AlignMap

According to the Wall Street Journal article, UnitedHealth To Give Discounts For Adhering To Prescriptions,¹ UnitedHealth will offer

$20 discounts off monthly co-pays for members who refill certain prescriptions within about 30 days after the last prescription runs out – essentially rewarding patients for adhering to treatment plans,

The pilot program applies to only certain medications for asthma and depression and cannot be used for the initial prescription.

While the article speculates that program is triggered by “the weak economy has caused consumers to put off filling prescriptions or switch to cheaper generics,” the decrease or elimination of co-pays in return for high adherence made sense long before the current fiscal crisis erupted and is, in fact, a recommendation I have made for years.

Aligning the mutual interests of the patient, the payer, the pharmaceutical companies, and the clinicians is the key to enhanced compliance rates. Using a discount on medication costs as a financial incentive to effect this alignment is a great start.

I’ll be eager to see the results.

1. Peter Loftus, UnitedHealth To Give Discounts For Adhering To Prescriptions, Wall Street Journal. August 27, 2009↩

The Presentation

Compliance With Capecitabine Therapy Very High Among Swiss Cancer Patients: Presented at ASCO-GI ¹  summarizes a presentation of study results² made on January 17 at the American Society of Clinical Oncology’s 6th Gastrointestinal Cancers Symposium (ASCO-GI), cosponsored by the American Gastrointestinal Association Foundation, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

The findings are encouraging – but there is a caveat. Pertinent excerpts follow:

Patients who were prescribed oral capecitabine for treatment of breast or gastrointestinal (GI) cancer appear to be highly compliant in taking the oral medication, according to a study conducted in Switzerland.

… For the study, patients receiving capecitabine either as monotherapy or in combination with other chemotherapeutic agents recorded their daily capecitabine intake and any adverse effects on a diary. After completion of therapy for a maximum of 8 cycles, the data were transferred to a questionnaire in which the reasons for discontinuation were also collected.

…  Of the overall cohort, 91% took capecitabine as prescribed for the entire course of treatment. Reasons for interrupting therapy included forgetting to take treatment (56%), adverse effects (25%), and misunderstanding instructions (19%).

… Dr. Winterhalder said that the 16 patients who did make compliance errors included 9 instances in which the patients forgot to take the medicine. He said that despite the impressive compliance figures seen in the study, there are ways to improve the compliance further.

“Patient management systems such as patient diaries may further improve compliance and adherence with treatment,” he said during his poster presentation. “Compliance may be further improved by educating patients about how to recognise and manage treatment toxicities.”

Commentary Or What’s Wrong With This Premise?

Maybe I’m missing something, but I think this study declares that using a medication diary enhances compliance – based on compliance rates measured by the patients’ entries in a medication diary.

And, as far as I can determine, there is no control group for comparison.

Either the summary of this study is incomplete or the quality of the evidence must be considered suspect.

1. Compliance With Capecitabine Therapy Very High Among Swiss Cancer Patients: Presented at ASCO-GI By Ed Susman. Doctor’s Guide. January 19, 2009↩
2. Presentation title: Compliance With Capecitabine: Findings From a Prospective Cohort Analysis. Abstract 420↩

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.↩

Alignmap In Cites Goes Video

A plethora of compliance-pertinent videos are now available online.  I’ve begun posting some of these flicks on this blog’s tumblelog counterpart, AlignMap In Cites.

Videos selected for the AlignMap In Cites Patient Compliance Theater meet one or more of the following inclusion criteria:

1. Presentations of patient compliance research that briefly and clearly present highlights of findings
2. Tips targeted to patients or clinicians that may improve adherence
3. Demonstrations of and infomercials about devices that ostensibly enhance adherence – or at least amuse me.
4. Testimonials from patients and pontifications from clinicians that provide useful information, reveal pertinent attitudes that could have a positive or negative impact on patient compliance, or surpass a difficult to articulate but easy to recognize threshold of – oh, let’s call it eccentricity.
5. Anything else that strikes my fancy.

