Speaker 1 (00:04):
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Speaker 3 (01:02):
Hey there, welcome to the, the pharmacy podcast nation. Um, it's called today's beyond the vial transform your pharmacy services. This is about medication adherence. Um, 20 to 30% of new prescriptions never get filled. And 50% of Medicaid, uh, for chronic disease are not taken as prescribed. And non-adherence represents, they're saying between 150 to 300 billion, um, as an impact to our, uh, national healthcare system. And worse of all, we have over 120 to 150,000 people die annually from not taking their medication as prescribed by a physician. This is a serious issue, and I couldn't have thought of a, of a better opportunity during this pandemic to really drill down into medication adherence and what that means for community farm and ultimately what that means for your communities and your patients. And what we wanna do today is really feature some expertise. You know, me in the pharmacy podcast, it's all about how pharmacists are leading our healthcare system.
Speaker 3 (02:18):
And I really take a lot of pride in finding some of the most brilliant minds in C. And one of those people are a, are a feature speaker for us today. And the other two are pharmacy owners, which is absolutely amazing to have them here. I'd like to introduce, uh, Doug Nierman. He, um, is a pharmacy owner, uh, Steve Mackey. Who's also a pharmacy owner and Dr. Andrew Peterson, who is a professor, um, with us sciences as well as a pharm D and, um, and professor of health policy. I wanna welcome you today to, um, our webinar beyond the vial transform your pharmacy services. Welcome gentlemen.
Speaker 4 (03:02):
Good to be here. Thank you, John
Speaker 3 (03:04):
Featured speaker today is Dr. Andrew Peterson, a pharm D uh, PhD, um, excited to have found you on LinkedIn. Absolutely love LinkedIn, and how it's kind of brought us together more importantly now during this pandemic than ever. And, um, you have 20 years of research experience in pharmacy management in medication compliance, and you've written a lot of really interesting studies in papers. One of the ones which I'm gonna reference today talks about something called initial medication adherence, which was a new concept to me until I really started digging into your research, which was absolutely fascinating. And it really is, is what starts the entire medication non-ad issue, um, adherence issue, right from the beginning. And it's that, um, it's that way that we're getting our patients to really understand through education, the impact is sticking to their medication has. So, first of all, I wanna open this up and do introductions. I wanna, I want Doug you to introduce yourself first, then we're going to talk with Steve, and then we're gonna open this up to Andrew to setting the stage for today about medication adherence. So with that, I would like to introduce Doug.
Speaker 5 (04:21):
Hi, my name is Doug Neman. I own, uh, two different pharmacies. One is a telepharmacy, uh, I've been going at it for seven years as an ownership and been outta school now for 11 years or so and glad to be on here. Great,
Speaker 3 (04:38):
Speaker 4 (04:40):
Hi, I'm I'm Steve Mackey owner at Spoo mountain pharmacy in Jane May. I've been a pharmacist for 25 years and I've owned and operated Spoo mountain pharmacy for 11 years, starting in 2009. Um, and excited about giving, given my feedback and, and what, um, compliance medications done for us and compliance in general for our patients.
Speaker 3 (05:03):
Dr. Peterson. Welcome. Thank
Speaker 6 (05:05):
You very much. Thanks having me Todd, appreciate it.
Speaker 3 (05:07):
So I wanna say thank you to RX a for hosting this, uh, webinar. They have been a, um, a vital partner of our publication for over five years and have really helped to lead the way in medication here in technology and medication adherence packaging. So I wanna give a shout out to them for, uh, for sponsoring this event. And if you're listening in as a podcast with this will be distributed through our network as a podcast, you will find all of the information today in our show notes, as well as, um, access through LinkedIn to our guests. So please link up with these, um, with our participants and, um, and Dr. Peterson. So with that, I wanna get started. I wanna, uh, start off and kick this off with, um, with an introduction from, uh, Dr. Peterson, you wrote an extensive paper about initial medication adherence, and I want you to give our audience and our listeners, uh, just an overview of what initial medication adherence actually is.
Speaker 6 (06:11):
Sure. Thanks very much, Todd. I appreciate it. Um, so initial medication adherence has been near and dear to my, my heart for, uh, at least 15 years or so. It was actually part of my dissertation for my PhD. One of the things that I noticed a lot, uh, particularly as electronic prescribing came out was that there were more and more prescriptions that were being what we call abandoned at pharmacies because a, an electronic prescription was being and sent from the physician's office to the pharmacy, but it was never being picked up. And as you had said earlier in your introduction is that upwards about 30% of prescriptions are never even picked up, uh, or, uh, brought or used by the patient for that very first time. And that's what we call initial medication adherence. We've gotta get the, to be able to retrieve that medication from the pharmacy before we, and before they even begin to take it.
Speaker 6 (07:04):
Uh, and then we went, we wind up measuring adherence after that, but that whole idea that people aren't taking it is a problem way back when we would see people who were, who would leave a physician's off with a four or five prescription women may put 'em in her pocketbook and get to the pharmacy and pull out four of them because she didn't remember how many she had and, and got four out of those five filled that other one was in her pocketbook a week or two later, she realized it. And she said, ah, I don't feel so bad. I'm not gonna get it filled anyway. Or sometimes patients go to the pharmacy, uh, and they, it was sent to air maybe electronically. They go to the pharmacy and all of a sudden somebody says to them, the pharmacy says them, well, that's not a formulary item for you, and it's gonna cost you $150, or, uh, that's a, you know, a tier two and it's gonna cost you $25.
Speaker 6 (07:52):
And each one of those other four are gonna cost you $25. And the person says I don't have the money to pick them all up, help me decide, which will one of these I should take now. Uh, and that whole idea of that initial medication adherence is, is just sticking to it. And some people, when they walk out of the, uh, prescriber's office, also look at those prescriptions, say, uh, my aunt Tilly took that one and she got a bad reaction from that. I'm not even taking it. I'm not even gonna present it to the pharmacy for are filling. So all of those are the factors that go into that initial medication adherence. And we really need to get patients to start that process so that they know that it's an important piece of their, uh, treatment regimen. So they can manage their chronic disease or get cured of their infection or things like that.
