AlignMap

Half Of US Pregnancies Unintended

An article in the  Health Journal portion of the 20 April 2010 Wall Street Journal, The Birth-Control Riddle by Melinda Beck, offers these impressive statistics regarding unintended pregnancies:

Almost half of all pregnancies in the U.S.—some 3.1 million a year—are unintended, according to the most recent government survey, from 2001.¹ One out of every two American women aged 15 to 44 has at least one unplanned pregnancy in her lifetime. Among unmarried women in their 20s, seven out of 10 pregnancies are unplanned.

While the causes of the problem may be, as the article’s title indicates, a riddle, its mechanics  are not:

Almost half (48%) of unintended pregnancies involve contraceptive failures. In 52% of cases, couples used no birth control at all. Cost is a factor for some of them. Even though most insurers now cover contraceptives, co-pays and deductibles can still present obstacles.

And many young people are in “the fog zone” in which their beliefs about pregnancy don’t match their behaviors, according to a 2009 report by the National Campaign to End Teen and Unplanned Pregnancy. In a survey conducted by the Guttmacher Institute of 1,800 single men and women aged 18 to 29, more than 80% of both sexes said it was important to them to avoid pregnancy right now, yet 43% of those who are sexually active said they used no contraception or used it inconsistently.

The following chart from the CDC (not in the WSJ article) offers confirmation of the premise that most couple incidents of unintended pregnancy were the result of not using any contraceptives.

CDC Data

The CDC 2002 PRAMS Surveillance Report: Multistate Exhibits – Unintended Pregnancy and Contraceptive Use also provides these sobering indicators that the problem is not lessening:²

In 2002, among women who reported that their pregnancy was unintended, the prevalence of contraceptive (any method) use at the time of pregnancy ranged from 38.7% (Hawaii) to 53.3% (Vermont).

During 2000–2002, the prevalence of contraceptive (any method) use at the time of pregnancy among women with an unintended pregnancy decreased in 4 states (Florida, New Mexico, New York, and North Carolina).

Education And Technology As Solutions

After delineating the problem, the article  (The Birth-Control Riddle) notes,

Some population experts say the rates of unintended pregnancy would be far lower if more women used IUDs and implants that prevent pregnancy for years at a time. Only about 3% of American women currently do.

“There are terrible misperceptions about these methods— and about all forms of contraception,” says James Trussell, director of the Office of Population Research at Princeton University.

Many traditional forms of contraception have been updated in recent years. Here’s a look at the latest developments: …

A summary of the pros and cons of various contraceptive methodologies, under the headings, The New IUDs, The Implant , Hormone Pills, Patches And Rings,Condoms, Caps And Sponges, Emergency Contraception, Permanent Birth Control, and Vasectomy Variations, completes the piece.

The Problem With Education And Technology As Solutions To Noncompliance

The advancements in effectiveness, safety, and ease of use of contraceptive technology are important and may well trigger incremental improvements in the rate of use of these methods. Nonetheless, the emphasis on improved technology begs the question of why none of the previously available, well publicized contraceptive methods (e.g., birth control pills, abstinence, diaphragms) were used in half of all unintended pregnancies.

And, educating patients beyond the basics  (i.e., the instructions for safe and effective treatment implementation and a simple explanation of how the medication, diet, surgical procedure, etc. works) has rarely proved successful in significantly ameliorating noncompliance.

The most problematic aspect of the focus on education and technology, however, is that it distracts from other possible factors, including the cultural, socioeconomic, and psychological issues that may prevent a woman and her partner from using any contraceptive method regardless of their understanding or appreciation of the technology.

Given that unintended pregnancy has been shown to influence a woman’s behavior and experiences during pregnancy and in the post-natal period  to the detriment of  the health of her infant, this is a noncompliance problem that merits a more inclusive response than appeals for more education and tbetter technology, however worthy those  efforts may themselves be.

1. The same article goes on to note: “An updated version of those numbers from the 2006 National Survey of Family Growth is expected to be released next month. But population experts don’t anticipate much change; the rate of unplanned pregnancy was the same in 1994, and smaller studies have found that even newer birth control methods haven’t made much of a dent.”↩
2. Note: PRAMS data is not collected in all states. In 1999, for example, data was collected in 17 states: Alabama, Alaska, Arkansas, Colorado, Florida, Illinois, Louisiana, Maine, New Mexico, New York, North Carolina, Ohio, Oklahoma, South Carolina, Utah, Washington, and West Virginia↩

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. ↩

From Medco Perspectives: A Prescription for National Healthcare Reform

The David Snow Healthcare Policy Speech: Background

On September 19  2008 at the National Press Club, David Snow, who by most accounts has performed well since being appointed Chairman and CEO of Medco Health Solutions in 2003,  moved beyond the boundaries of corporate healthcare to offer, in the words of his press release,

… a pragmatic blueprint for fixing America’s inefficient health care system that, for the first time, is designed to address the root causes of the problem. Unifying the strengths of both the public and private sectors, Snow’s plan is designed to reduce the nation’s health care expenses by as much as $1 trillion – almost 50 percent of current expenditures – while extending affordable, high-quality care to more Americans.

While this post focuses primarily on a reference within that speech to patient compliance as a major healthcare problem, the context in which that reference occurred is also significant. Because few of the accounts of the speech I have found devote any attention to this background material,  I am providing some basics before addressing the issue of treatment adherence.