The following videos in the list that follows have been posted to AlignMap In Cites in the past 24 hours. The links below go directly and only to the post indicated. These posts can also be accessed en masse by going to the AlignMap In Cites home page and scrolling back through the chronologically listed posts.

Now Showing
The AlignMap In Cites Patient Compliance Theater

Infomercial about the e-Pill Cube Pill Timer and Pillbox My first impression, based on the rather complex explanation of its operation, is that the device might be better positioned as a test of cognition rather than a convenient medication dose reminder.

Tips to enhance adherence to medication regimen Nothing unusual but potentially helpful ideas about remembering to take ones medications. Targeted to patients.

Medication compliance survey: Moderately self-serving presentation and recommendations from The National Community Pharmacists Association.

Infomercial about the e-Pill MD2 dispenser

Psych Medication Non-compliance: A patient’s own story of medication noncompliance.

Adherence to ARVs — Part 1 and Adherence to ARVs — Part 2: Poignant patient educational video from Baragwanath Hospital, Soweto, South Africa  promoting adherence to anti-HIV ARV drugs.

How to Improve Patient Compliance in Dyslipidemia Diagnosis: Medscape produced video report on study affirming value of electronic patient reminders.

Importance of Patient Compliance in Healing: Presented by a clinician and targeted to patients. Excerpt: So, do what the doctor tells you. Try to be compliant. Try to get better. And if you need our help, we’re Baker Chiropractic. We put patients first.

Source: Great(er) Expectations John Lauriello, M.D., Am J Psychiatry, 164:377-379, March 2007

Expectations For This Post

The following excerpts are from an editorial written by John Lauriello, M.D. in the March 2007 American Journal of Psychiatry. While I have selected those portions that are most pertinent to the goals of treatment for schizophrenia and patient compliance, the entire essay is accessible, well written, and insightful – it is, all in all, a worthy read.

I have little to add to Dr Lauriello’s thoughts on these issues. Consequently, I offer these excerpts with no further elaboration.

At least for now.

“Take nothing on its looks; take everything on evidence. There’s no better rule.”

—Charles Dickens, Great Expectations

Although the successful treatment of schizophrenia is most often measured by symptom reduction and relapse prevention, the quality of everyday life and the ability to function independently are equally important to patients and families. To date, antipsychotic medications have not yet been shown to directly impact quality of life, particularly social and vocational functioning, to the degree hoped. Clinicians are challenged to prescribe medications that not only reduce symptoms but somehow also enable patients to become better functioning members of society. Presumably, as positive and negative symptoms of schizophrenia subside, subjective quality of life and objective measures of psychosocial functioning might be expected to improve. In this issue, two interesting and somewhat complementary articles focus on quality of life and competitive work performance of patients with schizophrenia. Both examine the promises and the limits of our current means of improving psychosocial functioning in these patients.

In the first article, Marvin Swartz and colleagues expand on findings of NIMH’s Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, presenting results derived from Quality of Life Scale ratings. The analysis concentrated on those patients who continued their assigned medications for at least 12 months (a third of the overall sample). …

Contrary to predictions, researchers found no evidence to favor any of the second-generation antipsychotic medications with regard to improving Quality of Life Scale scores. As expected, patients’ baseline quality of life ratings showed impairment, especially in the vocational domain. After 12 months, only modest improvements were associated with any of the randomly assigned medications, with no differences found among any of the individual medications. ……

The Swartz et al. study confirms that improving quality of life does not come prepackaged in a medication bottle. As these authors state, “More intensive psychosocial rehabilitative services, including cognitive rehabilitation, may be needed to affect more substantial gains in functioning…. For patients unable to work, with limited access to vocational and rehabilitative services, even optimal medication may not be reasonably expected to improve … community functioning.”