Speaker 6 (08:38):
This initial medication adherence is such an important step. We've gotta get people to get over that hump to get that medication to begin with before then we can even have them continue on cuz your other point was Todd was that about 50 after about a year 50% of the medications aren't taken as prescribed. And that's another set of variety of reasons, but that's the whole idea for me is that initial medication adherence, we thought that electronic prescribing was going to solve that problem because then they're not being, they're not lost, they're not in pocket books or things like that. They're sent to the pharmacy, but there's a policy piece that came along with that too. And that was that abandonment. A lot of medications were being filled, left on the counter and then they had to be, uh, restocked that's effort, time and money, uh, wasted because patients weren't taking them. So that was what we started to think about. And that's some of the issues there's a lot more that goes into it, but I'm gonna stop there for a second. And I wanna ask, uh, Todd, uh, uh, Doug and Steve, what their experience is with this kind of, uh, initial medication adherence or people getting sticker shock or things like that.
Speaker 5 (09:46):
Speaker 3 (09:47):
I'd like to start out with Doug because as a pharmacy owner and, and also Steve, we're gonna follow up with Steve. Tell us about you. You're seeing your patient 10 times more on average than the primary care physician who made that prescription. So what is happening when the patient reaches you and, and what are they conveying because of the trust that they have in you as their pharmacist?
Speaker 5 (10:12):
Yeah, I'd say cost is definitely an issue with, um, a variety of medications, whether the doctor realizes what the copay cost would be to the patient, or if they just got outta the hospital. A lot of times they'll put 'em on the medications that are on their formulary and then they come and get 'em and they can't afford what they were taking in the hospital. So they'll just abandon it or, um, maybe pick up one or the two, um, like you said, um, but there's, you know, if they have a, a copay card that sometimes helps with that issue and, um, able to save them money, but in the long term, they may pick up that, you know, short term they'll pick up the expensive prescription the first time, but will they pick it up the rest of the time? Cause they don't have the funds to pay for it going forward. So, um, I find that that's a, a big issue is the cost initially picking it up, um, and trying to find ways around that isn't always possible. So especially if they're on Medicare
Speaker 6 (11:08):
And we found Doug just to let you know, one of our PhD students did a study and, uh, if the copay was, uh, $16 or more, it was twice as likely to be abandoned then if it was less than, and that $16. Um, so that, that, that dollar amount really has a lot to do with it. Particularly when patients are getting, you know, four or five prescriptions, you know, $16 send four or five that's, 80 bucks, that's a lot of money to even just start with and then realize that's $80 on a monthly, on an ongoing basis to somebody's budget. That's hard to hard, hard to swallow
Speaker 3 (11:45):
Steve, um, pharmacy owner as well. And, and you're seeing this all the time. So what are your thoughts around initial adherence?
Speaker 4 (11:55):
It it's a tough nut to crack. Um, I know in our experience here, it's that first touch. It's getting, um, medication into the hands of the patient, um, and explaining to them the importance of adherence, importance of getting the medication and being able to take it with them. Um, and it's hard to of these disease states are, are not symptomatic. Um, so you're taking a blood pressure medication, but you're not showing any outward signs. You're not feeling ill, you're not looking sick. Uh, why do I need to take this medication, diabetes medication? Um, you know, I don't feel bad. Why do I need to take my diabetes medication? Um, a lot of the times that we're doing in here is that my, my staff works very hard with doctors, um, and other providers, uh, for that first touch to say, okay, it's a tier two or a tier three drug. Can we look at trying to find a, a drug to be able to afford that patient, to get into that medication, to be able to use it, to get the outcome that we're trying to trying to achieve?
Speaker 3 (12:58):
So, Dr. Peterson, when I think of some of the stage that has been set so far and what, um, Doug and, and Steve has shared as pharmacists, you're seeing their patients every day, um, you know, convey a cost, uh, conveying, um, you know, the, the worry, uh, of the strain of ongoing, uh, chronic condition. Um, what, uh, data do you have, um, to share with other issues that probably the patient aren't necessarily even sharing with their primary care or their pharmacist as to reasons that, uh, medication adherence is such an,
Speaker 6 (13:38):
So there's a, a bunch of things that go along with it. The, the cost oftentimes is a bit of an excuse, but not always. I mean, uh, it is one of, uh, probably the biggest reason why patients don't, uh, adhere to their medication begin with. But, uh, and Steve, you had kind of mentioned that a little bit. Um, sometimes the there's a, maybe a misunderstanding or, uh, a lack of recognition by the patients on the value of that medication towards the long term treatment, if they are not feeling those symptoms like they have with hypertension or, um, high, uh, hyperlipidemia, they are less likely to take it, uh, versus, and we, there's some really a good data showing that, uh, uh, symptomatic disease states such as, uh, thyroid disease allergies and like have a much higher both initial and continuing adherence because then patients, um, cuz then patients are, uh, relieved of those symptoms.
Speaker 6 (14:34):
And we did a study, uh, and they called it a fixed choice study where we took, uh, diabetes, hypertension and hyperlipidemia. And we said, if you added to choose, uh, only one of these two, a diabetes versus a hypertension, hypertension versus lipid, those kinds of drugs, lipid, uh, drugs almost always got, went down to the bottom. They were the ones that they, that the patients could would say, I won't pick that one up, uh, if I don't have to, but I will take my diabetes that almost always came out to be the top one, then hypertension, uh, the lipid one was so much lower. A lot of that has to do with two with the education that the providers are giving, uh, when the prescription is delivered or as Steve, you had mentioned kind of that first touch when you're getting it, when there's a healthcare provider, educating that patient about the need for that medication now, and in the future, the, uh, data show that the, uh, people are, uh, upwards about the 20 years. So percent more likely to take it and continue those medications, uh, because they, they know why they're gonna be taken. And there's a sense of belief that, that medication has gone to help them when they don't understand why it's gonna help them or how it's gonna help them. Uh, they're less likely to take it.
