Heads in the Sand: Obama, the CDC and Claims of Ebola Preparedness

Thousands of people have travelled from West Africa to the US in the last 6 months.  While the CDC and others throughout the Obama administration continue to reassure everyone that the US is 100 percent prepared for an outbreak,  potential cases and exposures continue to surface all across the country.  In Dallas, the first confirmed case of Ebola remains in critical condition.  Even more concerning is the fact that the patient initially presented to the Emergency Room with a fever at Texas Health Presbyterian Hospital (and even though he provided a high risk travel and exposure history) we was sent HOME.  Initially, the hospital blamed the fact that he was sent home with high risk features (his records documented the fact that he had just travelled from Liberia) was that there was a “technical glitch” in the electronic medical record and that physicians were unable to access the data obtained by the triage nurse.  Days later, the hospital rescinded their comments and admitted that the data was there for anyone involved in the case to see but in fact, no one even noted his West Africa travel history and released him from the ER.  These missteps resulted in the potential exposure of nearly 100 contacts AND the isolation of several family members.  But today, the director of the CDC, Dr. Tom Frieden, continues to proclaim on the national media that the US is well prepared and that all local healthcare agencies have policies and procedures in place to avoid major outbreaks and exposures.

Really?  Its Time for the CDC and our administration to get its collective head out of the sand!  

According to the WHO, the number of Ebola cases is expected to continue to rise sharply in the month of October.  The CDC estimates that there may be as many as 1.4million cases before the current outbreak is over.  Others worry that the disease is now so far out of control in West Africa that it will soon become endemic.  Currently, most families in West African countries actually spend nearly 80% of their monthly income on food–now prices are increasing and food is becoming even more scarce.  As West African nations become increasingly economically challenged by the outbreak, it is likely that many will flee the country illegally (and untracked and unscreened)–resulting in further spread of disease and wider contact with individuals from other nations.  The first US case admitted to lying on his immigration forms before fleeing Liberia and would have been considered high risk due to close contact with family members with documented Ebola.  At this point, the CDC and its leadership continue to proclaim that they are “looking at possible actions” to help prevent the entry of Ebola into the US.  However, there are no specific plans in place and no real travel protocols have been established.  US air carriers admit to confusion about what to do and how best to screen passengers.  One particular airline has told its employees to treat all bodily fluids on flights as potentially infectious.

Now certainly, we should not panic.  I agree that the US is better equipped to handle an outbreak of an infectious disease than any other country in the world.  We have state of the art isolation facilities, an abundance of medical resources and the wisdom of many of the worlds’ brightest physicians.   Our advantages in treating any potential Ebola cases in the US are huge—However, we must put policies and procedures in place NOW–not after more cases appear stateside.

What steps can we take to prevent Ebola spreading in the US?  First, we need to make sure the virus does not arrive here–and when it does we must have a plan in place to isolate and contain any potential carriers

 

  1. Initial standardized screening of people travelling from endemic countries must be set into place now.  We must consider travel bans and Pre Flight 21 day quarantines prior to travel to the US in order to ensure that no patients with disease are inadvertently admitted to the US.
  2. Airline personnel must have standard protocols in place should a passenger become sick–isolation equipment and protective gear must be readily available and crews should be provided with specific training designed at protecting themselves as well as other passengers.
  3. Improved education for healthcare providers, emergency department personnel and first responders.  We must put protocols for response in place that are easily implemented when confronted with a suspected case.  Travel history and exposure history must become the first line of defense–we cannot afford to send a high risk patient home again.
  4. Immigration and Passport control should also screen all high risk travelers (from endemic countries) upon entering the US as well.  Those that are considered to pose a risk must be quarantined upon arrival for 21 days.
  5. Private industry resources must be focused on the mass production of vaccines such as ZMAPP and other potentially life saving drugs. While government should play a role in development and deployment, the private sector should be leading the charge in order to avoid the inevitable slow downs associated with government led initiatives.  These drugs should be fast tracked and studied while being put to use in West Africa.  While the science behind their effectiveness is solid thus far, there have not been nearly enough clinical trials and standard safety and efficacy trials put in place.   However, these drugs must be tested in practice in areas of outbreak.  We do not have time to await months to years of clinical trials in healthy subjects.

So, where is our government in all of this?