This statement provides a perfect segue to the second paper, in which Susan McGurk and colleagues examine the effect of cognitive training on supported employment services at two community health centers … . In this study a small number of patients with schizophrenia were randomly assigned to receive supported employment alone or supported employment with cognitive training with the goal of increasing competitive work. Competitive work, the gold standard of vocational functioning, means competing in the marketplace for real work and real wages. Rates of competitive employment for patients with schizophrenia range from 10%–20%. The cognitive training administered by trained cognitive specialists, the “Thinking Skills for Work Program,” consisted of an extensive analysis of the cognitive work difficulties, computer-based training, planning sessions, and ongoing on-the-job assistance. Both study sites were also rated on the fidelity of their adherence to the supported employment model utilizing a standardized scale.

… The good news was that those in the combined program (supported employment with cognitive training) were more likely to work, held more jobs, worked for a longer time, and made more money. An additional benefit to those randomly assigned to the combined strategy was an improvement in depressive and autistic preoccupations as measured by the Positive and Negative Syndrome Scale (PANSS) at 3 months. In other words, those who worked more were less depressed and less internally isolated. The not-so-good news was that despite these noteworthy efforts, the mean number of weeks worked over the 2-year follow-up was only 27 weeks, roughly 6 months. Working for a quarter of the evaluation period (significantly better than the 5 weeks worked by those in the supported employment alone group) is laudable but still falls far short of independent self-sufficiency. One further note: although both study sites embraced the concepts of supported employment and cognitive training, one site scored lower on “fidelity” to the supported employment model. In turn, patients at that site performed worse than those at the more adherent site.

So what do these two studies together tell us about the psychosocial functioning of patients with schizophrenia? The Swartz et al. study coupled with the results of other CATIE publications demonstrate that medication adherence is challenging and that no one medication seems to be a clear winner when balancing all factors. But medication adherence is the stable platform that reduces exacerbations and rehospitalization. And this stability is necessary before any sustained psychosocial treatment can be applied. Supported employment with cognitive training appears to be one good next step for stable patients. The McGurk et al. study shows that adding cognitive training significantly improved time at work and reduced depressive preoccupations and isolating thinking. However, as with medication treatment, functional gains were limited and clearly dependent on adherence to the treatment. (emphasis added)

Zuri – Medication Reminder and Compliance Recorder

An article in today’s (August 19, 2008) Wall Street Journal, Tools Help Patients Interface With Doctors By Victoria E. Knight, opens with this excerpt, a success story about the Zuri, an electronic medication reminder and compliance recorder still in beta:

The article goes on to extol the virtues and promise of

In oversimplified terms, both Intel’s Health Guide and Microsoft’s HealthVault store, organize, analyze, and distribute a variety of healthcare data gathered from a wide array of sources.

The Evolution Of The User Interface In Healthcare Technology

On reading the WSJ article, my first response was – well, OK, my first response was “Where do you sign up to have the WSJ open an article with five paragraphs of a success story featuring your business’s product?”

My very next thought, however, was that the user interface of these gizmos is likely to evolve as have other technological marvels, such as the automobile and the computer. The extent to which new tools are put into use by the population, however obvious their value, is limited by the difficulty, expense, and unfamiliarity of that tool.

In other words, what are the chances my Aunt Hazel from Broken Arrow, Oklahoma will find the Zumi a must-have healthcare device as long as it is a $200 pseudo-iPod with a $40 per month fee that technicians have to set up?

Of course, Aunt Hazel wasn’t interested in driving a car until automatic transmissions became widely available and her best friend began driving her own Ford.

I suspect the the responses by patients to the instruments like the Zuri fall into one of three broad classes:

1. Patients like Ms Shah who have the right problem, the right circumstance, and the right perspective to embrace and use the tool as is, right off the shelf.²
2. Patients who mistrust and are adamantly resistant to (choose one or more) electronics, doctors, healthcare recommendations, sharing personal information, …
3. Patients, like Aunt Hazel, who won’t use a medical tool like the Zuri until it is easier, cheaper, more well known, …

Group #1 is on board already. Group #2 is unlikely to buy into the process regardless of logic, persuasion, or receiving lottery tickets as incentives. But Aunt Hazel’s group? That’s where the action is. Make those electronic whizbangs less intimidating, less difficult, and less expensive.