Speaker 3 (15:50):
So Steve, I'm thinking of the pressures that you're under as a pharmacy owner, you know, better than anyone, you know, as well as Doug does that of the pressures to run a business, be an employer, be a conduit of health. Uh, sometimes a healthcare destination and communities where the community pharmacy is the only medical provider for miles and miles away. And, and now during this pandemic, it's just one layer of stress on you as a, as a business owner and as a, as a clinician, as a pharmacist. So I think of the community pharmacy owner with the initial dispensing event taking place. And I think our pharmacy owners able in pharmacists able to emphasize and stress specific medications, not saying that all medications aren't serious, of course they are when they're prescribed. But if you know that this is a life saving medication is a diabetes med or hypertension me what emphasis during that initial dispensing, can you do and have the time to do with everything else that you have to be doing in order to really emphasize and stress to the patient that this is extremely serious and really could mean you as a patient going back into the hospital or worse yet, um, having, um, you know, an adverse reaction to it that could put them, um, you know, in, in the grave and it could, it could kill them, but how do you handle something like that?
Speaker 4 (17:23):
From my perspective, I've always worked with patients saying, let's look at I'm a minimalist. Um, if you don't need to be on six different prescriptions, when three will do the job that builds trust and rapport with my patients, to be able to say, you know, something we don't need all of these medications, let's look at what we need to focus on. Let's look and be able to decide, um, from an outcome standpoint, what's gonna work best for you. Understand that if you choose not to take your lipid medication, here's your side effects. Here's the potential issues with you down the road. You may not be symptomatic now, but we all know that cardiovascular events are more likely to occur if you're not on statin medication or lipid reduc medications. Um, so it, it is kind of that building the rapport with the patients, counseling with them, uh, talking with them about how, how important it is for you to take your medication. Um, but from a timeline standpoint, it, we need to take the time to do that. That's our job as pharmacists to be able counsel our patients, the spend the time with them and make sure they understand their medication, the doctors or the providers have done their job at prescribing understanding the patient disease state. But now it's up to us to kind of bring the ball home with them and say, okay, this is why you need to take your medication. This is why you need to be compliant with it.
Speaker 3 (18:46):
Doug, when I think of the complexity of that cascade prescribing, and you have a patient that possibly has moved now, they're moving into your community. They come to you, they have, you know, 6, 8, 12 medications that they're managing. What's an element, or what's a strategy that you do in counseling. Those patients when it comes to, um, these saving chronic, uh, disease states that they're experiencing, how are you managing and how are you connecting with your patients, um, to really emphasize the, the severity of, of staying adherent?
Speaker 5 (19:23):
Yeah, so we would look at their medication regimen, make sure that first they know why they're on 'em, but they're for, and make sure they're taking 'em, uh, appropriately, whether it's with food without food time of day. Um, and just, you know, in emphasizing the importance of why they're on the medications, why they need be taking it to kind of help with their outcomes, um, as far as feeling better from day to day, but also keeping them outta the hospital in the future. Um, there is an issue with cost or anything like that, that they're moving in. Um, we'll do our best to help them and maybe talk to their new provider about how we can, um, maybe Decar their burden, um, as well as try and maximize the medications that they're on. A lot of times we have patients who are on, you know, four different medications, but none of 'em have been no maximize their full potential. Um, so that's another good way to gain trust with the patient. Um, potentially save them money as well.
Speaker 3 (20:24):
Dr. Peterson, I've thought of the research that you've kind of, um, dug into and, and even defining initial medication adherence and what that means. What other data have you come across in your research, um, beyond the financial burden and, and I liked what you said, you said sometimes that's an excuse and, um, because there's other questions that they may, the patient may be, um, access to health literacy. There might be an issue with really understanding, um, you know, the, the, the, the clinical effect of their disease and, and the medications on their disease. So talk to me about health literacy and reducing complex of medication regimes and, and what you've studied and, and what you've uncovered.
Speaker 6 (21:11):
Sure. So the complexity of the medication regime is probably the easiest one. We did some, uh, good meta-analysis where showing that, uh, those studies where patients took, uh, one up to two, uh, once a day to twice a day, medication had a much higher, uh, upwards of close to a 40%, uh, greater compliance, uh, long term than if they were taking medications that were taken three or four times a day. And that just makes kind of intuitive sense. Uh, the, uh, drug manufacturers been doing this for years when they've made everything from, you know, three, four times a day to once a day and extended release pills. And that was part of it. Uh, and that's because patient patients are a lot more compliant, particularly when they connect it with, uh, a a day to day activity. The data also show that, uh, medication adherence is best when it's connected to another type of activity.
Speaker 6 (22:06):
So if they, if they brush their teeth every day or twice a day, uh that's when they should be taking their medications once or twice a day, or if they're, they need to take it with breakfast, that they do it with breakfast at those times. And to even have the placement of those medications nearby, where that activity is gonna be. So once it's connected to another day to day activity, the, the compliance, uh, will increase about it, increase with the health literacy component is a huge issue. Um, oftentimes we are giving patients a medication with a, uh, package, a patient insert that describes the medication. And ideally it's a sixth to eighth grade level, half the time they do read it and half the time that they don't and when they do read it, sometimes they don't understand it. Even the language might be a little high, but it's usually okay.
Speaker 6 (22:55):
But at the same time, it also may induce some fear and fear is probably one of the bigger drivers that drives people away from taking medications. Uh, they're afraid of the side effects. They're afraid of what might happen. They're afraid of the unknown, even if it's a small risk, it becomes, uh, problematic for them in their mind, so they don't want, they don't wanna take it. Uh, and we've seen some of that even lately with all the stuff that's going on with COVID and the vaccine, and like that, that fear, uh, is a huge driver for it. But the other piece of health literacy, uh, that we need to think about is, um, not just the reading part of it, but the, the true understanding of what it takes, uh, and what the implications are of these diseases. People don't have the, uh, without help the, the thought of what those consequences are a year or two down the line.
