Engaged, not merely compliant: Ensuring patients get the right medication at the right time isn’t about just following orders
As I write this, I revisit my distress about two news stories that illustrate harm to patients caused by avoidable issues within our health care system.
We hear so much about adherence being the silver bullet to optimize medication use. But poor adherence accounts for less than 15% of the medication therapy problems.1 Adherence gets outsized attention—and funding. Other problems, such as the wrong medication (or combination of medications) for an individual’s genetic makeup—or an incorrect dose being prescribed—or medications that aren’t even necessary—don’t receive the same attention—or funding.
Why? Think about it: Adherence programs drive revenues. Other approaches to medication optimization, such as deprescribing or changing the medication plan, may not. Misguided adherence programs can be disastrous: If you are compliant and adhere to the wrong medication, it could kill you.
This isn’t a hypothetical situation. Just look at a recent issue of JAMA Internal Medicine.2
Just take as prescribed: even after medications discontinued
A pharmacist, a physician and a physician/pharmacist recently wrote up the case of a 69-year-old woman who ended up in the emergency department after three months—three months!—of recurrent falls, gait instability and vomiting.
She had a history of epilepsy, and her seizures were well controlled while taking levetiracetam. At one point, phenytoin was added after a seizure, but that seizure ended up being a result of running out of levetiracetam. So her neurologist discontinued phenytoin and made the change in the EHR—six months before the ED visit.
But she was still taking the phenytoin. She was unaware of the change made to her medication plan and so was her pharmacy. The pharmacy kept dispensing both medications.
She was compliant. She adhered. And she could have died.
She’s not an outlier: Despite imbedded PBM safety programs, a patient must know a medication has been discontinued and alert the pharmacy. Otherwise, widely used e-prescription platforms with no connection to the patient’s EHR fail to stop refilling prescriptions and overworked pharmacists or pharmacy techs miss dangerous combinations. Where’s the accountability?
I also need to point out that, had the patient been fully included in her care plan, this may not have happened. That’s why comprehensive medication management is essential: The CMM process
recognizes the patient as a full member of the care team. They are involved in the development of their own medication plan. It makes it much harder for this sort of nonsense to occur.
At least this patient had the right diagnosis. I have another story for you that shows how the wrong diagnosis inflicts suffering on the most vulnerable. To make matters worse, the misdiagnoses in this case appears to be intentional, designed to keep patients—wait for it—compliant.
Drugged into compliance
A New York Times
investigation found that at least 21% of nursing home residents are on antipsychotic drugs. Why? The headline says it better than I can: “Phony Diagnoses Hide High Rates of Drugging at Nursing Homes”
Here’s an excerpt:
Antipsychotic drugs—which for decades have faced criticism as “chemical straitjackets”—are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
The risks to patients treated with antipsychotics are so high that nursing homes must report to the government how many of their residents are on these potent medications. But there is an important caveat: The government doesn’t publicly divulge the use of antipsychotics given to residents with schizophrenia or two other conditions.
So, a simple “diagnosis” and you have compliance—in every sense of the word. Again: Where’s the damned accountability? (Don’t ask those involved. Read the article
and you’ll see a lot of finger-pointing.)
And while this is happening, well-meaning physicians, nurses, clinical pharmacists and—of course!—pundits chastise patients for not being compliant enough.
Now, don’t get me wrong, medication adherence—at least as defined by the World Health Organization
—is crucial. By that definition, adherence is “the extent to which a person’s behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with the agreed
recommendations from a healthcare provider.” But to solve drug therapy problems, it’s important to first address the issue of appropriate medication use. That’s one of the fundamental tenets of the GTMRx Institute
Get the medications right, the first time
The road to better therapy begins with the right diagnosis.
In the GTMRx What We Believe
statement, you’ll find the following: Appropriate diagnosis and access to advanced diagnostics with companion/complementary and pharmacogenetics (PGx) testing is essential to target correct therapy.
Here’s what’s so galling: PGx is complex. The issues I’ve highlighted are not at all complex or sophisticated. We’re simply talking about giving the right diagnosis; ensuring health information technology systems advance safe, effective and appropriate medication use; and prescribing the right medication for that diagnosis. We are also taking about stopping the wrong medication.
It shouldn’t be so hard.
If you know me, you know that I am not a clinician, but I am passionate about this fight. I can talk your ear off about the policy issues related to comprehensive medication management. I’m also enthralled by advances in genetics and genomics and find PGx as a tool to be used to target correct therapies utterly fascinating.
But what drives me? Ending the nonsense. One-off medication adherence programs will not effectively do this. A comprehensive approach to the loss of 275,000 lives and waste of $528B each year due to non-optimized medication is needed.3
We need policy and payment changes to make this comprehensive approach a standard of quality care. We need personalized medicine. But they are a means to an end.
I want to stop seeing the sad patient stories. I want us to get the medications right.
- Comprehensive medication management in team-based care. American College of Clinical Pharmacy. https://www.accp.com/docs/positions/misc/CMM%20Brief.pdf
- Shervani S, Madden W, Gleason LJ. Electronic Health Record Interoperability—Why Electronically Discontinued Medications Are Still Dispensed. JAMA Intern Med. 2021;181(10):1383–1384. doi:10.1001/jamainternmed.2021.4881
- Watanabe J, et al. “Cost of Prescription Drug–Related Morbidity and Mortality.” Annals of Pharmacotherapy, March 26, 2018. journals.sagepub.com/eprint/ic2iH2maTdI5zfN5iUay/full