Mr. Snow has more than 25 years of experience working in healthcare organizations prior to signing on at his current job. He previously held executive positions at Oxford Health Plans, American International Healthcare, Inc. and US HealthCare, Inc. as well as creating and running Managed Healthcare Systems, Inc. (now renamed AmeriChoice).

His ascension to the leadership of  Medco, described below in the excerpt from Newsweek, is itself of interest:

In March, it [Medco] named David Snow Jr. as its new CEO. In January, Snow bolted the No. 2 job at WellChoice (WC ) operator of Blue Cross & Blue Shield insurance plans in New York. Just weeks before, WellChoice CEO Michael Stocker was diagnosed with prostate cancer. Snow’s move left Stocker and others at WellChoice puzzled. Snow did not explain his move then and declined to explain it now. A Medco spokesman told me Snow left WellChoice when it became clear he was still some years away from realizing his ambition to be a CEO.

His work at Medco has been well compensated.  In 2004, his total compensation, according to Salary.com, was a bit over $9 million.  His 2006 total compensation, calculated by a different formula and reported in Forbes, was $1.9 million. Pharmalot dec;ares Snow “earned a $1.18 million salary last year [2006], along with $1.7 million from a non-equity incentive plan, and stock and options that were valued at $7.2 million at the time these were awarded a year ago. Snow, 52, also received $44,809 in ‘other compensation.’” In any case, Mr. Snow earns a nice living.

At the National Press Club Speech, Snow, according to The  Kaiser Daily Health Policy Report, not only presented his healthcare strategy but also critiqued  the healthcare policy  proposals of both presidential candidates:

… Medco Health Solutions CEO David Snow on Tuesday at the National Press Club in Washington, D.C., said that the McCain health care proposal would “create chaos,” Bloomberg/Bergen Record reports. Snow said, “I’m very frightened of the conversations that try to shift responsibility away from employers to individuals,” adding, “There will be more uninsured.” Snow said that the health care proposal of Democratic presidential nominee Sen. Barack Obama (Ill.) also would pose problems, adding that he is “not a big supporter of either” candidate.

Finally, the tone of Snow’s presentation is, I believe, meaningful.  Consider this excerpt from the same press release:

“Despite the urgent need, experience shows that health care reform must be evolutionary, not revolutionary, to be accepted by the American public,” Snow said. “We must agree upon an end-to-end strategic road map now, so that we can begin the journey to reform in earnest. Our commitment to this road map needs to persevere over an extended period of time to realize this opportunity. The payoff for doing this right is huge; the penalty for failure will burden generations to come.”

Not exactly your standard businessman’s, matter of fact, Chamber of Commerce speech, is it?  Along with the implicit nationalistic evangelism and recruitment to a crusade, those phrases are convey  a certain political panache, not unlike, say, a future candidate’s speech?

I am a tad disappointed I couldn’t find a  “My fellow Americans” sort of cliche in the speaker’s notes or locate a form on the Medco web site for ordering “Vote For Snow” bumper stickers. Consequently, the only support I have for my speculation that this presentation was an audition of sorts for a potential political candidate is my observation that an ambitious, successful, experienced business executive gave a ruffles and flourishes speech before the National Press Club calling the nation to the task of fiscally responsible healthcare reform and criticizing the healthcare proposals of the two major presidential candidates.

Just call it a hunch.

David Snow On Patient Compliance – And Other Issues¹

One reason the context is important is that it may explain David Snow’s predilection for absolute pronouncements in this speech.

He offers, for example, “Three Rules for Reform:”

• First, keep it simple – in business, complex solutions always fail.
• Second, revolutionary reform is rejected by our society; instead, we need incremental, evolutionary change with a deliberate and phased approach.
• Finally, and most importantly, we must define the roles of the private sector and the government. Each has an important but distinctly different responsibility and every time we cross those lines it results in failure – without exception.
  • The government’s function is to promulgate and regulate.
  • The private sector’s function is to operate and innovate.
    [emphasis mine]
    

The final tally: three points, two explicit absolutes (with bonus points for the redundant “without exception”).²

I, for one, find it difficult to believe that someone with 30 years experience in the healthcare industry, a field enamored of needlessly complex responses to problems, has never once been aware of a complex business solution succeeding, if only by random chance. I can certainly call to mind a few strategies that succeeded in spite of their complexity (not to mention inaccurate premises, mediocre execution, and bad timing – being lucky is a wonderful thing).

I suggest, as an alternative explanation, that Mr. Snow may have been speaking figuratively rather than literally – in sound bites.

Keep that in mind when considering the compliance points from the speech.

The crux of the speech resides in the specific policy recommendations:

I have five suggestions.  Each is simple [emphasis mine] and leverages the appropriate roles of the public and private sectors in a manner that, taken as a whole and aggressively pursued in a phased approach, creates an opportunity to reduce current healthcare expenditures by as much as $1 trillion.  They include:

•  Wiring Healthcare
•  Fixing Medicare’s Financial Fundamentals
•  Eliminating Medical Liability and Defensive Medicine
•  Increasing Compliance and Reducing Errors
•  Promoting Healthy Lifestyles

Mr. Snow goes on to elaborate briefly on each of these points. I have excerpted the portion dealing with patient compliance:

Encourage Compliance and Reduce Errors
It has been independently documented that we could save another $177 billion related to improving compliance and reducing errors.

The fact of the matter is that doctors are well paid to offer their advice, but all too often, patients simply don’t follow the instructions. In the case of diabetes, which currently afflicts 5 percent of the population and whose treatment accounts for 15 percent of all drug spending, only 7 percent of diabetic patients are controlling the three primary factors that could mitigate the effects of their disease and allow them to live a healthy and productive life.

