Help patients synchronize their prescription drugs

Here’s the scenario: on the 2nd of the month, a patient with diabetes on metformin and high blood pressure on benazepril sees her family physician for a routine follow up.

The patient’s blood pressure is elevated and the decision is made to add carvedilol to help get the blood pressure to goal. The patient’s metformin and benazepril “drop” (are renewed) at the pharmacy on the 18th of every month, a date determined by the patient’s last doctor’s visit. However, the latest doctor’s appointment now “requires” the carvedilol be renewed on the 2nd of every month.

To make matters more confusing, the patient has 2 months left of metformin and benazepril yet has a follow up appointment in 6 months with her family doc. So in 2 months the patient will go to the pharmacy and her prescription medication for benazepril and metformin will have run out. The pharmacist will have to call the doctors office to request a refill. The patient may have to return the next day to pick up the medicine — if she decides to show up at all.

In addition, the patient self-referred herself to a kidney doctor for protein in the urine that was picked up during an insurance physical. She does not tell her primary doctor about the consultation and doesn’t mention that her nephrologist did “something” to help her kidneys because the purpose of her current visit is blood pressure control. The patient does not make the connection that these 2 conditions are related.

Finally, the patient had a sudden bout of back pain. She went to an emergency room the week prior to her appointment. The emergency room doctor started her on “something” for pain. Again, she does not mention the medication to her primary doctor. She doesn’t realize that perhaps that medication is the cause of her elevated blood pressure.

Given the inherent problems presented in this case study, what can the pharmacy do to help the patient synchronize her prescriptions?

Patient centric models of care are popping up all over the country. Examples of patient centric models of care include the patient centered medical home and the patient centered pharmacy. I have a lot of experience with this concept of care. As a kidney doctor, I take care of dialysis patients in conjunction with a team of supporters and advocates for the patients. Our goal is to keep kidney dialysis patients healthy and out of the hospital. The model is sound, and it works!

The patient centered pharmacy is a brilliant concept to help coordinate prescription medication to help patients take their medication correctly. Let me quote the brochure a local Omaha pharmacy is using to promote the project:

“It’s easy and convenient. It saves time and trouble by having all your prescriptions refilled on the same day each month. Everything is handled for you, and you only make one trip to the pharmacy to pick up your prescriptions. Even better, it is free at participating pharmacies. Moreover, the synchronized prescription refill service facilitates adherence to medication and decreases the risk for medication error.” Here is how it works:

You choose an appointment day — the date each month you wish to pick up all of your prescriptions. A week or so prior to this appointment day, you will receive a call from your pharmacy to confirm which prescriptions you want to fill.

Your pharmacist will review your prescription list each month, monitor changes after your doctor visits or hospital stays, and check for possible drug interactions. Best of all, you will have time to talk with your pharmacist and ask any questions you may have about your medications.

You receive free consultations, the convenience of a single monthly trip to the pharmacy, and freedom from worries about forgetting to call for your refills or running out of your medications.

By synchronizing your prescriptions, you simplify your life. The appointment date at the pharmacy drives the system.

How does the pharmacy benefit? With limited resources available, the pharmacist can provide comprehensive care once a month, instead of multiple times, and improve efficiency. Phone calls are drastically reduced — the docs will love this one because they can spend more time with their patients providing world class care!

In what other ways does the health care system benefit? This system helps doctors identify medication non-adherence. I’m told that compliance is boosted to nearly 100% in enrolled patients. Patients who take appropriately prescribed medication stay healthier, stay out of the hospital, and save everybody money. The patient is able to work. The employer has a healthy patient who is working, not costing. Health care costs in general go down because there are fewer hospitalizations. Everybody wins!

Now back to the clinical vignette. At the kidney doctor’s office, the patient was started on lisinopril and asked to hold the benazepril. The patient didn’t understand the directions and was taking both lisinopril and benazepril. The patient is therefore on 2 medications that do the same thing. The medication she was given for pain, ibuprofen (a non-steroidal ant-inflammatory drug), likely worsened the patient’s blood pressure in the setting of taking 2 ace inhibitors. Arguably, the carvedilol is unnecessary because the primary doctor is treating drug-induced hypertension. Can you see how a patient centric pharmacy can help here?