Then, ask Aunt Hazel to try it out.

Footnotes

1. The quotation marks enclosing self-care are the work of the WSJ folks, and, no, I don’t know the rationale for this punctuation practice.↩
2. It isn’t clear that if Ms Shah was charged for the Zuri’s use or if it is offered free while still in beta. An out of pocket cost of $240 to enhance compliance of a 3 week course of treatment might have rendered the Zuri less attractive to Ms Shah↩

Source: One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic, Andreas Storm, Stig Ejdrup Andersen, Eva Benfeldt, Jørgen Serup Journal of the American Academy of Dermatology. 59:1, 27-33

The Study

Using the Danish National Electronic Pharmacy Register, which contains all prescriptions issued within the past 2 years, Storm et al studied 322 people, who were prescribed a total of 390 medications.

At four weeks after the medications were prescribed, 30.7 percent of the subjects had not filled the prescriptions while most people who did obtain the medication did so within the first week after receiving the prescription.

Older patients and those who were treated by specialists were among those more likely to have filled their prescriptions while those with chronic disorders were less likely (when compared to patients treated for acute diseases).

Commentary

There are no surprises; these findings are in line with those of earlier, similar studies.

These confirmatory results do, however, have practical implications for treatment. For example, given how common it is for large numbers of patients to never begin a prescribed medication, clinicians must always give nonadherence a high priority on the differential diagnosis of any treatment failure.

That importance of that reactive step is clear. In addition, I would also suggest a less obvious, proactive step.

One of the few things worse than one-third of all patients not filling their prescriptions is the clinician not knowing that one-third of his or her patients did not get their prescriptions filled. I believe a solid case can be made for working with patients in such a way a to encourage them to disclose that, in this case, they did not obtain the medications prescribed rather than hide it from their healthcare professional. My take on this matter is part of the post in which I originally suggested this tactic:

How To (Correctly) Not Take Medications As Prescribed

The Medication Blister Pack Lottery Ticket¹

Aetna-sponsored Clinical Trial Of Lottery As Incentive For Coumadin Therapy Adherence

This story has been kicking around for over a month, evoking a variety of responses from the lay press, healthcare-oriented blogs, bioethicists, and the occasional patient compliance junkie.

Apparently, I can’t resist getting in on the action.

The Clinical Trial

The Aetna Foundation is funding a University of Pennsylvania clinical trial to determine if chances to win a daily low-stakes lottery effectively promotes adherence among coumadin patients.

According to the Hartford Courant,²

Patients who do not report taking their medications are also notified if they would have won the cash but were ineligible because they did not follow their medication regimen.

The Responses

Many reports provided a straightforward account of the trial, but others have played up the cash incentive and the lottery/gambling angles. An example of the those focused on the money, by my subjective evaluation, is Bribe Me, Doc.³ The title notwithstanding, the reporting is reasonably balanced (several articles and, especially, posts attacked the use of cash incentives more aggressively on moral grounds), but the questioning of the compliance enhancement strategy being studied is reflected in these excerpts:⁴

Commentary

A full discussion of compliance-enhancing incentives is beyond the scope of this post and has been addressed in this blog previously. Instead, I’ll offer some comments on pertinent issues that were not been covered in the 20 or so articles about this study I’ve read.

Several healthcare professionals raised similar points to that made by Richard Ashcroft, i.e., the use of cash incentives diminishes the personal responsibility of the patient.

