Wednesday, April 21, 2010

Not Filling Prescriptions After Hospital Discharge: Here's How To Fix It

The Disease Management Care Blog remembers the thick carpeting on the way to the hospital's flourescently lit and windowless administrative conference room. Copy machines were whispering in the background while photos of past Board members smiled at us from behind their ground-breaking spray-painted shovels. No, said the Vice President, we can't require our discharge planners to notify your disease management program about patients' going home. They're too busy and we're understaffed. Have a nice day.

Fast forward to the Disease Management Care Blog giving the Booster Shots Blog a hat tip for the timely alert about this just released article by Michael Ho and colleagues about the prescribing patterns of clopidogrel (a.k.a., the generic name of the drug "Plavix") for patients sent home after getting a coronary artery stent.

Stents are used to treat blocked coronary arteries. Yet, while they work great at opening arteries, the stents themselves are prone to thrombosis. The surfaces of these spring-like scaffolds can be irritating to the blood platelets which, in turn, can lead to clotting.

That's why persons with stents should generally take blood thinners every day. The most widely prescribed blood thinner for stent patients is clopidogrel. It's typically started in the hospital and continued for at least a year after discharge. That's because it's been known years that stopping clopidogrel in the weeks or months after getting a stent leads to thrombosis which, in turn, causes another heart attack or stroke.

But how about persons who fail to fill their clopidogrel prescripion on the day of discharge from a hospital?

Ho and colleagues looked at the records of approximately 7400 patients who 1) had at least one coronary stent placed and 2) who also had health insurance and a pharmacy plan through Kaiser of Northern California, Kaiser of Colorado or Health Partners of Minneapolis. The study authors were interested in how much time elapsed between the day of discharge and getting the clopidogrel prescription filled. About 1200 or 16% or about 1 in 6 discharged patients went at least a day without their medication. For those who went without, the median was 3 days. What's more, 165 patients or about 2% never filled any prespription for the drug.

Any delay in filling the clopidogrel prescripiton was associated with an increased likelihood of death or heart attack during the median of 664 days of follow-up. Even after adjusting for the use of other medications, the difference, compared to persons who filled their prescriptions right away, remained statistically significant.

What does the DMCB think?

While medication use for persons with chronic illess is a common quality measure, the DMCB doesn't believe measures of medication use focusing on persons just discharged from the hospital has been widely adopted. That needs to change.

The authors noted that during January 2004 to December 2007 period of study, medication co-pays ranged from $20-$35. Even small out of pocket expenses for high-value and life-saving medications can make a difference in medication compliance. In the meantime, value-based insurance designs for pharmaceuticals are one answer to addressing a one-size-fits-all pharmacy benefit. Those inflexible benefit plans need to change.

While the absence of any health insurance is certainly a formidable barrier to accessing good health care, this article shows that simply getting persons insurance is not a health reform panacea. We still have our work cut out for us. Formulating health care policy that doesn't recognize that needs to change.

While policy makers, providers and insurers have lately been hostile to the role of pharmaceutical companies having any role outside of manufacturing and selling their products, companies like sanofi-aventis (which makes clopidogrel) have a wealth of information on how to incent consumers to take their product. Maybe our national unwillingness to engage with big pharma on issues like this needs to change.

We have a comparative effectiveness boondoggle headed our way, but in the meantime, there are entities like Kaiser and HealthPartners that can access their huge data bases today to come up with insights that are immediately useful. While not mentioned above, the authors identified some patient characteristics that seemed to be associated with not getting a prescription filled. This information can be used prior to discharge to focus on persons at special risk. The low use of the databases that are already at hand needs to change.

The Feds have obviously declared war on avoidable readmissions by not paying for them. Their willingness to pay for the readmission of a patient that a) should have been taking their clopidogrel and b) went without any documented outreach by the hospital or the insurer may be something that needs to change.

While physicians are also responsible, their good intentions in the absence of systems changes in partnership with hospitals and insurers is not enough. That's why disease management's and the patient-centered medical home's track records of remotely communicating with patients and deploying state-of-the-art interventions that optimize self-care are so important. Many DMOs already emphasize medication management in their patient engagement strategies. Not recognizing how powerful this is among policy makers is something that needs to change.

Last but not least, the unwillingness of hospital leaders - especially those outside of the few integrated delivery systems - to play nice with disease management organizations, pharmacy benefit managers and outpatient physicians is intolerable. If it were up to the DMCB, insurers would be allowed to deduct a percentage of the hospital payment if they were not notified on the day of discharge about a patient over and beyond the no-payment "nuclear option" described above. Traditional discharge planning has got to change.

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