» 82 percent of American adults take at least one medication and 29 percent take five or more ;
» ADEs cause approximately 1.3 million emergency department visits and 350,000 hospitalizations each year ; 2
» $ 3.5 billion is spent on excess medical costs of ADEs annually ;
» More than 40 % of costs related to ambulatory ( nonhospital ) ADEs might be preventable .
care system , now to be managed by the patient and / or caregiver . All physicians have had experiences with patients who do not understand the instructions , or whose caregivers have an alternate philosophy . This may produce a set of pharmaceuticals being managed by the patient / caregiver , untrained in the impact of these drugs , who choose to take them wrongly : sporadically , at lower or higher doses , with interfering foods , or not at all . For those patients who have a caregiver , that person ’ s bias plays havoc with the patient ’ s compliance . For example , if the caregiver believes that diuretics should be used intermittently based upon dependent edema , then the patient needing daily diuretics for blood pressure management may have wide variance in blood pressure readings .
HEALTH EQUITY
The Robert Wood Johnson Foundation formed a consensus panel whose definition of Health Equity was published in Health Affairs : 2
“ The fair and just opportunity to be as healthy as possible . This requires removing obstacles to health such as poverty , discrimination , and their consequences , including powerlessness and lack of access to good jobs with fair pay , quality education and housing , safe environments , and health care .”
In this perspective , the use of medications has both the pharmacologic capacity to improve health , but the prescription must also take capacity to pay for it . Prescriptions unfilled or taken sporadically have less capacity to improve health , so contribute to health disparities , rather than health equity . Health equity implies that all should have the same opportunity to achieve the health outcomes of the healthiest segment of the population . This applies to differences in outcomes based upon culture , race , gender or socioeconomic status . Health equity does not apply to natural physiologic differences . An 80-year-old may wish to enjoy the health of a 25-year-old , but all the social impacts on health cannot reverse the aging process .
As part of the discussion at the NQF meetings , the physicians have modified these “ Medication Safety Pain Points ” to be seen more from the perspective of the prescriber . Most physicians think in terms of medication acquisition in the traditional terms of the physician writing the prescription for the patient , now through an electronic format . That may be directed to a neighborhood pharmacy or to a mail order pharmacy . The responsibility for educating the patient on the prescribed drugs rests with the doctor and with the pharmacist — if one is available . Doctors generally recognize that their patients may be also directly obtaining OTC drugs and herbals which may create drug-drug interactions . We must be cautious and rely on the pharmacist or ePocrates to catch these possible medication safety issues . Patients typically do not report when they try the pills used by friends or neighbors ; and must have real trust in their doctor before they report the use of street drugs .
Within this NQF Action Team , a small group of physician members , modified the “ Medication Safety Pain Points ” into different categories that we thought were more in line with conventional physician thought processes . There are those very real forces contributing to or mitigating unsafe medication use by patients . These forces are ones outside of the normal doctor-patient interaction but certainly are important and include the following :
IMPACT OF CARE GIVERS
While the doctor may make medically appropriate decisions , the caregiver often amends them . Typically , it is the youngest , oldest and sickest patient who has a caregiver who is often not present when the doctor writes the prescription . Thus the biases of that caregiver cannot be voiced . A caregiver who has read the side-effect profiles may independently stop or change the medicine . Ideally , the caregiver is present , questions are asked , and the caregiver participates in shared decision making with the patient : how often does this really happen ?
ROLE OF THE HOSPITAL AND HEALTH PLAN
Other entities are involved in reviewing prescriptions generated by doctors . While performed as quality exercises , these may still confuse the patient . CMS has its Medication Therapy Management program ( MTM ). Medicare patients enrolled in a Part D ( drug ) benefit who have two or more chronic conditions and four or more medications one of which is considered “ high risk ” become enrolled in the MTM program . 3 The Part D pharmacist will call the patient to go over the medications and suggest the beneficiary “ talk with his / her physician ” about the drugs .
Hospitals have been using “ medication reconciliation ” practices at discharge for the past decade . 4 This was mandated by The Joint Commission as a patient safety measure . But a study from the Pennsylvania Patient Safety Reporting System showed that “ up to 91 % of medication reconciliation errors are clinically significant and 1 – 2 % are serious or potentially life-threatening .”
BARRIERS TO EFFECTIVE MEDICATION ADHERENCE
FEATURE
Most physicians are well aware of the issues with health literacy and health numeracy where patients may not understand what a pill is for , or how to take it . Studies show significant deviation from
( continued on page 20 ) AUGUST 2021 19