My first and almost automatic response is that adherence to healthcare is not exclusively an individual’s personal issue. Noncompliance increases healthcare costs for all of us, one way or another, and unnecessarily uses the resources to the loss of all those individuals (that would be you and me) who may require healthcare services. Productivity is decreased when health problems of workers are not properly treated. Noncompliance may lead to lack of treatment or inadequate treatment of communicable diseases that consequently puts others at risk for the same disorder in the short term and for even more virulent or more difficult to treat forms of the disorder if inadequate treatment leads to the formation of resistant strains of the disease. If the consensus is that forced treatment or quarantine is necessary in some cases to protect the public, then it is difficult to condemn a less rigorous tactic if that is sufficient for public protection.⁵

On consideration, I’m not fully convinced of the premise that cash incentives necessarily destroy personal responsibility. To make that argument, it seems to me, one would also have to protest against penalties for noncompliance on the same grounds. E.g., fines for traffic violations are unethical because they diminish personal responsibility. Individuals should stop at red lights and adhere to speed limits because of internal motivators rather than external coercion. Of course, my reaction may be skewed by too many years on the parent-child battle line, efforts that long ago caused me to abandon the second half of the proposition “you [my son] must do the right thing and do it for the right reason.” A more pragmatic attitude toward motivation prevails on the home front these days.

I do enthusiastically agree with Richard Ashcroft’s observation that “in the health field that people aren’t always rational in their decision-making.” In fact, if I ever ascend to the role of Universal Emperor Of Healthcare, my first decree shall be to require all healthcare theorists to write that line 1,000 times on the chalkboard. Today, however, I will only add that there are few, if any, fields of personal functioning (e.g., caring for ones health, managing money, finding a career, falling in love, … ) in which decision-making is rational.

I find almost no discussion of the impact the lottery aspect of the incentive might have on the patient-doctor relationship. Is there, for example, any risk that the patient who forgot to take his pill for the first time last night, might, on receiving word that he would have won last night’s jackpot had he been compliant, be miffed at the doctor, who will inevitably be seen as representing the incentive system? Or if there is a snafu,⁶ are the folks whose legitimate winnings dissipate in a computer error going to blame the clinician? Who will be responsible for explaining this to the patient, re-establishing a working relationship, taking the time to fix the errors, etc?⁷

As long as incentives are being passed out to patients, how about providing parallel incentives to the responsible clinicians and any family or friends who take the role of care provider on an everyday basis so that all those involved in treatment are headed toward the same goal? Gee, what’s the word for that? Oh yeah, that would align the stakeholders.

In any case, by using the electronic monitoring device described, the researchers are actually testing if chances to win a daily low-stakes lottery effectively promotes the pressing of a “Yes, I took my medicine” button among coumadin patients. My hunch is that it will.

I will also repeat the recommendation I made in a previous post

1. Consider the Medication Blister Pack Lottery Ticket AlignMap’s contribution to pharmaceutical packaging↩
2. The Courant story, the primary source of this information for most of the blogged and printed reports, is no longer available via live link. I accessed it through the Google cache at Courant Page 1 and Courant Page 2.↩
3. Misty Harris , Bribe Me, Doc, Canwest News Service. July 01, 2008↩
4. It should be noted that those involved in the Aetna funded University of Pennsylvania study also recognize the ethical issues involved. Their stance holds that if the incentives prove successful in enhancing compliance, the moral and ethical points should be debated after the study is complete.↩
5. Some of the argument I make in this paragraph may be implicitly included under “public health” references made in some articles.↩
6. Oh my, I just flashed on the concept of the healthcare system as I know it taking on the management of a lottery system. What could possibly go wrong?↩
7. For what it’s worth, classic contingency management, a behavioral system with much supportive evidence, would provide each patient with $X in his account on day one and remove a fraction of that every day the patient was noncompliant. Regardless of how effective the scheme might prove in improving compliance, I cannot imagine approaching, say, my borderline patients, at every session to announce that their compliance last week had cost them $29. It would not be a pretty sight.↩

Source: Effects of Depression and Selective Serotonin Reuptake Inhibitor use on Adherence to Highly Active Antiretroviral Therapy and on Clinical Outcomes in HIV-infected Patients Michael Alan Horberg, MD, MAS, FACP; Michael Jonah Silverberg, PhD, MPH; et al. J Acquir Immune Defic Syndr. 2008;47(3):384-390.