At present, both the Obama administration and the CDC continue to downplay the threat of Ebola in the US.  I fear that while government rhetoric continues to highlight the absolute preparedness of the US in the case of an outbreak, the reality of Ebola cases in the US (the one documented case thus far was sent home from the Emergency Room with a fever) are quite concerning.  I wonder if we could quickly coordinate an effective response should more cases arise?  The situation in Dallas–while contained now, had the potential to spread to more than 100 people during the initial presentation of the patient.  Today, the President will meet with the director of the CDC.  It is my hope that we will soon put policies in place to protect Americans from the spread of the disease.

We must Act rather than discuss.  We must Prevent rather than respond.

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Should We All Die at 75?: Addressing the “Emanuel Principe” in Obamacare

Ezekiel Emanuel, one of the authors of the Affordable Care Act spoke publicly this week about his own desire to “die at 75” in a article published in the Atlantic.  In his piece, he argues that as he ages, he wishes to stop all preventative medical measures and “let nature take its course” as he approaches the age of 75.  This includes screenings such as colonoscopy as well as taking flu shots for the prevention of communicable illness.  While currently in excellent health, Mr Emanuel believes that while death is a loss–”living too long is also a loss.” He argues that the American obsession with living longer results in a larger number of elderly, disabled citizens.  I take significant issue with this position and fear that this is simply the beginning of a new phase in the ACA debate–the rationing of care. From the outset, many of us in healthcare and scholars of healthcare policy have seen Obamacare as a way to promote the rationing healthcare (particularly for the elderly).  While the administration has vehemently denied these claims throughout the legislative and implementation phases of the new healthcare law, it is particularly revealing that one of the principal architects of the law firmly believes that we should not pay attention to life expectancy statistics beyond the age of 75.  Medical advances have made it increasingly possible for seniors to lead healthy, productive exciting lives well into their 80s.  Now, I certainly am not arguing for providing futile care in the setting of terminal illness but–Why then should government (instead of doctors) now have the right to determine how healthcare resources are utilized and who gets what?  Is it all about age?  Do we value the young more than the more “seasoned” citizens? The US healthcare system, while certainly imperfect, offers some of the greatest technological advances in the world and the most significant thing that has always set US healthcare apart form others has been CHOICE.  With Obamacare in place, we now have less choice in our healthcare and very little improvement in access.  This latest article by Mr Emmanuel is no surprise–he has been clear about his belief in allocating health care dollars away from activities which may extend lifespans for Americans.  While, Mr Emmanuel certainly has the RIGHT to refuse care for himself at a certain age neither he (NOR OBAMA or any GOVERNMENT agent) should be able to determine an “acceptable” life span for each of us. Quality of life and health status can be very subjective and care must remain individualized rather than mandated (or withheld) based on actuarial tables or government rationing of resources. Medicine is all about innovation and the development of new technologies.  Through technology we are able to provide longer, more productive lives for our patients.  Our patients are able to retire from a life of work and enjoy spouses, family and friends–well into their 80s and 90s WITH a quality of life.  In fact one of my favorite “golf buddies” is 80 years old and going strong–He can still shoot in the 80s from time to time and never misses a game. In MEDICINE one size does not fit all.  OBAMACARE wants to force a ONE SIZE FITS ALL healthcare system on all of us and as a physician I find this to be unacceptable.  Just as we must cater therapy to individual patients—when (and how) you die must also be catered to each individual patients needs, desires and beliefs. Chronological age such as 75 may be different for different people AND we must respect individual needs.  Medicine is a clearly a science but in many cases the practice of medicine –particularly when making decisions about end of life issues–makes it more of an ART.  The government has no place in dictating ART.  Government should help to preserve and curate art–not regulate and mandate the way in which medical care is delivered to individual patients based on age. Ultimately, left to its own devices, I believe that the ACA will create rationing of care for Americans and we will have two classes of people–those that are wealthy and can afford private care and can pay cash for it–these can make their own healthcare decisions and decide when enough is enough.  The others–most of us–will be lumped into the disaster that IS obamacare and will have little or no choice in how our healthcare is delivered.  Waiting lists for advanced procedures and denials of advanced care for the elderly will be the standard–Just as Mr Emanuel envisioned it when he crafted the law just a few short years ago.