Speaker 6 (23:49):
Uh, so they, they think very short term, uh, and what's gonna happen now. And there is, that's a component of that literacy and understanding of what the consequences of their disease are. Uh, so we need to continue to reinforce, uh, what the consequ, as if non-adherence for diseases are in the long term, and we should be doing that on a regular basis with our patients, not each and every time you don't wanna keep hammering it at them, but, you know, have an understanding of what it might be and ask them questions about their disease, how they're feeling, how things are, are developing and have a conversation with them, get them to be literate about their disease. So they have a good understanding of
Speaker 3 (24:26):
Steve. I think of you, again, as that community pharmacy owner and the education that you provide on an ongoing basis, the way your pharmacy technicians have built relationships with, um, your clients, your patients, customers that come in, how are you addressing health literacy, um, as a, as a barrier to medication and adherence,
Speaker 4 (24:47):
It can vary. It depends upon the patient. Um, I, I think unfortunately some of the, the literacy issues come from as, as Dr. Peterson was referring to, um, non verified sources, um, while my, my brother said, or, or while I had a family member, once that, um, a bad experience, uh, it, it's hard to sometimes, and in today's world with social media and news outlets, 24 hour news cycles, there's a lot of information out there. There's a lot of misinformation out there. Um, even as a pharmacist, I sometimes find it hard. What sources are viable? What sources do I constantly run to when site and work with, um, to be able to be able to have conversations with my patients, um, and to be able to give them sources so they can empower themselves to do their own research, if they have questions or concerns.
Speaker 4 (25:40):
Um, but we're always working with our patients to say, we're a phone call away, call us with questions. If you have concerns. Um, you know, my, my staff works very well at kind of filtering out what's the, you know, refill question as opposed to the Hey, Steve needs to talk to this patient because they're having concerns about side effects, um, or drug interactions. Um, and that's, that's really kind of the crux of, of where that trust and where that communication comes from, uh, trying to alleviate the fears of patients from taking their medications, um, and giving them the opportunity to, to kind of take their own healthcare into their hands, by knowing they've got a, a healthcare team around them. That's looking out for them,
Speaker 3 (26:25):
Dr. Peterson, we have a question that I was going to ask and sure enough, Kathleen asked at one of our attendees and she said, can you speak to whether the abandoned medications are new medications or refills? And the reason is, is that there's these patients that, um, you know, they start a new medication there's reluctance, um, compared to a chronic one that they're used to taking. So it's that new medication that, that, you know, that's entered in. So can you speak to the, the abandonment issue and if it is a new medication or refill?
Speaker 6 (26:57):
Sure. The data that Dr. Farell my P the PhD student graduated a couple years ago did was, uh, based solely on new medications. So she looked back, um, six months or more to make sure the patients were on it. And when we talked about new medications, it was, we also took a look at the class of medications. So it wasn't just that they started a, uh, a new statin, but it was any statin, or if it was a new diabetes, a agent, it was, uh, any diabetes agent. So these people were naive to any within that class. So it was a new start, uh, and those, uh, abandonment data, uh, and the costs that I had mentioned earlier were based on that, uh, because abandonment issues, uh, and the reluctance to pick up that medication, uh, are different for, or new starts than they are for people who are chronically using it.
Speaker 6 (27:47):
It may be abandoned for a chronic user because of an adverse reaction. And they are choose not to pick it up anymore because they don't want to continue that medication, or because of the cost, or because their, uh, physician told them not to, or because their aunt until told them not to, uh, in, in this case, in the case of a new start, it's often because of a, uh, because of the sticker shock that they may get, or somehow, or another, they have gotten some information, uh, not for a fan experience, but some information from one of those sources that suggests that they shouldn't take it for whatever reason might be. So the differences are, are, uh, unique to the, whether it to start or not.
Speaker 3 (28:26):
So when I think of simplicity and the new term to me was initial medical adherence, which is why, um, we featured Dr. Peterson today and, um, really have him, uh, setting the stage, uh, for what that means. Part of initial medical adherence. It is the, the approach and the simplicity that a community pharmacy is delivering, um, the entrance of that new medication or the existing medication, especially if there's four, six, you know, 10 medications that they're on all in these vials, uh, always having, you know, have to open the cab and, and pour the medication or fill up their Monday through Sunday, uh, flip top, uh, containers as, as we know that, that people are going through the classes and the seminars that have been put on, for example, by RX safe, which is shown the simplicity of, of packaging medications in a way to make it that it's 8:00 AM.
Speaker 3 (29:31):
Um, Dr. Peterson suggested, Hey, I'm brushing my teeth after I'm done brushing my teeth. I'm gonna go take my medication. I walk up to my, uh, package, um, it's a, it's a square box. It has all the directions on it. I pull a strip out, uh, inside that strip for my 8:00 AM pass is now, um, three medications. I rip it open. I take my chem medication to me, the, the, the, the advent and the entrance of me compliance packaging has been so key in developing simplicities. So I want to hear from Doug on those simplicities in setting the stage to simplify the complexity of multi doses and multi passes per day. And, um, and, and you're experiencing in using, uh, medication and compliance packaging.
Speaker 5 (30:23):
Yes. We have multiple patients who are on, you know, mul over 10 medications. Um, I just think of myself, I try and take that. Like, I I'd probably miss some in the morning, some in the evening cuz you know, a lot of these people, you know, did I take that one? I don't know if I took that one. So we'd have people's coming in before we got this strip packaging machine that would like, oh I got plenty of that one and you ask them, well, why don't you need that one? It's just a month supply. Oh, I take it every day. I don't know why I have more. You must have gave me more than the 30 days. Like, well that didn't happen. Uh, and you can't convince them and otherwise like they took their medication, but you know, they didn't. Um, so by putting in the pouches and having it organized for them, they have come in, you know, on the 30 day supply every time they're not saying they don't need the one particular medication anymore because they're actually taking their meds.
Speaker 5 (31:18):
Um, and they're getting it, they were getting it every 25 days now they're getting every 30. So it's really increas a compliance for that and simplified the patient's medication regimen. Cause they know when to take it and they're better at taking it. And if it's during the day, they can rip off the pouch and take it with them. Um, I feel like that was another big issue for the midday, um, medications, cuz they might not be home and they don't have their medications with them. So now they can, you know, take that with them and make sure they're taking their meds. It's, it's been a huge, uh, plus for our pharmacy as well as our patients.
