surprise that children are dependent on their parents to make healthcare decisions and that ones attitude toward the usefulness and dangers of medication affect adherence to that medication dosage schedule. Still, that this assumption has been verified by research is heartening.

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Health Beliefs, Disease Severity, and Patient Adherence: A Meta-Analysis. DiMatteo, M Robin PhD; Haskard, Kelly B. MA; Williams, Summer L. MA. Medical Care. 45(6):521-528, June 2007.

The Study

The study is a meta-analysis of 116 articles published from 1948 to 2005 that dealt with “the relationship between patient adherence and patients’: (1) beliefs in disease threat; (2) rated health status (by physician, self, or parent); and (3) objective disease severity.”

Results & Conclusions Excerpted From The Abstract

The authors speculate that “patients may have doubts about the efficacy of their treatments, particularly if some have failed them, and their expectations for and interactions with their providers may be reduced in quality as they grow more severely ill. For patients in poor health with serious disease conditions, adherence may even seem futile, and patients may become depressed, pessimistic, socially withdrawn, and hopeless about surviving.”¹

Commentary

While the finding that patients with the most serious illnesses are least likely to adhere to treatment is counterintuitive to the common sense notion that those facing the greatest threat would be the group most likely to follow healthcare instructions, this result resonates with my clinical and personal experiences.

As DiMatteo and colleagues note, anxiety and depression associated withs severe disorders may play interfere with a patient’s ability to understand or execute a treatment plan or deplete a patient’s energy or motivation.

Also, however, more severe disorders may call for more rigorous, costly, and complex treatment regimens which could negatively affect compliance.

Regardless of the cause, however, this evidence that these individuals afflicted with the most serious illnesses are especially vulnerable to noncompliance should be a concern physicians automatically consider and monitor in the treatment of such patients.

Footnotes

1. Sickest Patients Less Likely to Follow Doctors’ Orders, UCR Study Finds ↩

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The Study and The Real World

In Office Visits and ADHD Meds, yesterday’s post at Spotlight On ADHD, Dr. Brian Doyle points to a study¹ which he finds unsettling because of the implications its findings would have for practices treating these patients.

The only summary of the study I was able to find online this morning was in New and Emerging Data in the Management of ADHD, the source of these excerpts:

From this data, the researchers postulated “a direct relationship between the number of office visits and the number of prescriptions filled, suggesting a positive link between office follow-up and compliance” and suggested that “more frequent
office follow-up may lead to improved medication adherence among patients with ADHD.”

Dr. Doyle’s concerns are summarized in this excerpt from his post:

Commentary

First, in the spirit of full disclosure, I should clarify that

1. When I was involved in office practice, I treated batches of ADHD kids (although, I suspect, not as many as Dr. Doyle does) and my scheduling protocol for ADHD adolescents was almost precisely identical to his. Once the patients were stabilized, I would routinely see them once every three months for 15-30 minutes unless there was a specific problem that required more time or more frequent visits (this was a rarity). Almost all the ADHD patients I treated with medication were seen more often by a non-psychiatric therapist. I saw patients every three months because that’s how the psychiatrists I knew handled patients taking AHDH medication.
2. I am also the parent of an ADHD child who was on medication for several years. In treatment with four or five different pediatricians and psychiatrists over the years, he was almost always seen for medication check-ups once every three months for 15-30 minutes.

Given my clinical and family background, I may well be reacting defensively. Nonetheless, until I know some details of the study that are currently unavailable to me, I’m unable to generate much angst about my previous practices or enthusiasm to promote the idea that “more frequent office follow-up may lead to improved medication adherence among patients with ADHD.”