As a result, this noncompliance may lead to blindness, renal failure, amputations, increased hospitalization, and other complications that magnify the suffering and the expense related to diabetes.

The burden is not the patients’ alone. Research shows that it currently takes 17 years from the time a medical protocol is proven effective to the time that it becomes a widely used standard of practice by physician. …³

One cannot help but note that no solutions are offered for the “simple” problem of noncompliance. In contrast, Mr. Snow explicitly assigns responsibility for correcting the other four problems to the federal government and gives some direction on how to go about those tasks. Excerpts follow:

Wire Healthcare

This is an area where government leadership through policy could become a catalyst for an immediate positive response by the private market. It’s happened once before. In the 1970s, hospitals billed Medicare using a paper-based system that in its best day was inefficient and expensive. To stimulate change, the government promulgated  payment rules whereby hospitals would be reimbursed only for claims that were submitted electronically. The private sector stepped in with technology solutions and, virtually overnight, electronic claims clearinghouses sprang up and all hospitals began billing electronically. Problem solved.

Fix Medicare

Culturally, we are conditioned to expect and implement heroic methods, even in cases where treatment is futile, and often resulting in unintended negative and painful consequences for the patients and devastating financial consequences for Medicare. This inherently uncomfortable issue forces us to confront our own mortality and requires strong leadership with candid conversation – it can’t be left to doctors, hospitals, or insurers. Government needs to set policy and establish rational rules for the level of care based on medical science – it’s not the private sector’s role to pass judgment on hope. Protocols based on scientific standards would ease the burden on families, physicians and, yes, patients. This is not withholding or rationing essential healthcare – it’s stepping up to the important and necessary reality so that resources are available to those who can be helped.

Address Litigation and Defensive Medicine

Tort reform eliminates ridiculous litigation, averts the waste related to physicians performing unnecessary tests as they practice “defensive” medicine, and could reduce healthcare costs by another $200 billion a year.

Wellness and Prevention

Here’s where we must have inspired and credible political leadership to fill the current void and raise the collective national consciousness.

Most of us can remember how government-led campaigns changed behavior through vivid imagery that etched into our memories messages with impact:  Smokey Bear’s sad reminder that “Only you can prevent forest fires”; the crash-test dummies Vince and Larry, serving as a testimonial for seatbelt safety by suggesting that “You can learn a lot from a dummy”; …

The private sector can never be expected to drive behavioral change, although we’ve seen employers make valiant attempts at implementing programs to lower healthcare costs – efforts that unfortunately are doomed to fall short. These range from positive reinforcement – discounted health club memberships and bonuses for employees who meet certain fitness targets – to surcharges for employees who smoke. Meantime, HMOs and other insurers have adopted low- or no-cost preventative programs for baby wellness visits, routine check-ups, mammographies, and other procedures that are designed to detect issues early instead of simply providing treatment after the fact.  Such initiatives are only likely to succeed if we make wellness a national imperative, something that requires political leadership and personal responsibility. In the end, each of us must take on greater accountability for making positive choices in our lifestyle.

I do think one could make the argument that a parallel strategy to that suggested for enhancing Wellness and Prevention (i.e., “inspired and credible political leadership to fill the current void and raise the collective national consciousness”)  could also be implemented to enhance compliance. Even so, kind of public service announcements and ad campaigns to which Mr. Snow points have not, to my knowledge, shown more than short term gains when applied to patient compliance (e.g., ad campaigns to encourage participation in mammogram screening). And, more to the point, Mr. Snow did not himself suggest that as a compliance solution.

In closing, Mr. Snow observes that while the federal government, individual patients, clinicians, and hospitals have either directly caused this set of problems or failed to take advantage of opportunities to correct them, there are – thank goodness – some organizations making heroic efforts to save us from ourselves.

After earlier bemoaning the unfair demonizing of HMOs, he approvingly notes that

HMOs and other insurers have adopted low- or no-cost preventative programs for baby wellness visits, routine check-ups, mammographies, and other procedures that are designed to detect issues early instead of simply providing treatment after the fact.

And, he modestly allows that “At Medco, we’re doing our part,” and goes on to list the specific ways in which Medco is indeed doing its part, including, with respect to adherence,

Leveraging the power of information to prevent errors and drive greater compliance, we’re a founding member of one of country’s largest organizations to process electronic prescriptions, creating the equivalent of a superhighway that shuttles information between the prescriber, payer, and pharmacy.

I suppose I should have expected the commercial; still, it hardly lends credibility to the remainder of the talk and it tends to polarize stakeholders in healthcare. As a physician who didn’t automatically follow every idiotic protocol shoved at me⁴ and as a sporadically noncompliant patient, I’m a tad miffed about the tenuous proposition that, in contrast to the sins of my fellow clinicians and patients, HMOs and Medco are “doing their part” to increase the effectiveness and efficiency of healthcare.

Conclusions

The good news is that David Snow wants to put adherence to treatment on the national agenda, albeit as part of a group of healthcare issues that inflate the cost of medical care. I may have mentioned once or twice my conviction that patient compliance should be a national healthcare priority.

And, some of his points are so on target (i.e., I agree with them) that they do seem to be no-brainers. For example, tort reform⁵ seems an area in which it is possible for government to act quickly and decisively to effect a sweeping change that could save huge amounts of money, in this case by eliminating the necessity to practice defensive-expensive medicine.