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Engaging Patients with an Apple and Health Apps: Watches Are No Longer Just for Telling Time

Today patients are increasingly connected.  The fastest growing demographic on Twitter is actually those that are between 45 and 65 years old.  Our patients are becoming better informed and are flocking to the internet and to social media to discuss and learn more about disease.  Prevention of disease is becoming more of a priority in our healthcare system as we begin to adjust to the mandates provided for in the Affordable Care Act and physicians are now expecting patients to take a more active role in their healthcare.  In the last 5 years, the concept of the electronic patient has emerged and is becoming more and more prevalent among mainstream patient populations.  These patients often come to office visits armed with information and data collected on the internet and are very technologically savvy.  They embrace new devices and are eager to track health indicators such as blood sugar, blood pressure and heart rate through easy to use phone applications.

This week, Apple intends to announce a new smartwatch and a group of associated health applications.  These innovations will further allow the electronic patient to become more of a mainstream phenomenon.  However, in order to be effective, physicians and other healthcare providers must embrace these technologies and begin to better understand their utility in all patient populations.  According to the Wall Street Journal, the announcement of the new smartwatch is expected to introduce no less than ten new sensors for monitoring health indicators.  Apple has created a data repository that will allow health related information to be stored (with the user’s permission) and directed to healthcare providers if so desired.  This assimilation and collection of massive amounts of health indicator data may be a significant game changer in the fight against chronic disease.  With many patients, compliance with medication or lifestyle modification plans is a challenge.  Many diseases such as hypertension do not produce immediate ill health effects–rather they accumulate over time.  However, if we can clearly demonstrate to patients the positive responses to interventions on a daily (or even hourly basis) they may be much more likely to comply with prescribed treatment plans.  Glancing at a smartwatch and noting a response to exercise or to a completed dose of medication can be a powerful motivational tool.

What if all of the data is collected simply by wearing a watch?

If we make collection and organization of information simple and user friendly, then important information can be transmitted to a physician who can review the data prior to the next face to face office encounter.  Real time feedback can then be provided to the patient and this may ultimately result in increased engagement and may actually spur change in habits or behaviors that are detrimental to a particular patient’s health.  Moreover, according to the WSJ, the new Apple operating system will include a Health icon that will allow for the development of a dashboard with many health indicators that are easily accessible in one place–lab results, heart rate, blood pressure, weight–even calories consumed and burned in a given time period.  The engaged patient can see what they are doing right, what they are doing wrong and can track improvements in habits rather quickly.  Having the data all in one place will likely increase compliance and improve overall health of the adopters of this technology.

What about security of sensitive personal healthcare data?

As with most new advances in medicine, there are significant concerns about data breaches and compliance with the federal Health Insurance Portability and Accountability Act (HIPAA) regulations.  According to a story in the New York Times, Apple is working with application developers as well as the federal government in order to ensure that any stored or tracked healthcare data will remain secure.  Partnerships with application designers, insurance companies, healthcare systems and physicians will be critical to the success of the new Apple smartwatch.  As these new technologies are rolled out and continue to develop, efforts to secure data will continue to evolve.

The development of new and exciting healthcare technologies and applications will continue to bolster the development and of the growing number of electronic patients.  Ultimately, the Apple smartwatch and other soon to be developed health indicator monitors, trackers and data repositories will only serve to further engage both patients and doctors and, in my opinion, significantly improve our ability to intervene EARLY and prevent the terrible consequences of chronic disease.

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Setting the record straight: New stool DNA test for Colorectal Cancer Screening (A guest Blog by @DrDeborahFisher)

 

A bit about today’s Blog Post…..

Dr Deborah Fisher is a brilliant Gastroenterologist at Duke University Medical Center.  She is also a fantastic wife and mother.  A Twitter fanatic, Dr Fisher has taken to Social Media to promote issues in Gastroenterology.  Today, she writes about a very controversial subject in GI–Does a New stool DNA test Replace Colonoscopy and is the Media Creating Confusion in the Market? 

Setting the record straight: New stool DNA test for Colorectal Cancer Screening (A guest Blog by @DrDeborahFisher) 

An occupational hazard of being married to a rising media star is that when I expressed my concern and exasperation at the misinformation being circulated about a newly FDA-approved colorectal cancer screening test, his response was “write a guest blog for my blog page”. Another occupational hazard is having the local NBC-affiliate news truck parked in front of our house at 9:30 on a random summer evening. But that is for another blog.

For full disclosure, I am a gastroenterologist and much of my research and clinical focus is colorectal cancer screening. Some of my previous comments on the new stool DNA test, Cologuard, have already been published in the New York Times as well as in a previous issue of @MedPageToday. However, I have recently noticed a number of misleading articles in various newspapers across the country and wanted to address these, likely common, misconceptions about the new test.