Speaker 3 (31:52):
Steve, what's the outcome of your patient base? Um, that has been introduced, uh, to a Medi medication sync program that includes, um, compliance packaging.
Speaker 4 (32:05):
It's been remarkably well received on I, uh, by my patients. Um, it's, it's been a, uh, ability for us to give them something addition, uh, additional compliance, additional help, um, allows caregivers to kind of follow up, uh, with elderly parents or uh, with their kids. Sometimes I've got a mom, um, who has in a divorce situation where she splits custody. She knows she can send enough medication with her daughter to go to the ex-husband's house for the weekend and not worry about bottles, not coming back because the medication's traveling with her. And then she's got the bottles. Uh, she's got the pack when she comes home, uh, from visiting her dad's house. Um, so we've found some really unique things that I hadn't even thought of to be able to utilize this, uh, strip packaging, uh, in the pharmacy, but kind of working with customers, talking with them, how they take the medication.
Speaker 4 (33:06):
When do they take the medication, um, you know, discovering little nuances about, well, I take all my medication together, you taking Leal thyroxine and you're throwing it in with the rest of your medications in the more and studies have indicated that it's a better off at a different time, separated from other products, same thing with Coumadin based products. We wanna make sure we're separating that and doing a dose in the afternoon for lab value testing. Um, so we've really kind of helped utilize our skill set, um, to make sure patients are compliant and getting the best use of the, the medication. So it's really been a, a win-win situation for, for our patients and our staff.
Speaker 3 (33:46):
So what's the suggestion Dr. Peterson and what's interesting is you've had an extensive amount of, um, experience in a hospital system, pharmacy as a pharmacist that was there, um, uh, helping, uh, patients ongoing when you have a patient that has a hospital stay, it's easy to, to regimen, obviously their medication therapy when they're released now, you know, you're hoping and praying that they're connected to a, a community pharmacy that, that, uh, that they trust and that they're gonna utilize. How have you seen compliance packaging impact medication adherence, um, through any of the studies that you've, that you've uncovered?
Speaker 6 (34:30):
That's a good question. And the, you know, the compliance packaging concept actually goes back years. Um, uh, long term care pharmacies. Uh, I used to work in a, the VA medical center, uh, and we used to service a, a long term care unit out of that. And we would put, uh, and package the medications by time of the day for the nurses to make it easier for them and allow patients who had the autonomy to be able to take the medications as necessary all of those at a certain time. And they were able to read it and, and things. So this is not a new concept, uh, to proved medication here, even for healthcare providers, but bringing it out into, uh, the world now and allowing people to do it. It, it makes it so much easier. The, um, the fact that they don't have to carry around bottles with them during the middle of the day, uh, and, or forget them if they are giving 'em out somebody, Steve, I think you'd mentioned that, uh, when they travel somewhere between two half house, two households, having the, having a very spec specific, this is the, the time that you need to take this one and without having to do it, there are so many particularly elderly patients who don't have the, the dexterity, the vision, or the ability to put together those medication cassettes, where, you know, you gotta take it, you know, morning, noon night, Monday through Sunday.
Speaker 6 (35:48):
Uh, and oftentimes the, the children or caregiver has to do all of that stuff. But even having the dexterity to open those things, then take those medications out. It becomes very difficult. So all of these things have improved the ability for a variety of different people to be able to comply with a medication regimen, just have, remember, they want, they have to wanna take it. Um, but when they're packaged in this way, uh, they have, uh, less of a choice, uh, as much they don't they say, oh, I don't have to take this one in one in the bottles, or they don't have to take this one. They'll open that package. And if all three of the medications that's supposed to take on that time, they're more likely to take all three of them at once than if they had to open up these, uh, bottles.
Speaker 6 (36:28):
So there's a, a huge improvement in medication adherence, uh, long term because of this packaging and, and the other one by the way, is we know it, uh, also started, uh, decades ago, uh, oral contraceptives. If we think about that those oral contraceptive packs, uh, those blister packs were one of the first ones that were out there. Uh, and this way people could account for make sure that they took a dose every single day. And they knew when they missed one. Uh, and then they were also given instructions to what to do when they missed one, uh, Z max, when it came out with it, packaging was, uh, a big one too. So there's, uh, the packaging piece, uh, and the frequency of dosing, all improved medication complies dramatically.
Speaker 3 (37:10):
Thank you for that. And so I'm thinking of the concept of meeting people where they are. And I think of seniors, I think of my own ad, who, um, is a huge user of, uh, Facebook, uh, some of the, uh, comments and, and things that he gets into. Um, sometimes I wish he wasn't as good of a user as Facebook as he is, but, um, all the political stuff and the fake news and all that, that crazy stuff that, that comes out of our, our social media. But when I think of meeting patients where they are, I think of communications and, you know, pharmacists, we can only expect you to do so much. Um, you know, I, you can only educate the patient. You can, um, you know, you can com you can put the compliance packaging together and invest in that, make an investment into a, uh, your, your systems with, with an RX safe technology, a, a machine, but what about ongoing communications in an automated fashion through like texting every day or twice a day, or whatever regimen that they're on, so that we're, we're in we're employing technologies that they're already used to, you know, the cell, the mobile phone usage.
Speaker 3 (38:27):
I got my first mobile phone, I think in 1996. And it was a big box thing. And I think it cost like $3 a minute or something like that. But today it's, you know, every single one of us is, is carrying one of these. And the majority of our patients have access to, um, a mobile phone, not all, but a lot of them do. So I wanna ask the pharmacy owners, how have you embraced te G how have you embraced even something as simple as a text to, to couple with a medical, um, medication regime to keep, uh, patients compliant, I'll start out with Doug.