On the other hand, the idea that the Feds can, as Mr Snow suggests, shift public opinion and clinical practice sufficiently to rescue Medicare by curtaining care for those for whom there is little medical hope⁶ seems a mathematically valid concept formulated in an ivory tower than a politically pragmatic program. Perhaps it’s a negotiating point – or one of those ideas floated as a trial balloon early in a campaign.

Because, however, I am familiar with and have thought much about treatment adherence, I especially object to the notion that there is anything “simple” about noncompliance other than the fact that it is, indeed, a prominent and very expensive problem.

Providing a few of the many available statistics that indicate the extent and cost of noncompliance is hardly a step toward a solution. If that were so, every review of patient compliance and every web site on the subject (including this one) would have eradicated the scourge years ago.

I agree that noncompliance is a problem. The thrust of this speech is that straightforward solutions exist when I’m not convinced an accurate model or conceptualization of the problem exists.

Returning readers may recall an earlier post which dealt with the claim that a prosthetic tooth capable of releasing a controlled dose of medication at regular intervals would, in the words of its press release, “mean, finally, an end to the 2500 year-old patient compliance conundrum.”

Marshall Molar, Medication Modulator

My vision of the tooth hailed as the solution to patient noncompliance

The conclusion to that post included this admonition:

IntelliDrug [the drug-dispensing tooth] seems a legitimate, scientific project that could have an impact in some cases in which medication noncompliance is too dangerous or too costly to risk and the patient is cooperative.

Transforming an expensive potential tactic to improve adherence among a relatively small group of individuals into “an end to the 2500 year-old patient compliance conundrum” makes the project seem a joke and leads to mistrust of any future claims of effectiveness, however reasonable they might otherwise be.

My recommended solution to this problem follows:

Don’t make ridiculous claims for a
compliance-enhancing device or program

David Snow doesn’t claim he can put “an end to the 2500 year-old patient compliance conundrum,”  but in his National Press Club speech he does implicitly claim that noncompliance (or at least the cost of noncompliance) can be simply and significantly improved.  My contention is that this has a remarkable resemblance to a ridiculous claim and that no such simple solution is possible. In any case, none is offered in the National Press Club talk.

If there is a solution, Mr. Snow should spell it out.

Alternatively, I am available for appointment in Mr. Snow’s adminstration to a cabinet level position – say, Grand Exalted and Beloved Vizer of Healthcare Alignment – from which I could promulgate any treatment adherence policy necessary.

If nominated, …


Footnotes

1. Mr Snow’s complete presentation is available at Medco Perspectives↩
2. The absence of an “always,” “never,” “none,”   “without exception,” or similar absolute qualifier in the second point causes one to wonder if Mr. Snow is less confident of its validity.↩
3. Note that patient compliance with treatment recommendations and clinician compliance with medical protocols are conjoined. While both are legitimate concerns, combining them seems more complex and confusing than helpful. Consequently, this post focuses only on patient compliance.↩
4. For the record, not every protocol is idiotic. And, I did follow the idiotic ones that only robbed me of my time and effort but didn’t seem to hurt anyone↩
5. I suspect is is my occupational biases that prompt me to immediately think of tort reform as an example.↩
6. Snow phrases it as “Government needs to set policy and establish rational rules for the level of care based on medical science – it’s not the private sector’s role to pass judgment on hope.”↩

This excerpt from the New York Times article, Los Angeles Stages a Fast Food Intervention,¹ not only describes the latest example of a government taking action to nudge its citizens toward better nutrition but also succinctly summarizes analogous efforts in the recent past:²

I especially admire that wording of the fundamental issue,

I don’t have an answer, but I am convinced that the preceding question, adjusted for other healthcare issues, deserves far more attention on a national scale.

Until a consensus is reached, the determining factor in such decisions defaults, it seems, all too often to the individual or group who has become invested in a cause to the point of promoting – or coercing – that program. For example, consider Arkansas Governor Mike Huckabee’s interest in passing regulations to halt obesity that was triggered by his personal 100 pound weight loss.³ His efforts may be well intentioned and the resulting laws and resolutions may even be good policy, but depending on the enthusiasms, prejudices, and political motivations of powerful leaders hardly makes for an organized approach to the underlying problems.

And, until a means of distinguishing between personal choice and public health concern is reached, dietary regulations, restrictions on tobacco and alcohol use, mandated mental health treatment, directly observed TB therapy, … will continue to be passed and enforced erratically. And, it will continue to be difficult to provide a scientific explanation why, for example, banning trans-fats is viewed as an acceptable exercise of government while no one appears to be pushing obligatory exercise.

Finally, how about this scenario: The newly elected Governor of Illinois, desperate to keep his campaign promises to hold down state healthcare costs stumbles across the AlignMap web page outlining the costs of medication noncompliance. The Governor checks with the Director of Public Health who explains that the state has long passed laws and regulations regarding, for example, treatment of communicable diseases, including mandated, observed treatment for some disorders. The Governor extends this principle in a bill that mandates total treatment compliance for all patients covered by state run or managed programs under penalty of permanent disbarment from the program. By tying the compliance regulation to anticipated improved health for those covered, the Governor cowes the legislature into passing the bill.

Scary, eh?

On the other hand, as long as we continue the hodge-podge sysemn (or lack of system) now in place, we certainly don’t have to worry about those nasty hobgoblins of consistency (whether foolish or not)

Credit Due Department: The hobgoblin pictured above, I find belatedly, is employed, when not illustrating Emersonian expressions, as mascot for The Wychwood Brewery, producers of Hobgoblin Ale.


