Health Outcomes- The Role of the Patient

In a recent editorial published in the May/June edition of the Journal of the Advanced Practitioner in Oncology (JADPRO), Drs. Ramirez and Campen exposed systemic failures in detecting drug-drug interactions (DDIs) in the oncology setting. Their article was an extrapolation of a Chicago Tribune exposé that addressed the same issue albeit in the community pharmacy setting. Ramirez and Campen basing their editorial on the "Swiss cheese model" identified 4 gaps: (1) prescriber knowledge, (2) computer screening, (3) pharmacist knowledge, (4) patient education. The authors concluded that "The system is failing, and the problem only seems to be growing".

Where do we go from here? how do we fix such a problem? in previous posts, I mentioned the shift toward a new healthcare paradigm of patient outcomes data collections. Perhaps one of the most important contributor to the gaps exposed by Ramirez and Campen is the use of multiple pharmacy as a provider of pharmaceuticals. For instance, a patients may receive his chronic illness therapies from a mail order supplier, his acute medications from his local drug-store and his oncology or immunological therapy from speciality pharmacy. Not to mention that all these medications maybe prescribed by various specialists and general practitioners. In addition, the availability of apps and websites that provide cost comparison and coupons promoting patients to shop for medications from various sources compound the multi-pharmacy use problem. There is enough evidence in the literature that indicates that this issue reduces adherence to medication, and increase the risk of unchecked DDIs.
Historically, pharmacists enjoyed the highest level of trust to provide drug information to patients, improved adherence by reminding patients of due refill, promoting medication therapy management (MTM), avoid dispensing medication causing potential DDIs without discussion with prescribers.
However today, in the multi-pharmacy use model that centralized one pharmacist is removed and the patient's safety is therefore compromised.

As we move into this new paradigm change in healthcare where costs trumps all, there seem to be two options to keeping a centralized data on the patient's medication therapy.
1) Health insurance agency (governmental or non-governmental): data is maintained and reviewed in real-time, screened for the potential drug-drug interaction, duplication of therapy, dosage appropriateness...etc (not to mention these services are currently sporadically available). In addition, there must be some routine review conducted by health insurance agency in the like of case management. However, inherent in such a model, are ethical concerns and conflicts of interests that need to be addressed. For instance, how would cost influence choice of therapy? or how would the agency use patient's data?
2) Patient portal data gathered from various healthcare providers is stored to a secured patient portal with ease of use. Patient is then educated on the its use and it is ultimately the patient that grant access to the healthcare providers. Furthermore, built in application to enhance health literacy and engaging the patients in a meaningful way to take charge of their health. This seems to be the best model, relying on a universal electronic health record (EHR) as opposed to a multiple provider-dependent variations of electronic medical record (EMR). However, this model is not without shortcomings, mainly patient literacy. Yet this can be overcome with patient education and user-friendly customization according to the patient's health literacy level. Ultimately, the onus is therefore on the patient to take charge of his/her records and disseminate this information to his/her clinicians.

Improving patient's health outcomes is not simply the burden of the "system" as if the "system" is some extrinsic entity. Improving patient's health outcomes relies significantly on education the patient and improving their health literacy so that the patients take charge of their health.

Measuring Patient Outcomes- An Elusive Proposition?

Improving patient health has been the question that plagued the medical society for years if not decades. In fact, I dare to say, that improving patient health is the impetus of the medical community.
In our modern era, improving patient health is rapidly becoming synonym with patient outcomes. With economic concerns over cost of diagnoses, therapies and subsequent monitoring, the third-parties (governmental or private) cost reimbursements leave us scrambling to find what works and what doesn't. While articles after articles in peer-review journals and in common news outlet speaks of novel therapy or newly discovered diagnostics, the burden of new information is crippling health care professionals and/or is pigeon-holing them into a super-specialties. Furthermore, continuing education, an ethical obligation for healthcare professionals, should be designed to meet certain objectives that address performance (Moore's level 5) and patient health (Moore's level 6).
However, our poor attempt to categorize patients according to their age/gender/race and disease or attempt at bucketing diagnostics/therapies into a one group, have led to unsatisfactory results in measuring patient outcomes. At best, some were subjectives on part of the clinicians, or retrospective and anecdotal evaluation. In addition, the lack of guidance on patient outcomes measurement compound the problem even further.
What now? The question remains; how do we measure patient outcomes? This elusive endeavor can prove challenging in the modern paradigm of healthcare. Are objective biomarkers for a particular disease state a determinant of positive or negative patient outcomes? In other words, if for example we manage a patient with diabetes to attain a hemoglobin A1C below 7%, does that mean we have a positive outcome? How about that patient weight? complications? yes, I submit that the diabetic guidelines account for all of these, and perhaps on a singular patient level a clinician may have evaluated all known factors. But chasing these factors and numbers reduces the practice of medicine into a fruitless play of cat and mouse.  Healthcare practitioner after all "do not treat numbers but treat people".