Some of the pertinent questions about the research, it seems to me, include the following:

• Was the frequency of patient visits a function of the specific case (i.e., did the clinicians in the study vary how often they requested visits by the difficulty of the case), the clinician (i.e., did some clinicians routinely schedule visits more often than others such that frequency of visits was a proxy for different groups of clinicians), or the patient and family (i.e., did the patients who did not show up at the office as often miss scheduled appointments)?
• Did the frequency of visits vary with the course of treatment (i.e., given that the patients were all “newly diagnosed,” did the clinicians use the same paradigm Dr. Doyle and I used, seeing the patient frequently at first and then decreasing the frequency)?
• What proportions of the patients fell in each age group and how did frequency of visits correlate to age (e.g., were young children routinely seen more frequently so compliance might have varied by age rather than frequency)?
• Did the clinicians provide prescriptions at times other than office visits?

Because such variables could clearly affect the suggestion that increased frequency of visits could increase compliance with medication, I suspect that some or all of them have been addressed, but until I review that information, I would hesitate to make further scheduling demands on the patients who are doing well (and their parents) based on these findings.

Footnotes

1. Hodgkins P, Boken M, Capone NM, et al: Office visits and prescription fill rates in patients with ADHD. Poster 119, presented at the 19th Annual US Psychiatric and Mental Health Congress; November 16, 2006; New Orleans, LA.↩

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The Problem Of Painful Pediatric Immunizations

A quote from Neil L. Schechter, MD, from the Pain Relief Program at Connecticut Children’s Medical Center in Hartford, Connecticut, and colleagues succinctly summarizes the issues:

Consequently, a consensus conference on this topic was held to review the existing literature and generate recommendations for best practices to reduce injection pain. An evidence-based review published in the May issue of Pediatrics discusses these results.¹

The Medscape article goes on to provide specific suggestions dealing with anatomical locations for injection sites, parental attitude, variations based on the age of the child, use of distraction and pressure to diminish discomfort, multiple Vs sequential injections, selective use of sucrose and topical anesthetics, preparation of the child, needle length and gauge, and specific properties of the injectate, among others.

The article concludes with (1) the observation that there has been little organized effort to address moderating the pain associated with immunizations, probably because of the abundant benefits of the procedure and (2) the sobering speculation that

Commentary

While any proof is lacking, I agree with the authors that it seems possible and perhaps likely that the traumatic injections received as a child could have long-term consequences that inhibit seeking needed healthcare. I have vivid childhood memories of fearing visits to the doctor because they were so closely associated with “getting a shot.” That question certainly merits further study as does the issue of of decreasing the pain of injections, a goal worthy of evidence-based methodologies if for no other reason than reducing unnecessary stress to kids, parents, doctors, and nurses.

Source:
Recommendations Issued for Reducing Pain of Pediatric Immunizations Laurie Barclay, MD Medscape May 7, 2007

CME: Valid for credit through May 7, 2008. Credits Available: Physicians – maximum of 0.25 AMA PRA Category 1 Credit for physicians; Family Physicians – up to 0.25 AAFP Prescribed credit for physicians. All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation. To obtain CME credit, go online to article site on Medscape and follow instructions under heading, “FOLLOW THESE STEPS TO EARN CME/CE CREDIT” near bottom of page.

Footnotes

1. Pediatrics. 2007;119:e1184-e1198.↩

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Literature Source For Failed Transplant Cost Calculation

In summarizing the article by Willoughby, et al, Health insurance considerations for adolescent transplant recipients as they transition to adulthood,¹ the 14 March 2007 AlignMap blog post, Out Of Pocket Costs and Transplant Failures Rise In Concert, included the statement that “… the healthcare costs of failed [kidney] transplants are 10 times higher than functioning transplants.”

While the cost calculation was noted in the Willoughby article, its original source is

This citation has also been added to the original post.