Footnotes

1. Los Angeles Stages a Fast Food Intervention by Kim Severson, New York Times August 13, 2008↩
2. OK, I’m disappointed that the list didn’t include Chicago’s recently overturned foie gras ban, but otherwise it’s a representative listing↩
3. See Schools, Healthcare, & Dietary Regulations↩

Are Prescription Labels Readable? Clues From The Marketplace

The preceding post, Check The Fine Print For Noncompliance – Part 1, included a couple of studies indicating that, indeed, there are problems deciphering the medication information and instructions printed on prescription pill bottles in a font size technically known – on this blog – as “too damn small.” That these texts are too often smudged, faded, irregular, and disorganized, as well as plastered onto a curvilinear surface, is just a bonus.

In addition, the marketplace also suggests that the difficulty of reading prescription labels is a recognized and widespread problem.

Otherwise, why would products like the Label Enlarger exist?

Label Enlarger

This Label Enlarger and gadgets like it can be purchased from a number of sources for less than $10.

A more sophisticated device, the pill bottle capable of providing audible label information, was originally developed for blind patients but is now marketed to a wider market, including those with age-impaired vision.

The Talking Pill Bottle

Like the Label Enlarger, the Talking Pill Bottle is available in several versions and from several sources.

Specialized labels, warning symbols, and large print labels are available to patients to transform prescription bottle label information into a format that is clearer and less given to misinterpretation.

Pill Bottle Labels

This, of course, begs the question of why patients have to provide this service for themselves.

What Have We Learned?

The proposition that follows is my own idiosyncratic take on the matter, but it is so basic that I am confident I can defend it easily enough.

1. If special aids are required to read medical instructions on pill bottles, those instructions are too hard to read.
2. Instructions that are too hard to read will not be read as often or as accurately as instructions that are easy to read.
3. Instructions that are not read accurately or not read at all will cause unintentional noncompliance.
4. Noncompliance leads to unnecessary fiscal costs and increased morbidity and mortality.

Other Lessons From The Marketplace

The problem with font size is not limited to prescription medicines.

And the problem doesn’t seem to be going away on its own.

Wanna see something scary? The label formats displayed below are currently offered for sale to pharmacies (I have changed only the pharmacy name; otherwise, these are exactly as shown in their presentation on the printing company’s web site).

Prescription label form sold to pharmacies (click image to enlarge)

Prescription label form sold to pharmacies (click image to enlarge)

Imagine these overfilled, pre-faded labels affixed to the curved surface of a pill bottle. Imagine my Aunt Hazel and Uncle Foster, both in their 90s, trying to read that text.

The Solution and Why It’s Important

Before Ross Perot was a third-rate third-party presidential candidate, he was a creative, successful businessman who would, on occasion, observe, “If you see a snake, just kill it – don’t appoint a committee on snakes.”

Well, in this case, the snake is pretty obvious: The US population is aging with the huge boomers cohort approaching the age when visual changes make reading small print more difficult. Many prescription labels contain medication information and instructions written in especially small type. The inability to read a prescription label or, even worse, the inaccurate interpretation of medical instructions because of impaired vision and tiny print leads to unintentional noncompliance and that, my friend, is a snake.

Having identified this specific snake, killing it turns out to be a straightforward matter – at least, hypothetically. How about this? The government simply passes a regulation forbidding the use of a font size below, say, 12 points, on prescription labels.

Some may protest that providing sufficient information in larger print on a small label is a physical impossibility. Solving that design problem seems, however, less complex than, for example, decreasing automobile pollutants and increasing fuel mileage to meet those progressively more demanding governmental mandates.

Further, some pharmacies have already been at work on this problem. I came upon this example of from HealthPartners.com.

Even the “After” label isn’t perfect but it’s certainly a significant improvement.

Another heartening example I serendipitously discovered comes from Pharmacy In Focus, the Ulster Chemists’ Association’s official trade publication:

While Mr Perot might point out that there seems to have been more snake committee-forming in this process than was essential, especially since the nurses were already aware that “patients had raised previous concerns about their medicines,” a better label system was introduced.

I suspect clever designers could come up with a variety of inexpensive, easy to implement solutions, but even an unsophisticated approach, such as a page attached at one corner to the pill bottle that folded out to reveal the information in readable text, would be better than ignoring the fact that a large and growing number of people can’t reliably read the the essential information about their medication from the labels.

Larger fonts on medication labels is not a panacea for all noncompliance, nor is it a sexy issue likely to attract a high ranking celebrity as spokesperson for the cause.

Instead, it’s a simple problem with simple solutions. Mainly, it requires dropping the pretense that the use of small, unreadable print is a necessary annoyance and changing a few printers to eliminate a lot of grief, decrease the course of treatment for many, and save more than a few lives.

Inadequate Font Size As A Cause Of Noncompliance

While young at heart, I am presbyopic of vision. Consequently, I have become aware of the difficulty reading certain types of texts that one routinely encounters on a frequent basis. The day to day category that has proved most troublesome is, by a wide margin, prescription medication labels.

It will surprise no one familiar with my interest in patient compliance that I have been speculating on the likelihood that misunderstanding and frustration engendered by problems reading the instructions jammed onto these labels lead to unintentional noncompliance with medication.