Speaker 5 (39:10):
Um, as far as reminding them through their mobile device, I, you know, recommend it to the patients if they are having issues remembering just saying, well, this is an easy fix for you. Um, the one thing we use through our pharmacy software is, um, anytime we have a fill that's completed, um, it'll send a tech. We, if the patient agrees to it can send a text message out to them saying that they have a prescription ready to pick up. Um, and I think a lot of pharmacies do that. Um, sometimes it's not always processed in the right way where the patient comes to get it. And they're like, I dunno what you're talking about, but it's done, right. It's a, it's a great tool, um, to use. And, uh, and I know with our, our pharmacy app that there's, uh, features in there where they can set reminders, um, to take their medication, um, whether they've downloaded the app or not, or, um, who knows, but, um, they can also send us, um, direct questions through the app that we are using as well. So if they did have a question, um, about their medication, or if they just needed a refill, they can send us a text message and we can get back to them, uh, quickly. But that's the main things that we've done as far as technology.
Speaker 3 (40:21):
Steve, what have you done in your community pharmacy in, in, in embracing the, the tech, uh, aspect of this in, in compliance with your, with your patients?
Speaker 4 (40:32):
Yeah. Technology can sometimes be a double-edged sword, unfortunately, um, you know, multitude of platforms, uh, different mechanisms of communication. Um, I've worked really hard at trying to make sure that we have the single voice, um, sent with the, patient's not getting inundated with, uh, text messages from one platform, from another platform saying, oh, okay. Uh, yeah, your prescriptions are ready for pickup, or, uh, you are due for use three prescriptions. Would you like us to fill them? Um, just as a reminder, you're coming up due seven days for, you know, unfortunately technology can sometimes be an overload or burden to our, our people that aren't used to dealing with it or not used to the technology. Um, I think a lot of what we are working with is once again, coming back to that touch, um, doing the med sync program the way we're supposed to do it, and to make sure that we're talking to the patient saying, Hey, we see that you're coming up due with your medications.
Speaker 4 (41:31):
Uh, we're gonna run pill pack for you, uh, any change to anything that we need to be aware of before we run pill pack for you. Um, and it gives that rapport with the patient, uh, and my staff to say, what's going on, what's up to date. Um, do we need to get the pharmacist involved from a clinical standpoint to, uh, evaluate a situation to evaluate, uh, me, um, you know, have there been changes that we were unaware of? Um, so I, I think it gives us a, a little bit more of an opportunity to, to be that hands on, uh, utilize technology when it's available. And when it's there, you know, shoot the emails of the patient saying, Hey, your prescriptions are ready for pick up the text messages. Hey, your prescription's ready pickup. Um, uh, don't forget, you know, you have that partial that you need to pick up, cuz we could only, we only had a week on hand. Um, so I, I, I, I like technology. I embrace technology, but I don't always love technology.
Speaker 3 (42:27):
Very good. So Dr. Peterson, I think of, um, the current state of our nation in, and the pandemic placing a lot more stress and pressures on, on people throughout the nation and our community pharmacies as well. And, and first line, um, responders and people that are out there. Um, you know, in, in the position of, of asking, uh, hearing all of the questions, getting all of these crazy probably questions that, that, um, that patients are hearing. So I, I think of the depression angle of this, what in your research have you uncovered where depression is, is adding to the complexity of medication adherence?
Speaker 6 (43:16):
So, uh, great question first, let me say thanks to, uh, all of the pharmacists and others who are out there, uh, on that, on the front line, helping to, uh, field the questions that these, uh, patients have filling the medication for 'em being out there during the pandemic, uh, in these higher risk situations wanna say thank you very much for, uh, being there and being part of that. I appreciate it a lot. Uh, and the, the piece about the depression, we've, we've all heard about what's going on that, uh, it's increasing people's anxiety, uh, isolation, depression. There are a lot of those factors that, that do decrease medication here. And the idea that people are, uh, being had been told initially, and still, you know, uh, shelter in place stay, stay at home, you know, minimize going out only if you have to pharmacy was a place that they could go.
Speaker 6 (44:04):
There was a lot of, uh, elderly patients who were just afraid to go out, weren't going out. So they were relying on a lot of people to get their medications and that wasn't happening. Uh, so there was the, the impact of the pandemic itself on it. But the depression there, people are like, why am I doing this? Patients who are depressed typically are not taking their medications as much. They, they have the, I don't care kind of attitude, or why should I do it, or even they are not feeling good enough about themselves to be able to take the medications that they need. Uh, so that is a, a big problem. Uh, and then you're trying to then add on an antidepressant to help them, uh, and that's just another burden for them to be able to do so it really does take a lot of that high touch and communication with those patients to be able to kind of get then to take those antidepressants for the four to six weeks that they need for them to work, if that was the right one to begin with for the, in the first time.
Speaker 6 (44:58):
So it, depression really does impact it in multiple ways, cuz you're adding a pill burden to 'em, you know, the depression itself decreases their desire to, uh, take medications. So, um, there's so many different factors that go along with it, the worry that comes along with it, when people worry about things, um, that may not be depression, but that worry itself also contributes to, uh, their medication adherence and the best way to, to kind of combat that is through communication, uh, healthcare to professional healthcare professional. And I, you know, we're talking pharmacist to patient, but I also wanna encourage pharmacists to a physician if there is a concern. Um, oftentimes the, uh, prescriber doesn't know that the patients aren't taking their medications, they may be going and they could be telling the, the prescriber, yes I am. But the data are showing that they're not getting refills. Uh, so if there's a communication between the pharmacist and the physic and that might help, uh, and then also encouraging and given the physician, uh, the, the time if possible, to communicate with the patient so that the triangle is really important to have a level of communication.
Speaker 3 (46:05):
So there was a study out just recently from the Kaiser family foundation. I'm gonna have a link into the show notes, uh, from this study that said four in 10 adults have reported symptoms of anxiety or depression, which is up from one in 10 adults who reported the same symptoms less than a year ago. And that's once again, tied back to this pandemic, tied back to the extra stress, um, that this has played based on, uh, uh, people in general. So I immediately, because my heart goes out to pharmacist first, cuz you're my favorite providers. I think of you both, uh, Doug and, and Steve and all of the Pharmac owners listening, um, with your own mental health, what are you guys doing to, um, to, to kind of, uh, take on a little bit extra of the pressure that you're under right now during a pandemic and serving your community. Um, Doug, what are you doing to, to kind of take care of yourself to, in to ensure that you're continuing to, to be a champion for your community?