Michael Aaronson is a nephrologist who blogs at his self-titled blog, Michael L. Aaronson M.D.

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  • stargirl65

    You just told the story of my every day.

    Just today patient came in with 2 ER visits for severe headache. She got CT scans and IV meds for her headaches. Said she was on lisinopril 10. Cards note said lisinopril 40 and also hctz which she never even mentioned. She admitted she hadn’t been taking any since she had no insurance and couldn’t afford her visits and therefore couldn’t get her meds.

    Now she has 2 ER visits and a head CT to pay for. If only she had just kept up with her primary care visits, or even went to her primary care doctor for the headaches.

  • Lacey

    I’m a pharmacy technician for the busiest non 24-hour pharmacy in the district for the city I live in, for a very well known pharmacy chain.

    Non-synchronized refills are one of the biggest customer complaints that I see, and I certainly see where this could be beneficial on many levels, but I would love to know where my pharmacists are supposed to find the time to hand-hold non-compliant and/or clueless patients. In busy retail pharmacies, especially when Corporate keeps us chronically understaffed and we are constantly struggling to meet the demands of an often aggressively ignorant public, we need all hands on deck, and I have a hard time imagining where the time will come from.

    I also have reservations about whether this is workable on a financial level. At least with MTM (Medication Therapy Management- sitting down with the patient, reviewing all meds they take and why, making sure there are no duplicates and answering all questions the patient may have) retail pharmacies are compensated by insurance companies- who will conpensate pharmacies for this? Pharmacist salaries, while deserved, aren’t insubstantial, and the time you spend doing things like this is time not doing the things that pay the bills.

    Where’s the time and the money going to come from?

  • http://www.edhayes.com Edmund Hayes, R.Ph., M.S., Pharm.D., FASCP

    Sounds like an area where collaborative practice agreements (collaborative drug therapy management or CDTM) would help greatly.

  • http://warmsocks.wordpress.com/ WarmSocks

    Yes, going to the pharmacy separate times for multiple prescriptions can be inconvenient. I don’t think, however, that patients need a babysitter. I’ve used a few different solutions to this issue.

    When my doctor writes a new prescription to replace an old one, it’s very easy to ask if I should fill it right away, or stick with the existing rx until it’s time to refill everything.

    Another way to handle it is to get an early refill of the med that’s off-schedule with everything else. This requires paying cash one time, but it’s worth not having to make multiple trips to the drug store.

  • http://myheartsisters.org/2009/05/22/know-and-go-during-heart-attack/15/reporting-impaired-incompetent-doctors/ Carolyn Thomas

    As heart attack survivor from Canada, I may be out to lunch here, but when I go to my local pharmacy for an Rx refill, all of my prescribed meds are listed online in my file. My pharmacist knows more about my condition than my GP does!

    When I see my cardiologist for regular ongoing visits, his standard office instructions are to “bring ALL your meds with you”. This includes OTC items like L-arginine and CoEnzyme Q10 too. He then quickly reviews my substantial ziploc bag of meds, cross-checking it against my master list to see if any new non-cardiac stuff’s been added.

    And the introduction of PowerChart patient records means that every hospital visit will include an online drug list of what my pharmacist is seeing too.

    Doesn’t this make sense?

  • gzuckier

    Of course, all the insurance companies are offering prescription scrutiny to catch drug-drug interactions, drugs contraindicated by some comorbidity, therapeutic duplication, drugs that just don’t make any sense for the patient in question, etc. etc. so the insured and his/her doctor can rest assured that things like that will be caught. Often catching things that the doctor misses even with full knowledge of what’s being prescribed.

    Until the patient realizes he/she can get the hctz for $4 cash at Walmart instead of $11 via the insurer’s captive mail-order pharmacy, so the insurer doesn’t get a record of the script, so now we’re back to square one.

  • http://www.georgevanantwerp.com George Van Antwerp

    I believe there has been some research recently that showed that this is a contributing issue to non-adherence so coordination of fill dates and decreasing the complexity of the patient’s therapy can help address the $300B issue of non-adherence.