The potential for problems of this sort seems so high, in fact, that I have been surprised how infrequently this issue is listed as a possible cause. Illiteracy and instructions being written in a language other than the patient’s, for example, are much more common in the literature.

This week, I happened onto an exception to this pattern: Barriers to Medication Adherence in Poorly Controlled Diabetes Mellitus by Peggy Soule Odegard, PharmD and Shelly L. Gray, PharmD,¹ identifies challenges to adherence behaviors in 77 patients taking diabetic medication. The pertinent results show that “taking more than two doses of DM medication daily and difficulty reading the DM medication prescription label were significantly associated with higher hemoglobin A1c.”²

The Variability and Quality of Medication Container Labels

Shrank and colleagues published The Variability and Quality of Medication Container Labels³, an assessment of “the format, content, and variability of prescription drug container labels dispensed in the community.”

Excerpted from the abstract:

To illustrate the results of materials printed font sizes, I have provided, in the graphic that follows, lines in Arial typeface in those same font sizes, rounded to the nearest whole number (which is given in parentheses).

Dr. Shrank’s findings are damning, and there is more, but that’s the next post.

Next
Small Print and Noncompliance – Part 2: More Evidence, Solutions, and Why This Issue Is Important (and not just to me)

1. Peggy Soule Odegard, PharmD and Shelly L. Gray, PharmD, Barriers to Medication Adherence in Poorly Controlled Diabetes Mellitus The Diabetes Educator, Vol. 34, No. 4, 692-697. 2008↩
2. Increased A1c is used here as a proxy for poor adherence↩
3. William H. Shrank, MSHS, MD; Jessica Agnew-Blais, et al. The Variability and Quality of Medication Container Labels. Arch Intern Med. 2007;167(16):1760-1765.↩

Contestant in Australian Rules Medication Compliance tournament receives scores

OK, as far as I know, there are no medication compliance tournaments, but, according to Scores help patients keep pace with prescriptions, by Adam Cresswell in The Australian (March 29, 2008),

Patients will be scored on how closely they follow their doctor’s orders in taking their prescribed medications, in a move designed to lift adherence rates and improve outcomes for people with chronic conditions.

The article goes on to point out,

The scores will be expressed as a “mark” out of 100, and will be colour-coded to indicate increasing levels of concern as scores get lower. Pharmacists will be encouraged to help patients whose scores are slipping into the red, by packing multiple medicines into blister packs that make it easier to see which drugs are due to be swallowed at particular times. For more difficult cases, patients may be asked to see their GP for a home medication review, which is designed to simplify a patient’s drug regimen.

However, the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores. (Emphasis mine)

The basic mechanisms of the plan are outlined in these excerpts:

The new scheme will work by comparing the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times.

The MedsIndex scheme has been devised by the Pharmacy Guild, which has already run it as a successful four-month pilot, mainly in Victoria and Queensland.

Pharmacy Guild president Kos Sclavos said research showed patients’ adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take. Among patients taking one pill per day, compliance was about 80 per cent, but fell to 72 per cent for those taking two pills — and to just 64 per cent among patients taking three pills every day. Sclavos said even an 80 per cent compliance raised concerns, as “drug manufacturers don’t confirm their drugs remain efficacious if you are missing one dose in five”. A score of 90 out of 100 suggested room for improvement, but Sclavos said the Guild would ask pharmacists to consider packing medicines in labelled blister packs for patients with scores below 80. “If it’s 75 or lower, they should be seeing their doctor about a home medicine review,” he said. Sclavos said the 200 patients involved in the pilot — which was run merely to ensure the IT systems worked properly — became obsessed by their scores and did not want to come off the scheme. “We’ve had patients coming back saying ‘Please measure me again’ — that’s how enthusiastic patients have been,” Sclavos said. Aaron D’Souza, a pharmacist in Brisbane’s CBD, helped devise and trial the scheme and described its reception by patients as “absolutely fantastic.” “A typical response (to a low score) is ‘Really? I knew I missed some medicines sometimes, but not that much’,” D’Souza said.

Commentary

I am wholeheartedly in favor of compliance with prescribed healthcare measures, including medications, being monitored – in theory. Simply put, noncompliance will not be recognized, let alone be rectified, unless ongoing, routine monitoring is in in place.

Heck, I think it is even possible that compliance monitoring can be accomplished in practice if sufficient care and planning is invested in the effort.

I do, however, have qualms about the proposal written up in The Australian.

First among them is the notion that “the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores.” I’m fully willing to believe that this statement reflects the intent of those responsible for the program.

It does not require much effort, on the other hand, to imagine scenarios in which certain parties would face temptations to change or illicitly abuse this principle.

Not being familiar with systems of Australian healthcare payment or the medico-legal system, I’ll give an example or two based on how the American healthcare system operates.

As healthcare expenses increase, somebody in the government, the insurance industry, or a payer (e.g., an employer) is going to have the epiphany that patients who don’t adhere to prescribed medication dosing cost more than those who do. Clearly it would be not only a cost-saving but also justifiable to reduce the benefits or increase the personal fees paid by this group, members of whom could be identified by an adjustment in the system.

Somewhere else, a lawyer defending a physician accused of malpractice will seek judicial leave to present the patient’s compliance score of 45 as evidence that the treatment failed because of poor adherence rather than the doctor’s error.

And, those justifications may indeed be legitimate. My point is only that there will be pressure to use these scores in ways not currently intended. And once recorded, this compliance rating will be vulnerable to the intrusions of politicians, lawyers, healthcare officials, and others.