Speaker 5 (47:13):
Uh, I always try not to get too overwhelmed and just kinda I'm out of the work environment. Try to just be away from work, not, you know, connect back to the pharmacy system and try to do more work, but just to be present with the family, you know, put away my phone. So I'm not distracted and I can just unwind a little bit. Um, it's not always easy, especially with doing COVID shots and everything, cuz we're working extra hours and it's just more stress and it just seems like there's more things to get done, but I still try to make a conscious effort to put away all the electronic devices and just be present with family or friends that I'm surrounded by. And that just seems to kind of help melt away a little bit of the, the stress before the next day starts. And uh, you know, obviously getting the right foods and getting enough sleep is, uh, huge as well, especially sleep for me. But, um, those are the main things that I've tried to incorporate in my daily life is just unwind and get away from electronics as much as I can.
Speaker 3 (48:14):
Steve, we, we expect so much out of you, um, to, to keep it going, keep pumping out the 300, 600, you know, 1200 prescriptions a day, taking care of your staff, taking care of your patients that need extra attention. And what are you doing for yourself? What are you doing for you and your family?
Speaker 4 (48:33):
Uh, a lot of it is just self care. You know, like Doug was talking about when you mentally punch out at 6 37, o'clock whenever you close the store down, finish up what you need to do, go home, uh, you know, the problems, the issues, the things that you're gonna are gonna be there the next day, make your list, uh, you know, follow up, follow up, uh, make sure that you're taking care of what you need to take care of, make sure you're taking care of yourself, make sure you're taking care of your staff. Um, and just, you know, try and there's so much negativity. There's so much frustration. There's so much bad things. I'm a hockey guy. Um, if I, that feeling the little bit of stress in the day, all right, I'm gonna go home. I'm gonna watch a miracle. I'm gonna go, I'm gonna do something for myself that, Hey, I love that movie. I'll watch it. And I feel better, you know, it's, it's it, it's those simple little things. Um, just get the mental health clear the head, shake things off and say, okay, I'm back at let's roll.
Speaker 3 (49:33):
That's awesome. Dr. Peterson, what are you doing to be construct and kind of get the pressure off of what you're going through as a, as a professor and as a pharmacist yourself.
Speaker 6 (49:46):
Good. Yeah, for me. Uh, so I'm fortunate enough that I've been able to work from home most of the time, but transitioning from two, uh, teaching in a classroom to tell the teaching was a little bit stressful and difficult for both me and the students. Uh, so taking time for myself was an important one. I'm a big fan of going out for, uh, walks. I, I have to separate, um, my home office from my home. Uh, and that's a, a hard thing. Last week I took a bit of a stake. Uh, I had some stuff that I had to do. It was, it was a nice week, uh, outside. So I spent most of the time outside doing some work on my backyard and the like, but I will tell you, you know, my computer sitting here on my desk, I'd walk in and I'd see it.
Speaker 6 (50:27):
And it was a little hard to kind of separate. So I had to close those, close it down. Uh, and I would say to myself, I'm only gonna open it up at these certain times. So I, I really did have to make some of those, uh, stretches to be able to, uh, of, of time for myself away from the computer. Uh, but you know, taking walks, going, uh, outside and connecting as much as, uh, with people as I can. I've actually doing a lot more letter writing, note writing and things for people. Um, it, uh, it's instead of an email, uh, it just, it was a little bit more therapeutic for me.
Speaker 3 (51:03):
That's really interesting. That's a, that's a great idea. I, I'm a big dog purse and I've tried to get outside as much as possible with, uh, the weather finally breaking in, in Western Pennsylvania, uh, for you pharmacy owners that are down south, like therea toll down in Sebastian, Florida. That's my, that's my, um, my father's, uh, uh, pharmacist is, is there and she's in Sebastian. So they have some really good weather for walking and, and I think of community events. And I think of how do we embrace the community in a fun, more uplifting environment, especially with the weather coming and, and getting better. Um, but being cognizant of this pandemic and, you know, and, and E you know, um, being, uh, cognizant of, of being smart, uh, in, in a community event, but that sense of community can be so powerful. And I'm wondering at those times, is it a, is it an opportunity to, to show the humanism in all of us and sharing with patients of the impact that that adherence has on the community and the health of the community and, and sharing that it's, sometimes it's not only about the individual, sometimes it's about making sure that we're a strong community together so that it's not drawing down on the finances of a community or the finances of the, um, because of, uh, of that cascade because of the domino effect of not being, um, adherent and wondering, um, as community pharmacy owners, what are you guys gonna do in the day and age of, of post pandemic with, with community events and to community events, work for you as small business owners to, to kind of open up, uh, what you guys do as community pharmacists?
Speaker 3 (52:56):
Speaker 4 (52:58):
Um, one of the things that we used to do is the lions club locally would host a spring fling, um, or a spring community event, uh, where local businesses would be able to come in and talk, uh, has set up booths, uh, you know, show what they can do. Um, and it, it was kinda like a, kinda like a home show. Um, and they approached me and said, would you be interested? And I kinda scratched my head for a second. What's a community pharmacy gonna do at a home show. Sure enough, I took a leap on it and I said, let's do it. Um, first year was kind of, you know, some pamphlets, you know, me hanging out, talking to people, you know, it, and it was kind of fun. And the next year we got a little bit more creative. Well, let's bring out some of our compounding equipment up with us.
Speaker 4 (53:42):
Let's bring the ator, let's bring some cream, let's some essential oils and let's make some stuff for patients. Well, okay. Now we're gonna market our compounding, uh, lab and our compounding facility. Um, so just a little community outreach thing like that, that was outside of the comfort zone for me and outside of what you would normally expect a community pharmacy to do. Um, was all of a sudden me talking to patients about the me, uh, you know, understanding that yeah, we're in a public setting and I'm not gonna get into the details of it, but saying, Hey, you know, some, that's a really good question. Let's talk Monday about that. Um, or let me make a note, see if I can order that and follow up with you. Um, so it was really a, a, a neat opportunity. Um, and like I said, something outside of the, the box, I mean, I've, I've done on youth sports, I've done youth coaching. Um, I've been involved in the community that way. Um, and that's all kind of gone on the back burner since COVID nineteens hit us. Um, but I'm, we're looking forward to that. I'm looking forward to sponsoring the local youth sports teams, local, uh, high school teams, um, in, and getting community back together, um, in, in a positive environment. Um, and not, not realizing what separates us, but what really can bring us together.