First, I want to openly acknowledge the positives about Cologuard. The study in the New England Journal of Medicine examining its ability to find a colon or rectal cancer as a one-time test (compared to colonoscopy as the gold standard) was large, well-designed and well-executed. It showed that as a one-time test Cologuard was 92% sensitive for cancer. It also showed that the false positive rate was about 13%.

The problem has arisen in how the study results are being spun in the media. Here are a couple emerging myths to debunk:

  • Cologuard is for patients who absolutely positively want to avoid colonoscopy.

                                                     FALSE

While colonoscopy is the most common test used in the US to screen for colorectal cancer , it is not the only test. It is not even the “best” test. It is the most accurate test for finding cancers and polyps but that is not the same as the “best” because there are clear downsides including cost, risk of complications, access. A screening strategy of using a non-invasive test first can greatly decrease the need for colonoscopy but does not eliminate colonoscopy because Positive Screening Tests Should Be Followed By a COLONOSCOPY. Therefore, a positive stool DNA test needs to be evaluated with colonoscopy or the point and potential value of screening is lost.

The fecal immunochemical test, aka FIT, is also a non-invasive colorectal cancer screening test. It has been around for decades, and in its current form is a widely available test that is included in all the US colorectal cancer screening guidelines

In fact, I will argue that it is a better test for your patient who is not completely against screening but would prefer to avoid colonoscopy if possible because 1) its false positive rate is 5% vs. 13% for Cologuard. Therefore it carries a lower risk of leading to an unnecessary colonoscopy 2) it is currently covered by all insurance carriers

  • Cologuard will increase colorectal cancer screening rates in the US population

                                                       FALSE

Or perhaps a more accurate response might be “We have no idea” since it is a new test and the only people who have used it were in a research study.

On the other hand, we have compelling data that FIT increases screening rates compared to the older guaiac-based fecal tests and among patients who were previously unscreened.

 

  • Cologuard is the best non-invasive test for colorectal cancer screening

                                                       FALSE

And a bit of a trick question because we really do not have a Best Test at this point. Nonetheless, Exact Science is clearly going after the screening market leftover after colonoscopy takes its lion’s share. In addition to my general case for no “best” test, I would argue that Cologuard has not accumulated enough data to knock FIT off its best non-invasive test perch.

Yes, Cologuard had a higher rate of diagnosing cancer in one-time testing compared to a single FIT product in a single study, but

1) Screening is not a one-time test. FIT is meant to be repeated annually (or biennially in most screening programs outside the US). We have no idea if after 2 or 3 rounds of FIT the higher sensitivity (detecting cancer among individuals with cancer) of Cologuard will remain.

2) The interval of annual FIT testing has a wealth of data support vs. no data whatsoever supporting ANY testing interval for stool DNA tests (currently CMS is considering a 3 year interval

3) In a healthy population, it is important to consider harms and the higher rate of false positives leading to colonoscopy could translate into an increased rate of adverse events.

4) FIT is $25 vs. $600 for Cologuard

 

Now, some might say, “hey colonoscopy is the most expensive, risky option out there”. To which I say touché. Perhaps unfortunately, no headlines are claiming any test is better than colonoscopy. That might be another blog. Poor Dr Campbell is creating a social media monster.

Deborah Fisher, MD, MHS

Associate Professor of Medicine

Duke University Department of Medicine

Division of Gastroenterology

@DrDeborahFisher

Photo on 6-16-14 at 2.49 PM #3

Turf Battles and Collateral Damage: Are We Really Putting the Patient First?

Last week, Medpage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice.  In her piece, Ms Wallan explores the ongoing battle between Dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice. According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year–this has Dermatologists seeking practice limits–ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

In response to this controversy and the article, I was asked to provide commentary for Med Page Today’s Friday Feedback.  Each week, the editors at MPT discuss a controversial topic and have physicians from all over the country share their feelings on the issue in order to provide readers with a mulit-specialty perspective.  This “Friday Feedback” feature is typically released on the web near the end of the day on Fridays and often spurs a great deal of social media activity and discussion.  Based on reaction to Ms Wallan’s article our topic this past Friday was “Specialty Turf Battles”.  Each respondent was asked to provide commentary on the growing angst between Dermatologists and Allied Health Professionals.    As I began to reflect on the issue itself and its potential impacts on all aspects of medicine, I felt that a complete blog would be a more complete forum to discuss my thoughts.