The Study

This large (3359 patients) retrospective cohort study was designed to “determine the impact of depression on highly active antiretroviral therapy (HAART) adherence and clinical measures and investigate if selective serotonin reuptake inhibitors (SSRIs) improve these measures.”

Design & Results: (Excerpted)

Commentary

Conclusions:
Depression significantly worsens HAART adherence and HIV viral control. Compliant SSRI use is associated with improved HIV adherence and laboratory parameters.

The conclusions¹ drawn by the authors are straightforward, immediately useful to clinicians, and heartening, an all too unusual set of qualities for a clinical study dealing with patient compliance.

Moreover, while the researchers are appropriately careful to limit these conclusions to those being treated for HIV, a disorder frequently accompanied by depression (a prevalence of greater than 30% in some studies in HIV-infected patients), it is certainly possible that depression and SSRI treatment have analogous effects on adherence to the treatments of other disorders. There is little evidence that depression associated with HIV is a different pathology than free-standing depression or depression associated with other diseases or that patterns of compliance and noncompliance with HAART are fundamentally different from adherence and nonadherence to other disorders.

Because adherence is a life or death matter for HIV patients and because the HAART regimen has been an especially rigorous and difficult protocol for patients to follow, clinicians and researchers working with this disorder have been long been concerned about compliance issues and their efforts have resulted in advances in clinical practice. My subjective impression is that the results of these labors have sometimes remained isolated to those working in this field. If so, perhaps it’s time for an organized effort to assure that patient compliance research is distributed across diagnostic and professional boundaries.

Footnotes

1. In more expanded form, the conclusions read … depression negatively affects adherence and clinical parameters among HIV-infected patients taking HAART, including the odds of achieving at least 90% adherence over 12 months and achieving an HIV RNA level <500 copies/mL by 12 months. We found that improved SSRI adherence is associated with improved HAART adherence, leading to improved HIV RNA levels and CD4 T-cell counts approaching or even exceeding results seen with nondepressed HIV-infected patients. SSRI use is likely beneficial in depressed HIV-infected patients if they can be compliant with their SSRI medication.↩

Patient Compliance Enhancement System Wins Columbia Business School Outrageous Business Plan Competition

According to With This Plan, Everyone Wins, a system for packaging a patient’s medication by dosing schedule (e.g., instead of dispensing a month’s supply of the patient’s five different medications each in its own bottle, the pharmacist would repackage the medications into that patient’s prescribed doses – 1 tablet each of medications A, B, and C on awakening, 2 tablets of medication D with breakfast, lunch, and dinner, and 1 tablet of medication E at bedtime) was adjudged the best entry in the Ninth Annual Outrageous Business Plan Competition,¹ an honor accompanied by a $4,575 award.

The referenced post goes on to note that

Prescription noncompliance costs billions in healthcare dollars and thousands of lives each year. Geoffrey Reed ’09 saw the problem first-hand last summer when his grandfather mixed up his medications and ended up in the hospital. Now Reed and Eric Chesin ’09 have come up with a way for pharmacies to organize medications that increases the chance of compliance. The idea, Bluepak, recently won CBS’s 2008 Outrageous Business Plan Competition; their elevator pitch is below.

Commentary

As was the case with the MIT Yunus Challenge award,² it is heartening to find patient compliance recognized as a problem worthy of the efforts of student competitors at these elite universities.

And, I think the idea is reasonable and and worthy of a trial. I am, however less certain a medication repackaging scheme warrants the “outrageous” tag.³ Hospitals have used this strategy for years, and some pharmacists have long provided the service for some patients. Heck, I’ve suggested this idea myself without one person in the audience retorting “That’s outrageous.”