Footnotes

1. Full citation: Lisa M. Willoughby, Sumina Fukami, Suphamai Bunnapradist, Jeffrey A. Gavard, Krista L. Lentine, Karen L. Hardinger, Thomas E. Burroughs, Steven K. Takemoto, Mark A. Schnitzler (2007) Health insurance considerations for adolescent transplant recipients as they transition to adulthood Pediatric Transplantation 11 (2), 127–131.↩

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[Note: This graphic is not illustrative of the actual device discussed below.¹]

Automating Motivation With Medication Dispensing

The following are excerpts from the patent application for Patient compliance system and method to promote patient compliance:²

Description

Incentives

Commentary

A significant number of devices that automatically dispense medication at the appropriate time and alert the patient or care provider and documents that the medication was “administered” (in this context, “administered” almost always means the medication was removed from the container, “whether or not the pharmaceutical was successfully ingested, inhaled, etc. by the patient”) are on the market. In some cases, the failure to remove a dose from the machine within a given time causes a notification to be sent to a caregiver (e.g., a concerned family member), prescribing physician, pharmacists, or another healthcare professional or organization.

In most cases, no specific incentive for compliance is given. If these devices provide motivation for compliance, it is typically a negative reinforcement (e.g., the implied threat that a family member or a clinician will be notified of noncompliance or the persistence of a noxious reminder, such as a recurrent auditory signal, until the medication is administered³ ). The device described in this patent application does directly address incentives, which have been shown in other situations to be effective compliance enhancements.⁴

I harbor doubts about the practicality and effectiveness of the specific incentive scheme suggested. Deferred rewards (e.g., coupons or codes to be redeemed at a later date) are less effective, especially for children, than immediately available reinforcements. And, one wonders who will purchase the “toys, games, clothes (hats, scarves, t-shirts, etc.), jewelry (e.g., pins, ear rings, pendants, necklaces, bracelets, rings, etc.), candy, books” used as incentives. Further, it is a behavioral modification 101 principle that reinforcements must be selected for their appeal to a given subject and must be varied over time to sustain that appeal.

Consequently, I laud the notion of automating incentives but suspect the reward program in the application, based on a oversimplified concept of behavioral modification, would be far more effective if a more sophisticated, research-based reinforcement system were used.

The Slot Machine Illustration
I happened onto the slot machine graphic while searching for an illustration for this post (I don’t have access to the drawings in the patent application). I decided to use it even though it wasn’t the kind of graphic I had in mind because, it occurred to me, a reward scheme that emulated a slot machine would ameliorate although not completely resolve some of the problems I describe with this device.

• “Buying a chance to win” with compliance would appeal to some, albeit not all, individuals
• Intermittent reinforcement is more effective than continuous reinforcement
• Rewarding incentives only on “winning” doses rather than every dose reduces the number of incentives needed and lessens the frequency with which they must be changed

Just a thought.

1. For an explanation of the use of the slot machine graphic in this post, see section labeled, "Commentary"↩
2. Patent Application #20070039624↩
3. For an outstanding example of this latter strategy and the marketing utility of compliance definitions, see 98.6% Medication Compliance↩
4. I have not made a thorough survey of all such devices, and it is possible and even likely that devices providing positive enforcement for compliance exist. This is the first that has come to my notice↩

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Lisa M. Willoughby, Sumina Fukami, Suphamai Bunnapradist, Jeffrey A. Gavard, Krista L. Lentine, Karen L. Hardinger, Thomas E. Burroughs, Steven K. Takemoto, Mark A. Schnitzler (2007) Health insurance considerations for adolescent transplant recipients as they transition to adulthood Pediatric Transplantation 11 (2), 127–131.

What Happens When The Money Runs Out?

Advances in medical and surgical techniques often prolong life and decrease mortality but also create new problems.

In this case, improved immunosuppression and allograft outcomes have resulted in more than 90 percent of pediatric and adolescent patients not only surviving but doing well one year post-operation. That means there is also a growing number of patients taking expensive immunosuppressive medications for the rest of their lives.

While the costs of most transplantation procedures in the USA currently are covered by Medicare, these benefits end 36–44 months after transplantation or when the patient reaches adulthood. Immunosuppressive drugs can cost in excess of $13,000 a year, representing a significant financial burden for even those families with private health insurance because of co-payments . The patients themselves, especially young adults, can rarely afford to pay for these drugs, especially since only about 30 percent of young adults have health insurance.