First of all I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our Residency and Fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.  Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to Dermatology–nor or they limited to MDs vs AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with Radiology over the performance of Peripheral Vascular Interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Dr Cam Patterson) decided to make a change.  The UNC Heart and Vascular Center was created–Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons–all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach–Electrophysiologists and Cardiothoracic surgeons perform hybrid Atrial Fibrillation ablation procedures, Vascular surgeons and Interventional Cardiologists discuss the best way to approach a patient with carotid disease–all working together to produce the BEST outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the Private Practice are limited–more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as Dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.  However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients FIRST–turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room–and make sure that ultimately patients get exactly what they need.

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The Dangerous Stranger Lurking in the Dark: Using the AliveCor Device to Identify Asymptomatic Atrial Fibrillation

Surgery has many well defined risks–we perform procedures when the benefits far outweigh the risks.  As healthcare providers, it is our job to carefully discuss the risks and benefits of any medical procedure with our patients prior to the planned procedure and make sure that they understand what we are doing, why we are doing it and what our ultimate goals include.  We often discuss bleeding, infection, and other common post operative risks and then other risks that are specific to the particular procedure being performed.  Now there may be a new perioperative clinical marker–atrial fibrillation–that can identify patients at risk for other complications such as stroke, long after discharge from the hospital.  Atrial fibrillation is the most common heart rhythm problem in the entire world and is associated with stroke in patients who are at risk.

This past week the Journal of the American Medical Association published a new study examining both the incidence of atrial fibrillation after ANY surgery as well as the conferred risk of stroke.  The study involved over 1 million patients and the results were quite alarming–nearly 28K patients had peri-operative atrial fibrillation and of those, almost 14K patients experienced strokes that occurred after discharge.  Even more disturbing was the fact that the rate of atrial fibrillation was even higher in non cardiac surgery patients (as compared to those undergoing cardiac surgery).  Many surgical patients may be discharged without knowing that they have atrial fibrillation or that they are at risk.  Some may present with cryptogenic strokes and suffer life changing devastation.  The data is very clear about the prevention of stroke in atrial fibrillation.  Based on a risk score (known as the CHADS2-vasc) we are able to quickly calculate and assess risk for stroke (based on several common predisposing factors) and appropriately choose an anticoagulant for each patient.  It is also clear that anticoagulation in high risk populations reduce stroke rates significantly.

There is no doubt that atrial fibrillation results in significant morbidity and mortality in the US today.  According to data from Circulation published in 2013, one in every 19 deaths is due to atrial fibrillation related stroke and nearly $37 billion dollars is spent on patient care due to this disease.   Even  more disturbing is the fact that many patients with atrial fibrillation are totally asymptomatic and may not even know they have the arrhythmia at all—many patients’ first presentation with atrial fibrillation is sadly a presentation with a devastating stroke.  The recent article in JAMA further emphasizes the negative impact that silent atrial fibrillation can have on patients.  As clinicians, we remain vigilant for the presence of atrial fibrillation and often we are able to identify and screen those at high risk–however, many patients are missed and preventative therapy with anticoagulation is never prescribed.

What is the Answer?  How can we better screen asymptomatic patients for atrial fibrillation in a cost effective, broad based way?

The Alive Cor iPhone EKG application and device is the first of its kind.  It is an FDA approved device that can record a single lead electrocardiogram directly from your fingertips, display the tracing on the iPhone screen and transmit the tracing to the cloud for review.  The device is now available direct to consumers for purchase and no longer requires a physician prescription.  In May, a clinical trial was published that demonstrated that the Alive Cor device could be used to easily screen large groups of consumers for atrial fibrillation in a cost effective way.  In the study, which was published in May in Thrombosis and Haemostasis, investigators screened 1000 asymptomatic pharmacy customers for atrial fibrillation using the Alive Cor device and found that 1.5% of them actually had atrial fibrillation upon screening.  The cost effectiveness per stroke saved in the US was estimated to be a cost savings of nearly 20%.

Given the high prevalence of both symptomatic and asymptomatic atrial fibrillation worldwide, it is essential that healthcare providers strive to do a better job screening for this sometimes silent disease.  The identification of patients at risk for stroke from atrial fibrillation (and subsequent anticoagulation) is the best way to reduce both the cost and devastating morbidity and mortality associated with the disease.  With technology such as the AliveCor device readily available to both patients and clinicians it is essential that we begin to utilize this device for massive, cost effective screening efforts.  As healthcare reform shifts focus on prevention of costly disease,   we must continue to focus on improving screening and care for those at highest risk.