My other area of concern is that this important change is predicated on a four month study of 200 patients – “which was run merely to ensure the IT systems worked properly” – and research that “showed patients’ adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take.”

While studies tend to show that decreased compliance is coupled with an increased number of doses per day, that research is not unanimous. Nor are the remedies listed, blister packs of medication and simplified drug regimens, both of which are reasonable responses and which are beneficial to some
patients, panaceas for all nonadherence. And, since most physicians try to minimize dosing for all patients, it is difficult to see how that measure will have a dramatic effect.

The enthusiasm demonstrated by some of those 200 patients notwithstanding, one wonders if the novelty of this program may not wilt after a few months with a corresponding decrease in interest by patients and clinicians.

There are other imperfections as well. The compliance formula, which “compar[es] the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times” has several built-in potential flaws, the most significant of which is perhaps that picking up ones prescriptions at the correct times is not synonymous with taking the medications as prescribed. In the US, it is not unusual for a patient to semi-surreptitiously obtain medications from other countries to reduce costs. Doing so would, I assume, bypass the monitoring system.

Perhaps the point of this jeremiad disguised as a post is that monitoring the compliance of all patients in a practice, an insurance group, or a country offers great opportunity to improve healthcare – but not if it addresses only one area of noncompliance with one set of responses, especially since it puts those those patients at some risk of their compliance records being used to make their healthcare more expensive or less accessible.

And Bloggers On John Edwards

Were one to draw the Venn diagram of patient compliance and presidential campaigns, one would anticipate the intersecting portion would be minuscule if it existed at all. Further restricting that intersection to an overlap patient compliance, presidential campaigns, and public controversy certainly, one would think, doom that result to the ignominy of the null set.

Well, as of 2 September 2007, one would be wrong.

That day, presidential candidate, John Edwards elaborated on his healthcare plan to the folks in Tipton Iowa in a speech described in Edwards Backs Mandatory Preventive Care, the AP news story by Amy Lorentzen:

From the lighting of that fuse to explosions of outrage in the conservative blogosphere required only a few hours.

Consider, for example, a Newsalert post published at 7:52 PM the same day the speech was given:

And, just in case the reader doesn’t pick up on the subtle political connotations of “Comrade Edwards,” the post is headed by the following emblem:

How about a few other examples, just for grins?

From the post with my favorite title, Healthcare Part VIII – Drop that Twinkie or I’ll Shoot! at Angry Bear,

And from John Edwards: “you can’t choose not to go to the doctor for 20 years” posted at Althouse, come these passages:

Daystar51 goes beyond lambasting Edwards for promoting “mandatory preventive health care” to speculating on the possible origins of this notion buried in the candidate’s psyche:

An blog/article, dated September 5, 2007, in US News & World Report wields the British healthy practices incentives plan as a blunt instrument to batter the obligatory preventive care Edwards espouses:

Weird Is Relative, writing in What’s the punishment for noncompliance? Endless jury duty?, implies that the Tipton Iowa speech may be fatal to the Edwards candidacy:

It would be difficult to misunderstand the perspective of Not Larry Sabato, who exclaims in John Edwards on Health Care,

In fairness, not every blogger or commenter was bashing Edwards, but pro-Edwards postings are difficult to find. Plunderchat is a one of those few who straightforwardly support the mandatory preventive care, declaring in John Edwards Looking Good on Health Care that

Commentary

1. It turns out that the complete healthcare plan Edwards supports apparently allows folks to opt out of the program if they wish to manage their own healthcare without government mandates. This discovery disappoints me; when I read about the Tipton speech, I envisioned a post about Edwards declaring Patient Compliance “Mission Accomplished.” Then, I would go on to sardonically observe that “the answer to noncompliance was right in front of us – just issue a presidential proclamation that compliance was obligatory. And so on. If folks have the alternative of leaving the system, the obligatory preventive care lacks the extremity of arrogance that would otherwise render this notion an appealing target.

2. Few bloggers noted that we already have a batch of healthcare mandates on the books, including reporting and quarantine of various infectious diseases, undergoing certain vaccinations, obligating parents to follow doctor’s orders re their sick children, lest they be made wards of the state, and, more recently, restrictions on smoking and intake of some foods.

3. I have to wonder if Mr. Edwards and his advisers have considered the difficulty of monitoring, let alone enforcing patient compliance. While checking attendance records to determine who kept and didn’t keep a doctor’s appointment seems simple enough (although distinguishing between appointments missed because of traffic, scheduling snafus, and family emergencies from those missed through noncompliance may require compliance interrogations abetted by bright lights, good copy-bad cop tactics, and polygraphs), medication compliance, for example, is notoriously difficult to determine, and adherence to diet, exercise, and similar non-medication prescriptions is rarely even attempted. Enforcement methods, short of the Pill Police, are relatively easy to come by; e.g., dropping healthcare coverage for noncompliant patients or tying official authorizations such as driver’s licenses to certificates of healthcare compliance would be simple enough, but even a compliance-pusher like me recognizes that this would be a major shift in the patient-clinician relationship as well as in the role of government in this country.

Ted Nugent On Compliance and Healthcare Policy

Appearing on the Glenn Beck Program on CNN Headline News this morning (the screenshot atop this post is from that show), Ted Nugent (AKA Great Gonzos, The Motor City Madman), the hard rock guitarist-singer with a long list of hits, including “Wang Dang Sweet Poontang,” “Fred Bear,” “Cat Scratch Fever,” “Motor City Madhouse,” “Paralyzed,” “Great White Buffalo,” and “Wango Tango,” offered his take on national healthcare and personal responsibility in a single phrase:

Nugent elaborated, suggesting that, for example, the first step for smokers obtaining healthcare would be to stop smoking.