The consequence of this economic predicament is that preventable rejections of many transplanted organs take place and patients’ lives are shortened. In one reviewed study, the rate of graft loss doubled with the termination of Medicare coverage. And, once the transplanted kidney no longer works, the risk of death increases by a factor of 9. Further, the healthcare costs of failed transplants are 10 times higher than functioning transplants.¹

Commentary

The message is simple and stark: Chronic diseases require chronic care and entail chronic costs.

Individuals, families, and society must make difficult decisions about the long-term consequences of interventions such as transplantation – specifically, how costs and compliance can be managed.

1. G. Machnicki, L. Seriai, M. Schnitzler, Economics of transplantation: a review of the literature. Transplantation Reviews, April 2006. Volume 20, Issue 2, Pages 61-75↩

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In 1975, Mattar and colleagues analyzed the extent to which 300 pediatric patients received their prescribed medication regimen (from their parents) for the treatment of acute otitis media.¹ The results follow:

• 36% of the children received an insufficient number of doses
• 37% of the children did not receive a complete course of antibiotic because the parents unilaterally discontinued the medication early
• 20% of the children received the wrong dosage because of incorrect labeling, misunderstood instructions, and other unintentional errors
• 7% of the children received the medication exactly as prescribed

Commentary

While these blog posts usually deal with more contemporary research or events, the Mattar article is today’s focus because it is one of the first studies I happened to read that led to my realization of the remarkable extent and pervasiveness of noncompliance. In this case, thorough adherence to treatment is the aberration and noncompliance is the norm.

Footnotes

1. Mattar ME, Markello J, Yaffe SJ. Inadequacies in the pharmacologic management of ambulatory children. J Pediatr. 1975;87:137-41.↩

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A Randomized Controlled Trial Testing an HIV Prevention Intervention for Latino Youth Antonia M. Villarruel, PhD, RN; John B. Jemmott III, PhD; Loretta S. Jemmott, PhD, RN. Arch Pediatr Adolesc Med. 2006;160:772-777.

Successful Anti-HIV Program Targets Hispanic Teens Yahool News Tue Aug 8, 11:47 PM ET
________________________________

550 Latinos aged 13 through 18 years were enrolled in the study. Control interventions consisted of six 50-minute modules delivered by adult facilitators to small, mixed-gender groups in English or Spanish while the HIV intervention focused solely on HIV prevention. The HIV prevention program also incorporated issues thought to be especially significant in the Hispanic culture, such as the importance of family.

Those in the HIV intervention were, according to the abstract, “less likely to report sexual intercourse (odds ratio, 0.66; 95% confidence interval [CI], 0.46-0.96), multiple partners (odds ratio, 0.53; 95% CI, 0.31-0.90), and days of unprotected intercourse (relative risk, 0.47; 95% CI, 0.26-0.84) and more likely to report using condoms consistently (odds ratio, 1.91; 95% CI, 1.24-2.93).”

Commentary

While encouraging, it must be noted that this study, as is true with many others, depends entirely on self-report from the adolescents studied.

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Published Article:
Use of human immunodeficiency virus postexposure prophylaxis in adolescent sexual assault victims
Olshen E, Hsu K, Woods ER, Harper M, Harnisch B, Samples CL.
Arch Pediatr Adolesc Med. 2006 Jul;160(7):674-80.

Release To Lay Press:
Teen sexual assault victims rarely finish HIV-exposure drugs
Advocate.com Reuters. July 15, 2006
________________

Results

The stark numbers of a study by Elyse Olshen & colleagues tell a terrifying story:

• 145 adolescent patients (97% female) seen within 3 days of sexual assault









• 129 were offered HIV postexposure prophylaxis









• 110 agreed to its use









• 86 began the protocol









• 13 completed the full course of treatment

The authors conclude:

Commentary

Given the extreme degree of noncompliance and the long-term risk to these adolescents and to those with whom they come into contact, “patient education” and follow-up programs “to encourage PEP adherence” may not represent a proportionate response to the situation. It would seem that a more aggressive approach, perhaps Directly Observed Therapy, is warranted.

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