Speaker 3 (54:51):
Doug, what about you in your community pharmacy?
Speaker 5 (54:55):
Yeah, so at the, at our telepharmacy one, but we support like all the local events as much as we can, um, donate whatever. Um, at our other pharmacy that we were just looking to start getting into all these key needed advance right before COVID and kind of show how we can help them with the strip packaging adherence and everything like that. Well, soon as we got comfortable and wanted to do those things, everything got shut down. So we had put that on the back burner. Um, but now that people are getting vaccinated, those things are starting to open up again. So we have reached out to, um, a community center for will needs people and said, Hey, can we come do a ice cream social? And they're like, yes, please do. Um, so we're gonna look to do more of those types of things. Can they get out there with senior citizens or senior centers as well? Um, and just trying to show 'em how we can help their health, but also, you know, bring some fun to their, their days as well.
Speaker 3 (55:49):
So I just wanna make a statement. So if you're listening to this as a podcast and you didn't get to actually participate on this live event, um, with, uh, with Doug and with Steve and, and Dr. Peterson, I want you to reach out to RX safe and the pharmacy podcast network, if there's anything that we can do for you and your community, um, as a pharmacy owner, um, those are ideas on marketing. Those are ideas on implementing a PGX program, implement, um, um, something to, to embrace, um, you as a pharmacy owner. Um, it, this is about a new age that we're in and we have to be here for each other. And when we want to be, I know that RX safe wants to be, I wanna be, I wanna use our publication to, to assist community pharmacy owners. Uh, in this trying time in the show notes, you will find the initial medication adherence review and recommendations for good practice and outcomes, research and IPO medication adherence and persistent special interest group report, which, uh, one of the authors was Dr. Andrew Peterson is an excellent, uh, paper. Um, I'll have a link in the show notes for, uh, Dr. Peterson, I wanna say, thank you so much for being part of this. This was very special that you took the time out today, um, to share, uh, your insights on initial medication adherence, helping us to define that as well as giving some of your background in medication adherence and how serious of a, of a issue that this is, is
Speaker 6 (57:24):
Thank you very much. I'm, uh, humble and grateful, uh, to be part of this. I really do appreciate it, Todd. Uh, thank you,
Speaker 3 (57:32):
Doug. I wanna thank you for participating. You are my hero, a pharmacy owner, a pharmacist, and what you do for your community and, and, and what you go through as a pharmacy owner. I wanna thank you.
Speaker 5 (57:44):
Appreciate it. Thank you for letting me come on board
Speaker 3 (57:48):
And Steve, once again, a hero of mine, a pharmacist, a pharmacy owner, uh, anything that, that we can do for you and, and ideas, sharing ideas, putting other panels together to get us as, as a community pharmacy organizations. Um, we need to share more with each other, and I thank you so much for your sharing, your insights and information and what you're doing as a community pharmacy owner. Thank you, Steve.
Speaker 4 (58:15):
You're welcome, Todd. Thank you very much for putting this together. Thank you for state I for sponsoring. Um, and you know, let's keep those lines of communication open. Let's talk.
Speaker 3 (58:24):
Absolutely. If you're are listening to the podcast today, once again, please reach out to us, let us know what you think. Give us some of your own ideas. Uh, send us an email. You can find us on social media at RX safe on all of the social media platforms or the pharmacy podcasts at pharmacy podcast. Uh, once again, our guests information will be in the show notes. Please link up with them on LinkedIn, tell them that you got to hear them, ask them questions, carry these conversations beyond, uh, just this presentation and, and do things together. Um, I, I can't thank you enough for what you do as pharmacists. You are my heroes. Um, and, and with that, I wanna close out today and say, thank you so much for listening to the pharmacy pie and, uh, thank you for being an RX safe customer. And, um, please, uh, reach out to RX safe, go to RX safe.com. Um, that team is ready to help you in any way that they can. And with that, I thank you so much.
June 02, 2021
How can pharmacists use the IMA process in communications with physicians? — Explain
how pharmacists can educate patients about better adherence with their initial prescriptions
—What are the main reasons for medication non-adherence?
Background: Positive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription.
Objective: to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed. Using “Initial Medication Adherence” IMA rigorously & include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.
For example: the IMA process begins with a prescriber and patient interaction in an emergency room/ department, hospital, or other clinic setting (step 1) that results in a prescribing event (step 2)—the first of the two key events needed for an IMA measurement. When a prescribing event occurs, data collected from the perspective of either a prescriber or a patient will capture it, whereas data collected from the perspective of a pharmacist will not. To qualify as IMA, however, the prescribing event must relate to a patient’s first prescription within a therapeutic class (step 4).
Otherwise, the dispensing event becomes part of a PIMA metric (step 5).
Data from either the patient or the prescriber should be able to determine whether the prescribing event is an initial event. The pharmacist becomes aware of prescribing events only when these events are communicated to the pharmacist for filling (step 6).
Therefore, the pharmacist does not know how many prescribing events have occurred, only how many have been communicated. However, once the pharmacist receives the prescription (step 7) and fills it (step 8), the pharmacist must dispense the prescription to the patient (step 9). The dispensing event is the second key event needed for measuring IMA (step 10).
With dispensing the medication to the patient, both the pharmacist and the patient know that the IMA is achieved, but the prescriber does not. If a pharmacist does not dispense a filled prescription, the prescription becomes abandoned to the pharmacist and is restocked (step 11).
If an abandoned prescription is not transferred to another pharmacist (step 12) and subsequently dispensed, the patient will be initially nonadherent (step 13). Either the pharmacist or the prescriber may transfer the prescription from one pharmacy to another, but neither may know that the prescription has been dispensed.
— How can pharmacists use the IMA process in communications with physicians? — Explain how pharmacists can educate patients about better adherence with their initial prescriptions—What are the main reasons for medication non-adherence?