Ted Nugent Offstage

For the past decade, Nugent has been an outspoken proponent of a politically conservative point of view, emphasizing his anti-drug, anti-alcohol, and pro-hunting beliefs. He supports the Ted Nugent Kamp for Kids (which combines a curriculum of hands-on hunting, conservation, archery and a strong anti-drug message aimed mainly at underprivileged inner-city children), the National Field Archery Association, Mothers Against Drunk Driving, Big Brothers Big Sisters of America, and the National Rifle Association.

Commentary: Celebrities And Their Healthcare Causes

I’ve long lamented, primarily as a rhetorical technique, that no organization has dedicated itself to increasing public awareness of and raising funds for research into medical noncompliance although it is a healthcare problem of epidemic proportions. Similarly, no celebrity has associated himself or herself with or served as the spokesperson for such a movement.

This is hardly a trivial issue. As Arthur L. Caplan points out in Cause célèbre – Why every disease needs a celebrity

Well, noncompliance isn’t an illness, but it surely qualifies as a cause, and it clearly lacks the celebrity spokesperson it needs. Perhaps Ted “The Atrocious Theodocious” Nugent is the man for the job.

While “If you don’t care about your health, how dare you ask for healthcare,” may be a tad oversimplified, most one line slogans dealing with messy political, bureaucratic, and medical issues are likely to suffer from that flaw. And, there is something compelling about the notion of sentient adults taking responsibility for their own health in keeping with their role in a workable healthcare system. If nothing else, one knows where Ted Nugent stands on a given question.

Besides, take a look at the second verse of his best known single, Cat Scratch Fever:

The first time that I got it
I was just ten years old
I got it from some kitty next door
I went and see the Dr. and
He gave me the cure
I think I got it some more

The guy is stricken with a childhood disorder, goes to the doctor, gets cured, and then has a recurrence. No more than a minor rewrite would be required to create an anthem to the need for adherence to treatment.

Heck, if a guy wielding a semi-hollow Gibson Byrdland guitar, a crossbow, and a deer rifle recommended I follow my doctor’s orders, I’d pay attention.

Update: Ted Nugent Redux

Source:
Directly Observed Highly Active Antiretroviral Therapy for HIV-Infected Children in Cambodia Patricia Myung, David Pugatch, Mark F. Brady, Phok Many, Joseph I. Harwell, Mark Lurie, John Tucker Am J Public Health. 2007 Jun;97(6):974-7. Epub 2007 Apr 26.

Directly Observed Therapy

While Directly Observed Therapy is typically associated with the treatment of tuberculosis and is often viewed as expensive and draconian, this study of suggests that those stereotypes may be inaccurate and may unnecessarily restrict its implementation.

Abstract

Commentary

While the vital information is contained in the abstract, it may be helpful to think of the statistics for these children in these terms:

• T helper cells tripled
• Children gained weight
• Drug toxicities were rare and easily managed
• The annual cost per child broke down to $400 for medications; $60 to pay the professionals who administered the drugs

This preliminary study does not prove the value of the program. As the authors point out, a randomized, controlled trial comparing Directly Observed Therapy with standard care is necessary, as is a cost-benefit analysis

The study does, however, lend support to the notion that Directly Observed Therapy could prevent some cases of drug resistance and reduce the number of treatment failures and the number of cases requiring a shift to less efficient alternative therapies – an extraordinarily encouraging prospect.

Impact Of Asthma Screenings Blocked by Nonadherence

An American Thoracic Society workshop reports that while population screenings make sense in theory, the benefits are unproven for children with asthma.






According to Lynn Gerald, Ph.D., M.S.P.H., workshop co-chair,

Commentary

I’ve focused on this concern that noncompliance blocks implementation of clinical action when screenings detect possible pathology because it spotlights a hidden cost of nonadherence.

It is an often overlooked albeit obvious fact that the time, human resources, and money expended to discover a case of untreated asthma – or any other disease – are lost unless the that patient pursues clinical confirmation of the disorder and any necessary treatment.

The reality of noncompliance is crystallized in Dr. Gerald’s recommendation that the limited resources of public health should be used for children with active symptomatology rather than screenings.

Source:News-Medical.Net

The Annual Report on Suicide Prevention

Source: National Suicide Prevention Strategy For England – 2006 Report

In a generally optimistic report by the National Institute for Mental Health in England on the effort to reduce suicide in that nation by 20 per cent by 2010, there is a somber note about the role of noncompliance in suicide:


The Avoidable deaths report published last year estimated that 56 mental health patients discharged from hospital die every year following non-compliance with medication or loss of contact with services. Supervised Community Treatment, a measure to improve clinical risk management that the Government is introducing in its Mental Health Bill, has the potential to help prevent those deaths. Having a severe mental illness is a known risk factor of suicide and a significant number of suicides occur during in-patient care or shortly after discharge. Avoidable deaths showed around 200 suicides a year – or 14 per cent of all suicides – follow non-compliance with treatment. Better compliance with treatment and closer supervision were highlighted by clinicians as the main ways of reducing suicide risk.

Commentary

I’ve selected this as the focus of today’s post to serve as a dramatic reminder of the importance of compliance enhancement efforts.