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What Color is My Pill Doc? Using Technology to Improve Medication Compliance

It is clear that patient compliance with prescribed medications is critical to success in the treatment of any chronic disease process.  In addition, patient engagement and co-management of their disease has been proven to improve outcomes.  This past month a new study from the Annals of Internal Medicine suggests that any changes in the appearance of a medication may result in a decrease in compliance–when a pill looks differently patients often simply stop taking them as prescribed.  In this study, a change in pill color was associated with a 34% increase in medication discontinuation and a change in pill shape was associated with a 66% increase in medication discontinuation.  In cardiovascular patients in particular, the sudden discontinuation of medications can result in increased hospitalizations for chest pain, congestive heart failure and other more serious acute cardiovascular events. For other disease processes such as diabetes, medication non compliance can be devastating and life threatening as well.

The Challenges of Managing Poly-pharmacy

In general, today’s patients are taking more medications for a multitude of ailments and even for the most astute patients keeping track of doses and regimens can be a challenge.  Add in changes in color and appearance of chronic medications and the task can often be overwhelming for elderly patients with cognitive decline.  According to a study published in the Journal of the American Medical Association in 2008, nearly 81% of adults aged 57-85 took at least one pill and 29% took 5 or more drugs.  In addition, nearly 50% took concomitant over the counter drugs and/or supplements as well.  Side effects, drug-drug interactions and other concerns have led many physicians to attempt to streamline medication use and avoid the dreaded “poly-pharmacy” patient.  However, this serious public health problem is further complicated by patient non-compliance issues.  Many regulators argue for more FDA intervention as well as requiring generic drug makers to conform to non generic shapes and colors when manufacturing generic substitutes.  However, I believe that this data argues for a more comprehensive, patient centered approach to increasing medication compliance.

Leveraging Technology in Seniors

Technology today is ubiquitous in nearly all age groups. According to a Pew Research poll, most seniors utilize the internet and a large majority of these users interact via tablets, computer or other mobile devices.  As we age, we tend to live with more chronic illnesses and seem to require more daily medications.  Given the fact that now seniors are actively engaged on the internet, it makes sense for medical professionals to use these powerful tools to assist patients with management of their disease.  Many EMR systems already incorporate “patient portals” which allow for direct patient access to certain parts of their medical record such as test results, appointments, etc.  In addition, there are websites such as Pill Identifier that allow patients and physicians to search a large database of drug images in order to more accurately identify a medication–this is particularly useful when a patient approaches a visit in an Emergency Room or has a consultation with a new physician.

Based on the newly released study in Annals, it is clear that pill identification (and consistency of appearance) is critical in maintaining patient compliance with chronic medical regimens. Regulatory agencies are slow to act–forcing private generic drug makers to keep the size, shape and color of the generic consistent with the brand name is not realistic.  I believe that we can use tablet technology to quickly address this issue.  What if we create an application (downloadable to mobile phone, tablet and laptop) that is able to quickly identify all shapes colors and sizes of a particular drug? Currently there is a pill identifier app on the market but it requires the user to enter color shape and size in order to identify the correct medication–are there better apps yet to come? Ease of use and accuracy will be key components to any new medical applications aimed at older adults.

What Are Potential Solutions?  What Can WE Do Now?

As healthcare providers, we must do a better job encouraging the use of technology to help identify drugs and promote compliance.  The Annals study is a stark reminder that even though we may prescribe the best, most evidence based regimen to treat disease, it takes very little for our patients to become sidetracked–something as simple as a change in shape or color may result in the discontinuation of an effective, potentially life-saving medical treatment.  As physicians, we sometimes forget the “simple things” such as the importance of consistency and routine for our patients.  The culture of healthcare in the US no longer allows for the extended office visit and frequent follow up in order to ensure that patients are compliant with their treatment plans–we are asked to see more patients, in less time and the documentation requirements have become paramount in practice.  We must look for alternative ways to assist our patients with managing their disease while at home–I believe technology is the answer.  We must provide education and resources for our patients and assist them in the identification and use of medical applications.  With technology, we may be able to extend our reach–and support for our patients–well beyond the walls of our office.

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