Ultimately the outcomes measurement is only achievable in a holistic, multi-disciplinary approach that relies on the three main pillars of medicine: the physician, the pharmacist and the nurse. This endeavor is attainable when all three pillars are interconnected and not standing alone; physician feels safe being challenged on certain therapy choice, pharmacist welcomes the nurse's input on the patient's concern or shortcoming, and the nurse provides accurate and complete patient information and relays patient's concern to the physician. This leads me to my first proposition: there must be a genuine and complete open communication across the healthcare medium. 

However, for this communication to be successful it should be patient driven. All conversations of patient outcomes should be put aside until the patients themselves take charge. Although patient apathy is a different issue for a different discussion, recognizing the submissive, inherent attitude of patients as subordinate to their healthcare providers should be noted. Because this patient behavior is well documented in lower socioeconomic environment, special effort should not be spared in providing compatible education. Which leads me to the my second proposition: patient education material should be engaging with less text and more infographics providing the appropriate contexts.

In summary, measuring patient outcomes will continue to be elusive, but it is not illusive. It is attainable provided we approach the subject in a systematic, comprehensive way and are willing to challenge and be challenged by a new healthcare paradigm.

CMS Expands Pharmacist's Role in LTC- Is it Enough?

The Center for Medicare and Medicaid Services (CMS) issued its final ruling in September on the requirements for long term care (LTC) facilities. Emphasizing the importance of pharmacological therapy oversight by the pharmacist, the final ruling requires LTC to provide a pharmacy services section in the resident's medical chart. and invite individual LTC facilities to utilize consultant pharmacy services as part of the healthcare team. While consultant pharmacist routinely (monthly) review resident's medication record and provide recommendations, CMS ruling did not mandate the consultant pharmacist participation in interdisciplinary team (IDT), but left it open to LTC to include or exclude pharmacist from the IDT. Furthermore, LTC facilities are asked (1) to incorporate  quality assurance and performance improvement (QAPI) programs with focus on systems of care, outcomes and quality of life, (2) develop infection control and prevention program that include antibiotic stewardship program and (3) take an active role in developing and implementing a baseline care plan for resident upon admission within 48 hours. All of which can have a significant role for the consultant pharmacist. 

However, when reading the ruling, it appears that most of the exclusions and the comments that CMS received on the role of pharmacist in LTC pivot on considering the pharmacist a health care provider under the Social Security Act, and the cost increase that LTC may incur secondary to the increase of responsibilities delineated to the consultant pharmacist. While the role of pharmacist has been somewhat expanded in the management of psychotropic medications, and infectious disease programs in LTC, the basic foundational role as a member of the health care team seems elusive. 

It is unfortunate that pharmacists continue to be envisioned as "dispenser of pharmaceutical products" and here lies their source of income. While today a large portion of pharmacists are involved in patient care and continue to show their value by increasing positive patient outcomes, some organizations continue to associate the cost of consultant pharmacist services to "products"; albeit hourly rates, or à la carte services, or in the form of indirect cost to state Medicaid and Medicare Part D programs. This subconscious approach to reimbursement undermine the several decades of advancement of the pharmacy profession. Disassociating pharmacy services from products is necessary for any inclusion of pharmacist in the health care team, and ultimately be considered as providers. 

While CMS places an important role on the pharmacy services that are provided to LTC, their remains a need for individual LTC to acknowledge the untapped resources made available to them through the consultant pharmacist, and on the consultant pharmacist to rise to the challenges by shedding the subconscious prejudice when it comes to financial gains.  

Trend Analysis in LTC why it is needed?

Today, basic foundational economic principles are being applied to medicine. Demands for affordable, and high-quality care is placed on physicians, nurses, pharmacists, administrators and institutions. The delivery of such quality of care at an affordable costs to an aging population residing in various settings has perhaps taken the back seat for more than we care to acknowledge.

Health economics, the term coined to couple two disciplines (health and economics) is build on two principles; cost-effectiveness and clinical-effectiveness.

To be able to measure any effectiveness, the inherent linchpin of health economics is health outcomes. And here lies the difficulties. It is not sufficient for example to claim that reduction in blood pressure (BP) or HbA1c by a certain percentage is an acceptable outcomes. Clinicians have to ask the ultimate question; for instance, if BP or HbA1c is reduced by a certain percentage, what does that mean in terms of long-term cardiovascular complications, survival of patients and quality of life (QoL). In other words, clinicians must be in-tune to the latest studies or even surveys addressing long-term effects and QoL. 