More to the point, Bluepak appears similar to onePAC, a service featured recently on this blog,⁴ and the questions I asked about onePac (see previous posts) would apply to Bluepak. ⁵

Happily, being outrageous or even original, is not a prerequisite for a clinical valid, commercially viable program to enhance medication compliance. Those of us with vested interests in treatment adherence will be interested to see how Bluepak, onePAC, and similar ideas fare in the real world.

Footnotes

1. From the Columbia Business School press release: To enter the competition, teams comprised of at least one Columbia MBA or EMBA student, submit an executive summary of their business plan and tape a two-minute elevator pitch. A panel of judges, comprised of executives from venture capital firms as well as several entrepreneurs who developed their own successful ventures while students at Columbia Business School, evaluated the pitches and narrowed the field down to five teams. In the final round of competition, each team delivered a formal 10 minute presentation to the judges and the audience. Based on these presentations, the judges decided how much money they would award each venture.↩
2. See Yunus Challenge Award Focuses On Patient Compliance and CellCentives Reconsidered – Still Not DOTS↩
3. According to the previously noted Columbia Business School press release, “The competition, organized by the Columbia Entrepreneurs Organization and the Entrepreneurship Program, encourages students to develop and present creative entrepreneurial ideas that are sufficiently ambitious in scope and scale to be considered “outrageous.”↩
4. See Individualized Dose Packets Simplify Medication Adherence, Answers To Questions About onePAC, and More Answers To Questions About onePAC↩
5. I have, in fact, emailed those queries to the Columbia Business School.↩

AlignMap readers will, I suspect, find little new in “Doctors Without Orders,” an article about medication noncompliance by Jessica Wagner at Slate.com.

In fact, the material may seem very familiar to those readers of AlignMap posts because much of the article is indeed based on an interview with me and data drawn from the AlignMap site.

Even the material dredged from these archives, however, seems altogether more impressive when Ms Wagner writes it under the Slate aegis.

Jessica Wagner’s Slate.com essay on medication noncompliance can be found at

One Packet Manages Multiple Medications Per Dose

Graphic adapted from myonePAC web site

In a press release issued yesterday, Pharmacists Customize Prescriptions By Patient, Day and Dose with onePAC(TM) Packaging, Parata, which offers automated pharmacy services, announced the availability of onePac, a system allowing local pharmacies to provide all of a specific patient’s oral and topical medications packaged by dose.

According to the release,

One of the potential benefits of the pharmacy generated single dose packs is the elimination of many of the errors some patients make in distributing their medications in simple SMTWTFS pillboxes, reducing unintentional noncompliance.

Similar systems have been in place for some time at inpatient facilities and have been offered by some pharmacies to some patients. To my knowledge, this is the first widely available packaging system of this sort.

Unknown Issues Re onePAC

Because my information at this time is limited to a press release and whatever I could glean online, several important questions are unanswered.

What, for example, is the incremental cost and is it anticipated that the local pharmacy will absorb it or will it be passed along to consumers? Will third party payers cover this benefit?

On the technical side, can the onePAC system handle prescriptions calling for non-daily dosing, such as risedronate (Actonel) which is taken once a week?

If all of a patient’s prescriptions are processed and sold in 30-90 day bundles, how are changes in that patient’s medication regimen handled, both logistically and financially?

Is there research demonstrating that this type of packaging increases compliance?

I have emailed Parata with these questions and will share their responses here.

Update: Two of these questions are answer at Answers To Questions About onePAC. The remaining questions should have responses, I’m told, in the new day or two.

The Potential Utility of Individualized Dose Packets

If the system is practical (e.g., affordable, simple to use), this would be a potentially signficant compliance enhancement for anyone taking more than a single medication daily. Of course, my evaluation may be skewed by the fact that I have previously recommended such a program.

There is a significant gulf between good ideas and research-proven methodologies. And, as software manufacturers have repeatedly discovered, some flaws in any system are not apparent until that system is subjected to widespread implementation by actual end-users.

Nonetheless, onePAK does strike as a dandy idea and one that could benefit folks like my mother – and me.