However, in controlled settings such as long-term care (LTC) or skilled nursing facilities (SNF), collecting data, and trending it ultimately improves patients outcomes and can be readily accessible. 

In 2010, the Center of Medicaid & Medicare Services (CMS) pursuant to the provision in the Affordable Care Act, launched best practices in nursing homes quality assurance performance indicator (QAPI). This program provides the framework for reviewing exciting policies and procedures redesigning new ones when needed, engaging the leadership team in the process, collecting data and feedbacks, designing a performance improvement and circling back with a systemic review and analysis. This structured approach to quality assurance and performance improvement must utilize established rules of engagement such as standardized care, enhancement of patient safety, management of chronic disease and preventive care. 

Trend analysis in SNF or LTC  is not the holly grail of patient outcomes, it is only a tool, when used in a systematic and comprehensive way, will certainly provide positive results in patient's care. Consultant pharmacists should be at the forefront of such endeavor by liaising and bridging the clinical-cost effectiveness of therapy. Hence bringing to the table clinicians and administrators. 

JC Rx Consulting and IO Solutions Call Center Joined Efforts

 JC Rx Consulting, LLC. is happy to announce a partnership with IO Solutions Call Center Inc. This partnership will provide customers of JC Rx Consulting access to a state of the art call center.

IO Solutions Call Center is a privately owned and operated Business Process Outsources (BPO) with years of experience. IO Solutions through JC Rx Consulting will be able to offer compliant turnkey specialized and dedicated healthcare business process solutions ranging from general billing inquiries, technical support, and related inquiries.

JC Rx Consulting’s expertise in healthcare combined with IO Solutions’ technology will allow healthcare customers to customize and scale needed services.

The services that would be provided to healthcare consumers as well as healthcare agencies range from the multi-channel communication, social media management, to direct customer care.

JC Rx Consulting and IO Solutions look forward to this joint partnership in providing streamlined, high quality, and exceptional outcomes to their clients’ healthcare needs. 

JC Rx Consulting LLC was founded on the principles held by the National Quality Strategy. We believe that the duty of every healthcare professional to develop the skills and provide a patient centric care that promote the national strategy put forth by the National Institute of Health (NIH), National Academy of Medicine (NAM, formerly Institute of Medicine), and other national health care organization. JC Rx services individually or collectively are geared to incorporate evidence-based medicine in line with the applicable clinical and regulatory guidelines. To ultimately serve the patients and their caregivers JC Rx provides the healthcare facility setting with consulting services, business solutions and medical communications.

IO Solutions Call Center, privately owned and in operation since 2007, is a Business Process Outsourcer head-quartered in Prince Edward Island. Years of experience in several fields have given IO Solutions flexibility in its delivery capabilities. IO Solutions offers compliant turnkey specialized dedicated business process solutions ranging from general billing inquiries, retail and technical support, financial solutions to healthcare related inquiries. IO Solutions technology is customizable and scalable to the needs of their clients and is secured and architected for stability. IO Solutions provide their clients with multilingual multitask delivery optimized by skill-based routing and analytics from onshore and offshore locations for Business to Business and Business to Consumer needs.

Significant increase in insulin use among nursing home residents

A presentation by Dr. Andrew Zullo et al. at American Diabetes Associations (ADA) 76th scientific sessions conference revealed a dramatic increase in the incident use of rapid-acting insulin and a modest increase in short-acting insulin between 2008 and 2010 in a national cohort of nursing home (NH) residents.

Data on medication use was assessed using Medicare Part D drug claims. Resident and facility characteristics were assessed prior to medication initiation using Medicare Part A, Minimum Data Set (MDS), and Online Survey, certification and Reporting (OSCAR) database. 

N= 11,531 (65 years or older, 90 days or more stay as NH residents)	2008	2010	% Change in 12 quarters
Sulfonylurea	25.4%	11.7%	13.7% ê
Metformin	12%	18.8%	6.8% é
Dipeptidyl peptidate-4 inhibitors	0.9	2.7	1.8% é
Thiazolidinedione	4.7	1.9	2.8% ê
Meglitinide	1.5%	0.3%	1.2% ê
Insulin	51.7%	68.3%	16.6% é
Rapid-acting insulin	11%	29.4%	18.4% é
Short-acting	22.6%	30.3%	7.7% é

Zullo AR, Dore DD, Daiello L, et al. National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010. J Am Med Dir Assoc. 2016 Jul 1;17(7):602-8.